240 Children a Day: Tuberculosis Mortality at Ages 0–19 Years and the Widening Estimation Divide, 1990–2023

1. Introduction

1.1. Background and Motivation

1.1.1. A Preventable and Curable Disease That Still Kills About 240 Children Every Day

Tuberculosis (TB) is again the world’s leading cause of death from a single infectious agent, killing an estimated 1.25 million people in 2023 [1]. Its youngest victims are also its least visible: children with TB typically have paucibacillary disease, cannot produce sputum for microbiological confirmation, and are diagnosed clinically if at all [2,3]. Our aggregation of Global Burden of Disease (GBD) Study 2023 estimates indicates that TB caused approximately 87,764 deaths at ages 0–19 years in 2023—about 240 deaths every day—alongside roughly 1.67 million incident cases [4,5]; an estimated 96% of children who die of TB never accessed treatment [6].

1.1.2. An Ambitious Policy Architecture with a Narrow Pediatric Window

The WHO End TB Strategy set 2025 milestones of a 75% reduction in TB deaths and a 50% reduction in the TB incidence rate relative to 2015 [7,8]; Sustainable Development Goal target 3.3 embeds the same endpoint [9]. United Nations High-Level Meetings, the WHO Roadmap towards ending TB in children and adolescents [10,11], and WHO’s 2022 guidelines (a four-month regimen for non-severe pediatric disease [12]) added child-specific commitments. Yet monitoring remains anchored to a single 0–14-year aggregate: adolescents aged 15–19 years, frequently presenting with adult-type disease [13,14], are rarely reported as a distinct segment [15].

1.1.3. Two Estimation Systems, a 2.5-Fold Disagreement on Child Deaths

How many children die of TB depends on which estimation system is asked. WHO’s pediatric estimates combine notification data with case-detection adjustments and dynamic modeling [1,16,17]; for 2023, WHO estimated 191,000 TB deaths at ages 0–14 years (166,000 HIV-negative; 25,000 HIV-positive) [1]. The GBD instead models TB mortality with its Cause of Death Ensemble model (CODEm) on vital-registration and verbal-autopsy data [4]; our aggregation of GBD 2023 yields 66,146 deaths at ages 0–14 years—about 40% of the like-for-like WHO figure. This roughly 2.5-fold divergence sets the denominator for End TB accountability in children.

1.2. Research Gap

1.2.1. What Existing Analyses Do Not Provide

The GBD 2021 tuberculosis capstone reports progress toward the 2020 milestones, but its pediatric reporting is embedded in broad age bands [18]; the official GBD 2023 capstone, published online on 1 July 2026, reports the round’s all-age burden stratified by HIV status and drug resistance [19]. A dedicated pediatric account of GBD 2023 remains absent: the two existing pediatric secondary analyses use the superseded GBD 2021 round and terminate in 2021 [20,21], and neither evaluated the pandemic window, reconciled GBD estimates with WHO’s, or tracked the End TB 2025 milestones.

1.3. Objectives and Contributions

This study provides comprehensive estimates of the TB burden at ages 0–19 years from 1990 to 2023, computed from raw GBD 2023 Results Tool downloads [5] within the GBD 2023 analytical framework [4]. Four contributions follow. First, to our knowledge this is the first dedicated 0–19-year pediatric secondary analysis of GBD 2023—complementing the round’s official all-age capstone [19]—disaggregated into four pediatric age bands across 204 countries and territories, 21 GBD regions, and five Socio-demographic Index (SDI) quintiles. Second, we quantify the extreme concentration of the residual burden—nine in ten deaths in low- and low-middle-SDI countries, a 531-fold mortality-rate gradient, and ten countries carrying 58.5% of global deaths—and decompose the gradient into its incidence and case-fatality components. Third, we provide a systematic GBD–WHO reconciliation for the pediatric segment and track the 2015–2023 trajectory against the End TB 2025 milestones. Fourth, we identify the populations progress has left behind and document a methodological contrast: the GBD pediatric series shows no pandemic-era rebound of the kind reported in WHO’s all-age estimates.

