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

  • Institute of Epidemiological Diagnosis and Reference (Instituto de Diagnóstico y Referencia Epidemiológicos

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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.
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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
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 2019Accepted 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.
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
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.
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.
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” and the National Council of
Population (Consejo Nacional de Población
The data obtained were analysed in the statistical
software package R© ( 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].
Escobar-Gutierrez et al. Geospatial tuberculosis in Tonala, Jalisco J Infect Dev Ctries 2020; 14(2):207-213.
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.
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 3075% 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.
n (%)
182 (50)
Treatment completed
73 (20)
Treatment failed
64 (17)
25 (7)
Loss to follow-up
20 (5)
Not evaluat ed
2 (1)
366 (100)
Treatment success
(cured +
97 86 90 81 68 48 303 (70)
Table 2. Characteristics of patients with tuberculosis in Tonala, Mexico 2013 -2015.
n (%)
16 (4)
91 (25)
123 (33)
84 (23)
over 60
52 (14)
366 (99)
107 ( 29)
259 (70)
366 (99)
Escobar-Gutierrez et al. Geospatial tuberculosis in Tonala, Jalisco J Infect Dev Ctries 2020; 14(2):207-213.
addition to several lung infection cases. In the
municipality of Tonala, the infection localization was
randomly distributed over the whole city.
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
Escobar-Gutierrez et al. Geospatial tuberculosis in Tonala, Jalisco J Infect Dev Ctries 2020; 14(2):207-213.
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.
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.
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
Conflict of interests: No conflict of interests is declared.
... Mexico's incidence of pulmonary tuberculosis is of 22 cases per 100,000 inhabitants, and 23,000 new cases were reported in 2018. The prevalence of aspergillosis secondary to tuberculosis is estimated at 1.2 million cases, one-third of them been aspergillomas [14]. ...
Full-text available
Introduction: Pulmonary aspergilloma is commonly associated with comorbidities that cause immunodeficiency such as diabetes mellitus, tuberculosis, human immunodeficiency virus/acquired immunodeficiency syndrome and/or a pre-existing parenchymal lung disease such as chronic obstructive pulmonary disease. Predisposing factors can further increase the risk of acquiring this mycosis. Our objective was to determine the frequency, clinical and microbiological characteristics of pulmonary aspergilloma in immunocompromised patients. Methodology: Retrospective case series of patients diagnosed with pulmonary aspergilloma in a respiratory care unit in Mexico City from 2000 to 2019 was studied. Bronchoalveolar lavage cultures on Sabouraud-dextrose agar and serum galactomannan determination were performed on each patient. Results: We identified twenty-four patients with pulmonary aspergilloma (sixteen male and eight female), thirteen had a history of tuberculosis (54%), seven of diabetes mellitus (29%), three of human immunodeficiency virus/acquired immunodeficiency syndrome (13%) and one of chronic obstructive pulmonary disease (4%). The most commonly reported symptoms were hemoptysis in eighteen patients (75%), dyspnea in sixteen patients (67%) and chest pain in thirteen patients (54%). Aspergillus fumigatus was identified in all cultures and galactomannan was positive in 21 serum samples (87%). Conclusions: Coexistence of diseases that could suppress the immune system predispose to pulmonary aspergilloma; clinical presentation is often confused with other systemic diseases. A high degree of clinical suspicion is important for early detection.
... Many studies have shown that tuberculosis is more prevalent among males and elderly people. [12,13] Similarly, the majority were from upper lower or lower class as found in other studies and there is increased risk of TB in persons with a lower socio-economic background. [14] This study found that around 52% of patients were malnourished and thus is a matter of concern as we have known that malnutrition adversely affects treatment outcome and compliance of tuberculosis patients. ...
