Trends in MDR-TB incidence
During 1990 and 1999, the incidence of MDR-TB had a pronounced rising trend globally, with the overall age-standardized incidence rate (ASIR) increasing by an annual average of 17.63% (EAPC=17.63, 95%CI: 10.77 to 24.92). The upward trends of ASIR occurred in all SDI areas and geographic regions, expect high-income North America (Table 1; Figure 1A). At national level, the ASIR of MDR-TB showed increasing trends in 186 countries/territories, particularly Turkmenistan, Somalia, and Kyrgyzstan, with the EAPCs were 66.78 (95%CI: 55.5 to 78.89), 66.08 (95%CI: 55.93 to 76.89), and 63.94 (95%CI: 51.99 to 76.84), respectively. However, the downward trends of ASIR were observed only in United States (EAPC=−6.78, 95%CI: −8.19 to −5.36) (Supplementary table 4; Supplementary figure 7A-C).
Table 1
the percentage changes in absolute number and EAPCs of MDR-TB incidence from 1990 to 2017 in global, sexes, SDI areas and geographic regions
|
1999
|
1990–1999
|
2017
|
2000–2017
|
Characteristics
|
Number
× 103 (95% UI)
|
ASR per 100 k
No. (95% UI)
|
Percentage Change in
absolute number (%)
|
EAPCs
(95%CI)
|
Number
× 103 (95% UI)
|
ASR per 100 k
No. (95% UI)
|
Percentage Change in
absolute number (%)
|
EAPCs
(95%CI)
|
Overall
|
383.50
(290.12–517.25)
|
6.41
(4.85–8.64)
|
558.06
|
17.63
(10.77–24.92)
|
432.77
(254.61–726.95)
|
5.55
(3.29–9.29)
|
8.29
|
−1.37
(− 1.62–−1.12)
|
Sex
|
|
|
|
|
|
|
|
|
Male
|
215.27
(165.10–285.45)
|
7.36
(5.63–9.77)
|
575.03
|
17.89
(11.09–25.1)
|
240.92
(145.81–396.46)
|
6.17
(3.75–10.14)
|
7.13
|
−1.58
(− 1.81–−1.34)
|
Female
|
168.23
(124.10–232.42)
|
5.55
(4.10–7.66)
|
537.55
|
17.30
(10.36–24.67)
|
191.85
(109.57–334.02)
|
4.99
(2.86–8.66)
|
9.80
|
−1.13
(− 1.4–−0.86)
|
SDI
|
|
|
|
|
|
|
|
|
Low
|
57.85
(31.12–110.89)
|
8.17
(4.30–16.14)
|
2054.73
|
32.73
(24.72–41.25)
|
121.88
(60.13–247.13)
|
11.23
(5.28–23.28)
|
90.22
|
1.08
(0.85–1.3)
|
Low-middle
|
82.58
(47.27–145.63)
|
7.59
(4.25–13.67)
|
1243.54
|
26.40
(18.82–34.46)
|
145.89
(70.89–263.95)
|
9.32
(4.44–17.28)
|
61.69
|
0.47
(0.11–0.84)
|
Middle
|
135.47
(87.38–194.95)
|
8.14
(5.26–11.8)
|
366.99
|
13.27
(6.4–20.59)
|
96.80
(48.14–175.83)
|
4.44
(2.22–8.1)
|
−28.73
|
−3.9
(− 4.17–−3.63)
|
High-middle
|
98.64
(66.20–143.87)
|
7.90
(5.26–11.56)
|
463.10
|
15.79
(8.51–23.55)
|
64.68
(42.19–96.12)
|
4.12
(2.70–6.14)
|
−35.78
|
−4.08
(− 4.63–−3.54)
|
High
|
6.05
(3.90–10.40)
|
0.54
(0.34–0.94)
|
183.49
|
9.29
(4.32–14.50)
|
2.86
(1.75–5.15)
|
0.22
(0.14–0.38)
|
−52.36
|
−6.25
(− 6.93–−5.57)
|
Regions
|
|
|
|
|
|
|
|
|
East Asia
|
174.58
(118.01–246.69)
|
13.08
(8.89–18.48)
|
272.72
|
11.31
(4.02–19.11)
|
35.78
(8.19–111.13)
|
2.22
(0.51–6.96)
|
−78.58
|
−10.98
(− 11.66–−10.29)
|
South Asia
|
88.80
(32.12–200.49)
|
7.82
(2.84–17.74)
|
4328.87
|
42.85
(32.57–53.93)
|
216.16
(59.52–491.95)
|
12.96
(3.54–29.61)
|
112.02
|
1.91
(1.34–2.49)
|
Southeast Asia
|
18.74
(9.13–47.79)
|
4.01
(1.98–10.04)
|
891.37
|
21.07
(11.74–31.17)
|
20.14
(11.97–32.22)
|
3.11
(1.85–4.94)
|
4.47
|
−1.36
(− 1.6–−1.13)
|
Central Asia
|
5.85
(3.87–9.25)
|
8.23
(5.42–12.93)
|
6722.47
|
