The First exploratory spatial distribution analysis of tuberculosis and associated factors in Tonala, Mexico

Abstract

Introduction:
The US-Mexico region is at high risk of elevated tuberculosis (TB) incidence due to mobility and migration. Knowledge of how socio-demographic factors varies geographically, provides clues to understanding the determinants of tuberculosis and may provide guidance for regional prevention and control strategies to improve public health in Mexico. The aim of the present study was to describe the epidemiologic characteristics and spatial patterns of the incidence of tuberculosis in Tonala, Jalisco (Mexico) from 2013-2015.

Methodology:
The Surveillance System Database from the Health Department, complemented by information from the National Institute of Statistics and Geography, was used to obtain data for a spatial-temporal analysis of TB cases. For the geographical analysis map creation and geoinformation storing, ArcGIS software was used.

Results:
This study sought to characterize problem areas and jurisdictional locations of TB via a spatial approach based on analyses of case distributions and individual patient variables. The study found that tuberculosis cases were dispersed throughout Tonala County and were mainly concentrated on the Guadalajara city border. The TB cases were mainly individuals between 31 and 45 years old. Most of the cases reported during the observation period were male patients, and most cases primarily had lung involvement; however, there were quite a few cases with lymph node and intestinal disease.

Conclusion:
Our findings show that TB cases are essentially located in areas close to the city of Guadalajara and that most TB cases were pulmonary cases spread throughout the whole jurisdiction.

Full text

Brief Original Article
First exploratory spatial distribution analysis of tuberculosis and associated
factors in Tonala, Mexico
Alejandro Escobar-Gutierrez1, Armando Martinez-Guarneros1, Gustavo Mora-Aguilera2, Carlos Arturo
Vazquez-Chacon1, Gerardo Acevedo-Sanchez2, Manuel Sandoval-Díaz3, Juan Carlos Villanueva-Arias3,
Natividad Ayala-Chavira4, Maria Elena Vargas-Amado5, Ikuri Alvarez-Maya5
1 Institute for Epidemiologic Diagnosis and Reference (InDRE) Ciudad de México, México
2 Laboratory of Phytosanitary Epidemiology Risk Analysis (LANREF) Campus Montecillo; Phytophatology,
Postgraduates College, Texcoco, Estado de Mexico, Mexico
3 Health Ministry of Jalisco, Guadalajara, Jalisco, Mexico
4 Jalisco State Public Health Laboratory, Health Ministry of Jalisco, Guadalajara, Mexico
5 Medical and Pharmaceutical Biotechnology, Center for Research and Applied Technology in Jalisco (CIATEJ)
Guadalajara, Mexico
Abstract
Introduction: The US-Mexico region is at high risk of elevated tuberculosis (TB) incidence due to mobility and migration. Knowledge of how
socio-demographic factors varies geographically, provides clues to understanding the determinants of tuberculosis and may provide guidance
for regional preventi on and control strategies to improve public health in Mexico. The aim of the present study was to describe the
epidemiologic characteristics and spatial patterns of the incidence of tuberculosis i n Tonala, Jalisco (Mexico) from 2013-2015.
Methodology: The Surveillance System Database from the Health Department, complemented by information from the National Institute of
Statistics and Geography, was used to obtain data for a spatial-temporal analysis of TB cases. For the geographical analysis map creation and
geoinformation storing, ArcG IS software was used.
Results: This study sought to characterize problem areas and jurisdictional locations of TB via a spatial approach based on analyses of case
distributions and individual patient variables. The study found that tuberculosis cases were dispersed throughout Tonala County and were
mainly concentrated on the Guadalajara city border. The TB cases were mainly individuals between 31 and 45 years old. Most of the cases
reported during the observation period wer e male patients, and most cases primarily had lung involvement; however , there were quite a few
cases with lymph node and intestinal disease.
Conclusion: Our findings show that TB cases are essentially located in areas close to the city of Guadalajara and that most TB cases were
pulmonary cases spread throughout the whole jurisdiction.
Key words: Tuberculosis; spatial distr ibution; ri sk factors; Mexico.
J Infect Dev Ctries 2020; 14(2):207-213. doi:10.3855/jidc.11873
(Received 25 July 2019 – Accepted 29 January 2020)
Copyright © 2020 Escobar-Gutierr ez et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction
Tuberculosis (TB) remains a major public health
issue in the world. The WHO estimated 282,000 new
and relapsed TB cases for the Americas in 2017.
Infectious disease transmission along the U.S.–Mexico
border is an area of particular concern. In Mexico,
tuberculosis has become a serious public health
problem, mainly due to the appearance of multidrug-
resistant strains (MDR) and comorbidities, such as
diabetes mellitus. In 2017, more than 28,000 new cases
of TB occurred in Mexico, with more than 2,000 deaths
[1].
Several studies have used GIS as a strategy for the
jurisdictional characterization of TB patterns by
evaluating disease concentration case responses and
designing strategies for TB control [2,3]. Health
departments are developing many diverse approaches
that may influence decision makers.
The worldwide prevalence of TB is mainly
associated with social inequality, poverty,
overcrowding and migration [4]. According to the
Institute of Mexicans Abroad, through the issuance of
high security consular registration plates, 814,000 new
migrants in the United States were registered in 2016;
of this total, 7.5% are from Jalisco. During 2017, there
were 60,767 new migrants from Jalisco in the United
States [5].

