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Global tuberculosis (TB) burden estimates are aggregated at the national level, despite the likelihood of uneven distribution across and within regions in the same country. Subnational estimates are crucial to producing informed policies and informing budget allocation at more granular levels. In collaboration with the National TB Programme (NTP), we applied a simple and transparent tool to estimate the subnational TB burden in Pakistan. We tailored the SUBnational Burden Estimation for TB (SUBsET) tool to account for the district-level hierarchy of Pakistan. Districts were assigned weighted scores based on population size, level of urbanisation, households with one room, and food insecurity levels. Using the 2022 national TB incidence estimate, we first allocated the burden across administrative units based on data from the 2010-11 TB prevalence survey and subsequently refined this distribution to reflect weighted scores specific to each district. The estimated TB incidence was compared with pulmonary TB notifications to calculate the case detection rate (CDR) for each district. Utilising the updated SUBsET model, we assigned weight scores to 150 districts spanning seven provinces/regions in Pakistan. The estimated TB incidence varied significantly, ranging from 110 (95%CI: 80-145) to 462 (95%CI: 337-607) per 100,000 inhabitants per year. The provinces bearing the highest burden was Sindh (292; 95%CI: 213-384), followed by Khyber Pakhtunkhwa (269; 95%CI: 196-354) and Punjab (243; 95%CI: 177-320). The CDR was below 70% in three-quarters of the districts and over-reporting (>100%) was observed in 10 districts, primarily within Punjab, which suggests that individuals with TB may be crossing district lines to access care. The application of the SUBsET tool through active collaboration with the NTP revealed high heterogeneity in subnational TB incidence in Pakistan, urging a more granular and tailored approach to TB prevention and care. This approach ensured transparency and acceptance of the findings for wider in-country dissemination., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Schwalb et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The provision of tuberculosis preventive treatment is one of the critical interventions to reduce tuberculosis incidence and ultimately eliminate the disease, yet we still miss appropriate tools for an impactful intervention and treatment coverage remains low. We used recent data, epidemiological estimates, and research findings to analyze the challenges of each step of the cascade of tuberculosis prevention that currently delay the strategy implementation. We addressed research gaps and implementation bottlenecks that withhold key actions in tuberculosis case finding, testing for tuberculosis infection, provision of preventive treatment with safer, shorter regimens and supporting people to complete their treatment. Empowering communities to generate demand for preventive therapy and other prevention services in a holistic manner and providing adequate financial support to sustain implementation are essential requirements. The adoption of an effective, universal monitoring and evaluation system is a prerequisite to provide general and granular insight, and to steer progress of the tuberculosis infection strategy at global and local level., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Matteelli et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Macronutrient and micronutrient deficiencies are associated with tuberculosis (TB) incidence. However, evidence is limited on the impact of micronutrient (vitamins and minerals) supplementation among underweight individuals. We conducted a secondary data analysis of a randomised controlled trial of lipid nutritional supplements with and without high-dose vitamin and mineral supplementation (LNS-VM vs LNS) for underweight (Body Mass Index [BMI] <18.5 kg/m2) adults with human immunodeficiency virus (HIV) initiating antiretroviral therapy (ART) in Tanzania and Zambia (2011-2013). Incident TB disease diagnoses were extracted from trial records. We used multivariable Cox regression to estimate hazard ratios (HR) for the impact of receiving LNS-VM on TB incidence, and the dose-response relationship between baseline BMI and TB incidence. Overall, 263 (17%) of 1506 participants developed TB disease. After adjusting for age, sex, CD4 count, haemoglobin, and C-reactive protein, receiving LNS-VM was not associated with TB incidence (aHR [95%CI] = 0.93 [0.72-1.20]; p = 0.57) compared to LNS alone. There was strong evidence for an association between lower BMI and incident TB (aHR [95%CI]: 16-16.9kg/m2 = 1.15 [0.82-1.62] and <16kg/m2 = 1.70 [1.26-2.30] compared to 17-18.5kg/m2; linear trend p<0.01). There was strong evidence that the rate of developing TB was lower after initiating ART (p<0.01). In conclusion, the addition of micronutrient supplementation to LNS was not associated with lower TB incidence in this underweight ART-naive population., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Schwalb et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)