2. Methods

2.1. Study Design and Data Sources

2.1.1. GBD 2023 Analytical Framework

This study is a secondary analysis of the Global Burden of Disease (GBD) Study 2023 (Institute for Health Metrics and Evaluation) [4], covering 204 countries and territories, 21 GBD regions and five Socio-demographic Index (SDI) quintiles. Causes of death are modeled with the Cause of Death Ensemble model (CODEm), with garbage codes redistributed [4,22]; 95% uncertainty intervals (UIs) are the 2.5th and 97.5th posterior-draw percentiles [4].

2.1.2. Direct Download and Author Aggregation

All pediatric estimates were derived from raw GBD Results Tool downloads [5] (reproducible queries: deaths and incidence, numbers and rates with 95% UIs, official <5-year aggregate plus 5–9-, 10–14- and 15–19-year groups, both sexes, 1990–2023); complementary extractions covered the 20–24-year band, 204-country deaths and incidence, and sex-stratified deaths. No estimate was transcribed from any previously published article.

2.1.3. Age-Band Definition and Population Denominators

The 0–19-year total sums the official GBD aggregate “<5 years” plus the 5–9-, 10–14- and 15–19-year groups; the 0–14-year total is used only for the WHO comparison (published for ages 0–14 years). Age-band populations were back-calculated from the published number and rate rows; the 2023 global 0–19-year population thus derived (2,670,651,217) was internally cross-checked. Aggregate crude rates equal Σ(number) ÷ Σ(population); rate UIs omit denominator uncertainty.

2.1.4. Comparison with Previous GBD Rounds

Because each GBD round re-estimates the entire time series, no estimate from any previous round enters any table, figure, or trend reported here; prior-round pediatric analyses [18,20,21] are discussed only for scope and pattern.

2.2. Case Definition

Tuberculosis was defined per the GBD cause hierarchy (ICD-9/ICD-10-mapped; drug-susceptible and drug-resistant forms) [4,18], restricted to HIV-negative individuals: TB deaths among people living with HIV are assigned to HIV/AIDS causes (cause IDs 948–950) [4,23]. WHO estimates that about 25,000 (14%) of the 191,000 TB deaths at ages 0–14 years in 2023 occurred in HIV-positive children [1]; the present analysis therefore systematically underestimates total pediatric TB mortality—by approximately one seventh on the WHO definition.

2.3. Metrics, Stratification, and Rate Definitions

Two measures are reported—deaths and incident cases—each as a number and a crude rate per 100,000 with 95% UIs, stratified by the four pediatric age bands, sex (global deaths only), SDI quintile, the 21 GBD regions, and 204 countries and territories. A deaths-to-incidence ratio serves as a case-fatality proxy.

2.4. Temporal Trend Analysis

2.4.1. Estimated Annual Percentage Change, 1990–2023

Long-term trends were quantified using the estimated annual percentage change (EAPC) from a log-linear ordinary least-squares regression of the rate on calendar year [24]; primary 95% confidence intervals (CIs) come from the slope’s standard error (t distribution; regression precision only; a Monte Carlo variant is archived in Supplementary Table S2). An EAPC is significant only when its 95% CI excludes zero.

2.4.2. The 2019–2023 Pandemic Window

The pandemic-era window was analyzed descriptively as net changes over two intervals (2019→2021 and 2019→2023) with Monte Carlo–propagated UIs; because these generally include zero, patterns are interpreted as directional only.

