Tuberculosis inequalities and socio-economic deprivation in Portugal

Post tuberculosis lung disease and tuberculosis sequelae: A narrative review

Post Tuberculosis lung disease (PTLD) and post tuberculosis sequelae is a global and poorly recognized problem, amplified by social factors and immunocompromising conditions, inadequate treatment, lack of effective prevention of tuberculosis (TB) infection and disease. As a disease, it remained until recently poorly defined, with studies heterogenous with regards to regions, population demographics, risk factors, cohort sizes, and methods. Pathophysiologically, even successfully treated pulmonary TB disease has sequelae i.e. involving central and peripheral airways, lung parenchyma and pleura, resulting in airway narrowing and dilatation, fibrocavitation and emphysema, pulmonary vascular changes as well as pleural fibrosis. Functionally patients have airflow limitation, restrictive disease or a mixture of both not rarely associated with respiratory, or even ventilatory failure. Quality of life is often impaired through disability, TB relapse, superinfections and through increased susceptibility to reinfection and persistent inflammation, leading to progressive lung function decline and an increased risk of cardiovascular disease and cancer. Premature mortality due to PTLD is very likely, but poorly described.

Lower socioeconomic status associated with higher tuberculosis rate in South Korea

BACKGROUND

Tuberculosis is an infectious disease influenced by social factors rather than a simple infectious disease. In this study, we investigated the relationship between tuberculosis rates and socioeconomic status.

METHODS

This study was conducted using data of the 49,483 participants of the Korean National Health and Nutrition Examination Survey (KNHANES) VI-VIII (2013-2021). The relationships between tuberculosis rates and the quartiles of monthly household income and education level were examined using a multivariate logistic regression analysis.

RESULTS

The KNHANES data revealed that the prevalence of tuberculosis as substantially related to monthly household income (odds ratio [OR], 6.0; 95% confidence interval [CI], 1.1-32.0 for lowest vs. highest incomes) and education level (OR, 3.8; 95% CI, 1.2-12.0 for 10-12 years vs. ≥13 years; OR, 4.1; 95% CI, 1.2-14.8 for ≤ 6 years vs. ≥13 years). Furthermore, current tuberculosis treatment was significantly related to monthly household income and education level.

CONCLUSION

There were substantial correlations between tuberculosis rates and socioeconomic status in South Korea.

Investigating the intensity of social contacts associated with tuberculosis: a weighted networks model

BACKGROUND

Tuberculosis is known as one of the principal health problems, especially in developing countries. This study aimed to visualize, statistically model, and describe the weighted networks to investigate the intensity of social contacts associated with tuberculosis.

METHODS

In this case-control study, we applied weighted network analysis to assess the network of person-time spent in stores, workplaces, restaurants, mosques, Police bases, homes, hospitals, colleges, hairdressers, schools, contact homes, health centers, cinemas, parks, and markets. Modules will be determined based on the similarities between the variables in a topology overlap matrix. The most important variables will be found considering the association between each variable and module eigenvalues.

RESULTS

The result shows the extracted modules of locations based on the connectivity followed by the person-time at each place. The correlation (p-value) between TB and the turquoise, blue, and brown modules was 0.058 (0.351), 0.004 (0.943), and 0.117 (0.039), respectively. The brown module is the most important one, demonstrating a significant connection between homes, contact homes, health centers, and hospitals. Therefore, an association was found between person-time in four places and the occurrence of TB.

CONCLUSION

The finding of this study showed that most transmission of tuberculosis infection occurs in homes, contact homes, health centers, and hospitals. These place evaluations allow the identification of people with more contact and in need of screening, so critically leading to the identification of more patients with active TB.

Geographic patterns and hotspots of pediatric tuberculosis: the role of socioeconomic determinants

OBJECTIVE

Children are an important demographic group for understanding overall tuberculosis epidemiology, and monitoring of childhood tuberculosis is essential for appropriate prevention. The present study sought to characterize the spatial distribution of childhood tuberculosis notification rates in continental Portugal; identify high-risk areas; and evaluate the association between childhood tuberculosis notification rates and socioeconomic deprivation.

