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Regan M, Barham T, Li Y, Swartwood NA, Beeler Asay GR, Cohen T, Horsburgh CR, Khan A, Marks SM, Myles RL, Salomon JA, Self JL, Winston CA, Menzies NA. Risk factors underlying racial and ethnic disparities in tuberculosis diagnosis and treatment outcomes, 2011-19: a multiple mediation analysis of national surveillance data. Lancet Public Health 2024; 9:e564-e572. [PMID: 39095133 DOI: 10.1016/s2468-2667(24)00151-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/20/2024] [Accepted: 06/20/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Despite an overall decline in tuberculosis incidence and mortality in the USA in the past two decades, racial and ethnic disparities in tuberculosis outcomes persist. We aimed to examine the extent to which inequalities in health and neighbourhood-level social vulnerability mediate these disparities. METHODS We extracted data from the US National Tuberculosis Surveillance System on individuals with tuberculosis during 2011-19. Individuals with multidrug-resistant tuberculosis or missing data on race and ethnicity were excluded. We examined potential disparities in tuberculosis outcomes among US-born and non-US-born individuals and conducted a mediation analysis for groups with a higher risk of treatment incompletion (a summary outcome comprising diagnosis after death, treatment discontinuation, or death during treatment). We used sequential multiple mediation to evaluate eight potential mediators: three comorbid conditions (HIV, end-stage renal disease, and diabetes), homelessness, and four census tract-level measures (poverty, unemployment, insurance coverage, and racialised economic segregation [measured by Index of Concentration at the ExtremesRace-Income]). We estimated the marginal contribution of each mediator using Shapley values. FINDINGS During 2011-19, 27 788 US-born individuals and 57 225 non-US-born individuals were diagnosed with active tuberculosis, of whom 27 605 and 56 253 individuals, respectively, met eligibility criteria for our analyses. We did not observe evidence of disparities in tuberculosis outcomes for non-US-born individuals by race and ethnicity. Therefore, subsequent analyses were restricted to US-born individuals. Relative to White individuals, Black and Hispanic individuals had a higher risk of not completing tuberculosis treatment (adjusted relative risk 1·27, 95% CI 1·19-1·35; 1·22, 1·11-1·33, respectively). In multiple mediator analysis, the eight measured mediators explained 67% of the disparity for Black individuals and 65% for Hispanic individuals. The biggest contributors to these disparities for Black individuals and Hispanic individuals were concomitant end-stage renal disease, concomitant HIV, census tract-level racialised economic segregation, and census tract-level poverty. INTERPRETATION Our findings underscore the need for initiatives to reduce disparities in tuberculosis outcomes among US-born individuals, particularly in highly racially and economically polarised neighbourhoods. Mitigating the structural and environmental factors that lead to disparities in the prevalence of comorbidities and their case management should be a priority. FUNDING US Centers for Disease Control and Prevention National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention Epidemiologic and Economic Modeling Agreement.
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Affiliation(s)
- Mathilda Regan
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA.
| | - Terrika Barham
- Office of Health Equity, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Yunfei Li
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Nicole A Swartwood
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Garrett R Beeler Asay
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ted Cohen
- Yale School of Public Health, New Haven, CT, USA
| | - C Robert Horsburgh
- Department of Epidemiology, Department of Biostatistics, and Department of Global Health, School of Public Health, Boston University, Boston, MA, USA; Department of Medicine, School of Medicine, Boston University, Boston, MA, USA
| | - Awal Khan
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Suzanne M Marks
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ranell L Myles
- Office of Health Equity, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Joshua A Salomon
- Department of Health Policy, Stanford University, Stanford, CA, USA
| | - Julie L Self
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Carla A Winston
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