Full-text available
Introduction: Under-nutrition increases the susceptibility to active tuberculosis and delays recovery. Nikshay Poshan Yojana provides a financial incentive of Rs. 500/month for each notified TB patient for a duration until the patient is on anti-TB treatment. Objectives: 1. To find out the utilization of the nutritional support scheme among TB patients. 2. To give evidence-based recommendations. Methods: It is a retrospective cross-sectional study conducted among TB patients. 2 DMC's in each of the 2TU (randomly selected from 12 TUs) were chosen. 83 patients responded to telephonic interview out of all patients registered in the last six months. The demographic details were collected from TB treatment cards and registers and other information by telephonic interview of 10-15 min each conducted over a period of 15-20 days. The quantitative data thus collected was analysed in terms of frequency, percentage and Chi-square test and qualitative data from patients and providers were analysed by thematic analysis. Results: Majority were of 40-60 years of age and were males. A total of 76 patients were aware of the scheme but only 17 patients had received their first instalment after two months in their account. Among the 17 who faced difficulty while getting the money, 13 TB patients spent it on nutrition. Lack of communication, stigma, unawareness, ignorance, illiteracy, multistep approval process and technical issues were few themes that emerged as difficulties encountered while utilisation. Conclusion: There is a large gap between demand and supply chain of services. A majority were unsatisfied and thus the administrative scale up for proper implementation of services and measures to bring down the stigma attached with the disease was recommended.
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Global retrospective human/plant epidemiology analysis exhibits a reactive cognitive development influenced by casuistic phenomena. Epidemic outbreaks of XXI century evidenced regression of the population-based approach to risk prevention and erosion of Public Health model, successful between 1950-1970. After 19 pandemics and 200 historical outbreaks, neither WHO nor public or private institutions, have not consolidated sustainable preventive models. Urban expansion and agricultural colonialism during the Industrial Revolution accelerated pandemic processes such as Black Death (Yersinia pestis), Cholera (Vibrio cholerae), Potato Blight (Phythopthora infestans) or Coffee Rust (Hemileia vastatrix). These factors contributed to the conception and application of the contagion and prevention principles by Snow/1854 or de Bary/1857, in the hygienism of Proust/1873, and the sanitation of Marshall/1882, before the etiological principle developed by Pasteur/1862 and Koch/1882. The contemporary scientific revolutions strengthened the reductionist hospital vision, with emphasis on cure as a principle, and on health privatization as a business strategy. The central epidemiology paradigm’s population is limited to the individual-patient or plant-damage. The COVID-19 cases curve (‘epidemic wave’) is not inherent to preventive epidemiology, ‘flattening’ lacks infectious basis, ‘healthy distance’ or ‘confinement’ are not sustainable mitigation strategies. The immunological emphasis did not generate the expected individual protection and ‘herd immunity’. Instead, it exacerbated the pharmaceutical-mercantilized vaccine ‘race’ to new variants; geopolitical protectionism; and unequal distribution of immunologicals. The SARS-CoV-2/COVID-19 pandemic evidenced the rational epidemiological framework deterioration; the absence of Surveillance Systems that articulate clinical detection and viral variants with community risks follow-up, enhanced with genomic and digital technology; the systematic failure of Public Health Systems; and the absence of a pansystemic model to integrate regional preventive models. Maximum case-fatality reduction from 15.2% in 2020 to 2.5 world average 2021, suggests an endemic transitional process. Worldwide reproduction rates Rt > 1 are consistent with more transmissible variants, such as Delta and Omicron, as sublethal survival ability of the virus. The pandemic has not been successfully intervened and its momentum is determined by biological attributes inherent to SARS-CoV-2.
