Our findings demonstrate a decreasing proportion of tuberculosis among people with silicosis over time, despite an increasing trend in isolated silicosis. Substantial underreporting and heterogeneity in diagnostic methods suggest the need for strengthening occupational epidemiological surveillance. Additionally, people-centered interventions addressing demographic disparities and high-risk occupational sectors, particularly mining, are urgently needed.

The significant disparity between the burden of silicosis and TPT implementation represents a missed opportunity for disease prevention. Our findings support the need for integrated care pathways between occupational health services and infectious disease services, with targeted interventions in municipalities with higher silicosis prevalence. Policy recommendations include shared care protocols, mandatory ILTB screening for all people with silicosis, regional training programs, and strengthening surveillance systems to reduce the deadly combination of tuberculosis and silicosis among Brazilian workers exposed to silica dust.