Tuberculosis (TB) is a highly infectious disease caused by Mycobacterium tuberculosis, primarily transmitted through airborne droplets (1). It is characterized by a prolonged incubation period, a lack of early symptoms, and high transmissibility (2). TB remains a major global health concern and is the second leading cause of death from infectious diseases. It poses a serious threat to public health and places a significant economic and social burden on countries worldwide. In 2021, the cost of TB diagnosis, treatment, and prevention services in low- and middle-income countries reached 5.4 billion USD (1). Despite these investments, model-based estimates in 27 countries indicate that TB morbidity and mortality may continue to rise (1).

China is among the high-burden countries for TB, ranking third among the 30 highest TB-burdened nations globally.

In 2022, China reported 500,000 new TB cases and 30,000 TB-related deaths, accounting for 7 and 2% of the global totals, respectively. Between 2015 and 2021, China’s TB control efforts achieved only an 8% reduction in incidence and a 15% reduction in mortality, falling significantly short of the WHO’s 2025 targets of a 50% reduction in incidence and a 70% reduction in mortality (3, 4). A growing concern is the country’s rapidly aging population, which may further hinder TB elimination efforts. The proportion of individuals aged 60 years and above in China increased from 13.26% in 2010 to 18.70% in 2021 and is projected to reach 28.0% (402 million people) by 2040. Notably, the prevalence of latent TB infection among the older population exceeds 30%, significantly higher than that observed in younger age groups (5). Moreover, studies indicate that older adults with TB exhibit a higher disease prevalence, lower treatment success rates, increased susceptibility to adverse drug reactions, and a greater risk of mortality (6), all of which present significant challenges to TB prevention and control in China. Therefore, a comprehensive assessment of the epidemiological characteristics of TB in China is essential to identify vulnerable populations and implement targeted intervention strategies (7).

Currently, the lack of high-quality data on TB incidence trends and the absence of a robust health monitoring system pose significant challenges to accurately assessing the TB burden and evaluating the effectiveness of public health policies and medical services (8). The GBD 2021 database, the largest international observational epidemiological research repository to date, includes comprehensive data since 1990, making it an ideal resource for studying long-term trends in TB incidence in China (9). Therefore, this study aims to analyze the TB burden in China from 1990 to 2021 using the latest GBD 2021 database. Additionally, we employ an ARIMA model and a BAPC model to predict future trends. Our findings will enhance the understanding of TB epidemiology and provide a theoretical foundation for the development of national public health policies.

This study analyzed the current prevalence of TB and the changing trends in disease burden in China from 1990 to 2021, based on the GBD 2021 database. The results indicate that as of 2021, China’s ASIR, ASPR, ASMR, and ASDR for TB all showed a year-on-year decline, with decreases of 66.60, 2.83, 90.72, and 89.53%, respectively, compared to 1990. From 1990 to 2021, there were significant gender differences in the TB burden in China. In most age groups, the trends in disease burden for males and females were consistent with the overall trend, with the ASIR, ASPR, ASR, and ASDR for males being higher than for females. This finding aligns with the WHO report, which indicates that the proportion of male TB cases is higher (1). Li et al. analyzed the age-specific reported incidence rate from the Chinese tuberculosis information management system (2008–2018) and found that the reported rate of pulmonary tuberculosis in males was more than twice that of females (15). Differences in TB incidence rates between sexes are evident, with controlling TB incidence rates being less effective in males than in females (8). Men in birth cohorts from countries with below-average population indices are at higher risk of TB progression (8). Studies have shown that in the male TB population, adverse factors such as smoking, alcohol abuse, diabetes, chronic obstructive pulmonary disease and chronic work stress are more closely associated with the disease. HIV-TB co-infection is a significant public health challenge as the two illnesses mutually aggravate one another, resulting in heightened morbidity and mortality rates (16). These factors not only significantly increase the risk of TB but also negatively affect treatment outcomes (8). Therefore, a gender-specific approach is essential in TB prevention and treatment strategies.

Zhang Ting and colleagues have shown that the global burden of tuberculosis is primarily concentrated in individuals aged 40–60, although the pathogenesis remains unclear (17). The susceptibility of the older population to multidrug-resistant TB increases due to prolonged use of anti-TB drugs and a gradual decrease in immunity with age (18). Teng Rencong et al. analyzed the Chinese TB information management system and found that, based on the registration of older population TB patients from 2015 to 2021, the reported incidence of TB in individuals aged ≥65 years showed a downward trend (19). However, the proportion of older population individuals among all TB patients has increased year by year, suggesting that the older population continue to be a key population in China’s TB prevention and control efforts. To achieve the TB control goals set by the WHO, TB prevention and control efforts in the older population in China should prioritize early case detection, improve the quality of TB treatment, and provide long-term treatment post-TB (20). The prevalence of TB is common among the older population, and the reporting rate gradually increases with age. Most cases of TB in the older population are related to the reactivation of the focus that was still dormant (6). Enhancing the primary health care system, particularly in rural regions, is advised to augment access to health care and the surveillance of the medical state of the older population (21).

