Global Burden of Disease Due to Rifampicin-Resistant Tuberculosis in 2020: A Mathematical Modelling Analysis

Background: In 2020 almost half a million individuals developed rifampicin-resistant tuberculosis (RR-TB). These individuals face major challenges accessing appropriate treatment, and experience worse health outcomes compared to rifampicin-susceptible tuberculosis (RS-TB). We estimated the global burden of RR-TB over the lifetime of affected individuals.Methods: We synthesized data on incidence, case detection, and treatment outcomes in 192 countries (99.99% of global tuberculosis). Using a mathematical model, we projected lifetime health outcomes for individuals developing tuberculosis in 2020 stratified by country, age, sex, HIV, and rifampicin resistance. We quantified disability-adjusted life years (DALYs) from the incremental mortality and non-fatal morbidity estimated for each modelled stratum. Findings: Incident RR-TB in 2020 was responsible for an estimated 6.9 (95% uncertainty interval: 5.5, 8.5) million DALYs, representing 5.4% (4.4, 6.3) of total tuberculosis-attributable DALYs. Of this total burden, 56% (46, 69) accrued during the disease episode. We estimated an average 17 (14, 21) DALYs per person developing RR-TB, 34% (12, 56) greater than for RS-TB. RR-TB burden per 100,000 was highest in former Soviet Union countries and southern African countries. Estimated RR-TB DALYs per 100,000 were 39 (30, 52) times higher for HIV-infected versus HIV-uninfected individuals.Interpretation: RR-TB causes substantial short- and long-term morbidity and mortality that is only partially reflected in current epidemiological estimates. We found nearly half of the overall disease burden of RR-TB accrues amongst tuberculosis survivors, and is concentrated in countries with high levels of drug resistant tuberculosis as well as countries with co-endemic TB-HIV.