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Pelissari DM, de Lima LV, Pavinati G, Magnabosco GT, Silva JNDB, Bartholomay P, Johansen FDC. Time until tuberculosis recurrence and associated factors in Brazil: a populationbased retrospective cohort study using a linked database. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2024; 27:e240016. [PMID: 38655945 PMCID: PMC11027432 DOI: 10.1590/1980-549720240016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/12/2023] [Accepted: 01/12/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVE To calculate the rate of tuberculosis recurrence, estimate its average time until recurrence, and identify factors associated with recurrence in Brazil. METHODS Retrospective cohort study with a linked database from the Notifiable Diseases Information System. The study included individuals diagnosed with tuberculosis in 2015, focusing on those who experienced their first recurrence within 6.5 years. We estimated the relative risk (RR) and its 95% confidence interval (95%CI), as well as the population attributable fraction (PAF) or the population preventable fraction (PPF) of associated factors. RESULTS Within a 6.5-year period, 3,253 individuals (6.5%) experienced tuberculosis recurrence, with a median time of 2.2 years. Positively associated factors included: male sex (RR: 1.4; 95%CI 1.3-1.5; PAF: 22.9%), age 30 to 59 years (RR: 3.0; 95%CI 1.6-5.7; PAF: 36.0%), black race (RR: 1.3; 95%CI 1.2-1.5; PAF: 3.5%), mixed race (RR: 1.3; 95%CI 1.2-1.4; PAF: 10.6%), deprivation of liberty (RR: 1.9; 95%CI 1.7-2.1; PAF: 9.1%), pulmonary/mixed clinical form (RR: 1.7; 95%CI 1.4-1.9; PAF: 37.1%), acquired immunodeficiency syndrome diagnosis (RR: 1.8; 95%CI 1.5-1.9; PAF: 4.3%), and alcohol use (RR: 1.2; 95%CI 1.1-1.3; PAF: 2.9%). Negatively associated factors were: 12 or more years of schooling (RR: 0.5; 95%CI 0.4-0.6; PPF: 3.3%) and supervised treatment (RR: 0.9; 95%CI 0.8-0.9; PPF: 4.4%). CONCLUSION This study revealed high tuberculosis recurrence rates in Brazil, influenced by sociodemographic, compartmental, and social factors, both positively and negatively impacting disease recurrence.
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Affiliation(s)
- Daniele Maria Pelissari
- Ministério da Saúde, Coordenação-Geral de Vigilância da
Tuberculose, Endemic Mycoses and Non-Tuberculous Mycobacteria – Brasília (DF),
Brazil
| | | | - Gabriel Pavinati
- Universidade Estadual de Maringá, Postgraduate Nursing Program
– Maringá (PR), Brazil
| | | | - José Nildo de Barros Silva
- Ministério da Saúde, Coordenação-Geral de Vigilância da
Tuberculose, Endemic Mycoses and Non-Tuberculous Mycobacteria – Brasília (DF),
Brazil
| | - Patricia Bartholomay
- Ministério da Saúde, Department of HIV/Aids, Tuberculosis,
Viral Hepatitis and Sexually Transmitted Infections – Brasília (DF),
Brazil
| | - Fernanda Dockhorn Costa Johansen
- Ministério da Saúde, Coordenação-Geral de Vigilância da
Tuberculose, Endemic Mycoses and Non-Tuberculous Mycobacteria – Brasília (DF),
Brazil
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Li Y, Regan M, Swartwood NA, Barham T, Beeler Asay GR, Cohen T, Hill AN, Horsburgh CR, Khan A, Marks SM, Myles RL, Salomon JA, Self JL, Menzies NA. Disparities in Tuberculosis Incidence by Race and Ethnicity Among the U.S.-Born Population in the United States, 2011 to 2021 : An Analysis of National Disease Registry Data. Ann Intern Med 2024; 177:418-427. [PMID: 38560914 DOI: 10.7326/m23-2975] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Elevated tuberculosis (TB) incidence rates have recently been reported for racial/ethnic minority populations in the United States. Tracking such disparities is important for assessing progress toward national health equity goals and implementing change. OBJECTIVE To quantify trends in racial/ethnic disparities in TB incidence among U.S.-born persons. DESIGN Time-series analysis of national TB registry data for 2011 to 2021. SETTING United States. PARTICIPANTS U.S.-born persons stratified by race/ethnicity. MEASUREMENTS TB incidence rates, incidence rate differences, and incidence rate ratios compared with non-Hispanic White persons; excess TB cases (calculated from incidence rate differences); and the index of disparity. Analyses were stratified by sex and by attribution of TB disease to recent transmission and were adjusted for age, year, and state of residence. RESULTS In analyses of TB incidence rates for each racial/ethnic population compared with non-Hispanic White persons, incidence rate ratios were as high as 14.2 (95% CI, 13.0 to 15.5) among American Indian or Alaska Native (AI/AN) females. Relative disparities were greater for females, younger persons, and TB attributed to recent transmission. Absolute disparities were greater for males. Excess TB cases in 2011 to 2021 represented 69% (CI, 66% to 71%) and 62% (CI, 60% to 64%) of total cases for females and males, respectively. No evidence was found to indicate that incidence rate ratios decreased over time, and most relative disparity measures showed small, statistically nonsignificant increases. LIMITATION Analyses assumed complete TB case diagnosis and self-report of race/ethnicity and were not adjusted for medical comorbidities or social determinants of health. CONCLUSION There are persistent disparities in TB incidence by race/ethnicity. Relative disparities were greater for AI/AN persons, females, and younger persons, and absolute disparities were greater for males. Eliminating these disparities could reduce overall TB incidence by more than 60% among the U.S.-born population. PRIMARY FUNDING SOURCE Centers for Disease Control and Prevention.