2.4.3. Uncertainty Propagation and Aggregation

UIs for percentage changes were propagated by Monte Carlo simulation (20,000 draws), modeling each published value as truncated-normal with standard deviation (upper − lower)/3.92; ratio UIs are Monte Carlo medians with 2.5th/97.5th percentiles, and the independence assumption renders them conservative. Sums across age bands and countries were approximated by root-sum-of-squares pooling of UI half-widths and are somewhat narrower than an official joint-distribution aggregation. Monte Carlo UIs for compositional shares are wide (2023 under-5 share of deaths: median 55.5%, 95% UI 30.2–86.0); shares are therefore reported as point values with qualitative language. All reported change and ratio values are means of the propagated Monte Carlo distributions; because the mean of a ratio or percentage-change distribution differs from the ratio of point estimates, endpoint ratios recomputed from rounded point estimates can differ from the reported Monte Carlo means by a Jensen-effect bias of at most about 2–4 percentage points.

2.5. SDI Mapping and External Benchmarks

2.5.1. Fixed-2021 SDI Quintile Mapping

SDI aggregates were computed as country sums under a fixed SDI-quintile mapping based on the official GBD 2021 quintile table; for 22 large countries with subnational splits, quintiles were completed using the empirical thresholds on flagged national rows (Supplementary Table S7). These are not the official, dynamically regrouped GBD SDI aggregates; SDI-level incidence EAPCs (eleven key years) are approximate.

2.5.2. WHO Cross-Check

Author-aggregated GBD estimates at ages 0–14 years were compared with WHO Global Tuberculosis Report pediatric estimates for 2023 [1] and 2022 [17,25]; WHO all-age estimates for 2019–2023 [1] serve as the comparator for the pandemic-window contrast (Section 4.5). No WHO number is mixed into any GBD estimate.

2.5.3. End TB Strategy Milestone Tracking and Burden-in-Context Anchor

Progress against the End TB Strategy 2025 milestones (75% reduction in TB deaths; 50% reduction in the incidence rate versus 2015) [7,8] was assessed as the 2015→2023 percentage change at ages 0–19 years. Same-round GBD 2023 deaths from lower respiratory infections (LRI) at ages 0–19 years (711,713 in 2023) served as a relative-scale anchor.

2.6. Ecological Covariate Analyses

An author-compiled country covariate table (215 countries; gross domestic product [GDP] per capita, Gini index, World Bank income classification, climatic indicators; Supplementary Data S1) was extended with the universal health coverage (UHC) service coverage index (Sustainable Development Goal indicator 3.8.1; 2021 or 2019; 192 of 215 countries) [26,27]. The national case-fatality proxy was analyzed for the 93 countries with at least 500 incident cases (99.8% of country-level deaths): Spearman correlation against log GDP per capita, multivariable regression of the log proxy on log GDP per capita with the Gini and UHC indices in levels, and a best-quartile counterfactual bounding avertable deaths. An a priori subset of 66 island and compact coastal nations related the 2023 outcomes to 15 covariates by Spearman and partial correlations controlling log GDP per capita, with Benjamini–Hochberg adjustment. All Section 2.6 analyses are ecological and hypothesis-generating.

2.7. Statistical Analysis, Ethics, and Reporting

Aggregation and all derived quantities were computed in Python 3.11; no new GBD model runs were performed. This secondary analysis of publicly available, de-identified, aggregate data was exempt from institutional review board approval. Reporting follows the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) [28]. Raw and author-aggregated CSV files are provided as Supplementary Data S1.

3. Results

3.1. Global Burden at Ages 0–19 Years in 2023 and Long-Term Change (Table 1; Figure 1)

In 2023, tuberculosis (TB) caused an estimated 87,764 deaths (95% uncertainty interval [UI] 65,765–109,764) among children and adolescents aged 0–19 years worldwide, at a crude rate of 3.29 per 100,000 (2.46–4.11)—equivalent to about 240 deaths every day (Table 1). Incident cases numbered 1,665,272 (1,334,817–1,995,728), at a crude incidence rate of 62.35 per 100,000 (49.98–74.73).