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Background: Long-term survival and cause-specific mortality of patients who start tuberculosis treatment is rarely described. We aimed to assess the long-term survival of these patients and evaluate the association between vulnerable conditions (social, health behaviours, and comorbidities) and cause-specific mortality in a country with a high burden of tuberculosis. Methods: In this population-based, longitudinal study in São Paulo state, Brazil, we described the 5-year survival of patients who were newly diagnosed with tuberculosis in 2010. We included patients with newly-diagnosed tuberculosis, aged 15 years or older, and notified to the São Paulo State Tuberculosis Program in 2010. We excluded patients whose diagnosis had changed during follow-up (ie, they did not have tuberculosis) and patients who had multidrug-resistant (MDR) tuberculosis. We selected our population with tuberculosis from the dedicated electronic system TBweb. Our primary objective was to estimate the excess mortality over 5 years and within the group who survived the first year, compared with the general São Paulo state population. We also estimated the association between social vulnerability (imprisonment and homelessness), health behaviours (alcohol and drug use), and comorbidities (diabetes and mental disorders) with all-cause and cause-specific mortality. We used the competing risk analysis framework, estimating cause-specific hazard ratios (HRs) adjusted for potential confounding factors. Findings: In 2010, there were 19 252 notifications of tuberculosis cases. We excluded 550 cases as patients were younger than 15 years, 556 cases that were not tuberculosis, 2597 retreatments, and 48 cases of MDR tuberculosis, resulting in a final cohort of 15 501 patients with tuberculosis. Over a period of 5 years from tuberculosis diagnosis, 2660 (17%) of 15 501 patients died. Compared with the source population, matched by age, sex, and calendar year, the standardised mortality ratio was 6·47 (95% CI 6·22-6·73) over 5 years and 3·93 (3·71-4·17) among those who survived the first year. 1197 (45%) of 2660 deaths were due to infection. Homelessness and alcohol and drug use were associated with death from infection (adjusted cause-specific HR 1·60, 95% CI 1·39-1·85), cardiovascular (1·43, 1·06-1·95), and external or ill-defined causes of death (1·80, 1·37-2·36). Diabetes was associated with deaths from cardiovascular causes (1·70, 1·23-2·35). Interpretation: Patients newly diagnosed with tuberculosis were at a higher risk of death than were the source population, even after tuberculosis treatment. Post-tuberculosis sequelae and vulnerability are associated with excess mortality and must be addressed to mitigate the tuberculosis burden worldwide. Funding: Wellcome Trust.
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Background: Tuberculosis (TB) is the leading cause of death from an infectious disease in Ethiopia, killing more than 30 thousand people every year. This study aimed to determine whether the rates of poor TB treatment outcome varied geographically across Ethiopia at district and zone levels and whether such variability was associated with socioeconomic, behavioural, health care access, or climatic conditions. Methods: A geospatial analysis was conducted using national TB data reported to the health management information system (HMIS), for the period 2015-2017. The prevalence of poor TB treatment outcomes was calculated by dividing the sum of treatment failure, death and loss to follow-up by the total number of TB patients. Binomial logistic regression models were computed and a spatial analysis was performed using a Bayesian framework. Estimates of parameters were generated using Markov chain Monte Carlo (MCMC) simulation. Geographic clustering was assessed using the Getis-Ord Gi* statistic, and global and local Moran's I statistics. Results: A total of 223,244 TB patients were reported from 722 districts in Ethiopia during the study period. Of these, 63,556 (28.5%) were cured, 139,633 (62.4%) completed treatment, 6716 (3.0%) died, 1459 (0.7%) had treatment failure, and 12,200 (5.5%) were lost to follow-up. The overall prevalence of a poor TB treatment outcome was 9.0% (range, 1-58%). Hot-spots and clustering of poor TB treatment outcomes were detected in districts near the international borders in Afar, Gambelia, and Somali regions and cold spots were detected in Oromia and Amhara regions. Spatial clustering of poor TB treatment outcomes was positively associated with the proportion of the population with low wealth index (OR: 1.01; 95%CI: 1.0, 1.01), the proportion of the population with poor knowledge about TB (OR: 1.02; 95%CI: 1.01, 1.03), and higher annual mean temperature per degree Celsius (OR: 1.15; 95% CI: 1.08, 1.21). Conclusions: This study showed significant spatial variation in poor TB treatment outcomes in Ethiopia that was related to underlying socioeconomic status, knowledge about TB, and climatic conditions. Clinical and public health interventions should be targeted in hot spot areas to reduce poor TB treatment outcomes and to achieve the national End-TB Strategy targets.
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Objective: To examine how stratifying persons born outside Canada according to tuberculosis (TB) incidence in their birth country and other demographic factors refines our understanding of TB epidemiology and local TB transmission. Background: Population-level TB surveillance programs and research studies in low incidence settings often report all persons born outside the country in which the study is conducted as "foreign-born"-a single label for a highly diverse population with variable TB risks. This may mask important TB epidemiologic trends and not accurately reflect local transmission patterns. Methods: We used population-level data from two large cohorts in British Columbia (BC), Canada: an immigration cohort (n = 337,492 permanent residents to BC) and a genotyping cohort (n = 2290 culture-confirmed active TB cases). We stratified active TB case counts, incidence rates, and genotypic clustering (an indicator of TB transmission) in BC by birth country TB incidence, age at immigration, and years since arrival. Results: Persons from high-incidence countries had a 12-fold higher TB incidence than those emigrating from low-incidence settings. Estimates of local transmission, as captured by genotyping, versus reactivation of latent TB infection acquired outside Canada varied when data were stratified by birthplace TB incidence, as did patient-level characteristics of individuals in each group, such as age and years between immigration and diagnosis. Conclusion: Categorizing persons beyond simply "foreign-born", particularly in the context of TB epidemiologic and molecular data, is needed for a more accurate understanding of TB rates and patterns of transmission.
