To analyze the epidemiological trends and disease burden in chronic hepatitis B (including cirrhosis) from 1990 to 2021 globally and in China based on Global Burden of Disease Database (GBD) 2021 study, assess development-related inequality patterns and demographic drivers, and project China’s future burden and risk-factor contributions.

A secondary analysis was conducted on GBD 2021 data for 1990—2021 to extract the age-standardized incidence rate (ASIR), age-standardized prevalence rate (ASPR), and age-standardized disability-adjusted life-year rate (ASDR) globally (204 countries/territories) and in China, each with 95% uncertainty interval (UI). Joinpoint regression was used to estimate the average annual percent change (AAPC) with 95% confidence interval (CI). Combining sociodemographic index (SDI)-related inequality metrics, frontier analysis, and Das Gupta symmetric decomposition, differences in disease burden were quantified, and the relative contributions of population growth, population aging, and changes in age-specific rates to changes in absolute burden were also analyzed. Autoregressive integrated moving average (ARIMA) models were fitted to China’s annual series for 1990—2021 to forecast trends for 2022—2035. Within the GBD comparative risk assessment framework, the attributable burden from alcohol consumption and drug use were quantified.

Global ASIR, ASPR and ASDR in chronic hepatitis B were declined overall from 1990 to 2021 (all AAPCs, P<0.05). However, under the combined effects of population growth and aging, absolute numbers of cases and disability-adjusted life years (DALYs) did not decrease in parallel with age-standardized rates. The burden was concentrated primarily in low-middle SDI countries/territories in Asia and sub-Saharan Africa. In China, all 3 age-standardized indicators were decreased by more than 50% when compared with the values in 1990, and the burden was declined markedly in children; Nonetheless, middle-aged and old men remained the main high-burden group, with total cases and DALYs staying at relatively high levels. Decomposition analyses indicated that declines in age-specific rates (epidemiologic change) were the primary driver of reductions in China’s absolute burden, whereas changes in global DALYs were more readily offset or driven by population growth and aging. ARIMA projections suggested that, under continuation of historical control intensity, China’s ASIR and ASDR will decline slowly through 2035, while ASPR will remain comparatively high. Comparative risk assessment showed that alcohol consumption and drug use were important modifiable contributors to DALYs related to chronic hepatitis B (including cirrhosis) globally and in China; alcohol-attributable ASDR in China was higher than the global average.

From 1990 to 2021, the age-standardized burden of chronic hepatitis B (including cirrhosis) declined globally and in China, yet substantial absolute-burden pressure persists worldwide due to population growth and aging and is unevenly distributed. Despite major progress in China in vaccination, prevention of mother-to-child transmission, and antiviral therapy, strengthened management of prevalent infections and prevention of complications remain critical to further reduce residual burden. Countermeasures　In line with the 2030 goal of eliminating viral hepatitis as a public health threat of World Health Organization, we recommend sustaining high coverage of timely birth-dose and full-course hepatitis B vaccination and strengthening prevention of mother-to-child transmission (PMTCT); prioritizing middle-aged and old men and high-risk areas to improve coverage of screening, follow-up, and treatment; integrating alcohol reduction and services for substance use disorders into hepatitis B care; and directing testing and treatment resources toward low-middle SDI settings and other resource-limited areas to narrow burden disparities.