Figure 1. Global burden of tuberculosis in children and adolescents aged 0–19 years, 1990–2023 (GBD 2023; HIV-negative tuberculosis). (a) Global deaths (number, left axis; crude rate per 100,000, right axis), 1990–2023; shaded band is the 95% uncertainty interval (UI). (b) Global incident cases (number, left axis; crude incidence rate per 100,000, right axis), 1990–2023, with 95% UI. (c) Deaths-to-incidence ratio (case-fatality proxy), 1990–2023 (9.0% in 1990; 5.3% in 2023). (d) Deaths indexed to 2019 (=100), 2015–2023; the shaded window marks 2020–2021 (between the 2020 and 2021 annual points). Data: GBD 2023 Results (IHME). Notes. Ages 0–19 are defined as the official GBD under-5 aggregate plus the 5–9-, 10–14- and 15–19-year groups. Aggregate 95% UIs combine subgroup uncertainty half-widths by root-sum-of-squares under an independence approximation and are therefore narrower than a joint-draw synthesis. The series declines monotonically through the 2019–2023 pandemic window; see Section 4.5 for the methodological interpretation of the absent rebound.

Figure 1. Global burden of tuberculosis in children and adolescents aged 0–19 years, 1990–2023 (GBD 2023; HIV-negative tuberculosis). (a) Global deaths (number, left axis; crude rate per 100,000, right axis), 1990–2023; shaded band is the 95% uncertainty interval (UI). (b) Global incident cases (number, left axis; crude incidence rate per 100,000, right axis), 1990–2023, with 95% UI. (c) Deaths-to-incidence ratio (case-fatality proxy), 1990–2023 (9.0% in 1990; 5.3% in 2023). (d) Deaths indexed to 2019 (=100), 2015–2023; the shaded window marks 2020–2021 (between the 2020 and 2021 annual points). Data: GBD 2023 Results (IHME). Notes. Ages 0–19 are defined as the official GBD under-5 aggregate plus the 5–9-, 10–14- and 15–19-year groups. Aggregate 95% UIs combine subgroup uncertainty half-widths by root-sum-of-squares under an independence approximation and are therefore narrower than a joint-draw synthesis. The series declines monotonically through the 2019–2023 pandemic window; see Section 4.5 for the methodological interpretation of the absent rebound.

Table 1. Global tuberculosis burden at ages 0–19 years in 1990, 2015, 2019 and 2023: deaths and incident cases, numbers and crude rates per 100,000 with 95% uncertainty intervals.

Year	Deaths, n (95% UI)	Crude death rate per 100,000 (95% UI)	Incident cases, n (95% UI)	Crude incidence rate per 100,000 (95% UI)
1990	259,063 (192,673–325,453)	11.49 (8.55–14.43)	2,879,768 (2,342,781–3,416,755)	127.72 (103.90–151.53)
2015	117,762 (86,218–149,306)	4.60 (3.37–5.83)	1,968,427 (1,576,324–2,360,530)	76.89 (61.57–92.20)
2019	99,704 (75,060–124,347)	3.78 (2.85–4.72)	1,857,695 (1,498,914–2,216,476)	70.45 (56.85–84.06)
2023	87,764 (65,765–109,764)	3.29 (2.46–4.11)	1,665,272 (1,334,817–1,995,728)	62.35 (49.98–74.73)

Note: values are author aggregations of unmodified GBD 2023 Results Tool extractions; aggregate 95% uncertainty intervals (UIs) pool age-band half-widths by root-sum-of-squares under an independence assumption and are slightly narrower than official joint-distribution intervals; crude rates use populations back-calculated from the published number and rate rows, and rate UIs omit denominator uncertainty. The GBD tuberculosis cause excludes HIV-associated TB. The full annual series (1990–2023, including all interim years) is given in Supplementary Table S1. Source: recomputed from raw/tb_reg_p1–p3 in Supplementary Data S1 with code/tb_compute.py; archived key-year values (derived/T1_global_0-19_keyyears.csv) match this table exactly.

Table 1. Global tuberculosis burden at ages 0–19 years in 1990, 2015, 2019 and 2023: deaths and incident cases, numbers and crude rates per 100,000 with 95% uncertainty intervals.

