Zoonotic tuberculosis: When diagnostic and surveillance systems are not designed to detect it.

Zoonotic tuberculosis (zTB) remains a blind spot in TB control, sustained less by biological rarity than by diagnostic and surveillance design. Brazil illustrates this gap: despite endemic bovine TB and sustained zoonotic transmission risks, zTB is rarely identified because it is not actively targeted. We show that only two human zTB cases were notified between 2013 and 2024 following introduction of reporting, and six cases are described in the literature. Further detection of mono-pyrazinamide resistance may represent undiagnosed zTB, but diagnostic gaps prevent estimation. By outlining current diagnostic paths, we argue that the human-centric diagnostics obscures occupational, foodborne, and animal-linked infection. Emerging subnational One Health initiatives demonstrate that integrated animal-human surveillance is feasible. Therefore, we propose a risk-based, One Health diagnostic protocol for zTB within the Brazilian public health system, and argue that without structural and policy adaptation, human-TB elimination strategies will continue to exclude zTB by design, not only in Brazil.