Europe Grapples With Rising Childhood TB

Children under 15 account for 4.3% of all new and relapsed tuberculosis (TB) cases in the WHO European Region, which includes Europe and Central Asia, compared with 3.9% in 2022, a 10% increase.

The finding was released this week in the 2025 Tuberculosis Surveillance and Monitoring Report.

The news has prompted urgent calls for public health action. “Countries [in Europe] have robust tuberculosis surveillance systems,” Veronica Cristea, MD, scientific officer for TB at the European Centre for Disease Prevention and Control (ECDC), told Medscape Medical News. However, she added that this should be considered an early sign of what can happen in the coming years and that countries should be aware and prepared.

The trend is mirrored within the European Union/European Economic Area (EU/EEA), where pediatric TB cases have risen for a third consecutive year, also accounting for 4.3% of total cases. Between 2022 and 2023, this increase amounted to more than 650 additional child cases, signaling ongoing transmission within communities and families, Cristea explained.

Why Are Cases Increasing?

Experts attribute the rise in pediatric TB to multiple factors. The post-pandemic comeback of social interactions and increased travel to TB-endemic regions have likely contributed to the spread.

“We saw a decline in cases during the pandemic due to lockdowns, but once restrictions lifted, TB transmission resurged,” Elena Chiappini, MD, PhD, a pediatric infectious disease specialist at the University of Florence and Meyer Children’s Hospital, Florence, Italy, told Medscape Medical News. “Children visit relatives in high-burden TB countries or come into contact with visitors from these regions, increasing their exposure risk.”

Additionally, underreporting during the pandemic may have masked the true scale of childhood TB. “Some cases likely went undiagnosed as healthcare efforts focused on managing acute respiratory illnesses,” Chiappini said.

Cristea added that the pandemic diverted resources away from TB control efforts. She said many diagnostic laboratories were dedicated to COVID-19, and people with TB might not have been able to reach medical care because of the restrictions on movement. This disruption created a gap in care and delays in diagnosis and treatment, which are now reflected in recent surveillance data.

The Ukrainian refugee crisis and the consequential population displacement also contributed to the rise in cases, Cristea said. Before the war, Ukraine had the fourth highest TB incidence rate in the WHO European Region.

Diagnostic Challenges and Drug Resistance 

Diagnosing TB in children is more complex than in adults because of the nonspecific nature of symptoms and the difficulty in obtaining definitive microbiologic confirmation.

“Less than half of pediatric TB cases receive microbiological confirmation,” said Chiappini.

While tests like interferon gamma release assays are useful, they have limitations, including the possibility of false negatives. As a result, clinicians rely on a combination of clinical, epidemiological, and immunological assessments, she explained.

Children are also particularly vulnerable to severe forms of TB, such as disseminated disease and tuberculous meningitis. “We’ve seen central nervous system involvement, which underscores the need for prompt diagnosis and treatment,” Chiappini warned.

One major concern highlighted in the ECDC report is the high rate of incomplete TB treatment data in children across Europe, with 1 in 5 children with TB in the EU/EEA lacking records of treatment completion. 

Cristea explained the difficulties in tracking these data. She said that patients frequently move between countries or healthcare facilities, and communication between these facilities is not always seamless.

However, beyond logistical hurdles, patients sometimes fail to adhere to the entire course of treatment. “TB treatment is long and can have harsh side effects. Some patients stop taking their medication once they feel better, which is a major problem,” Cristea said. “It increases the risk of drug-resistant TB, as the bacteria can learn to defend itself against the medications. Also, patients who don’t finish their treatment can remain infectious, spreading TB to others.”

Treating drug-resistant TB in children is particularly difficult because there are limited pediatric versions of the necessary medications, and doctors often must rely on doses developed for adults, Chiappini added.

The ECDC actively monitors drug resistance through advanced genetic testing. “We use whole genome sequencing to track resistant TB strains, allowing countries to prepare and ensure they have the right medications on hand,” Cristea said. 

Will Cuts in US Aid Affect TB Control?

Beyond clinical challenges, experts warn that recent US aid cuts and the dissolution of US Agency for International Development could disrupt TB surveillance efforts. Askar Yedilbayev, MD, MPH, WHO/Europe’s regional TB adviser, cautioned that funding shortfalls may hinder countries’ ability to track TB transmission. “As money dries up, it could affect countries’ abilities to conduct proper TB surveillance. This means transmission may go unnoticed,” he told Medscape Medical News.

These concerns are particularly pronounced in Eastern Europe and Central Asia, where TB rates are highest. The withdrawal of US funding may also accelerate the spread of drug-resistant TB.

Additionally, the WHO European Region has an unrelenting HIV epidemic, with low uptake of pre-exposure prophylaxis and harm reduction to prevent new infections, and a high proportion of undiagnosed or diagnosed late and suboptimal treatment coverage, Yedilbayev said. “The combination of drug-resistant TB, HIV, and funding cuts could result in thousands of preventable deaths.”

Cristea, Chiappini, and Yedilbayev reported no relevant financial relationships.

Manuela Callari is a freelance science journalist specializing in human and planetary health. Her work has been published in The Medical Republic, Rare Disease Advisor, The Guardian, MIT Technology Review, and others.