METHODS

Using hierarchical Bayesian spatial models, we analyzed the geographic distribution of pediatric tuberculosis notification rates across 278 municipalities between 2016 and 2020 and determined high-risk and low-risk areas. We used the Portuguese version of the European Deprivation Index to estimate the association between childhood tuberculosis and area-level socioeconomic deprivation.

RESULTS

Notification rates ranged from 1.8 to 13.15 per 100,000 children under 5 years of age. We identified seven high-risk areas, the relative risk of which was significantly above the study area average. All seven high-risk areas were located in the metropolitan area of Porto or Lisbon. There was a significant relationship between socioeconomic deprivation and pediatric tuberculosis notification rates (relative risk = 1.16; Bayesian credible interval, 1.05-1.29).

CONCLUSIONS

Identified high-risk and socioeconomically deprived areas should constitute target areas for tuberculosis control, and these data should be integrated with other risk factors to define more precise criteria for BCG vaccination.

Classification of Deprivation Indices That Applied to Detect Health Inequality: A Scoping Review

INTRODUCTION

Many studies around the world are undertaken to establish the association between deprivation and public health indicators. Both separate indicators (e.g., income, education, occupation, public security and social support) and complex models (indices) include several indicators. Deprivation indices are actively used in public health since the mid 1980s. There is currently no clear classification of indices.

METHODS

In the current review, data related to deprivation indices are combined and analyzed in order to create a taxonomy of indices based on the results obtained. The search was carried out using two bibliographic databases. After conducting a full-text review of the articles and searching and adding relevant articles from the bibliography, and articles that were already known to the authors, sixty studies describing the use of sixty deprivation indices in seventeen countries were included in the narrative synthesis, resulting in development of a taxonomy of indices. When creating the taxonomy, an integrative approach was used that allows integrating new classes and sub-classes in the event that new information appears.

RESULTS

In the review, 68% (41/60) of indices were classified as socio-economic, 7% (4/60) of indices as material deprivation, 5% (3/60) of indices as environmental deprivation and 20% (12/60) as multidimensional indices.

CONCLUSIONS

The data stimulates the use of a competent approach, and will help researchers and public health specialist in resolving conflicts or inconsistencies that arise during the construction and use of indices.

Social determinants of tuberculosis: a nationwide case-control study, Denmark, 1990-2018

BACKGROUND

The global vision is a world free of tuberculosis (TB). Even in resource-rich TB low-incidence settings, we need more focus on the role of social risk factors to end the TB epidemic.

METHODS

Nationwide, retrospective register-based, case-control study from 1990 to 2018, including all TB patients in Denmark ≥18 years old (n = 9581) matched 1:3 on sex and age with population controls. TB risk factors were assessed in logistic regression models and estimated by odds ratio (OR).

RESULTS

All TB patients had considerably lower socio-economic status compared with controls (P < 0.0001). Among ethnic Danes, TB was mostly found among males, persons between 35 and 65 years, those living alone, those with low educational level, persons on social welfare benefits and those with low income. Conversely, for migrants, being younger, sex and living alone were less important, whereas having children was protective. In an adjusted multivariable regression model among Danes, key risk factors for TB were being on disability pension (OR = 2.7) and cash benefits (OR = 4.7). For migrants, fewer social risk factors increased TB risk, although low income and cash benefits did (OR = 3.1).

CONCLUSION

Even today in a resourceful setting, socio-economic status drives disparities in health. In our study, multifactorial social deprivation was highly associated with TB. Especially household structure, education, employment and income were important risk factors that should be addressed in the future to accelerate TB control and end the TB epidemic.

