The Porto Alegre paradox: social determinants and tuberculosis incidence

Neighbourhood factors and tuberculosis incidence in Cape Town: A negative binomial regression and spatial analysis

OBJECTIVES

Although the link between poverty and tuberculosis (TB) is widely recognised, limited studies have investigated the association between neighbourhood factors and TB incidence. Since the factors influencing different episodes of TB might be different, this study focused on the first episode of TB disease (first-episode TB).

METHODS

All first episodes in previously linked and geocoded TB notification data from 2007 to 2015 in Cape Town, South Africa, were aggregated at the neighbourhood level and merged with the 2011 census data. We conducted an ecological study to assess the association between neighbourhood incidence of first-episode TB and neighbourhood factors (total TB burden [all episodes] in the previous year, socioeconomic index, mean household size, mean age, and percentage males) using a negative binomial regression. We also examined the presence of hotspots in neighbourhood TB incidence with the Global Moran's I statistic and assessed spatial dependency in the association between neighbourhood factors and TB incidence using a spatial lag model.

RESULTS

The study included 684 neighbourhoods with a median first-episode TB incidence rate of 114 (IQR: 0-345) per 100,000 people. We found lower neighbourhood socioeconomic index (SEI), higher neighbourhood total TB burden, lower neighbourhood mean household size, and lower neighbourhood mean age were associated with increased neighbourhood first-episode TB incidence. Our findings revealed a hotspot of first-episode TB incidence in Cape Town and evidence of spatial dependency in the association between neighbourhood factors and TB incidence.

CONCLUSION

Neighbourhood TB burden and SEI were associated with first-episode TB incidence, and there was spatial dependency in this association. Our findings can inform targeted interventions to reduce TB in high-risk neighbourhoods, thereby reducing health disparities and promoting health equity.

[Tuberculosis and diabetes comorbidity in Brazil, 2012-2018: exploratory spatial data analysis and statistical modelingLa comorbilidad tuberculosis-diabetes en Brasil, 2012-2018: análisis exploratorio de la distribución espacial y modelización estadística]

Objetivo.

Descrever a distribuição espacial da comorbidade tuberculose-diabetes e identificar os determinantes sociais da dupla carga no período de 2012 a 2018 no Brasil.

Métodos.

Este estudo ecológico utilizou os municípios como unidade de análise. Incluíram-se todos os casos de tuberculose notificados de 2012 a 2018 ao Sistema de Informação de Agravos de Notificação. Como determinantes, foram analisadas variáveis socioeconômicas de emprego, renda e desenvolvimento e o indicador de cobertura da atenção básica. O índice de Moran global foi calculado para verificar a existência de autocorrelação espacial da comorbidade. O índice de Moran local foi utilizado para delimitar clusters de tuberculose-diabetes: alto/alto (municípios com alta proporção de tuberculose-diabetes cujos vizinhos também apresentaram altas proporções) e baixo/baixo (municípios com proporção abaixo da média, cercados por municípios com baixas proporções).

Resultados.

Observou-se elevação na proporção de tuberculose-diabetes na maioria das regiões brasileiras. Constatou-se autocorrelação espacial da comorbidade tuberculose-diabetes e identificou-se um cluster alto-alto de tuberculose-diabetes reunindo 88 municípios, pertencentes principalmente às regiões Nordeste, Sudeste e Sul, com média de prevalência da comorbidade de 28,04%. As variáveis “percentual da população que vive em domicílios com densidade superior a duas pessoas por dormitório”, “percentual de desemprego de pessoas maiores de 18 anos” e “renda per capita” relacionaram-se à ocorrência da comorbidade.

Conclusão.

Os resultados mostraram uma distribuição não aleatória da comorbidade tuberculose-diabetes, com áreas de alto risco e variáveis explicativas de sua ocorrência. Esses achado reforçam a necessidade de operacionalizar a colaboração entre programas de tuberculose e diabetes, com vistas ao controle tanto de cada agravo isoladamente quanto da sindemia.

Spatial analysis of tuberculosis and its relationship with socioeconomic indicators in a medium-sized city in Minas Gerais

OBJECTIVE

To analyze the tuberculosis spatial pattern and its relationship with socioeconomic indicators, from 2008 to 2015, in a priority city for tuberculosis control by the National Tuberculosis Control Program, Juiz de Fora, Minas Gerais.

METHODS

Ecological study in which the units of analysis were 81 urban regions of Juiz de Fora. Secondary data from Notifiable Diseases Information System and 2010 Demographic Census were used. Georeferenced data from 1,854 notifications were used to elaborate thematic maps in order to verify the distribution pattern of average tuberculosis rates and socioeconomic indicators within the city. Global spatial autocorrelation (Moran's I) and local (Local Indicator of Spatial Association) and multiple linear regression model were estimated to analyze the relationship between the average tuberculosis incidence rate and socioeconomic indicators.