Year	Deaths, n (95% UI)	Crude death rate per 100,000 (95% UI)	Incident cases, n (95% UI)	Crude incidence rate per 100,000 (95% UI)
1990	259,063 (192,673–325,453)	11.49 (8.55–14.43)	2,879,768 (2,342,781–3,416,755)	127.72 (103.90–151.53)
2015	117,762 (86,218–149,306)	4.60 (3.37–5.83)	1,968,427 (1,576,324–2,360,530)	76.89 (61.57–92.20)
2019	99,704 (75,060–124,347)	3.78 (2.85–4.72)	1,857,695 (1,498,914–2,216,476)	70.45 (56.85–84.06)
2023	87,764 (65,765–109,764)	3.29 (2.46–4.11)	1,665,272 (1,334,817–1,995,728)	62.35 (49.98–74.73)

Note: values are author aggregations of unmodified GBD 2023 Results Tool extractions; aggregate 95% uncertainty intervals (UIs) pool age-band half-widths by root-sum-of-squares under an independence assumption and are slightly narrower than official joint-distribution intervals; crude rates use populations back-calculated from the published number and rate rows, and rate UIs omit denominator uncertainty. The GBD tuberculosis cause excludes HIV-associated TB. The full annual series (1990–2023, including all interim years) is given in Supplementary Table S1. Source: recomputed from raw/tb_reg_p1–p3 in Supplementary Data S1 with code/tb_compute.py; archived key-year values (derived/T1_global_0-19_keyyears.csv) match this table exactly.

Between 1990 and 2023, deaths fell by 65.5% (95% UI −76.4 to −50.8) and incident cases by 41.6% (−56.1 to −24.1) (Table 1); the case-fatality proxy fell from 9.0% in 1990 to 5.3% in 2023, with the crude mortality rate declining by 3.96% per year (EAPC −3.96, 95% CI −4.07 to −3.85) and the incidence rate by 2.37% per year (−2.47 to −2.28).

3.2. The Development Gradient: Extreme Concentration of the Residual Burden (Figure 2)

The 2023 burden was steeply patterned by socio-demographic development: low- plus low-middle-SDI countries carried 79,246 deaths—90.3% of the global total (low-SDI alone 51.0%)—across an approximately 531-fold mortality-rate ratio between the low- and high-SDI quintiles (10.42 versus 0.0196 per 100,000) (Supplementary Table S7).

Improvement since 1990 occurred in every quintile but was slowest where the burden is highest (mortality-rate EAPCs −4.04 in low-SDI versus −10.46 in high-middle-SDI countries; Figure 2C; Supplementary Table S2). The middle-SDI quintile showed the slowest incidence decline (−0.96), a large-country composition effect (Section 2.5.1).

3.3. Regional Patterns and EAPCs (Figure 2)

Mortality was geographically concentrated in 2023: Western Sub-Saharan Africa carried the largest share of deaths (27,100; 30.9%), followed by Eastern Sub-Saharan Africa (21,302; 24.3%) and South Asia (14,946; 17.0%)—together 72.2% of all 0–19-year TB deaths. The highest regional crude mortality rates occurred in Central (12.04 per 100,000) and Southern (10.79) Sub-Saharan Africa.

Mortality rates declined significantly in all 22 study locations between 1990 and 2023 (Figure 2a), fastest in High-income Asia Pacific (EAPC −10.87) and East Asia (−9.89) and slowest in Southern Sub-Saharan Africa (−1.22, −1.80 to −0.64). Southern Sub-Saharan Africa was also the only region with a significantly rising incidence rate (EAPC +0.45, 95% CI +0.04 to +0.86), a pattern driven by South Africa (Figure 2b).