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Background Brazil is among the 30 countries with high-burden of tuberculosis worldwide, and Manaus is the capital with the highest tuberculosis incidence. The accelerated economic and population growth in Manaus in the last 30 years has strengthened the process of social stratification that may result in population groups that are less favored in terms of healthcare and are vulnerable to infection and illness due to tuberculosis. This study aimed to characterize inequalities associated with tuberculosis incidence in relation to the socioeconomic and demographic characteristics of the resident population of Manaus and to identify their determinants from 2007 to 2016. Methods An ecological study was conducted using the data from the Diseases Notification Information System. Tuberculosis incidence rates by population characteristics (gender, ethnicity, and socioeconomic level) were calculated for each year, studied, and represented in equiplot charts. To measure the disparity of tuberculosis incidence in the resident population in Manaus, the Gini index of tuberculosis in each neighborhood was calculated based on the incidence rates of the census sectors. A thematic map was constructed to represent the spatial distribution of tuberculosis incidence inequality. Linear regression models were used to identify the relationship between the tuberculosis incidence inequality and its social determinants. Results From 2007 to 2016, there was an increase in the tuberculosis incidence in Manaus, together with an increase in incident inequality among genders, ethnic groups, and socioeconomic level. The incidence of tuberculosis inequality was associated with the inequalities of its possible determinants (Gini of the proportion of male population, Gini of the proportion of indigenous population, Gini of the proportion of illiteracy, Gini of income, Gini of the proportion of households connected to the water network, and Gini of the mean number of bathrooms per inhabitant), the per capita income, and the proportion of cases with laboratory confirmation. Conclusions Disparities in tuberculosis incidence in the resident population in neighborhoods can be explained by the sociodemographic and economic heterogeneity. Our findings recommend that public policies and tuberculosis control strategies consider differences in the determinants of tuberculosis inequality for the development of specific actions for each population group.
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Background Tuberculosis (TB) transmission often occurs within a household or community, leading to heterogeneous spatial patterns. However, apparent spatial clustering of TB could reflect ongoing transmission or co-location of risk factors and can vary considerably depending on the type of data available, the analysis methods employed and the dynamics of the underlying population. Thus, we aimed to review methodological approaches used in the spatial analysis of TB burden. Methods We conducted a systematic literature search of spatial studies of TB published in English using Medline, Embase, PsycInfo, Scopus and Web of Science databases with no date restriction from inception to 15 February 2017. The protocol for this systematic review was prospectively registered with PROSPERO (CRD42016036655). Results We identified 168 eligible studies with spatial methods used to describe the spatial distribution (n = 154), spatial clusters (n = 73), predictors of spatial patterns (n = 64), the role of congregate settings (n = 3) and the household (n = 2) on TB transmission. Molecular techniques combined with geospatial methods were used by 25 studies to compare the role of transmission to reactivation as a driver of TB spatial distribution, finding that geospatial hotspots are not necessarily areas of recent transmission. Almost all studies used notification data for spatial analysis (161 of 168), although none accounted for undetected cases. The most common data visualisation technique was notification rate mapping, and the use of smoothing techniques was uncommon. Spatial clusters were identified using a range of methods, with the most commonly employed being Kulldorff’s spatial scan statistic followed by local Moran’s I and Getis and Ord’s local Gi(d) tests. In the 11 papers that compared two such methods using a single dataset, the clustering patterns identified were often inconsistent. Classical regression models that did not account for spatial dependence were commonly used to predict spatial TB risk. In all included studies, TB showed a heterogeneous spatial pattern at each geographic resolution level examined. Conclusions A range of spatial analysis methodologies has been employed in divergent contexts, with all studies demonstrating significant heterogeneity in spatial TB distribution. Future studies are needed to define the optimal method for each context and should account for unreported cases when using notification data where possible. Future studies combining genotypic and geospatial techniques with epidemiologically linked cases have the potential to provide further insights and improve TB control. Electronic supplementary material The online version of this article (10.1186/s12916-018-1178-4) contains supplementary material, which is available to authorized users.