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Affiliation(s)
- Yunfei Li
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Y.L., M.R., N.A.S.)
| | - Mathilda Regan
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Y.L., M.R., N.A.S.)
| | - Nicole A Swartwood
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Y.L., M.R., N.A.S.)
| | - Terrika Barham
- Office of Health Equity, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia (T.B., R.L.M.)
| | - Garrett R Beeler Asay
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia (G.R.B.A., A.N.H., A.K., S.M.M., J.L.S.)
| | - Ted Cohen
- Yale School of Public Health, New Haven, Connecticut (T.C.)
| | - Andrew N Hill
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia (G.R.B.A., A.N.H., A.K., S.M.M., J.L.S.)
| | - C Robert Horsburgh
- Departments of Epidemiology, Biostatistics, Global Health and Medicine, Boston University Schools of Public Health and Medicine, Boston, Massachusetts (C.R.H.)
| | - Awal Khan
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia (G.R.B.A., A.N.H., A.K., S.M.M., J.L.S.)
| | - Suzanne M Marks
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia (G.R.B.A., A.N.H., A.K., S.M.M., J.L.S.)
| | - Ranell L Myles
- Office of Health Equity, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia (T.B., R.L.M.)
| | - Joshua A Salomon
- Department of Health Policy, Stanford School of Medicine, Stanford University, Stanford, California (J.A.S.)
| | - Julie L Self
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia (G.R.B.A., A.N.H., A.K., S.M.M., J.L.S.)
| | - Nicolas A Menzies
- Department of Global Health and Population and Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (N.A.M.)
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Castro KG, Shah NS. Beyond the Bacillus: Closing Gaps in Tuberculosis Health Disparities Requires Targeting Social Determinants. Ann Intern Med 2024; 177:535-536. [PMID: 38560906 DOI: 10.7326/m24-0548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Affiliation(s)
- Kenneth G Castro
- Hubert Department of Global Health and Department of Epidemiology, Rollins School of Public Health, Emory University, and Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - N Sarita Shah
- Hubert Department of Global Health and Department of Epidemiology, Rollins School of Public Health, Emory University, and Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
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Ekramnia M, Li Y, Haddad MB, Marks SM, Kammerer JS, Swartwood NA, Cohen T, Miller JW, Horsburgh CR, Salomon JA, Menzies NA. Estimated rates of progression to tuberculosis disease for persons infected with Mycobacterium tuberculosis in the United States. Epidemiology 2024; 35:164-173. [PMID: 38290139 PMCID: PMC10832387 DOI: 10.1097/ede.0000000000001707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND In the United States, over 80% of tuberculosis (TB) disease cases are estimated to result from reactivation of latent TB infection (LTBI) acquired more than 2 years previously ("reactivation TB"). We estimated reactivation TB rates for the US population with LTBI, overall, by age, sex, race-ethnicity, and US-born status, and for selected comorbidities (diabetes, end-stage renal disease, and HIV). METHODS We collated nationally representative data for 2011-2012. Reactivation TB incidence was based on TB cases reported to the National TB Surveillance System that were attributed to LTBI reactivation. Person-years at risk of reactivation TB were calculated using interferon-gamma release assay (IGRA) positivity from the National Health and Nutrition Examination Survey, published values for interferon-gamma release assay sensitivity and specificity, and population estimates from the American Community Survey. RESULTS For persons aged ≥6 years with LTBI, the overall reactivation rate was estimated as 0.072 (95% uncertainty interval: 0.047, 0.12) per 100 person-years. Estimated reactivation rates declined with age. Compared to the overall population, estimated reactivation rates were higher for persons with diabetes (adjusted rate ratio [aRR] = 1.6 [1.5, 1.7]), end-stage renal disease (aRR = 9.8 [5.4, 19]), and HIV (aRR = 12 [10, 13]). CONCLUSIONS In our study, individuals with LTBI faced small, non-negligible risks of reactivation TB. Risks were elevated for individuals with medical comorbidities that weaken immune function.