48.26
(33.64–64.48)
|
15.00
(11.24–19.68)
|
16.14
(12.07–21.23)
|
112.47
|
1.87
(− 0.35–4.14)
|
High-income Asia Pacific
|
1.54
(1.13–2.20)
|
0.71
(0.51–1.03)
|
254.03
|
10.85
(5.12–16.88)
|
0.77
(0.18–2.12)
|
0.29
(0.07–0.82)
|
−50.42
|
−7.3
(− 8.7–−5.87)
|
Oceania
|
0.06
(0.01–0.20)
|
0.88
(0.18–2.77)
|
1528.54
|
28.75
(21.89–36)
|
0.57
(0.29–1.00)
|
4.80
(2.44–8.35)
|
710.75
|
9.53
(7.93–11.15)
|
Australasia
|
0.01
(0.005–0.02)
|
0.05
(0.02–0.10)
|
61.42
|
3.86
(1.31–6.47)
|
0.04
(0.03–0.07)
|
0.15
(0.09–0.24)
|
323.96
|
7.54
(7.09–8)
|
Eastern Europe
|
30.93
(22.15–42.10)
|
12.70
(9.12–17.28)
|
1667.60
|
31.15
(21.59–41.46)
|
41.35
(27.21–57.89)
|
17.64
(11.54–24.59)
|
21.56
|
1.41
(0.16–2.66)
|
Western Europe
|
0.70
(0.59–0.81)
|
0.18
(0.15–0.21)
|
144.69
|
9.58
(8.21–10.97)
|
0.73
(0.57–0.95)
|
0.18
(0.14–0.23)
|
0.56
|
−1.01
(− 1.51–−0.51)
|
Central Europe
|
0.79
(0.53–1.30)
|
0.60
(0.39–0.97)
|
354.42
|
14.17
(6.6–22.27)
|
0.58
(0.39–0.82)
|
0.45
(0.29–0.63)
|
−27.56
|
−2.29
(− 3.28–−1.29)
|
High-income North America
|
0.23
(0.19–0.28)
|
0.07
(0.05–0.08)
|
−38.50
|
−6.28
(− 7.68–−4.86)
|
0.12
(0.08–0.18)
|
0.03
(0.02–0.05)
|
−41.23
|
−2.96
(− 3.33–−2.59)
|
Andean Latin America
|
3.23
(1.59–5.84)
|
7.64
(3.76–13.79)
|
773.25
|
22.40
(18.12–26.83)
|
2.81
(2.05–4.19)
|
4.62
(3.36–6.9)
|
−18.48
|
−3.98
(− 4.41–−3.54)
|
Central Latin America
|
1.02
(0.59–1.81)
|
0.62
(0.35–1.08)
|
2211.58
|
31.07
(20.52–42.54)
|
1.42
(0.66–2.92)
|
0.56
(0.26–1.15)
|
28.99
|
−1.76
(− 2.35–−1.16)
|
Caribbean
|
0.17
(0.07–0.48)
|
0.44
(0.17–1.22)
|
167.35
|
8.51
(4.22–12.98)
|
0.10
(0.04–0.23)
|
0.20
(0.08–0.49)
|
−44.12
|
−5.79
(− 7.83–−3.71)
|
Tropical Latin America
|
1.40
(0.38–3.57)
|
0.84
(0.23–2.11)
|
5272.18
|
48.39
(39.68–57.64)
|
2.12
(0.48–5.78)
|
0.90
(0.21–2.46)
|
37.90
|
−0.51
(− 1.42–0.41)
|
Southern Latin America
|
0.17
(0.10–0.30)
|
0.32
(0.18–0.54)
|
511.06
|
19.46
(16.21–22.79)
|
0.11
(0.03–0.32)
|
0.16
(0.05–0.49)
|
−40.47
|
−5.83
(− 6.87–−4.79)
|
Eastern Sub − Saharan Africa
|
17.55
(10.87–28.72)
|
8.75
(5.23–14.98)
|
3920.28
|
40.07
(29.48–51.53)
|
34.27
(21.73–53.29)
|
9.62
(6.20–14.99)
|
78.79
|
−0.17
(− 0.7–0.35)
|
Southern Sub-Saharan Africa
|
8.03
(4.20–17.60)
|
12.38
(6.47–27.75)
|
707.05
|
23.11
(22.54–23.67)
|
11.15
(6.21–20.66)
|
13.79
(7.65–25.24)
|
20.43
|
−0.46
(− 1.86–0.96)
|
Western Sub-Saharan Africa
|
17.21
(7.77–38.43)
|
8.32
(3.76–18.33)
|
1164.55
|
24.50
(17.01–32.47)
|
30.44
(13.54–64.69)
|
8.59
(3.83–18.26)
|
62.28
|
−0.48
(− 1.02–0.06)
|
North Africa
and Middle East
|
6.76
(4.11–10.36)
|
1.74
(1.06–2.67)
|
1760.45
|
33.46
(28.65–38.46)
|
7.10
(4.65–11.81)
|
1.21
(0.8–2.00)
|
−2.84
|
−2.56
(− 2.73–−2.39)
|
Central Sub-Saharan Africa
|
5.72
(1.73–16.90)
|
10.17
(3.12–29.55)
|
673.46
|
18.11
(10.74–25.97)
|
12.01
(2.87–32.58)
|
12.33
(2.97–34.12)
|
99.63
|
0.65
(0.45–0.85)
|
MDR-TB: multidrug resistant tuberculosis; EAPC: estimated annual percentage change; ASR, age-standardized rate; CI, confidence interval; UI: uncertainty interval; SDI: socio-demographic index. |
