The concentration of tuberculosis within Paraguay's Indigenous population, 2018-2022: a retrospective population-based study.

Background: While over the past decade global incidence rates of tuberculosis (TB) have decreased, in Paraguay incidence has risen. A new reporting system implemented in 2018 has not previously been used to characterise trends in TB and identify areas to prioritise for the expansion of access to TB diagnostics and treatment programmes. Methods: We conducted a retrospective study of all TB cases notified to the Paraguay National Program for Tuberculosis Control (NPTC) from 2018 to 2022. We quantified trends in case notifications spatially and in specific populations identified as vulnerable by the NPTC and measured trends in access to GeneXpert testing. Findings: Of the 13,725 TB cases notified in Paraguay from 2018 to 2022, 2337 (17%) occurred among incarcerated individuals and 1743 (12.7%) occurred among self-identified Indigenous individuals. In 2022, the relative risk of TB was 87 and 6.39 (95% CI: 6.08-6.72) among persons deprived of liberty and Indigenous populations, compared to those who are not persons deprived of liberty and non-Indigenous populations respectively. We found significant heterogeneity in TB incidence across Paraguay's 17 departments. While 45% of TB cases among the Indigenous population occurred in the Chaco Region, in western Paraguay, notification among the Indigenous population was highest (1127.4 per 100,000) in the Capital, including the metropolitan area. Interpretation: TB cases are concentrated among Paraguay's incarcerated and Indigenous populations, both of which have extremely high relative risk of TB. Our findings highlight the urgency of expanding access to TB diagnosis, treatment, and prevention across the country and specifically, to the populations at heightened risk of TB. Funding: K01AI173385 (NIH, NIAID), University of Utah UROP.