National Tuberculosis Program of Brazil, Ministry of Health, Brasília, Distrito Federal, Brazil.
Department of Epidemiology, School of Public Health, University of São Paulo, São Paulo, São Paulo, Brazil.
PLoS One. 2017 Apr 18;12(4):e0176116. doi: 10.1371/journal.pone.0176116. eCollection 2017.
Although many studies have identified social conditions associated with tuberculosis, contextual and individual factors have rarely been analysed simultaneously. Consequently, we aimed to identify contextual and individual factors associated with tuberculosis incidence in general population in Brazil in 2010. We also assessed whether household crowding mediates the association between socioeconomic determinants and tuberculosis incidence. Individual data of tuberculosis cases were obtained from 5,565 municipalities in Brazil in 2010 (last year of national census), and merged with contextual variables. The associations were evaluated in a multilevel analysis using negative binomial regression. After adjusting for individual factors (age, sex and race) and geographic region, the following contextual factors were associated with tuberculosis incidence rate: AIDS incidence rate [incidence rate ratio (IRR), 1.21; 95% confidence interval (CI), 1.18-1.24], unemployment rate (IRR, 1.16; 95% CI, 1.13-1.19), Gini coefficient (IRR, 1.05; 95% CI, 1.02-1.08), proportion of inmates (IRR, 1.11; 95% CI, 1.09-1.14), mean per capita household income (IRR, 0.94; 95% CI, 0.91-0.97) and primary care coverage (IRR, 0.94; 95% CI, 0.92-0.96). Inclusion of household crowding in the multivariate model led to a loss of the associations of both Gini coefficient and mean per capita household income. In conclusion, our findings suggest that income inequality and poverty, as determinants of tuberculosis incidence, can be mediated by household crowding. Moreover, prison population can represent a potential social reservoir of tuberculosis in Brazil and should be addressed as a priority for disease control. Finally, the negative association between primary health coverage and tuberculosis incidence highlights the importance of this level of care as a strategy to control this disease.
尽管许多研究已经确定了与结核病相关的社会条件，但很少同时分析背景和个人因素。因此，我们旨在确定 2010 年巴西普通人群中与结核病发病率相关的背景和个人因素。我们还评估了家庭拥挤是否在社会经济决定因素与结核病发病率之间起中介作用。2010 年（全国人口普查的最后一年）从巴西的 5565 个城市获得了结核病病例的个体数据，并与背景变量合并。使用负二项回归在多水平分析中评估了关联。在调整了个体因素（年龄、性别和种族）和地理区域后，以下背景因素与结核病发病率相关：艾滋病发病率[发病率比（IRR），1.21；95%置信区间（CI），1.18-1.24]、失业率（IRR，1.16；95%CI，1.13-1.19）、基尼系数（IRR，1.05；95%CI，1.02-1.08）、囚犯比例（IRR，1.11；95%CI，1.09-1.14）、人均家庭收入中位数（IRR，0.94；95%CI，0.91-0.97）和初级保健覆盖率（IRR，0.94；95%CI，0.92-0.96）。在多变量模型中纳入家庭拥挤情况导致基尼系数和人均家庭收入中位数与结核病发病率的关联均消失。总之，我们的研究结果表明，收入不平等和贫困作为结核病发病率的决定因素，可以通过家庭拥挤来调节。此外，监狱人口可能代表巴西结核病的潜在社会储库，应作为疾病控制的优先事项加以解决。最后，初级保健覆盖率与结核病发病率之间的负相关突出了这一护理水平作为控制该疾病的策略的重要性。
