with TB-notification drops of ⩾20% [34]. The African region remarkably only showed a modest decline of 2.3% in 2020, with notification levels in 2021 above those of 2019 (figure 1) [34]. Declines in TB notifications were due to reduced access to TB services, along with increased stigma relating to the similarity between COVID-19 and TB symptoms [1, 35, 36]. These factors led to a decrease in the number of people seeking healthcare. At the same time, there were disruptions in the availability of medical care due to the enormous demands of the COVID-19 response on healthcare systems [37]. The result was that almost half of those with incident TB in 2021 were not diagnosed or treated – this was nearly 30% in 2019 (figure 2a) [1, 38]. In addition to disruptions to health services, people with TB were shown to be at additional risk of severe COVID-19 [39]. Along with the rise in TB mortality and the reduction in TB case notifications, the COVID-19 pandemic impacted the number of people accessing TB treatment (table 2), with a decline from 69% in 2019 to 58% in 2020, followed by a slight recovery to 61% in 2021 [31]. The number of people developing MDR/RR-TB was relatively stable throughout 2015–2020 but grew in 2020. This proportion partially recovered in 2021 but is not yet at pre-COVID-19 levels [1]. The COVID-19 pandemic also took a considerable toll on global funding for essential TB services and BCG vaccination [38], particularly in the American, South-East Asian and Western Pacific WHO regions [31]. This is consistent with reported reductions in childhood immunisation coverage, dropping from 86% in 2019 to 81% in 2021 [40]. In low- and middle-income countries, which account for 98% of the reported TB cases of 2021, investment in TB diagnostics, treatment and prevention dropped from US$6 billion in 2019 to US$5.4 billion in 2021, representing a further setback to reaching the global target for 2022 of US$13 billion [1]. While regions with a high TB burden did not necessarily feel the largest impact of the COVID-19 pandemic, they also did not have equal access to many of the tools used to counter the pandemic in other countries. For instance, by the end of January 2023, the African region only accounted for a cumulative 1.4% and 2.6% of all confirmed COVID-19 cases and deaths, respectively [41], which cannot be fully explained by underreporting or under-diagnosis [38, 42]. The COVID-19 TABLE 2 Number of people diagnosed and treated for TB/DR-TB, and TB deaths, in 2019–2021 2019 2020 2021 Percentage change 2019–2021 TB Incidence estimate 10 300 000 10 100 000 10 600 000 2.9% Case notifications #7 120 000 5 830 000 6 420 000 −9.8% Receiving preventive treatment 3 600 000 3 200 000 3 500 000 −2.8% Treatment coverage ¶ 69% 58% 61% −11.6% MDR/RR-TB Incidence estimate 450 000 437 000 450 000 0.0% Case notifications# 202 000 157 000 167 000 −17.3% Receiving treatment 181 000 150 000 162 000 −10.5% Treatment coverage ¶ 40% 34% 36% −10.0% TB deaths 1 400 000 1 500 000 1 600 000 14.3% #:newly diagnosed. ¶ :estimated as TB notification divided by the TB incidence. Therefore, those who are diagnosed and reported but not treated are included those who are diagnosed and treated but not reported are excluded. Data from [31, 34]. 24 https://doi.org/10.1183/2312508X.10023922 ERS MONOGRAPH |THE CHALLENGE OF TB IN THE 21ST CENTURY