ORIGINAL RESEARCH article
Front. Public Health
Sec. Infectious Diseases: Epidemiology and Prevention
Volume 13 - 2025 | doi: 10.3389/fpubh.2025.1658814
Disparities in the burden of tuberculosis associated with urbanization in 178 countries and territories: an observational study
Provisionally accepted
- 1Peking University, Beijing, China
- 2Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing, China
- 3World Health Organization China Office, Beijing, China
- 4Chinese Center for Disease Control and Prevention, Beijing, China
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Background Tuberculosis (TB) remains the leading cause of death from a single infectious agent. However, quantitative evidence on the impact of urbanization on TB burden is limited. We aimed to assess the association between urbanization and the TB burden globally. Methods Using multi-source data, we developed a composite index of urbanization across 178 countries and territories from 2012 to 2019, incorporating the proportion of urban population, the proportion of population using improved sanitation, nighttime light intensity, normalized difference vegetation index, and per capita gross domestic product. Fixed-effects linear models were applied to estimate the rate ratios (RRs) and 95% confidence intervals (CIs) for the association between urbanization and the incidence, prevalence, and mortality of total TB and three subtypes: drug-susceptible TB (DS-TB), multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB). Results Overall, higher urbanization scores were associated with significant reductions in the burden of MDR-TB and XDR-TB, but showed no effect on total TB or DS-TB. For MDR-TB, each additional urbanization score was associated with a 1.0% decrease in incidence (RR = 0.990; 95% CI: 0.985‒0.996), a 1.1% decrease in prevalence (0.989; 0.984‒0.994), and a 0.7% decrease in mortality (0.993; 0.988‒0.998). For XDR-TB, the corresponding reductions were 0.9% in incidence (0.991; 0.986‒0.996), 1.0% in prevalence (0.990; 0.985‒0.995), and 0.7% in mortality (0.993; 0.988‒0.998). These relationships persisted when considering a one-year lag in urbanization. In subgroup analyses, however, urbanization was associated with increased MDR-TB and XDR-TB burdens in upper-middle income countries. Conclusions Urbanization was linked to reduced MDR-TB and XDR-TB burdens globally, but to an increased burden in upper-middle income countries. Building well-managed and healthy cities is essential not only for sustainable urbanization but also for strengthening TB prevent and control, especially in rapid transitioning upper-middle income countries.
Keywords: Urbanization, Tuberculosis, Multi-drug resistant tuberculosis, economic inequalities, prevention
Received: 03 Jul 2025; Accepted: 26 Aug 2025.
Copyright: © 2025 Wang, Liu, Chen, Liu, Chen, Zhao and Liu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Jue Liu, Peking University, Beijing, China
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