Intra-urban variation in tuberculosis and community socioeconomic deprivation in Lisbon metropolitan area: a Bayesian approach

Background

Multidrug resistant tuberculosis (MDR-TB) is a recognized threat to global efforts to TB control and remains a priority of the National Tuberculosis Programs. Additionally, social determinants and socioeconomic deprivation have since long been associated with worse health and perceived as important risk factors for TB. This study aimed to analyze the spatial distribution of non-MDR-TB and MDR-TB across parishes of the Lisbon metropolitan area of Portugal and to estimate the association between non-MDR-TB and MDR-TB and socioeconomic deprivation.

Methods

In this study, we used hierarchical Bayesian spatial models to analyze the spatial distribution of notification of non-MDR-TB and MDR-TB cases for the period from 2000 to 2016 across 127 parishes of the seven municipalities of the Lisbon metropolitan area (Almada, Amadora, Lisboa, Loures, Odivelas, Oeiras, Sintra), using the Portuguese TB Surveillance System (SVIG-TB). In order to characterise the populations, we used the European Deprivation Index for Portugal (EDI-PT) as an indicator of poverty and estimated the association between non-MDR-TB and MDR-TB and socioeconomic deprivation.

Results

The notification rates per 10,000 population of non-MDR TB ranged from 18.95 to 217.49 notifications and that of MDR TB ranged from 0.83 to 3.70. We identified 54 high-risk areas for non-MDR-TB and 13 high-risk areas for MDR-TB. Parishes in the third [relative risk (RR) = 1.281, 95% credible interval (CrI): 1.021–1.606], fourth (RR = 1.786, 95% CrI: 1.420–2.241) and fifth (RR = 1.935, 95% CrI: 1.536–2.438) quintile of socioeconomic deprivation presented higher non-MDR-TB notifications rates. Parishes in the fourth (RR = 2.246, 95% CrI: 1.374–3.684) and fifth (RR = 1.828, 95% CrI: 1.049–3.155) quintile of socioeconomic deprivation also presented higher MDR-TB notifications rates.

Conclusions

We demonstrated significant heterogeneity in the spatial distribution of both non-MDR-TB and MDR-TB at the parish level and we found that socioeconomically disadvantaged parishes are disproportionally affected by both non-MDR-TB and MDR-TB. Our findings suggest that the emergence of MDR-TB and transmission are specific from each location and often different from the non-MDR-TB settings. We identified priority areas for intervention for a more efficient plan of control and prevention of non-MDR-TB and MDR-TB.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-022-00949-1.

Tuberculosis and Migrant Pathways in an Urban Setting: A Mixed-Method Case Study on a Treatment Centre in the Lisbon Metropolitan Area, Portugal

Tuberculosis (TB) is an infectious disease associated with poverty. In the European Union TB tends to concentrate in urban settings. In Lisbon, previous studies revealed, the presence of migrant populations from a high endemic country, is one of the risk factors contributing to TB. To better understand TB in foreign-born individuals in the Lisbon Metropolitan Area, a mixed-method case study was undertaken on a TB treatment centre in a high-risk part of urban Portugal. Quantitatively, annual TB cases were analysed from 2008 to 2018, dividing foreign-origin cases into recent migrants and long-term migrants. Qualitatively, we explored recent migrants’ reasons, experiences and perceptions associated with the disease. Our results showed that foreign-born individuals accounted for 45.7% of cases, mainly originated from Angola, Guinea-Bissau, and Cabo Verde. TB in recent migrants increased over the years for Angola and Guinea-Bissau, while for Cabo Verde TB cases were due to migrants residing in Portugal for more than 2 years. Recent migrants’ reasons to travel to Portugal were to study, to live and work, tourism, and seeking better healthcare. Visiting family and friends, historical links and common language were key drivers for the choice of country. Recent migrants and long-term migrants may present distinct background profiles associated with diagnosed TB.

The circuits of healthcare: Understanding healthcare seeking behaviour-A qualitative study with tuberculosis patients in Lisbon, Portugal

BACKGROUND

Understanding health delivery service from a patient´s perspective, including factors influencing healthcare seeking behaviour, is crucial when treating diseases, particularly infectious ones, like tuberculosis. This study aims to trace and contextualise the trajectories patients pursued towards diagnosis and treatment, while discussing key factors associated with treatment delays. Tuberculosis patients' pathways may serve as indicator of the difficulties the more vulnerable sections of society experience in obtaining adequate care.