3.4. Age Composition and Sex Differences (Figure 3a–c)

Children under 5 years accounted for 47,799 deaths (27,300–68,298) in 2023—54.5% of the 0–19-year total—with the 5–9-, 10–14- and 15–19-year bands contributing 9,248, 9,099 and 21,618 deaths (Supplementary Table S4). Improvement was slowest in the oldest band: between 1990 and 2023 deaths fell by 66.1% (95% UI −83.4 to −38.8) under 5 years versus 60.3% (−75.4 to −39.0) at ages 15–19 years, with the same ordering after 2019 (−10.6% under 5, −3.5% at 15–19 years).

Sex patterns were age-graded in point estimates (Figure 3c): the male-to-female ratio of deaths was below 1 at ages 10–14 and 15–19 years (0.78 and 0.85 in 2023), crossing above 1 at ages 20–24 years (0–19-year ratio 0.96); every 95% UI spans 1, so sex patterns are descriptive shapes only (UIs in Supplementary Table S5).

3.5. National Patterns (Figure 3d–E)

Ten countries accounted for 51,331 deaths—58.5% of the global total—in 2023: Nigeria (10,082), India (7,434), the Democratic Republic of the Congo (6,539), Pakistan (5,950), Niger (4,902), Ethiopia (3,843), Indonesia (3,465), Somalia (3,418), Mozambique (3,172) and Chad (2,527) (UIs in Supplementary Table S3); eight of the ten are African. The ten highest national crude mortality rates were all in sub-Saharan Africa (led by the Central African Republic, 31.7 per 100,000); the ten lowest were roughly 27,000-fold below the highest.

National trends were near-universally favorable: 203 of 204 countries showed a significant decline in the crude 0–19-year mortality rate between 1990 and 2023 (Supplementary Table S3). The single exception was Zimbabwe (EAPC +1.06, 95% CI +0.65 to +1.48), whose 2023 rate (20.4 per 100,000) simultaneously ranked fifth-highest globally (Section 4.4).

3.6. The Pandemic Window, 2019–2023: No Rebound in the GBD Pediatric Series

Global 0–19-year deaths declined monotonically through the pandemic window, from 99,704 in 2019 to 87,764 in 2023 (Supplementary Table S1): the 2019→2021 net change was −2.9% (Monte Carlo 95% UI −32.9 to +36.5), and no GBD region recorded a significant 2019→2021 increase (Supplementary Table S6). This contrasts with WHO’s all-age estimates, in which global TB deaths rose from approximately 1.4 million in 2019 to 1.6 million in 2021 before falling back (1.25 million in 2023) [1]—an estimation-methodology difference, not evidence that the pandemic spared children (Section 4.5).

3.7. GBD Versus WHO: A 2.5-Fold Pediatric Mortality Gap (Supplementary Table S8)

At ages 0–14 years in 2023, the author-aggregated GBD estimate of TB deaths (66,146 [45,116–87,177]) equaled 34.6% of WHO’s all-inclusive pediatric estimate (191,000) and 39.9% of the like-for-like HIV-negative comparator (Supplementary Table S8)—a roughly 2.5-fold gap. Incidence estimates were far closer: 1,010,204 (809,387–1,211,021) in GBD versus 1,250,000 (1.16–1.35 million) in WHO, a ratio of 80.8% with overlapping intervals. The age structure was highly consistent: children under 5 years accounted for 72.3% (point estimate) of GBD 0–14-year deaths versus 73% of HIV-negative deaths in WHO’s calibration.

3.8. End TB Strategy Milestone Tracking and Burden in Context

Against the End TB Strategy 2025 milestones, the pediatric trajectory is far off track. Between 2015 and 2023, deaths at ages 0–19 years fell from 117,762 (86,218–149,306) to 87,764—a decline of 23.9% (95% UI −48.5 to +9.6) against the targeted 75% reduction. Incident cases fell by 14.6% (−36.5 to +12.4) and the incidence rate by 18.0% (−38.8 to +7.8), against the targeted 50% reduction.