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Affiliation(s)
- Mina Ekramnia
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston MA, USA
| | - Yunfei Li
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston MA, USA
| | - Maryam B Haddad
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, U.S. Centers for Disease Control and Prevention, Atlanta GA, USA
| | - Suzanne M Marks
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, U.S. Centers for Disease Control and Prevention, Atlanta GA, USA
| | - J Steve Kammerer
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, U.S. Centers for Disease Control and Prevention, Atlanta GA, USA
| | - Nicole A Swartwood
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston MA, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven CT, USA
| | - Jeffrey W Miller
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston MA, USA
| | - C Robert Horsburgh
- Departments of Epidemiology, Biostatistics, and Global Health, Boston University School of Public Health and Department of Medicine, Boston University School of Medicine, Boston MA USA
| | - Joshua A Salomon
- Center for Health Policy / Center for Primary Care and Outcomes Research, Stanford University, Stanford CA, USA
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston MA, USA
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston MA, USA
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Zhou C, Li T, Du J, Yin D, Li X, Li S. Toward tuberculosis elimination by understanding epidemiologic characteristics and risk factors in Hainan Province, China. Infect Dis Poverty 2024; 13:20. [PMID: 38414000 PMCID: PMC10898115 DOI: 10.1186/s40249-024-01188-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/06/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND The disease burden of tuberculosis (TB) was heavy in Hainan Province, China, and the information on transmission patterns was limited with few studies. This atudy aims to further explore the epidemiological characteristics and influencing factors of TB in Hainan Province, and thereby contribute valuable scientific evidences for TB elimination in Hainan Province. METHODS The TB notification data in Hainan Province from 2013 to 2022 were collected from the Chinese National Disease Control Information System Tuberculosis Surveillance System, along with socio-economic data. The spatial-temporal and population distributions were analyzed, and spatial autocorrelation analysis was conducted to explore TB notification rate clustering. In addition, the epidemiological characteristics of the cases among in-country migrants were described, and the delay pattern in seeking medical care was investigated. Finally, a geographically and temporally weighted regression (GTWR) model was adopted to analyze the relationship between TB notification rate and socio-economic indicators. The tailored control suggestions in different regions for TB elimination was provided by understanding epidemiological characteristics and risk factors obtained by GTWR. RESULTS From 2013 to 2022, 64,042 cases of TB were notified in Hainan Province. The estimated annual percentage change of TB notification rate in Hainan Province from 2013 to 2020 was - 6.88% [95% confidence interval (CI): - 5.30%, - 3.69%], with higher rates in central and southern regions. The majority of patients were males (76.33%) and farmers (67.80%). Cases among in-country migrants primarily originated from Sichuan (369 cases), Heilongjiang (267 cases), Hunan (236 cases), Guangdong (174 cases), and Guangxi (139 cases), accounting for 53%. The majority (98.83%) of TB cases were notified through passive case finding approaches, with delay in seeking care. The GTWR analysis showed that gross domestic product per capita, the number of medical institutions and health personnel per 10,000 people were main factors affecting the high TB notification rates in some regions in Hainan Province. Different regional tailored measures such as more TB specialized hospitals were proposed based on the characteristics of each region. CONCLUSIONS The notification rate of TB in Hainan Province has been declining overall but still remained high in central and southern regions. Particular attention should be paid to the prevalence of TB among males, farmers, and out-of-province migrant populations. The notification rate was also influenced by economic development and medical conditions, indicating the need of more TB specialized hospitals, active surveillance and other tailored prevention and control measures to promote the progress of TB elimination in Hainan Province.