METHODS

We conducted 27 semi-structured interviews with tuberculosis patients attending a treatment centre in a suburban area of Lisbon. We invited nationals and migrant patients in active treatment to participate by sharing their illness experiences since the onset of symptoms until the present. The Health Belief Model was used as a reference framework to consolidate the qualitative findings.

RESULTS

By inductive analysis of all interviews, we categorised participants' healthcare seeking behaviour into 4 main types, related to the time participants took to actively search for healthcare (patient delay) and time the health system spent to diagnose and initiate treatment (health system delay). Each type of healthcare seeking behaviour identified (inhibited, timely, prolonged, and absent) expressed a mindset influencing the way participants sought healthcare. The emergency room was the main entry point where diagnostic care cascade was initiated. Primary Health Care was underused by participants.

CONCLUSIONS

The findings support that healthcare seeking behaviour is not homogeneous and influences diagnostic delays. If diagnostic delays are to be reduced, the identification of behavioural patterns should be considered when designing measures to improve health services' delivery. Healthcare professionals should be sensitised and perform continuous capacity development training to deal with patients´ needs. Inhibited and prolonged healthcare seeking behaviour contributes significantly to diagnostic delays. These behaviours should be detected and reverted. Timely responses, from patients and the healthcare system, should be promoted.

The Relationship Between Socio-Demographic Factors and Tuberculosis Mortality in the Republic of Korea During 2008-2017

The Republic of Korea has a high incidence of tuberculosis (TB) and TB-specific mortality rate. In 2019, it had the second highest TB-specific mortality among Organization for Economic Co-operation and Development countries. Understanding the factors associated with TB-specific deaths may help eradicate the disease. Therefore, we aimed to identify the general characteristics associated with TB-specific mortality among Koreans. Using Causes of Death Statistics data from Statistics Korea, we assessed the year of death, sex, age, occupation, area of residence, marital status, and education level reported between 2008 and 2017. Patient characteristics associated with TB-specific deaths were analyzed using the Chi-squared test, while influencing factors of TB-specific mortality were analyzed using logistic regression analysis to calculate adjusted odds ratios (AOR). Female (AOR: 0.509, 95% CI: 0.493–0.526), those with a graduate degree or higher (AOR: 0.559, 95% CI: 0.474–0.660) had lower TB-specific mortality rates than those of their counterparts. Conversely, those aged ≥70 years (AOR: 1.239, 95% CI: 1.199–1.280), single (AOR: 1.355, 95% CI: 1.315–1.396), and skilled agricultural, forestry, and fishery workers (AOR: 1.441, 95% CI: 1.359–1.529) had higher TB-specific mortality rates than those of their counterparts. In conclusion, TB-specific mortality rates differed according to the characteristics of the deceased patients. In order to establish effective TB control, multisectoral action on broader determinants should be strengthened.

Comparing the cost-effectiveness of two screening strategies for latent tuberculosis infection in Portugal

INTRODUCTION AND OBJECTIVES

Screening for latent tuberculosis infection (LTBI) in close contacts of infectious TB cases might include Tuberculin Skin Test (TST) and Interferon-Gamma Release Assays (IGRA), in combination or as single-tests. In Portugal, the screening strategy changed from TST followed by IGRA to IGRA-only testing in 2016. Our objective was to compare the cost-effectiveness of two-step TST/IGRA with the current IGRA-only screening strategy in immunocompetent individuals exposed to individuals with respiratory TB.

MATERIALS AND METHODS

We reviewed clinical records of individuals exposed to infectious TB cases diagnosed in 2015 and 2016, in two TB outpatient centers in the district of Porto. We estimated medical, non-medical and indirect costs for each screening strategy, taking into account costs of tests and health care personnel, travel distance from place of residence to screening site and employment status. We calculated the incremental cost-effectiveness ratio (ICER) as the cost difference between the two screening strategies with the difference number of LTBI diagnosis as a measure of cost-effectiveness, assuming that treating LTBI is a cost-effective intervention. We also calculated adjusted odds-ratios to test the association between diagnosis of LTBI and screening strategy and estimated the total cost for averting a potential TB case.