Escobar-Gutierrez et al. – Geospatial tuberculosis in Tonala, Jalisco J Infect Dev Ctries 2020; 14(2):207-213.
208
Previous studies have found both individual-level
and neighbourhood-level sociodemographic factors to
be predictors of TB transmission [6]. Individual-level
sociodemographic characteristics include younger age,
minority race/ethnicity status and male sex.
Neighbourhood-level characteristics include population
density and age composition, and relative
neighbourhood sociodemographic status has been
considered a predictor at both the individual and
neighbourhood levels [7-8]. Thus, knowledge of the
spatial distribution of TB and epidemiology of TB are
essential in developing public health strategies for
effective control [9].
In Mexico, several challenges faced by TB control
programmes at the local level are related to the early
detection of infection and identification of cases, as
well as difficulties in recording the outcomes of the
treatment of cases, such as the rate of cured cases,
dropouts, failure to treat, transferred cases, completed
treatment cases and deaths [10]. Moreover, few studies
performed to date have characterized the
sociodemographic factors and clinical manifestations
associated with tuberculosis in Mexico. In this study,
we describe the epidemiologic characteristics and
spatial patterns of the incidence of tuberculosis in
Tonala, Jalisco (Mexico), from 2013-2015.
Methodology
Study Setting
The city of Tonala is located in the eastern centre of
the state of Jalisco in Mexico, with the coordinates
20º31'50'' to 20º42'10'' north latitude and 103º08'30'' to
103º16'50'' west longitude, at an average height of 1,500
metres above sea level. It borders Zapotlanejo to the
north; El Salto and Juanacatlán to the south; San Pedro
Tlaquepaque and Guadalajara to the west; and
Zapotlanejo to the east. Its territory extends 166.1 km2
and has a population of 536,111 people (2015) [11]. In
2010, 6.8 percent of the Tonala population lived in
extreme poverty, and in 2015, it decreased to 3.9
percent of the Tonala population, which is equivalent to
21,008 people living in extreme poverty [12].
Data Collection
Exploratory spatial analysis was performed in
Tonala, Jalisco, in Mexico to analyse the demographic
characteristics, known TB risk factors, and clinical and
neighbourhood characteristics of TB in this state at the
county level. Geocoding methodology was used to
study the jurisdictional characteristics. No previous
characterization of the spatial-temporal distribution of
TB cases has been reported in this area.
A case database was provided by the Health
Ministry of Jalisco, Mexico, to analyse the
jurisdictional/district characteristics of TB cases.
During the processing of the information,
sociodemographic and clinical data were analysed to
determine the significant locations where TB could be
spread. The Surveilla nce System Database from the
Health Department collects several risk factors from TB
cases, and this study included factors such as county,
address, institution, localization of bacteria in the body,
diagnosis date, treatment start date, treatment round,
type of patient, status of the patient, and number of
people infected by the original case. This study was
complemented by information from the National
Institute of Statistics and Geography (Inst ituto Nacional
de Estadística y Geografía “INEGI”
http://www.inegi.org.mx/) and the National Council of
Population (Consejo Nacional de Población
“CONAPO” https://www.gob.mx/conapo).
The data obtained were analysed in the statistical
software package R© (https://www.r-project.org/) for
normalization and analysis. To identify problem areas,
the dataset was filtered, and then, the address of the
cases was used to perform a geocoding process to
transform the address into longitude/latitude
coordinates. To perform geocoding for TB in Tonala
and determine the locations of TB problem areas, a new
field was created in the database that contained the full
address of the patient (street name, zip code,
neighbourhood, and municipality). This occurred
throughout the country; therefore, many details must be
included in the address field to generate the best results
possible. A second review was further performed after
the geocoding step was executed to verify whether the
coordinates obtained were consistent with the address
stated for the patient.
Data Processing
For geographical analysis, map creation and
geoinformation storing, ArcGIS© 10.2.2 software was
used. The shapefile generated by the geocoding was
projected for fitting with the additional layers available
in the programme. A geodatabase was created to
generate more robust regulation over the
geoinformation. The geodatabase was completed with
several layers to create comparisons of new and
previous official information. To generate a general
overview of the information available, several maps
were created [13].

