Air Quality and Tuberculosis Transmission: Evaluating Environmental Predictors in Vulnerable Districts of Pakistan

Tuberculosis (TB) remains a critical public health challenge, especially in low- and middle-income countries like Pakistan where environmental and socioeconomic vulnerabilities exacerbate disease transmission. While conventional TB control emphasizes diagnosis and drug therapy, growing evidence suggests that environmental factors – notably air pollution and housing conditions – significantly influence TB incidence. This study investigates the relationship between ambient air quality and TB incidence in twelve environmentally vulnerable districts of Pakistan from January to May 2025. A cross-sectional research design was employed, integrating primary data from structured questionnaires administered to TB patients and secondary data from official TB case registries and air quality monitoring networks. Key air quality indicators (PM₂.₅, PM₁₀, NO₂, and the Air Quality Index, AQI) were analyzed alongside TB case counts using descriptive statistics, correlation analysis, and multiple linear regression. Results indicated persistently elevated ambient pollution levels across all districts (mean AQI >150; mean PM₂.₅ ~60 µg/m³), far exceeding World Health Organization guidelines. TB case notifications (n = 6,285) varied widely by region and peaked in March 2025, coincident with slight rises in PM₂.₅ and AQI. However, statistical analyses revealed no significant linear associations between short-term ambient pollutant levels and TB incidence in this timeframe. None of the examined pollutants emerged as a significant predictor of TB case counts (p > 0.1 for all in regression) despite a spatial overlap between high pollution exposure and high TB burden areas. These findings underscore the complexity of TB’s environmental etiology: while poor air quality imposes chronic stress on respiratory health, its acute influence on TB incidence may be obscured by the disease’s long latency and multifactorial nature. The study highlights the need for integrating environmental monitoring with TB surveillance and adopting a multi-sectoral approach to TB control. The implications for public health policy highlight the need for strengthened air quality management, healthier housing and indoor air environments, and climate adaptation as complementary strategies for tuberculosis prevention. TB should be addressed not only as a biomedical problem but also as an ecological and social concern – a paradigm shift essential for sustainable TB elimination efforts.