RESULTS

We compared 499 contacts TST/IGRA screened with 547 IGRA-only. IGRA-only strategy yielded a higher screening effectiveness for diagnosing latent tuberculosis infection (aOR 2.12, 95%CI: 1.53 - 2.94). ICER was €106 per LTBI diagnosis, representing increased effectiveness with a slightly increased cost of IGRA-only screening strategy.

CONCLUSIONS

Our data suggests that in Portugal LTBI screening with IGRA-only is more cost-effective than the two-step TST/IGRA testing strategy, preventing a higher number of cases of TB cases.

Mapping Geographical Patterns and High Rate Areas for Sexually Transmitted Infections in Portugal: A Retrospective Study Based on the National Epidemiological Surveillance System

OBJECTIVE

Monitoring disease variation using finer scales to identify high-rate communities is a critical aspect for precision public health and for efficient resource allocation. This study aimed to map the spatial patterns of chlamydia, gonorrhea, and syphilis; identify high-rate areas across Portuguese municipalities; and determine the association of these sexually transmitted infections (STIs) with socioeconomic deprivation, urbanicity level, and population density.

METHODS

The STI notifications at municipality level for the period 2015 to 2017 were obtained from Portugal's Epidemiologic Surveillance System (Sistema Nacional de Vigilância Epidemiológica). Spatial Bayesian models were used to calculate smoothed standardized notification rates, identify high- and low-rate areas and estimate associations (relative risk [RR], 95% credible intervals [95%CrI]).

RESULTS

There were 4819 cases of chlamydia, gonorrhea, and syphilis reported, accounting for 15.3%, 33.2%, and 51.5% of the notifications, respectively. The STI notification rates were substantially higher in Porto and Lisbon Metropolitan Areas and concentrically disperse around those. Notification rates of the 3 STIs were strongly correlated (r > 0.8). Rates of gonorrhea (Q1-lowest density vs. Q5-highest RR, 2.10; 95% CrI, 1.08-4.25) and syphilis (RR, 3.16; 95% CrI, 2.00-5.13) were associated with population density. Notifications of chlamydia (Q1-least urban vs. Q5-most RR, 9.64; 95% CrI, 1.73-93.59) and syphilis (RR, 1.92; 95% CrI, 1.30-2.88) increased with urbanicity level. We also found that notification rates of gonorrhea were associated with socioeconomic deprivation (Q1-least vs. Q5-most deprived RR, 1.75; 95% CrI, 1.07-2.88).

CONCLUSIONS

Wide spatial inequalities in STI notification rates were observed, which were predominantly concentrated in the 2 metropolitan areas of the country. Our findings can help guide more targeted interventions to reduce STIs incidence.

Assessing inequalities in geographical access to emergency medical services in metropolitan Lisbon: a cross-sectional and ecological study

OBJECTIVES

Studies have suggested that material deprivation is strongly associated with negative health outcomes, and lower usage of various levels of healthcare. We aim to analyse geographical access to emergency medical services (EMSs) and hospital emergency units by EMS in relation to deprivation in the Lisbon Metropolitan Area (LMA), Portugal.

DESIGN

This study estimates road network-based access times from the centroids of statistical sections (census block groups equivalent) to locations of EMS and hospital emergency services. Each statistical section has been linked to a Material Deprivation Index (MDI). A non-parametric analysis of variance (ANOVA) was undertaken to compare MDI-linked statistical sections in terms of access to emergency care. Geographical access analysis was conducted for 2018.

PRIMARY OUTCOME MEASURE

Road network-based access time (in minutes) for EMSs to statistical sections and then on to emergency units in hospitals.