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209
Results
Distribution of tuberculosis cases in Tonala County
In 2016, 139 new cases of tuberculosis were
detected in Jalisco during the first three months of the
year (Health Ministry of Mexico, 2016). The geocoding
data results showed the geographical distribution of TB
cases from 2013-2015, with 366 total cases analysed.
This study included 113 (30.8%) cases in 2013, 111
(30.3%) cases in 2014 and 142 (38.7%) cases in 2015.
The observation area was limited to cases identified in
the county of Tonala. The Health Department
recognizes boundaries that are different from the formal
municipal borders; therefore, this county includes more
than one municipality. The cases were consistently
concentrated in the northwest part of the city over the
three-year period observed (Figure 1). During 2015,
most of the cases appeared to be located on the
northwest side of Tonala near the border shared with
Guadalajara. During 2014, a slight decrease in disease
cases occurred; however, in 2015, the number of
tuberculosis cases increased considerably. This study
may provide guidance for regional prevention and
control strategies to improve public health in Mexico.
Spatial-temporal patterns of patients by age and gender
The ages of the patients at the time of tuberculosis
diagnosis based on the distribution of TB cases from
2013-2015 were analysed. We found that the proportion
of cases in the age range of 1 to 15 years (4%) did not
change, and cases less than one year of age had the
lowest proportion observed throughout the observation
period. The largest number of TB cases in Tonala from
2013-2015 was in the age range of 31 to 45 years,
representing 33.6% of all cases (Table 1). The
geospatial distribution was co-analysed with the
frequency distribution.
Figure 1. Distribution of tuberculosis cases in Tonala County. Spatial distribution of tuberculosis cases from 2013-2015 analysed spatially
showed marked TB distribution in Tonala, near the border shared with Guadalajara.

Escobar-Gutierrez et al. – Geospatial tuberculosis in Tonala, Jalisco J Infect Dev Ctries 2020; 14(2):207-213.
210
Spatial analysis of the data categorized by gender
throughout the analysis period showed that the
incidence of tuberculosis was lower in 2014 than in
2015 and 2013 (Table 1). Male patients had a higher
incidence (70%) than female patients (29%).
Treatment outcomes in patients with tuberculosis
Treatment predefined outcomes for TB patients
during 2013-2015 were analysed in the study
population including, cured (50%), treatment
completed (20%), treatment failed (17%), died (7%),
loss to follow-up (5%) and treatment success (70%)
(Table 2). The treatment outcome analysis find out that
half of the patients were cured after the treatment. Our
results highligth a moderate cure rate in concordance
with other studies in countries as India [14]. However
other estimates from Africa and Russia suggest that
treatment fails to cure 30–75% of patients with
drugresistant tuberculosis, wich indicate an increasing
incidence of drug-resistant tuberculosis reported by
WHO [15-16].
Location of disease
Analysis of the distribution of TB cases during the
three-year study period and the localization of bacterial
infection was performed. A total of eleven different
localizations of disease wer e reported to the Health
Department (Figure 2). Most of the cases wer e
pulmonary (72%); however, there were several cases of
lymph node (13%) and intestinal disease (5%). Only
two cases of ocular infection were reported (1%).
During 2013, tuberculosis in the lungs was present
in most cases (74%), followed by lymph node infection
(9% of cases). In 2014, most of the cases included
pulmonary tuberculosis (76%). In specific areas, we
found increased incidences of lymph node infection
(18%). Meanwhile, of the 142 total cases reported in
2015, pulmonary disease retained the highest
proportion of cases (72%). However, a greater diversity
of infection areas was observed in 2015 than in the
previous two years (Figure 2).
This study shows that most cases of TB were
pulmonary cases spread throughout the whole
jurisdiction. In Zapotlanejo, patients with lymph node
infection were localized to the centre of town, in
Table 1. Frequency of treatment outcome in patients with tuberculosis. Low frequency of complete treatment is observed during the study
period, 2013 -2015.
2013
2014
2015
Total
Cases
Frequency
(%)
Cases
Frequency
(%)
Cases
Frequency
(%)
Frequency
n (%)
Cured
68
60
66
59
48
34
182 (50)
Treatment completed
29
26
24
21
20
14
73 (20)
Treatment failed
2
2
9
8
53
37
64 (17)
Died
8
7
8
7
9
6
25 (7)
Loss to follow-up
6
5
3
3
11
8
20 (5)
Not evaluat ed
0
0
1
1
1
1
2 (1)
Total
113
100
111
99
142
100
366 (100)
Treatment success
(cured +
treatment
completed)
97 86 90 81 68 48 303 (70)
Table 2. Characteristics of patients with tuberculosis in Tonala, Mexico 2013 -2015.
2013
2014
2015
Total
Age
(years)
Cases
Frequency
(%)
Cases
Frequency
(%)
Cases
Frequency
(%)
Frequency
n (%)
0-15
5
4
6
5
5
4
16 (4)
16-30
26
23
24
21
41
29
91 (25)
31-45
42
37
35
32
46
32
123 (33)
46-60
24
21
30
27
30
21
84 (23)
over 60
16
14
16
15
20
14
52 (14)
Total
113
99
111
100
142
100
366 (99)
Gender
Female
29
26
41
37
37
26
107 ( 29)
Male
84
75
70
63
105
74
259 (70)
Total
113
101
111
100
142
100
366 (99)