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Affiliation(s)
- Changqiang Zhou
- Department of Biostatistics, School of Public Health, Cheeloo College of Medicine, Shandong University, 44# Wenhuaxi Road, Lixia District, Jinan, Shandong, 250012, People's Republic of China
| | - Tao Li
- National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, People's Republic of China
| | - Jian Du
- Clinical Center On TB Control, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, People's Republic of China
| | - Dapeng Yin
- Hainan Center for Disease Control and Prevention, Haikou, Hainan, 570203, People's Republic of China.
| | - Xiujun Li
- Department of Biostatistics, School of Public Health, Cheeloo College of Medicine, Shandong University, 44# Wenhuaxi Road, Lixia District, Jinan, Shandong, 250012, People's Republic of China.
- Research Center for Tuberculosis Control, Shandong University, Jinan, Shandong, People's Republic of China.
| | - Shixue Li
- Department of Biostatistics, School of Public Health, Cheeloo College of Medicine, Shandong University, 44# Wenhuaxi Road, Lixia District, Jinan, Shandong, 250012, People's Republic of China.
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7
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Humayun M, Mukasa L, Ye W, Bates JH, Yang Z. Racial and Ethnic Disparities in Tuberculosis Incidence, Arkansas, USA, 2010-2021. Emerg Infect Dis 2024; 30:116-124. [PMID: 38146997 PMCID: PMC10756389 DOI: 10.3201/eid3001.230778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
We conducted an epidemiologic assessment of disease distribution by race/ethnicity to identify subpopulation-specific drivers of tuberculosis (TB). We used detailed racial/ethnic categorizations for the 932 TB cases diagnosed in Arkansas, USA, during 2010-2021. After adjusting for age and sex, racial/ethnic disparities persisted; the Native Hawaiian/Pacific Islander (NHPI) group had the highest risk for TB (risk ratio 173.6, 95% CI 140.6-214.2) compared with the non-Hispanic White group, followed by Asian, Hispanic, and non-Hispanic Black. Notable racial/ethnic disparities existed across all age groups; NHPI persons 0-14 years of age were at a particularly increased risk for TB (risk ratio 888, 95% CI 403-1,962). The risks for sputum smear-positive pulmonary TB and extrapulmonary TB were both significantly higher for racial/ethnic minority groups. Our findings suggest that TB control in Arkansas can benefit from a targeted focus on subpopulations at increased risk for TB.
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Regan M, Li Y, Swartwood NA, Barham T, Asay GRB, Cohen T, Hill AN, Horsburgh CR, Khan A, Marks SM, Myles RL, Salomon JA, Self JL, Menzies NA. Racial and ethnic disparities in diagnosis and treatment outcomes among US-born people diagnosed with tuberculosis, 2003-19: an analysis of national surveillance data. Lancet Public Health 2024; 9:e47-e56. [PMID: 38176842 DOI: 10.1016/s2468-2667(23)00276-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/21/2023] [Accepted: 11/01/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Persistent racial and ethnic disparities in tuberculosis incidence exist in the USA, however, less is known about disparities along the tuberculosis continuum of care. This study aimed to describe how race and ethnicity are associated with tuberculosis diagnosis and treatment outcomes. METHODS In this analysis of national surveillance data, we extracted data from the US National Tuberculosis Surveillance System on US-born patients with tuberculosis during 2003-19. To estimate the association between race and ethnicity and tuberculosis diagnosis (diagnosis after death, cavitation, and sputum smear positivity) and treatment outcomes (treatment for more than 12 months, treatment discontinuation, and death during treatment), we fitted log-binomial regression models adjusting for calendar year, sex, age category, and regional division. Race and ethnicity were defined based on US Census Bureau classification as White, Black, Hispanic, Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and people of other ethnicities. We quantified racial and ethnic disparities as adjusted relative risks (aRRs) using non-Hispanic White people as the reference group. We also calculated the Index of Disparity as a summary measure that quantifies the dispersion in a given outcome across all racial and ethnic groups, relative to the population mean. We estimated time trends in each outcome to evaluate whether disparities were closing or widening. FINDINGS From 2003 to 2019, there were 72 809 US-born individuals diagnosed with tuberculosis disease of whom 72 369 (35·7% women and 64·3% men) could be included in analyses. We observed an overall higher risk of any adverse outcome (defined as diagnosis after death, treatment discontinuation, or death during treatment) for non-Hispanic Black people (aRR 1·27, 95% CI 1·22-1·32), Hispanic people (1·20, 1·14-1·27), and American Indian or Alaska Native people (1·24, 1·12-1·37), relative to non-Hispanic White people. The Index of Disparity for this summary outcome remained unchanged over the study period. INTERPRETATION This study, based on national surveillance data, indicates racial and ethnic disparaties among US-born tuberculosis patients along the tuberculosis continuum of care. Initiatives are needed to reduce diagnostic delays and improve treatment outcomes for US-born racially marginalised people in the USA. FUNDING US Centers for Disease Control and Prevention.
