Tuberculosis disease burden in China, Japan, and South Korea: A population-based observational study of trends from 1990 to 2023 and predictions for 2035

Tuberculosis (TB) remains a leading infectious killer worldwide, with the World Health Organization End TB Strategy targeting 90% and 95% reductions in incidence and mortality by 2035. Long-term comparative analyses across China, Japan, and South Korea remain lacking. This study aimed to systematically analyze trends in the TB disease burden in China, Japan, and South Korea from 1990 to 2023 and project future burden trajectories through 2035. Using the Global Burden of Disease 2023 database, data on TB incidence, prevalence, mortality, and disability-adjusted life years (DALYs) were extracted. The estimated annual percentage change was used to evaluate long-term trends in the age-standardized incidence rate (ASIR), age-standardized prevalence rate (ASPR), age-standardized mortality rate (ASMR), and age-standardized DALYs rate. The population attributable fraction was calculated to quantify the contributions of smoking, high alcohol use, and high fasting plasma glucose. The Bayesian Age-Period-Cohort model was applied to project disease burden from 2023 to 2035. From 1990 to 2023, ASIR, ASMR, and age-standardized DALYs rate declined continuously in all 3 countries, exceeding the global average of decline. By 2023, China had the highest ASIR (38.43 per 1,00,000) and ASPR (30,714.91 per 1,00,000), while Japan recorded the lowest ASIR (3.94 per 1,00,000); both Japan and South Korea fell below the global ASPR. China showed the greatest mortality reduction (estimated annual percentage change = -8.61), with all 3 countries' ASMR well below the global level (11.64 per 1,00,000). TB burden increased with age, with males consistently bearing a greater burden than females. While smoking remained the leading attributable risk factor, high fasting plasma glucose rose continuously across all 3 countries and surpassed smoking in South Korea as the primary contributor to TB deaths and DALYs. Bayesian age-period-cohort projections indicated a continued overall decline through 2035, except for a transient rise in China's ASPR before stabilization. The TB burden has declined steadily in China, Japan, and South Korea, though at different paces. Population aging and rising metabolic risk factors remain key challenges. These findings support region-specific strategies - integrated diabetes-TB management, latent TB screening in older adults, and sustained tobacco control - to advance the World Health Organization End TB 2035 targets in East Asia.