Risk of tuberculosis incidence and the tuberculosis infection care cascade among older adults in eastern China: A population-based cohort study

Background Older adults are increasingly contributing to the tuberculosis (TB) burden due to the high prevalence of life-long TB infection. This study aimed to evaluate TB incidence risk and identify attritions along the TB infection care cascade among older adults. Methods This study included TB symptoms screening, IGRA testing, and initiation of preventive TB treatment of eligible individuals during 2023-2024, and follow-up for incident TB through December 2025, among 54,948 residents aged ≥60 years in Deqing County, China. A care cascade beginning with TB infection identification and extending through TB preventive treatment (TPT) completion was constructed. Results Among 54,948 participants, 4497 (8.18%) were diagnosed with TB infection. During follow-up, TB was diagnosed in 59 individuals. IGRA-positive individuals had a significantly higher risk of incident TB than IGRA-negative individuals (hazard ratio 9.03, 95% CI 5.40-15.11). The largest attrition occurred between recommendation and initiation of TPT, with 48.5% of individuals who met TPT criteria refusing the treatment. Age, occupation, BMI, and smoking status were associated with TPT initiation. TB incidence was higher in those who did not initiate or complete TPT than in those who completed TPT. Conclusion Significant gaps were identified along the TB infection care cascade among older adults. Targeted interventions are warranted to improve TPT acceptance and adherence among high-risk subgroups.