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Affiliation(s)
- Mathilda Regan
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA.
| | - Yunfei Li
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Nicole A Swartwood
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Terrika Barham
- Office of Health Equity, National Center for HIV, Viral Hepatitis, STD, and TB prevention, US Centers for Disease Control and Prevention, Atlanta, GE, USA
| | - Garrett R Beeler Asay
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB prevention, US Centers for Disease Control and Prevention, Atlanta, GE, USA
| | - Ted Cohen
- Yale School of Public Health, New Haven, CT, USA
| | - Andrew N Hill
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB prevention, US Centers for Disease Control and Prevention, Atlanta, GE, USA
| | - C Robert Horsburgh
- Departments of Epidemiology, Biostatistics, Global Health, and Medicine, Boston University Schools of Public Health and Medicine, Boston, MA, USA
| | - Awal Khan
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB prevention, US Centers for Disease Control and Prevention, Atlanta, GE, USA
| | - Suzanne M Marks
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB prevention, US Centers for Disease Control and Prevention, Atlanta, GE, USA
| | - Ranell L Myles
- Office of Health Equity, National Center for HIV, Viral Hepatitis, STD, and TB prevention, US Centers for Disease Control and Prevention, Atlanta, GE, USA
| | - Joshua A Salomon
- Department of Health Policy, Stanford University, Stanford, CA, USA
| | - Julie L Self
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB prevention, US Centers for Disease Control and Prevention, Atlanta, GE, USA
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
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Allué-Guardia A, Torrelles JB, Sigal A. Tuberculosis and COVID-19 in the elderly: factors driving a higher burden of disease. Front Immunol 2023; 14:1250198. [PMID: 37841265 PMCID: PMC10569613 DOI: 10.3389/fimmu.2023.1250198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/11/2023] [Indexed: 10/17/2023] Open
Abstract
Mycobacterium tuberculosis (M.tb) and SARS-CoV-2 are both infections that can lead to severe disease in the lower lung. However, these two infections are caused by very different pathogens (Mycobacterium vs. virus), they have different mechanisms of pathogenesis and immune response, and differ in how long the infection lasts. Despite the differences, SARS-CoV-2 and M.tb share a common feature, which is also frequently observed in other respiratory infections: the burden of disease in the elderly is greater. Here, we discuss possible reasons for the higher burden in older adults, including the effect of co-morbidities, deterioration of the lung environment, auto-immunity, and a reduced antibody response. While the answer is likely to be multifactorial, understanding the main drivers across different infections may allow us to design broader interventions that increase the health-span of older people.
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Affiliation(s)
- Anna Allué-Guardia
- Population Health Program, Texas Biomedical Research Institute, San Antonio, TX, United States
| | - Jordi B. Torrelles
- Population Health Program, Texas Biomedical Research Institute, San Antonio, TX, United States
- International Center for the Advancement of Research and Education (I•CARE), Texas Biomedical Research Institute, San Antonio, TX, United States
| | - Alex Sigal
- Africa Health Research Institute, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
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10
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Campbell JI, Tabatneck M, Wilt GE, Sun M, He W, Musinguzi N, Hedt-Gauthier B, Lamb GS, Goldmann D, Sabharwal V, Sandora TJ, Haberer JE. Area-Based Sociodemographic Factors Associated with Latent Tuberculosis Infection in a Low-Prevalence Setting. Am J Trop Med Hyg 2023; 109:595-599. [PMID: 37580031 PMCID: PMC10484283 DOI: 10.4269/ajtmh.22-0788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 06/08/2023] [Indexed: 08/16/2023] Open
Abstract
Area-based sociodemographic markers, such as census tract foreign-born population, have been used to identify individuals and communities with a high risk for tuberculosis (TB) infection in the United States. However, these markers have not been evaluated as independent risk factors for TB infection in children. We evaluated associations between census tract poverty, crowding, foreign-born population, and the CDC's Social Vulnerability Index (CDC-SVI) ranking and TB infection in a population of children tested for TB infection in Boston, Massachusetts. After adjustment for age, crowding, and foreign-born percentage, increasing census tract poverty was associated with increased odds of TB infection (adjusted odds ratio [aOR] per 10% increase in population proportion living in poverty: 1.20 [95% CI, 1.04-1.40]; P = 0.01), although this association was attenuated after further adjustment for preferred language. In separate models, increasing CDC-SVI ranking was associated with increased odds of TB infection, including after adjustment for age and language preference (aOR per 10-point increase in CDC-SVI rank: 1.08 [95% CI, 1.02-1.15]; P = 0.01). Our findings suggest area-based sociodemographic factors may be valuable for characterizing TB infection risk and defining the social ecology of pediatric TB infection in low-burden settings.