Dong et al. used an age-period-cohort model to analyze the data and found that the risk of tuberculosis among young people (aged 20–24) and the older population (aged 70–74) was similar (22). This study indicates that the downward trend in the TB burden in China is not uniform across different age groups. From 1990 to 2021, the number of TB cases in children under 5 years old in China decreased significantly, but this age group remains the peak for TB incidence, a finding consistent with previous studies in the United States (23). Children under 15 years of age are also a vulnerable group for tuberculosis due to their weaker immune systems, and there is a significant issue of underreporting of TB cases in this demographic (24). Between 2015 and 2020, the incidence of TB in children under 15 years of age decreased by 16%, while the mortality rate fell by 34% (3). The WHO’s Global Tuberculosis Report 2023 indicates that children accounted for 2% of notified TB cases in China in 2022, which is much lower than the global estimated proportion of 12%. And the Centers for Disease Control and Prevention indicates that China has attained considerable clinical and societal advantages, swiftly decreasing the incidence of TB (21). China has made substantial progress in reducing the burden of childhood TB, with varying degrees of decline in both the number of cases and affected individuals, primarily due to increased BCG vaccination coverage and enhanced TB surveillance among children.

The COVID-19 pandemic has hindered the timely diagnosis, reporting, and effective treatment of TB, resulting in an increase in TB mortality and reversing the progress made by the WHO in reducing the TB burden before 2019 (25). Worldwide, countries are continuously optimizing their TB control programs to meet the 2035 targets. In China, especially for the older population, non-pharmaceutical interventions, traffic restrictions, and the reallocation of medical resources during the COVID-19 pandemic led to a decrease in TB consultations and disruption of medical services (26). However, analysis using the JPR regression model shows that from 1990 to 2021, China’s ASIR, ASMR, and ASDR for TB generally decreased, while the ASPR remained relatively stable. This stability may be attributed to the increase in population size, which resulted in a non-significant decrease in the prevalence rate. According to predictions from the ARIMA and BAPC models, the ASIR and ASMR for TB are expected to continue declining over the next 15 years for both men and women. The BAPC model provides a more optimistic outlook, predicting that the number of TB cases and deaths will approach zero by 2036. Despite an aging population and increasing life expectancy, both models offer optimistic predictions, likely reflecting ongoing improvements in TB treatment and China’s healthcare system. Meanwhile, Li et al. used a gray model [GM(1, 1)] to predict that the number of TB deaths in China will show a downward trend by 2027, which is consistent with the findings of this study (27). The Long Short-Term Memory model exhibits superior accuracy compared to the ARIMA and GM (1, 1) models. Its predictive outcomes can serve as a valuable tool for tuberculosis control strategies in China (28). Recent study indicates that regional disparities in the tuberculosis burden among China’s provinces are associated with societal factors and variations in prevention and control programs (29). The uncertainty range in the predictive model varies, considering alterations in population size, enhancements in TB control efficacy, and numerous influencing factors such as HIV infection, smoking, and diabetes. The interrelated and intricate aspects render precise forecasting of TB developments difficult. To continue reducing the disease burden of TB in China, there is a need for improved prevention and control strategies, stronger policy support, and increased financial investment (30).

In the fight against TB, china has actively promoted the disease control process and has achieved full coverage of the Directly observed treatment and short course chemotherapy (DOTS) strategy around 2004 (31). Chinese primary healthcare (PHC) sectors implement the TB Control Program to improve active case finding, referral, treatment adherence, and health education (32). To accelerate the progress toward ending TB, the Chinese government implemented the End TB Action Plan (2019–2022), Among the Plan, health promotion was conducted to improve the awareness of TB knowledge among Chinese people (33).

This study has several limitations in evaluating the trend of TB disease burden in China. First, the GBD database may introduce certain biases in data collection and model construction, and it faces issues such as incomplete data. Second, the disability weights used in the calculation of DALYs are based on survey data that may not be fully applicable to the historical context of China, and therefore, they may not accurately reflect the disease burden of TB patients in China over time. Third, our prediction of future TB burden is based on current trends and patterns, without considering the potential future impact of changes in risk factors, advances in treatment technology, or adjustments in healthcare policies. Fourth, this study primarily relies on aggregate data when assessing TB incidence and mortality, and does not fully incorporate individual-level factors that may influence the disease burden, such as BCG vaccination status or the prevalence of anti-tuberculosis treatment.

In summary, TB continues to impose a significant disease burden in China. However, due to the country’s emphasis on TB control and the ongoing improvements in the diagnosis and treatment of infectious diseases, the incidence and mortality rates of TB have been effectively controlled. The prediction models also suggest that the overall TB disease burden in China is expected to improve over the next 15 years.