Transmission heterogeneity among Mycobacterium tuberculosis complex lineages driven by economic initiatives and industrial structures.

The Belt and Road Initiative has promoted economic growth and population mobility in Kashgar region but also increased the risk of tuberculosis (TB) transmission. Therefore, we conducted clustering and phylogenetic analyses to delineate the recent transmission and population evolution of Mycobacterium tuberculosis complex (MTBC) in Kashgar since 21st century. The results revealed a high clustering rate of MTBC in Kashgar, reaching 44.1%, with 62.4% of cases involving cross-county transmission clusters. The clustering risk of Lineage 4 was significantly higher than that of other lineages (aOR, 6.53; 95% CI, 4.81-8.94). Phylogenetic and population dynamic analyses further uncovered heterogeneity among different MTBC lineages in terms of population expansion timing and spatial transmission patterns. Generalized linear model extension indicated that transmission directions were associated with differences in industrial and agricultural GDP among counties. We recommend routine molecular surveillance to monitor lineages with changing fitness and promptly identify potential drivers of these changes.