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Affiliation(s)
- Jeffrey I. Campbell
- Section of Pediatric Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Mary Tabatneck
- Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Grete E. Wilt
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Mingwei Sun
- Center for Research Information Technology, Boston Children’s Hospital, Boston, Massachusetts
| | - Wei He
- Center for Research Information Science and Computing, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicholas Musinguzi
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Gabriella S. Lamb
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Don Goldmann
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Vishakha Sabharwal
- Section of Pediatric Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Thomas J. Sandora
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts
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11
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Detelich JF, Kempker JA. Respiratory Infections. Clin Chest Med 2023; 44:509-517. [PMID: 37517831 DOI: 10.1016/j.ccm.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Pneumonia is one of the most common reasons for health care utilization in the United States. It can be caused by many different pathogens, but rarely is it able to be identified in specific cases. This has led most racial disparities research to focus on community acquired pneumonia and microbes of public health concern such as influenza, tuberculosis, and COVID-19. Differences have been shown to exist from prevention with vaccines to management and outcomes. COVID-19 has led to a significant increase in the awareness of this topic.
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Affiliation(s)
- Joshua F Detelich
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, 615 Michael Street. Ste 205, Atlanta, GA 30322, USA.
| | - Jordan A Kempker
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, 615 Michael Street. Ste 205, Atlanta, GA 30322, USA
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12
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Wu IL, Chitnis AS, Jaganath D. A narrative review of tuberculosis in the United States among persons aged 65 years and older. J Clin Tuberc Other Mycobact Dis 2022; 28:100321. [PMID: 35757390 PMCID: PMC9213239 DOI: 10.1016/j.jctube.2022.100321] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/06/2022] [Accepted: 06/10/2022] [Indexed: 11/04/2022] Open
Abstract
Tuberculosis (TB) is a preventable infectious disease that confers significant morbidity, mortality, and psychosocial challenges. As TB incidence in the United States (U.S.) decreased from 9.7/100,000 to 2.2/100,000 from 1993 to 2020, the proportion of cases occurring among adults aged 65 and older increased. We conducted a review of published literature in the U.S. and other similar low-TB-burden settings to characterize the epidemiology and unique diagnostic challenges of TB in older adults. This narrative review also provides an overview of treatment characteristics, outcomes, and research gaps in this patient population. Older adults had a 30% higher likelihood of delayed TB diagnosis, with contributing factors such as acid-fast bacilli sputum smear-negative disease (56%) and non-classical clinical presentation. At least 90% of TB cases among older adults resulted from reactivation of latent TB infection (LTBI), but guidance around when to screen and treat LTBI in these patients is lacking. In addition, routine TB testing methods such as interferon-gamma release assays were two times more likely to have false-negative results among older adults. Advanced age was also often accompanied by complex comorbidities and impaired drug metabolism, increasing the risk of treatment failure (23%) and death (19%). A greater understanding of the unique factors of TB among older adults will inform clinical and public health efforts to improve outcomes in this complex patient population and TB control in the U.S.
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Affiliation(s)
- Iris L Wu
- School of Public Health, University of California, Berkeley, Berkeley, CA, United States.,School of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Amit S Chitnis
- Tuberculosis Section, Division of Communicable Disease Control and Prevention, Alameda County Public Health Department, San Leandro, CA, United States
| | - Devan Jaganath
- Division of Pediatric Infectious Diseases, University of California, San Francisco, San Francisco, CA, United States.,Center for Tuberculosis, University of California, San Francisco, CA, United States
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