Escobar-Gutierrez et al. – Geospatial tuberculosis in Tonala, Jalisco J Infect Dev Ctries 2020; 14(2):207-213.
211
addition to several lung infection cases. In the
municipality of Tonala, the infection localization was
randomly distributed over the whole city.
Discussion
Epidemiologic and sociodemographic factors
collectively define Mexico as a high-priority country
for TB control in the Americas [17-19]. In this study,
some factors related to the development of TB [20-21],
as well as the diversity of infection localization [22-23],
were studied at the town level in Jalisco. Moreover, no
previous studies performed in Mexico have analysed
the spatial distribution of cases at the individual level,
as well as the sociodemographic characteristics of
tuberculosis patients.
The TB cases seem to be primarily located in the
areas close to the city of Guadalajara. It could be
estimated that these areas tend to b e urban, with a higher
population density, whereas areas wher e the other cases
are distributed have a much lower population density.
The control of tuberculosis in this region will requir e
the promotion of emergent health programmes.
The analysis showed that the highest incidence of
tuberculosis was in patients 31-45 years old, which
constituted the most active segment of society [24],
consistent with previous studies that identified middle
age as associate factor for TB [25-26]. These results can
aid in the design of high-priority control efforts.
This study contributed to the spatiotemporal
analysis of TB incidence in Tonala, Jalisco (Mexico),
yet it has certain limitations. The data were extracted
from official surveillance data, which cannot exclude
the possibility of cases being underreported in some
regions. Cases may be missed by routine notification
Figure 2. Location of disease. Since TB can be located in different organs in the body, the relationship between t he organ location and
year was spatially analysed. There was an increase in 2015 in pulmonary tuberculosis cases, primarily located along the border with
Guadalajara.

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212
systems because persons afflicted with TB often do not
seek care, remain undiagnosed or are diagnosed by
private providers that do not report TB cases to local or
national authorities when they do seek care [24-29].
The distribution of TB cases in Tonala was
determined by the geocoding methodology. The
knowledge generated by this study may provide
guidance for regional prevention and control strategies
to impr ove public health in Mexico.
Conclusion
Tuberculosis remains a significant public health
burden in the state of Jalisco, and our findings show that
there are significant spatial and temporal characteristics
of TB at the town level in the region. TB cases are
essentially located in areas close to the city of
Guadalajara, and most cases of TB were pulmonary and
spread throughout the whole jurisdiction. Therefore, the
findings of this study provide useful information
concerning the prevailing epidemiological status of TB
in Tonala using existing health data and could be used
to develop strategies for more effective TB control at
the town level. As strategies for better control of TB,
state programs include diagnosis, follow-up, treatment
and control of cases. There are case promoters and
contact studies, with intra and extra home visits, then
our findings can help to geographically referenced
health databases present unprecedented new
opportunities to investigate social and behavioral
factors underlying geographic variations in disease
rates at small-area scale.
Funding
This study was supported with funds provided by
CONACYT through grant PDCPN_2014_247879, Scientific
Development Projects to Attention National Problems.
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Corresponding author
Ikuri Alvarez-Maya PhD,
Department of Medical and Pharmaceutical Biotechnology, Center
for Research and Applied Technology in Jalisco (CIATEJ)
Av. Normalistas No. 800, CP 44270. Guadalajara, Jalisco, Mexico.
Phone +52 33 33455200
Fax :+52 33 33455200 ext. 1001
Email: ialvarez@ciatej.mx
Conflict of interests: No conflict of interests is declared.