RESULTS

Overall, 82.4% of the LMA population is located less than a 10 min drive from an EMS without transport, and 99.1% from an EMS with transport. Travel time from EMS with transport to hospital is potentially less than 20 min for 95.2% of the population. However, 63.1% of residents living beyond a 30 min threshold (total time from emergency call to hospital arrival) are in areas with very high MDI (18.8% in high MDI, 13.3% in medium MDI, 4.7% in low MDI, 0% in very low MDI). Kruskal-Wallis ANOVA confirms discrepancies in access times between better-off and poorer areas.

CONCLUSION

Poorer areas experience worse geographical access to EMS and hospital emergency units. More research is needed to explore the quality of services and their outcomes, and to refine the analysis by focusing on specific vulnerable groups.

Using Bayesian spatial models to map and to identify geographical hotspots of multidrug-resistant tuberculosis in Portugal between 2000 and 2016

Multidrug-resistant tuberculosis (MDR-TB) is a major threat to the eradication of tuberculosis. TB control strategies need to be adapted to the necessities of different countries and adjusted in high-risk areas. In this study, we analysed the spatial distribution of the MDR- and non-MDR-TB cases across municipalities in Continental Portugal between 2000 and 2016. We used Bayesian spatial models to estimate age-standardized notification rates and standardized notification ratios in each area, and to delimitate high- and low-risk areas, those whose standardized notification ratio is significantly above or below the country’s average, respectively. The spatial distribution of MDR- and non-MDR-TB was not homogeneous across the country. Age-standardized notification rates of MDR-TB ranged from 0.08 to 1.20 and of non-MDR-TB ranged from 7.73 to 83.03 notifications per 100,000 population across the municipalities. We identified 36 high-risk areas for non-MDR-TB and 8 high-risk areas for MDR-TB, which were simultaneously high-risk areas for non-MDR-TB. We found a moderate correlation (ρ = 0.653; 95% CI 0.457–0.728) between MDR- and non-MDR-TB standardized notification ratios. We found heterogeneity in the spatial distribution of MDR-TB across municipalities and we identified priority areas for intervention against TB. We recommend including geographical criteria in the application of molecular drug resistance to provide early MDR-TB diagnosis, in high-risk areas.

Bayesian spatio-temporal models for mapping TB mortality risk and its relationship with social inequities in a region from Brazilian Legal Amazon

BACKGROUND

Reducing TB mortality is a great challenge in Brazil due to its territorial extension, cultural variations and economic and political crises, which impact the health system. This study aimed to estimate in space and time the risk of TB mortality and test its relationship with social inequities.

METHODS

This was an ecological study that included deaths from TB between 2006 and 2016 in Cuiabá, Brazilian Legal Amazon. Bayesian models based on the integrated nested Laplace approximation approach were used to estimate spatio-temporal RRs. RRs for TB mortality were obtained according to the covariables representative of social inequities.

RESULTS

The risk of TB mortality was stable between 2006 and 2016 and high-risk areas were identified throughout the municipality studied. Regarding social inequities, income was an important factor associated with TB mortality risk, as an increase of 1 SD in income resulted in a 35.4% (RR 0.646; CI 95% 0.476 to 0.837) decrease in risk.

CONCLUSIONS

The results provided evidence of areas with higher TB mortality risks that have persisted over time and are related to social inequities. Advancing social policies and protections in these areas will contribute to achieving the WHO's End TB strategy.

Social risk and its association with tuberculosis mortality in a context of high inequality in South Brazil: A geo-epidemiology analysis

BACKGROUND

Tuberculosis (TB) is one of the top 10 causes of death worldwide; in 2016, over 95% of TB deaths occurred in low- and middle-income countries. Although the incidence and deaths from TB have decreased in Brazil in recent years, the disease has increased in the vulnerable population, whose diagnosis is more delayed and the chances for abandonment and deaths are significantly higher. This study aimed to identify high-risk areas for TB mortality and evidence their social determinants through a sensitive tailored social index, in a context of high inequality in South Brazil.

