Divergent Trajectories of Pediatric All-Form Tuberculosis and Multidrug-Resistant Tuberculosis from 1990 to 2021

Using Global Burden of Disease 2021 modeled estimates, we assessed the burden, temporal trends, and inequalities of pediatric all-form tuberculosis (TB) and multidrug-resistant TB (MDR-TB) from 1990 to 2021 across 204 countries and territories. Compared with all-form TB, pediatric MDR-TB showed a distinct and less favorable estimated trajectory. Although GBD-based estimates suggested overall declines in pediatric all-form TB incidence and mortality, the MDR-to-all-form ratio increased worldwide for both incidence and mortality, suggesting a growing proportional contribution of MDR-TB within the estimated pediatric TB burden. In 2021, pediatric MDR-TB remained concentrated in low- and low-middle-SDI settings, where modeled socioeconomic inequalities appeared to become more pronounced over time. Mortality relative to incidence was highest among children aged under 5 years, with particularly elevated and imprecise mortality-to-incidence ratios for MDR-TB. Sex disparities also evolved differently by disease type: they generally narrowed for all-form TB but were more heterogeneous and in some settings widened for MDR-TB. These GBD-based findings suggest that progress in overall pediatric TB control may not have translated evenly to drug-resistant disease and highlight the need for pediatric TB strategies that explicitly address drug resistance, early childhood vulnerability, and inequitable access to diagnosis and treatment. Due to the sparsity of global pediatric data, no independent external validation was performed; findings are based on internal sensitivity analyses of GBD estimates.