RESULTS

The average tuberculosis incidence rate was 48.3 cases/100,000 inhabitants/year. It was found that the urban regions corresponding to central regions of the city had lower rates with a progressive increase toward the urban regions representative of the most peripheral neighborhoods. All variables showed significant spatial autocorrelation. The regression model showed an association between the average tuberculosis incidence rate and the proportion of poor, household density, and aging index.

CONCLUSION

The dynamics of tuberculosis transmission in Juiz de Fora may be explained by the maintenance of social inequality and urban space organization process.

A população privada de liberdade e a tuberculose

Introdução: a tuberculose é uma das doenças infecciosas mais antigas do mundo. Causada pela bactéria Mycobacterium Tuberculosis, é transmitida através do ar – aerossóis. Segundo a Organização Mundial da Saúde cerca de 100 milhões de pessoas são infectadas a cada ano e, aproximadamente, entre 8-10 milhões desenvolverão a doença. Objetivos: o seguinte trabalho visa descrever o perfil epidemiológico da tuberculose no município de Porto Alegre, RS, na população privada de liberdade (PPL), no período de 2015 a 2017. Métodos: é um estudo descritivo de abordagem quantitativa, elaborado a partir de dados disponíveis no Sistema de Notificação e Agravos, sobre os casos de incidência notificados no município, observando-se a população em geral e a carcerária. Resultados: como resultados, em 2017 a população geral teve uma queda de 1378 casos novos e, a PPL cresceu, registrando 167 eventos. A taxa de cura entre os casos da população geral foi de 53,87% já na PPL foi de 77,3%. Ocorreu óbito em 75,4% dos pacientes carcerários e, em 16,6% da população geral, os casos de abandono representam 26,1% entre os apenados e 19,24% da população geral. Conclusões: conforme os resultados apresentados, evidencia-se que a tuberculose prevalece na população prisional e que as condições estruturais dos presídios dificultam a garantia do direito ao acesso à saúde.

Risk areas for tuberculosis among children and their inequalities in a city from Southeast Brazil

Background

The objective of the study was to identify areas of risk for the appearance of tuberculosis in children and their association with social inequalities in a municipality in southeastern Brazil.

Methods

Ecological study conducted in Ribeirão Preto, Brazil. To identify areas of spatial risk for tuberculosis in children, we used spatial scanning statistics. To analyze the association of cases of childhood tuberculosis with social vulnerability, we used the Social Vulnerability Index of São Paulo, and four explanatory statistical models were listed.

Results

There were 96 cases of childhood tuberculosis, of which 90 were geocoded through a process of converting addresses to geographic coordinates. A risk area was identified in the municipality, where children under 15 years old have 3.14 times greater risk of contracting tuberculosis than those living outside this area. The variables identified as risk factors were: number of private and collective households, proportion of children aged 0 to 5 years in the population, proportion of households without per capita income, and the proportion of private households with monthly nominal incomes of up to one quarter of wage minimums. The variables identified as protection factors were the proportion of women under the age of 30 years responsible for the household under and women responsible for the household with an average income over BRL 2344.

Conclusion

The study showed areas of risk for the occurrence of tuberculosis in children. The study is in line with the End TB Strategy and the 2030 Agenda, which aim to support strategic actions and, therefore, save the lives of children through the systematic, intensified, and comprehensive identification of children with tuberculosis respiratory symptoms in the community.

Social determinants of health and community health agent work

OBJECTIVE

To understand the social determinants of health from the perspective of the work of community health agents.

METHOD

A qualitative study conducted in a Health District Management in the city of Porto Alegre/Rio Grande do Sul, Brazil, through focus groups and semi-structured interviews with community health agents. The analysis took place through thematic categorization, and the social determinants of health were adopted as the analytical category.

RESULTS

Twenty-five (25) community health agent workers participated. Overlapping individual and collective themes emerged, from violence and drug trafficking to lack of sanitation, improperly disposed garbage, illiteracy and the health problems themselves.

CONCLUSION

The study revealed a complex relationship between the work of community health agents and the social determinants of health, reinforcing the need for a cohesive health team with intersectoral initiatives to address the different demands of the territories which are worked and lived in.

