Global Tuberculosis Burden Attributable to Household and Outdoor Air Pollution

Air pollution is an emerging risk factor for Mycobacterium tuberculosis infection and tuberculosis incidence and poor treatment outcomes, yet evidence has not been comprehensively synthesized or translated into burden estimates to inform policy. This systematic review and meta-analysis examines global evidence on household and outdoor air pollution and tuberculosis risk and outcomes and estimates tuberculosis burden attributable to fine particulate matter (PM2.5). We reviewed 140 studies published through August 2024, applying random-effects meta-analysis and Burden of Proof meta-regression to generate conservative effect estimates and quantify the tuberculosis burden attributable to PM2.5. Household solid fuel use was associated with higher tuberculosis incidence (risk ratio [RR] = 1.82, 95% confidence interval [CI]: 1.52-2.17), with larger effects in children (<15 years: RR = 2.25, 95% CI: 1.12-4.52) and females (RR = 2.62, 95% CI: 1.95-3.52). Short-term (≤3 months) exposure to outdoor PM2.5 (RR = 1.03, 95% CI: 1.00-1.05 per 10 µg/m³) was also associated with increased tuberculosis incidence. In 2023, there were an estimated 4.15 million tuberculosis cases (95% UI: 3.68-4.66 million), 23.58 million disability-adjusted life years (95% UI: 20.79-26.66 million), and 534,947 tuberculosis-related deaths (95% UI: 458,878-614,458) globally associated with PM2.5 exposure. We estimate that PM2.5 exposure was associated with 49.9% (95% UI: 44.5-55.5%) of tuberculosis cases worldwide in 2023. These findings suggest that exposure to household and outdoor air pollution are important risk factors for tuberculosis, supporting air quality interventions as a component of global tuberculosis control strategies.