3.9. National Case-Fatality Gradient, Service Coverage, and Climatic Correlates (Ecological Analysis; Supplementary Table S9)

The national case-fatality proxy varied 119-fold across the 93 countries with at least 500 incident cases in 2023 (0.16 in the United Kingdom to 19.2 in Somalia) and tracked development (Spearman ρ versus log GDP per capita −0.727, P = 5.0×10⁻¹⁶); its low-versus-high-SDI ratio widened from 3.6-fold in 1990 to 10.5-fold in 2023. The 531-fold mortality gradient thus decomposes into a roughly 51-fold incidence-rate gradient and a ~10.5-fold case-fatality gradient. In multivariable regression (R² = 0.63), log GDP per capita (β = −0.315, P = 5.6×10⁻⁴) and the UHC index (β = −0.021 per point; 10 points higher ≈ 0.81-fold proxy) were independently associated with the proxy, whereas the Gini index was not (P = 0.52). Applying the best-quartile proxy (2.00) to all 93 countries would have averted an estimated 56,055 deaths (95% UI 47,520–65,508) in 2023—64.1% of the analysis-set total. In the 66-nation island and compact-coastal subset, the death rate and case-fatality proxy rose with mean annual temperature (income-adjusted partial r = +0.496 and +0.560); these gradients are hypothesis-generating only (Supplementary Table S9).

Segmented (joinpoint) trend and inequality analyses. BIC-selected joinpoint regression of the global 0–19-year crude TB death rate (0–3 joinpoints; Supplementary Table S-JP1) (selection by BIC grid search rather than the permutation test of Kim et al. (2000)) identified breakpoints at 1996, 1999 and 2003: mortality decline accelerated from −1.83% per year (95% CI −2.07 to −1.58) in 1990–1996 to −5.05% (−5.33 to −4.77) in 1999–2003, then settled at −4.11% (−4.15 to −4.06) through 2003–2023 (AAPC 1990–2023 −3.73%, −3.77 to −3.70). Incidence rose slightly until 1995 (+0.44% per year, 0.28 to 0.60), declined thereafter, and fell fastest in 2020–2023 (−3.34% per year, −3.62 to −3.07; AAPC −2.17%, −2.20 to −2.14). A single-year (2023) SDI-quintile inequality assessment gave a slope index of inequality of −10.84 deaths per 100,000 (−15.82 to −1.76) and a concentration index of −0.505 (−0.727 to −0.115), confirming the strong concentration of pediatric TB mortality in low-SDI settings; the 1990 quintile comparison was not reproducible from the packaged data (Supplementary Table S-SII1).

4. Discussion

4.1. Principal Findings

This study provides, to our knowledge, the first dedicated 0–19-year pediatric secondary analysis of GBD 2023, complementing the round’s official all-age capstone [19]. Three findings define a daily toll of 240 children and a widening estimation divide.

4.2. Extreme Concentration: An Equity Failure, Not a Knowledge Failure

TB is preventable and curable [12]. The 531-fold low- versus high-SDI mortality gradient means that where a child is born determines whether TB is treatable or fatal. Within WHO’s framework, 96% of children who die of TB never received treatment [6]; consistently, the gradient splits into a ~51-fold incidence gradient and a ~10.5-fold, still-widening case-fatality gradient tracking service coverage rather than income inequality. Pediatric TB mortality is thus a case-finding and treatment-access indicator, and the core WHO Roadmap actions (contact tracing, integrated screening, preventive treatment [11,15]) are the interventions that reach the 96%.

4.3. The Measurement Gap as a Finding, Not a Nuisance

The roughly 2.5-fold GBD–WHO divergence in pediatric mortality (66,146 versus 166,000 HIV-negative deaths at ages 0–14 years in 2023) is structurally informative. WHO’s pediatric estimates adjust notification data for under-detection [6,16,17]; the GBD fits CODEm models to vital-registration and verbal-autopsy data, in which pediatric TB deaths are prone to misclassification [4,22]. The two systems’ near-agreement on incidence (80.8%) and on the under-5 share of deaths (72.3% versus 73%) localizes the divergence to the mortality ascertainment step: how many dying children had TB at all. Until reconciled, every End TB accountability metric for children carries a 2.5-fold ambiguity; reconciliation requires child-specific verbal-autopsy validation, age-disaggregated mortality reporting, and joint calibration.