Association of social deprivation and outdoor air pollution with pulmonary tuberculosis in spatiotemporal analysis

The objective of this study was to identify the association between social deprivation, outdoor air pollution, and tuberculosis (TB) incidence rate or mortality rate. The study sample comprised 25 districts in Seoul, Korea. We used two public data derived from the Community Health Survey and Seoul Statistics. The geographic information system analysis and random effects Poisson regression were applied to explore the association of social deprivation and air pollution with TB incidence and mortality. An 1 ppb increase in sulfur dioxide (SO₂) concentration was significantly associated with the risk of TB incidence (risk ratio [RR] = 1.046, 95% confidence interval [CI]: 1.028, 1.065). An 1 unit increase in the deprivation index was significantly related to a6% increase in the mortality of TB (RR = 1.063, 95% CI: 1.031, 1.097). : Our results imply that social deprivation and air pollution may affect the different TB outcomes. Effective policy-making for TB control should reflect the differing outcomes between TB incidence and mortality.

Social determinants of pulmonary tuberculosis in Brazil: an ecological study

Background

Social determinants may influence the incidence and control of tuberculosis (TB). The aim of this study was to evaluate the correlation between social determinants and pulmonary TB (PTB) incidence and treatment outcomes in different regions in Brazil.

Methods

In this ecological study, PTB incidence and treatment outcome rates as well as HIV incidence for all 5560 Brazilian cities as reported to the Brazilian Tuberculosis Program in 2010 were correlated with two social indicators, the Human Development Index (HDI) and Gini Index (GI). Cities were stratified into six groups based on location (metropolitan region or not) and size (small, medium, and large cities), and according to the regions of the country to which they belong. The Spearman correlation coefficient was used to assess the association between variables.

Results

In 2010, 68,729 new PTB cases were reported in Brazil, with an incidence rate of 36 cases per 100,000 inhabitants. Incidence rates and PTB mortality demonstrated a weak negative correlation with HDI and a positive correlation with GI. The correlation between HDI and GI with cure, relapse, and lost to follow-up of treatment greatly varied in the different groups of cities and regions of the country evaluated.

Conclusions

There is a weak correlation between HDI and GI and PTB incidence and mortality rate. However, there is great variation between the HDI and GI and cure, relapse, and lost to follow-up in the different groups of cities and regions of the country. This suggests that for TB determination, these outcome variables might be more related to the quality of healthcare provided by services than to social determinants in the general population.

A tuberculose e seus fatores associados em um município da região metropolitana do Rio de Janeiro

RESUMO: Introdução: A ocorrência da tuberculose tem sido relacionada à organização espacial e à melhoria das condições de vida da população. Contudo, essa relação não é de forma direta, e o adoecimento por tuberculose envolve processos de diferentes níveis de organização. Método: Estudo ecológico que analisa a relação entre condições de vida e tuberculose no município de Niterói, Brasil. Foram criados dois indicadores, socioambiental e programático, por meio de análise fatorial e analisados por regressão no período de 2008 a 2012. Foram construídos mapas temáticos com os dados referentes à taxa de incidência e aos indicadores, para verificar o padrão da distribuição da taxa de incidência e desses indicadores no município. Resultados: Os resultados apontaram associação direta e significativa entre os dois indicadores com a taxa de incidência de tuberculose. O aumento em uma unidade no indicador programático esteve associado com um aumento na taxa de incidência em 7%. Já o indicador socioambiental associou-se com uma taxa de tuberculose 27% mais elevada. Discussão: Os resultados do presente trabalho foram consistentes ao constatar relação direta entre tuberculose e condições de vida no município de Niterói. Conclusão: Podemos concluir que a dinâmica da transmissão da tuberculose no município de Niterói pode ser explicada pela ocorrência da doença em áreas de periferia social consolidada e pela vulnerabilidade social de grupos específicos.

Social determinants of tuberculosis via a zero-inflated model in small areas of a city in Southeastern Brazil

INTRODUCTION

This study aimed to analyze social factors involved in the spatial distribution and under-reporting of tuberculosis (TB) in the city of Vitória, Espírito Santo State, Brazil.

METHODS

This was an ecological study of the reported cases of TB between 2009 and 2011, according to census tracts. The outcome was TB incidence for the study period and the variables of exposure were proportions of literacy, inhabitants with an income of up to half the minimum monthly wage (MMW), and inhabitants associated with sewer mains or with access to safe drinking water. We used a zero-inflated process, zero-inflated negative binomial regression (ZINB), and selected an explanatory model based on the Akaike Information Criterion (AIC).

RESULTS

A total of 588 cases of tuberculosis were reported in Vitória during the study period, distributed among 223 census tracts (38.6%), with 354 (61.4%) tracts presenting zero cases. In the ZINB model, the mean value of p i was 0.93, indicating that there is a 93% chance that an observed false zero could be due to sub-notification.

CONCLUSIONS

It is important to prioritize areas exhibiting determinants that influence the occurrence of TB in the municipality of Vitória. The zero-inflated model can be useful to the public health sector since it identifies the percentage of false zeros, generating an estimate of the real epidemiological condition of TB in Vitória.