METHODS

A multistep statistical methodology was developed, based on spatial clustering, categorical principal components analysis, and receiver operating characteristic curves (ROC). This study considered 138 spatial units in Curitiba, South Brazil. TB deaths (2008-2015) were obtained from the National Information Mortality System and social variables from the Brazilian Human Development Atlas (2013).

RESULTS

There were 128 TB deaths recorded in the study: the mortality rate was 0.9/100,000 inhabitants, minimum-maximum: 0-25.51/100,000, with a mean (standard deviation) of 1.07 (2.71), and 78 space units had no deaths. One risk cluster of TB mortality was found in the south region (RR=2.64, p=0.01). Considering the social variables, several clusters were identified in the social risk indicator (SRI): income (899.82/1752.94; 0.024), GINI Index (0.41/0.45; 0.010), and overcrowding (25.07/15.39; 0.032). The SRI showed a high capacity to discriminate the TB mortality areas (area under ROC curve 0.865, 95% CI: 0.796-0.934).

CONCLUSIONS

A powerful risk map (SRI) was developed, allowing tailored and personalised interventions. The south of Curitiba was identified as a high-risk area for TB mortality and the majority of social variables. This methodological approach can be generalised to other areas and/or other public health problems.

Why does it take so long? The reasons behind tuberculosis treatment delay in Portugal

INTRODUCTION

Delayed diagnosis and treatment of tuberculosis contributes to the spread of the disease. In this study, we aimed to determine the patient and healthcare system delay among tuberculosis patients in Portugal and identify associated factors at individual and contextual level.

METHODS

We analysed all TB cases notified in Portugal between 2010 and 2014 using data from the national surveillance system. Patient and healthcare system delay were computed, log-transformed, and used as outcomes. Adjusted generalized linear models were fitted to identify sociodemographic, contextual and clinical determinants.

RESULTS

The study included 6838 patients. The median of patient and healthcare system were 33 and 17 days, respectively. Adjusted regression models revealed that higher patient delay occurred in foreign patients (exponentiated beta: 1.177, 95%CI 1.091-1.270) and those addicted to alcohol (1.169, 1.072-1.276) and drugs (1.153, 1.027-1.295). Higher healthcare system delay was observed among patients with extra-pulmonary TB (2.067, 1.885-2.268) and pulmonary comorbidities - lung cancer (2.391, 1.656-3.452), sarcoidosis (3.316, 1.370-8.022) and COPD (1.295, 1.059-1.584) - and in patients residing further from a healthcare service (1.040, 1.018-1.062).

CONCLUSION

We found that various individual and contextual factors affect the time delay in tuberculosis treatment. Our findings indicate that some strategies, such as facilitating the access to healthcare services among foreign patients and patients with addictions and increasing the awareness towards TB among healthcare professionals, may result in better TB control.

Deprivation-specific life tables using multivariable flexible modelling - trends from 2000-2002 to 2010-2012, Portugal

BACKGROUND

Completing mortality data by information on possible socioeconomic inequalities in mortality is crucial for policy planning. The aim of this study was to build deprivation-specific life tables using the Portuguese version of the European Deprivation Index (EDI) as a measure of area-level socioeconomic deprivation, and to evaluate mortality trends between the periods 2000-2002 and 2010-2012.

METHODS

Statistics Portugal provided the counts of deaths and population by sex, age group, calendar year and area of residence (parish). A socioeconomic deprivation level was assigned to each parish according to the quintile of their national EDI distribution. Death counts were modelled within the generalised linear model framework as a function of age, deprivation level and calendar period. Mortality Rate Ratios (MRR) were estimated to evaluate variations in mortality between deprivation groups and periods.

RESULTS

Life expectancy at birth increased from 74.0 and 80.9 years in 2000-2002, for men and women, respectively, and to 77.6 and 83.8 years in 2010-2012. Yet, life expectancy at birth differed by deprivation, with, compared to least deprived population, a deficit of about 2 (men) and 1 (women) years among most deprived in the whole study period. The higher mortality experienced by most deprived groups at birth (in 2010-2012, mortality rate ratios of 1.74 and 1.29 in men and women, respectively) progressively disappeared with increasing age.

