The conceptualisation of TB has evolved from a binary view to a spectrum, yet this shift isn't reflected in clinical practice. State-specific diagnostics and treatments are lacking due to undefined reference standards. Current conceptual frameworks rely on cross-sectional evaluation, leaving disease progression and regression poorly understood.

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Rich, high-quality cohort studies are crucial for understanding individual disease trajectories, especially in the absence of natural history. Notably for states such as incipient TB, or more recently termed “subclinical TB non-infectious” according to the ICE-TB framework, classification may only be possible longitudinally as the time dimension of progression is fundamental.

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A longitudinal approach aids in distinguishing between those who clear infection and those progressing to TB, which can inform diagnostic design and targeted treatment strategies. Overall, recognising TB as a spectrum impacts research, clinical decisions, and interventions and investing in longitudinal observational data is vital for future innovation.

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Below, among people with TB diagnosed within the ERASE-TB study, we will characterise their pathways to diagnosis and illustrated individual trajectories, underlining the undulating nature of the disease.