Predictors of noncompliance to pulmonary tuberculosis treatment: An insight from South America

PURPOSE

To investigate the factors associated with a higher risk of noncompliance to tuberculosis (TB) treatment in Porto Alegre, Brazil.

METHODS

We identified 478 adult patients for this case-control study undergoing treatment for confirmed pulmonary TB. Cases (noncompliance) were defined as patients who stopped treatment for more than 30 consecutive days (n = 118). Controls were defined as all patients who completed treatment and were cured (n = 360). Factors associated with noncompliance were calculated with unadjusted and adjusted odds ratio (OR).

RESULTS

The rate of noncompliance in our study was 25%. The factors of noncompliance after adjustments in the overall population were, in order of magnitude, living in an area of lower income (OR = 4.35, 95%CI: 2.50-7.58), abuse of drugs (OR = 2.73, 95%CI: 1.47-5.09), nonadherence to a previous treatment regimen (OR = 2.1, 95%CI: 1.28-3.45), and history of smoking (OR = 1.72, 95%CI: 1.00-3.00). Age, race, gender, level of education, HIV infection or diabetes status were not associated with a higher risk of noncompliance. In the subgroup of re-treatment cases, poverty (OR = 2.65; 95%CI = 1.06-6.66), smoking history (OR = 2.94; 95%CI = 1.09-7.92), male gender (OR = 3.25; 95%CI = 1.32-8.0), and younger age (OR = 4.3; 95%CI = 1.15-16.07) were also associated with a higher risk of dropout.

CONCLUSION

Predictors of poor compliance to TB treatment were low income, abuse of drugs, re-treatment cases and history of smoking.

Socio-spatial inequalities related to tuberculosis in the city of Itaboraí, Rio de Janeiro

INTRODUCTION

Tuberculosis remains as a global public health problem and its occurrence and distribution is associated with social inequalities. Itaboraí is among the priority Brazilian municipalities for tuberculosis control. The study aimed to combine social indicators into a composite indicator to measure differences in living conditions of the population in Itaboraí, as well as evidence of health inequalities related to tuberculosis.

METHODS

An ecological study, with spatial analysis of tuberculosis and its relation to socioeconomic and demographic status of households. Data were obtained from individuals declared in the Mortality Information System (SIM), notified in the Notification of Injury Information System - SINAN or Tuberculosis Special Treatment Information System - SITETB from 2007 to 2013.

RESULTS

Evidence indicates association between sociodemographic inequalities and occurrence of tuberculosis in the population. Findings point to a lower percentage of healing and a higher percentage of abandonment and death in areas with high social vulnerability, with a relative risk over twice as high than that found in areas of lower vulnerability.

CONCLUSION

The study showed strong evidence that the influence of unequal sociodemographic conditions have a negative impact on health conditions of the population in Itaboraí.

Spatial distribution of tuberculosis from 2002 to 2012 in a midsize city in Brazil

Background

Tuberculosis (TB) remains a major public health problem in many developing countries. Exploratory spatial analysis is a powerful instrument in spatial health research by virtue of its capacity to map disease distribution and associated risk factors at the population level. The aim of the present study was to describe the epidemiologic characteristics and spatial distribution of new cases of TB reported during the period 2002–2012 in Divinopolis, a midsized city located in the state of Minas Gerais, southeastern Brazil.

Methods

Sociodemographic and clinical data relating to the study cases were retrieved from the national Brazilian database and geocoded according to residential address. Choropleth and kernel density maps were constructed and a spatial-temporal analysis was performed. Tracts defined by the 2010 national census were classified as sectors with higher or lower densities of new TB cases based on the kernel density map. Multivariate logistic analysis was used to compare the two types of sectors according to income, level of literacy and population density.

Results

A total of 326 new cases of TB were reported during the study period. Residential addresses relating to 309 (94.8 %) of these were available in the SINAN database and the locations were geocoded and mapped. The average incidence of TB during the study period was 14.5/100,000 inhabitants. Pulmonary TB was the most predominant form (73.6 %) and 74.5 % of patients had been cured. The percentage of cases was highest in males (67.8 %) and individuals aged 25–44 years (41.1 %), and lowest in children aged less than 15 years (4.6 %). The disease was spatially distributed throughout the urban district. The incidence rate among urban census tracts ranged from 0.06 to 1.1 %, and the disease occurred predominantly in the downtown area (99.3 %). Higher population density was associated significantly with increased odds of living in a sector with a “higher density of cases”, even after adjusting for income and education (odds ratio = 13.7).

Conclusions

The highest density of cases was strongly associated with higher population density but not with lower income or level of literacy.