CONCLUSIONS

Persistent differences in mortality and life expectancy were observed according to ecological socioeconomic deprivation. These differences were larger among men and mostly marked at birth for both sexes.

The Portuguese version of the European Deprivation Index: Development and association with all-cause mortality

Socioeconomic inequalities are major health determinants. To monitor and understand them at local level, ecological indexes of socioeconomic deprivation constitute essential tools. In this study, we describe the development of the updated version of the European Deprivation Index for Portuguese small-areas (EDI-PT), describe its spatial distribution and evaluate its association with a general health indicator–all-cause mortality in the period 2009–2012. Using data from the 2011 European Union–Statistics on Income and Living Conditions Survey (EU-SILC), we obtained an indicator of individual deprivation. After identifying variables that were common to both the EU-SILC and the census, we used the indicator of individual deprivation to test if these variables were associated with individual-level deprivation, and to compute weights. Accordingly, eight variables were included. The EDI-PT was produced for the smallest area unit possible (n = 18084 census block groups, mean/area = 584 inhabitants) and resulted from the weighted sum of the eight selected variables. It was then categorized into quintiles (Q1-least deprived to Q5-most deprived). To estimate the association with mortality we fitted Bayesian spatial models. The EDI-PT was unevenly distributed across Portugal–most deprived areas concentrated in the South and in the inner North and Centre of the country, and the least deprived in the coastal North and Centre. The EDI-PT was positively and significantly associated with overall mortality, and this relation followed a rather clear dose-response relation of increasing mortality as deprivation increases (Relative Risk Q2 = 1.012, 95% Credible Interval 0.991–1.033; Q3 = 1.026, 1.004–1.048; Q4 = 1.053, 1.029–1.077; Q5 = 1.068, 1.042–1.095). Summing up, we updated the index of socioeconomic deprivation for Portuguese small-areas, and we showed that the EDI-PT constitutes a sensitive measure to capture health inequalities, since it was consistently associated with a key measure of population health/development, all-cause mortality. We strongly believe this updated version will be widely employed by social and medical researchers and regional planners.

Is there association between human development index and tuberculosis mortality risk? Evidence from a spatial analysis study in the south of Brazil

The goal of this study was to analyse the spatial pattern of tuberculosis (TB) mortality using different approaches, namely: mortality rates (MR), spatial relative risks (RR) and Bayesian rates (Global and Local) and their association with human development index (HDI), Global and its three dimensions: education, longevity and income. An ecological study was developed in Curitiba, Brazil based on data from Mortality Information System (2008-2014). Spatial scan statistics were used to compute RR and identify high-risk clusters. Bivariate Local Indicator of Spatial Associations was used to assess associations. MR ranged between 0 and 25.24/100.000 with a mean (standard deviation) of 1.07 (2.66). Corresponding values for spatial RR were 0-27.46, 1.2 (2.99) and for Bayesian rates (Global and Local) were 0.49-1.66, 0.90 (0.19) and 0-6.59, 0.98 (0.80). High-risk clusters were identified for all variables, except for HDI-income and Global Bayesian rate. Significant negative spatial relations were found between MR and income; between RR and HDI global, longevity and income; and Bayesian rates with all variables. Some areas presented different patterns: low social development/low risk and high risk/high development. These results demonstrate that social development variables should be considered, in mortality due TB.

Tuberculosis, social determinants and co-morbidities (including HIV)

The risk of exposure, progression to active tuberculosis (TB) and then to cure is a process affected by several risk factors. Along with well known risk factors such as human immunodeficiency virus (HIV), use of immunosuppressive drugs and being of young age, emerging risk factors such socio-economic and behavioral aspects play a significant role in increasing the susceptibility to infection, and unsuccessful treatment outcomes. This paper summarizes the effects of these socio-economic determinants and co-morbidities (including HIV) on TB infection and disease.