4.4. Off-Track Milestones and the Populations Left Behind

Pediatric deaths have fallen by 23.9% against the 75% End TB 2025 milestone and the incidence rate by 18.0% against the 50% target. Adolescents aged 15–19 years improved slowest in every window and sit outside both the under-15 monitoring frame and adult program design [13,14]. Zimbabwe is the only country with a significantly rising pediatric TB mortality rate (+1.06% per year) and the fifth-highest 2023 rate (20.4 per 100,000) [23]. Southern Sub-Saharan Africa is the only region with rising pediatric incidence (+0.45% per year, driven by South Africa) and the slowest mortality decline (−1.22% per year).

4.5. The Absent Pandemic Rebound: A Methodological Contrast

WHO’s all-age estimates show global TB deaths rising through 2020–2021 before receding (1.25 million in 2023) [1,29]; the GBD 2023 pediatric series declines monotonically through the same window. The most plausible reading is that GBD’s covariate-driven, year-smoothed, partly extrapolative CODEm machinery is structurally insensitive to short-run shocks, whereas WHO’s notification-anchored estimates respond to them directly. We explicitly do not claim that the pandemic spared children with TB; subsequent GBD rounds with observed pandemic-era data will make this contrast falsifiable.

4.6. Comparison with Previous Studies

The GBD 2023 TB HIV Collaborators capstone reports all-age 2015–2023 declines of 19.2% in the incidence rate and 22.6% in deaths [19]; our pediatric estimates (18.0% and 23.9%) sit close to that trajectory, cross-validating the author-aggregated series. The analyses are complementary: the capstone stratifies by HIV status and drug resistance, whereas we isolate the 0–19-year segment. Relative to the GBD 2021-round pediatric analyses [18,20,21], this study adds the pandemic-window evaluation; because each round re-estimates the entire series, we make no numeric comparisons with earlier rounds.

4.7. Limitations

Several limitations qualify these results. First, the GBD tuberculosis cause excludes HIV-associated TB (an estimated 25,000 pediatric deaths, 14%, in 2023 [1]); our analysis underestimates total pediatric TB mortality by approximately one seventh on the WHO definition. Second, all estimates are model-based, heaviest in the data-sparse settings where the burden concentrates, and the 2022–2023 values carry an extrapolative component. Third, aggregate UIs are narrower than official joint-distribution intervals and Monte Carlo change UIs are conservative; compositional shares are interpreted qualitatively. Fourth, SDI aggregates use the fixed-2021 mapping, SDI incidence EAPCs are approximate, sex-stratified estimates are global numbers only, and population denominators were back-calculated. Fifth, the Section 3.9 analyses are ecological, and the climatic gradients lack an established mechanism. Finally, no drug-resistance, risk-factor, or DALY decomposition was performed; multidrug-resistant pediatric TB—roughly 25,000–32,000 incident cases annually in WHO-calibrated modeling [30]—lies outside the present scope.

5. Conclusion

Even under the most conservative estimation framework—one excluding HIV-associated TB entirely—TB killed an estimated 87,764 children and adolescents in 2023, about 240 every day, alongside 1.67 million incident cases. The burden is concentrated (nine in ten deaths in low- and low-middle-SDI countries), under-measured (a 2.5-fold GBD–WHO mortality divide), and off track (23.9% progress against the 75% End TB 2025 milestone). Three actions follow: reconcile pediatric TB mortality estimation across the GBD and WHO systems; extend routine monitoring to ages 15–19 years; and concentrate case-finding, contact-tracing and preventive-treatment resources on the few countries where this epidemic now lives.