**Background:** Tuberculosis (TB) incidence data are scarce for indigenous populations in India, particularly for the Saharia—a Particularly Vulnerable Tribal Group (PVTG) in Madhya Pradesh with the highest reported TB prevalence in the country (1270–3294 per 100,000). This is more than ten times the national estimated prevalence of 320 per 100,000. The Saharia face poverty, under-nutrition, overcrowded living conditions, high tobacco and alcohol use, migration for work, and limited healthcare access. India aims to eliminate TB by 2025, five years ahead of the global End TB target, making incidence data in high-burden subgroups critical for monitoring and intervention planning.
**Methods:** A prospective cohort study was conducted in the Pohri block of Shivpuri district, Madhya Pradesh, central India. A baseline TB prevalence survey was carried out in 53 selected villages during 2012–13. All available household members aged ≥15 years were screened for symptoms suggestive of pulmonary TB (PTB): persistent cough ≥2 weeks, fever ≥1 month, chest pain ≥1 month, or haemoptysis within the last six months. Two sputum specimens were collected from presumptive TB cases and examined by Ziehl-Neelsen smear microscopy and Lowenstein-Jensen solid culture (with biochemical confirmation of M. tuberculosis). The sample size was calculated as 9,225 assuming a prevalence of 1,518 per 100,000 bacteriologically positive TB, with 25% precision at 95% confidence, design effect of 2, and 90% examination coverage. A total of 9,756 individuals were screened at baseline; 293 bacteriologically positive cases were excluded. The remaining 9,463 non-TB individuals formed the cohort. After excluding 419 individuals (12 unavailable, 218 deaths, 189 other reasons), 9,044 were re-screened in the endline survey during 2014–15. Incidence was calculated per 100,000 population with 95% confidence intervals, stratified by age and sex.
**Key Results:** At endline, 683 of 9,044 individuals had symptoms suggestive of PTB, and 136 were bacteriologically confirmed as new PTB cases. The overall incidence of bacteriologically positive (smear and/or culture) PTB was 1,504 per 100,000 (95% CI: 1,273–1,776). Smear-positive incidence was 1,106 (95% CI: 910–1,343), culture-positive incidence was 1,084 (95% CI: 890–1,319), and both smear- and culture-positive incidence was 686 (95% CI: 535–878) per 100,000. Incidence was 2.8 times higher in males (2,259 per 100,000; 95% CI: 1,857–2,745) than females (807 per 100,000; 95% CI: 589–1,106). Incidence increased with age: 625 (15–24 years), 1,209 (25–34), 2,245 (35–44), 2,326 (45–54), and 2,421 (55+) per 100,000. Smear-positive incidence was 3.1 times higher in males (1,706 vs 552 per 100,000), and culture-positive incidence was 2.8 times higher (1,637 vs 574 per 100,000). The highest smear-positive incidence was in the 35–44 age group (1,820 per 100,000), while the highest culture-positive incidence was in the 55+ group (1,895 per 100,000). Both smear- and culture-positive incidence was 3.4 times higher in males (1,083 vs 319 per 100,000), peaking in the 45–54 age group (1,123 per 100,000).
**Clinical Implications:** The PTB incidence of 1,504 per 100,000 in the Saharia tribe is nearly seven times the 2015 national average of 217 per 100,000 and far exceeds rates reported in other Indian indigenous groups (133–840 per 100,000). This alarmingly high burden in a PVTG demands urgent re-evaluation of current TB control interventions. The study highlights that males and older adults are particularly vulnerable, requiring targeted strategies such as smoking and alcohol cessation programmes, local employment generation to reduce migration-related transmission, and culturally appropriate, community-based screening using camp approaches or mobile vans. The absence of chest X-ray screening is a limitation that may have led to underestimation of true incidence. Nevertheless, these findings provide a critical baseline for monitoring the impact of the National TB Elimination Programme's Tribal Action Plan and underscore the need for intensified, multi-stakeholder efforts—including government, civil society, and research institutions—to bring TB incidence in this community closer to the national average and achieve India's 2025 TB elimination goal.