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Background Developing countries like India are heavily burdened with multidrug resistant tuberculosis (MDR-TB). Materials and Methods A retrospective study was carried out at the directly observed treatment short course chemotherapy plus site in our tertiary care center (All India Institute of Medical Sciences, New Delhi) where records of all patients enrolled between 2009 and 2013 were reviewed. The aim of this study was to calculate the frequency of predefined outcomes in these patients receiving standardized treatment for MDR-TB. Results Out of a total of 819 patients, the frequency of outcomes in these patients was as follows: Cured (n = 415, 52%), default (n = 199, 24%), death (n = 130, 16%), switched to category V (n = 27, 3%), transferred out (n = 12, 1%), treatment failure (n = 13, 1%), and treatment completed (n = 23, 3%). Conclusion The modest cure rate in concordance with other Indian studies highlights the need for continuing efforts to fight the menace of MDR-TB.
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Setting: Tuberculosis (TB) stigma is thought to delay or prevent the decision to seek health care, but the strength of this association and the prevalence of anticipated TB stigma in the general population in most countries is unknown. Objective: To examine epidemiological, cultural and sociodemographic factors associated with TB courtesy stigma in 15 surveys across 13 countries, and its link to health seeking for cough in children under five. Design: A multilevel survey weighted logistic regression model was used to analyse how individual characteristics and social contexts affect the occurrence of TB courtesy stigma. The same modelling approach was used to analyse associations between TB courtesy stigma and individual-level predictors of health-seeking behaviour of mothers for children with cough. Results: TB courtesy stigma varies greatly among countries. TB courtesy stigma was negatively correlated with knowledge of TB's curability (adjusted OR [aOR] 0.82; 95%CI 0.78-0.86) and human immunodeficiency virus (HIV) accepting attitudes (proxy for HIV stigma) (aOR 0.15, 95%CI 0.15-0.16). Mothers' health-seeking behaviour for children under five with cough was found to be positively correlated with HIV accepting attitudes (OR 1.16, 95%CI 1.08-1.25), but was marginally affected by TB courtesy stigma (OR 0.99, 95%CI 0.98-1.00). Conclusion: Improving the general awareness of the effectiveness of anti-tuberculosis treatment will help to diminish TB courtesy stigma, and should be prioritised over expanding knowledge of mode of transmission. Efforts to reduce HIV and TB stigma may increase care seeking for childhood TB symptoms.
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The purpose of this study was to develop a method for identifying newly diagnosed tuberculosis (TB) patients at risk for TB adverse events in Tamaulipas, Mexico. Surveillance data between 2006 and 2013 (8431 subjects) was used to develop risk scores based on predictive modelling. The final models revealed that TB patients failing their treatment regimen were more likely to have at most a primary school education, multi-drug resistance (MDR)-TB, and few to moderate bacilli on acid-fast bacilli smear. TB patients who died were more likely to be older males with MDR-TB, HIV, malnutrition, and reporting excessive alcohol use. Modified risk scores were developed with strong predictability for treatment failure and death ( c -statistic 0·65 and 0·70, respectively), and moderate predictability for drug resistance ( c -statistic 0·57). Among TB patients with diabetes, risk scores showed moderate predictability for death ( c -statistic 0·68). Our findings suggest that in the clinical setting, the use of our risk scores for TB treatment failure or death will help identify these individuals for tailored management to prevent these adverse events. In contrast, the available variables in the TB surveillance dataset are not robust predictors of drug resistance, indicating the need for prompt testing at time of diagnosis.