Globally, the incident number of MDR-TB was 432.70×103 (95% uncertainty interval (UI): 254.61×103 to 726.95×103) in 2017, with a decrease of 8.29% from 2000 to 2017. During 2000 and 2017, the ASIR had a decreasing trend (EAPC=−1.37, 95%CI: −1.62 to −1.12) (Table 1; Figure 1B). The downward trends of ASIR occured in SDI areas, expect low and low-middle SDI areas. In terms of 21 regions, the most pronounced decreasing trends were observed in East Asia and High-income Asia Pacific, in which EPACs were −10.98(95%CI: −11.66 to −10.29) and −7.30(95%CI: −8.70 to −5.87). Whereas the largest increasing trends occurred in Oceania (EAPC=9.53, 95%CI:7.93 to 11.15) (Table 1; Figure 1B, and Figure 2A-C). Among 195 countries/territories, the ASIR showed downward trends in 112 countries, and the largest one was in Slovenia from 2000 to 2017 (EAPC=−14.11, 95%CI: −15.36 to −12.83). On the other hand, the ASIR showed rising trends in 54 countries, particularly Papua New Guinea (EAPC=9.83, 95%CI: 8.23 to 11.45), followed by Australia and Finland (Supplementary table 5; Figure 3A-C). The EAPCs (2000-2017) had a positive correlation with the ASIR in 2000 at a national level (ρ=0.25, p<0.001) (Figure 4A), but no with the HDI in 2017.
Trends in MDR-TB prevalence
Globally, the ASR of prevalence showed an obvious upward trend from 1990 to 1999, with the EAPC was 17.57 (95%CI: 11.51 to 23.95). In SDI areas and geographic regions, the ASR of prevalence had the similar trends to that of ASIR from 1990 to 1999. (Supplementary table 1; Figure 1A). With regard to national level, from 1990 to 1999, the rising trends were observed in 185 countries/territories, and the largest one was Somalia (EAPC=67.92, 95%CI: 58.28 to 78.16), followed by Turkmenistan, and Kyrgyzstan. However, the trends of prevalence decreased only in United States, with the EAPC of −10.84(95%CI: −11.4 to −10.28) (Supplementary table 4; Supplementary figure 8A-C).
The number of MDR-TB prevalence was 464.12×103 (95%UI: 229.12×103 to 863.33×103) worldwide in 2017, with an increase of 9.92% from 2000 to 2017. During 2000 and 2017, the prevalence of MDR-TB had a downward trend globally, with the EAPC was −1.32 (95%CI: −1.38 to −1.26) (Supplementary table 1; Figure 1). The trends of prevalence rose in areas of low- and low-middle SDI, while decreasing in other areas. Among 21 geographical regions, the most pronounced downward trends were observed in High-income Asia Pacific (EAPC=−8.77, 95%CI: −9.98 to −7.55), while the largest increasing trends occurred in Oceania and Australasia. (Supplementary table 1; Figure 1B, and Supplementary figure 1A-C). At national level, the decreasing trends of prevalence were observed in 104 countries from 2000 to 2017, particularly Slovenia (EAPC=−13.69, 95%CI: −15.04 to −12.31). While the rising trends occurred in 55 countries, and the largest one was in Papua New Guinea (EAPC=9.28, 95%CI: 7.81 to 10.78), followed by Finland and Australia (Supplementary table 5; Supplementary figure 4A-C). The EAPCs (2000-2017) had a positive correlation with the ASR of prevalence in 2000 at a national level (ρ=0.18, p=0.02) (Figure 4B), but no with the HDI in 2017.
