Abstract
BACKGROUND: Although MDR-TB is recognized as a significant threat, systematic descriptions of its long-term (>30 years) global spatiotemporal evolution patterns are still limited. OBJECTIVES: This study conducted a 46-year spatiotemporal analysis of global MDR-TB (1990-2035) to provide key evidence for evaluating and refining the WHO End TB Strategy. METHODS: We used Global Burden of Disease data to identify identified temporal inflection points in ASIR, ASDR, and DALYs using Joinpoint regression. Spatial clustering was quantified using Moran's I and Getis-Ord hotspot analysis. A Bayesian age-period-cohort model projected MDR-TB incidence from 2022 to 2035. RESULTS: The male-to-female ratio was approximately 1.5:1. Incidence was highest at 30-60 years, deaths at 60+, DALYs peak at 45-60; children under 14 years of age significantly affected. ASIR rose from 0.97/100 k (1990) to 6.39/100 k (2000), then declined (APC: -3.15%) post-2005 to 5.62/100 k (2021); males exhibited a sharper increase (+2.39%) and slower decline (-0.71%). ASDR peaked at 2.12/100 k (2002; males 27% higher). DALYs peaked at 89.05/100 k (2003). Sub-Saharan Africa is hyperendemic (Moran's I = 12.38, p < 0.001; Somalia: 57.25/100 k), with high-high clusters in Africa/Kyrgyzstan. Projections: Global ASIR declines modestly (-1.62% by 2035), but 480,000 cases expected due to population growth; female incidence drops 7.27% (2025+), male trends stable. CONCLUSION: MDR-TB has proven more challenging than anticipated, with persistent hotspots in sub-Saharan Africa and a disproportionate impact on males, the older adults, and children. Despite a marginal decline in ASIR to 5.46 per 100,000, the absolute number of cases is projected to rise to 480,000 by 2035 due to sustained population growth and aging. This will seriously hinder the WHO End TB Strategy. Addressing MDR-TB should prioritize key populations and regions, targeted resources, tailored interventions, sustained investment in diagnostics and treatment, and stronger government support for patient care.