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Introduction Many studies have explored the relationship between diabetes mellitus (DM) and tuberculosis (TB) demonstrating increased risk of TB among patients with DM and poor prognosis of patients suffering from the association of DM/TB. Owing to a paucity of studies addressing this question, it remains unclear whether patients with DM and TB are more likely than TB patients without DM to be grouped into molecular clusters defined according to the genotype of the infecting Mycobacterium tuberculosis bacillus. That is, whether there is convincing molecular epidemiological evidence for TB transmission among DM patients. Objective: We performed a systematic review and meta-analysis to quantitatively evaluate the propensity for patients with DM and pulmonary TB (PTB) to cluster according to the genotype of the infecting M. tuberculosis bacillus. Materials and methods We conducted a systematic search in MEDLINE and LILACS from 1990 to June, 2016 with the following combinations of key words “tuberculosis AND transmission” OR “tuberculosis diabetes mellitus” OR “Mycobacterium tuberculosis molecular epidemiology” OR “RFLP-IS6110” OR “Spoligotyping” OR “MIRU-VNTR”. Studies were included if they met the following criteria: (i) studies based on populations from defined geographical areas; (ii) use of genotyping by IS6110- restriction fragment length polymorphism (RFLP) analysis and spoligotyping or mycobacterial interspersed repetitive unit-variable number of tandem repeats (MIRU-VNTR) or other amplification methods to identify molecular clustering; (iii) genotyping and analysis of 50 or more cases of PTB; (iv) study duration of 11 months or more; (v) identification of quantitative risk factors for molecular clustering including DM; (vi) > 60% coverage of the study population; and (vii) patients with PTB confirmed bacteriologically. The exclusion criteria were: (i) Extrapulmonary TB; (ii) TB caused by nontuberculous mycobacteria; (iii) patients with PTB and HIV; (iv) pediatric PTB patients; (v) TB in closed environments (e.g. prisons, elderly homes, etc.); (vi) diabetes insipidus and (vii) outbreak reports. Hartung-Knapp-Sidik-Jonkman method was used to estimate the odds ratio (OR) of the association between DM with molecular clustering of cases with TB. In order to evaluate the degree of heterogeneity a statistical Q test was done. The publication bias was examined with Begg and Egger tests. Review Manager 5.3.5 CMA v.3 and Biostat and Software package R were used. Results Selection criteria were met by six articles which included 4076 patients with PTB of which 13% had DM. Twenty seven percent of the cases were clustered. The majority of cases (48%) were reported in a study in China with 31% clustering. The highest incidence of TB occurred in two studies from China. The global OR for molecular clustering was 0.84 (IC 95% 0.40–1.72). The heterogeneity between studies was moderate (I² = 55%, p = 0.05), although there was no publication bias (Beggs test p = 0.353 and Eggers p = 0.429). Conclusion There were very few studies meeting our selection criteria. The wide confidence interval indicates that there is not enough evidence to draw conclusions about the association. Clustering of patients with DM in TB transmission chains should be investigated in areas where both diseases are prevalent and focus on specific contexts.
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Tuberculosis (TB) remains one of the leading causes of morbidity and mortality worldwide. Extrapulmonary tuberculosis (EPTB) constitutes around 15-20% of TB cases in immunocompetent individuals. Extrapulmonary sites that are affected by TB include bones, lymph nodes, meningitis, pleura, and genitourinary tract. Whole genome sequencing has emerged as a powerful tool to map genetic diversity among Mycobacterium tuberculosis (MTB) isolates and identify the genomic signatures associated with drug resistance, pathogenesis, and disease transmission. Several pulmonary isolates of MTB have been sequenced over the years. However, availability of whole genome sequences of MTB isolates from extrapulmonary sites is limited. Some studies suggest that genetic variations in MTB might contribute to disease presentation in extrapulmonary sites. This can be addressed if whole genome sequence data from large number of extrapulmonary isolates becomes available. In this study, we have performed whole genome sequencing of five MTB clinical isolates derived from EPTB sites using next-generation sequencing platform. We identified 1434 nonsynonymous single nucleotide variations (SNVs), 143 insertions and 105 deletions. This includes 279 SNVs that were not reported before in publicly available datasets. We found several mutations that are known to confer resistance to drugs. All the five isolates belonged to East-African-Indian lineage (lineage 3). We identified 9 putative prophage DNA integrations and 14 predicted clustered regularly interspaced short palindromic repeats (CRISPR) in MTB genome. Our analysis indicates that more work is needed to map the genetic diversity of MTB. Whole genome sequencing in conjunction with comprehensive drug susceptibility testing can reveal clinically relevant mutations associated with drug resistance.