Trends in MDR-TB related death
Globally, the age-standardized death rate (ASDR) of MDR-TB had a rising trend from 1990 to 1999 (EAPC=21.21, 95%CI: 15.96 to 26.69). During 1990 and 1999, the upward trends of ASDR were observed in all SDI areas and most geographic regions, whereas the decreasing trend occurred only in High-income North America (EAPC=−15.91, 95%CI: −18.52 to −13.22) (Supplementary table 2; Figure 1A). At national level, the downward trends of ASDR were observed in eight countries, particularly United States and Singapore. Whereas the upward trends were documented in 186 countries/territories, and the largest increasing occured in Somalia (EAPC=81.08, 95%CI:72.54 to 90.05), followed by Kyrgyzstan, and Turkmenistan. However, the decreasing trends were seen in six countries, particularly United States, in which the EAPC was −16.72(95%CI: −19.41 to −13.94) (Supplementary table 4; Supplementary figure 9A-C).
The number of deaths attributed to MDR-TB was 126.89×103 (95%UI: 70.06×103–202.17×103) in 2017, with a decrease of 10.17% from 2000 to 2017. Globally, the ASDR of MDR-TB had a decreasing trend from 2000 to 2017 (EAPC=−3.30, 95%CI: −3.56 to −3.04) (Supplementary table 2; Figure 1B). The ASDR had downward trends in all SDI areas and regions from 2000 to 2017, expect Oceania and Australasia. The most pronounced decreasing trends were documented in East Asia (EAPC=−13.57, 95%CI: −14.95 to −12.16), followed by High-income Asia Pacific and Southern Latin America (Supplementary table 2; Figure 1B, and Supplementary figure 2A-C). At national level, the decreasing trends were documented in 164 countries/territories from 2000 to 2017, and the largest one was in Slovenia (EAPC=−18.96, 95%CI: −20.82 to −17.06), followed by Maldives, and Laos. On the other hand, the upward trends of ASDR were observed in seventeen countries, particularly Singapore (EAPC=12.67, 95%CI: 10.6 to 14.78) (Supplementary table 5; Supplementary figure 5A-C). The EAPCs (2000-2017) had a positive correlation with the ASDR in 2000, and a negative correlation with the HDI in 2017 at a national level (ρ=0.27, p<0.001, Figure 4C; ρ=−0.18, p=0.017, Figure 5A, respectively).
Trends in MDR-TB-related DALYs
Pronounced increasing trend was observed in DALYs associated with MDR-TB from 1990 to 1999, with an EAPC was 21.90 (95%CI: 16.55 to 27.50). The increasing trends occured in all SDI areas and geographic regions. The largest rising trends of DALYs were observed in Central Asia (EAPC=62.87, 95%CI:47.83 to 79.44)), followed by Tropical Latin America, and South Asia (Supplementary table 3; Figure 1A). Rising trends of DALYs were observed in 163 countries/territories, with the most pronounced one being in Somalia (EAPC=79.93, 95%CI: 70.87 to 89.47), followed by Turkmenistan, and Kyrgyzstan. However, seven countries had decreasing trends, particularly United States (EAPC=−17.26, 95%CI: −19.91 to −14.54) (Supplementary table 4; Supplementary figure 10A-C).
Globally, the number of DALYs due to MDR-TB was 4647.99×103 (95%UI: 2663.04×103–7224.23×103) in 2017, with an increase of −17.71% from 2000 to 2107. The ASR of DALYs had a decreasing trend (EAPC=−3.32, 95%CI: −3.59 to −3.06) (Supplementary table 3; Figure 1B). During 2000 and 2017, the downward trends of DALYs were observed in SDI areas and regions, expect Oceania and Australasia. The largest decreasing trends in DALYs were observed in East Asia and High-income Asia Pacific, in which the EAPCs were −13.02 (95%CI: −13.58 to −12.46) and −12.62 (95%CI: −13.85 to −11.38), respectively (Supplementary table 2; Figure 1B, and Supplementary figure 3A-C). At national level, the downward trends occurred in 164 countries/territories, with the largest decreasing trend being in Slovenia, Maldives, and Laos, in which the EAPCs were −19.35(95%CI: −21.1 to −17.55), −17.50(95%CI: −18.33 to −16.66), and −14.63 (95%CI: −15.65 to −13.59), respectively. While upward trends were observed in nineteen countries/territories, with the largest one being in Singapore (EAPC=9.28, 95%CI: 7.78 to 10.79), followed by Papua New Guinea and Zimbabwe (Supplementary table 5; Supplementary figure 6A-C). The EAPCs (2000-2017) had a positive correlation with the ASR of DALYs in 2000, and a negative correlation with the HDI in 2017 at a national level (ρ=0.26, p<0.001, Figure 4D; ρ=−0.16, p=0.029, Figure 5B, respectively).