title: Tuberculosis incidence correlates with sunshine: an ecological 28-year time series study.
abstract: BACKGROUND
  Birmingham is the largest UK city after London, and central Birmingham has an annual tuberculosis incidence of 80 per 100,000. We examined seasonality and sunlight as drivers of tuberculosis incidence. Hours of sunshine are seasonal, sunshine exposure is necessary for the production of vitamin D by the body and vitamin D plays a role in the host response to tuberculosis.
  
  
  METHODS
  We performed an ecological study that examined tuberculosis incidence in Birmingham from Dec 1981 to Nov 2009, using publicly-available data from statutory tuberculosis notifications, and related this to the seasons and hours of sunshine (UK Meteorological Office data) using unmeasured component models.
  
  
  RESULTS
  There were 9,739 tuberculosis cases over the study period. There was strong evidence for seasonality, with notifications being 24.1% higher in summer than winter (p<0.001). Winter dips in sunshine correlated with peaks in tuberculosis incidence six months later (4.7% increase in incidence for each 100 hours decrease in sunshine, p<0.001).
  
  
  CONCLUSIONS
  A potential mechanism for these associations includes decreased vitamin D levels with consequent impaired host defence arising from reduced sunshine exposure in winter. This is the longest time series of any published study and our use of statutory notifications means this data is essentially complete. We cannot, however, exclude the possibility that another factor closely correlated with the seasons, other than sunshine, is responsible. Furthermore, exposure to sunlight depends not only on total hours of sunshine but also on multiple individual factors. Our results should therefore be considered hypothesis-generating. Confirmation of a potential causal relationship between winter vitamin D deficiency and summer peaks in tuberculosis incidence would require a randomized-controlled trial of the effect of vitamin D supplementation on future tuberculosis incidence.
authors.affiliation: Department of Infection and Tropical Medicine, Heartlands Hospital, Birmingham, United Kingdom. gavin.koh@gmail.com
authors.forename: Gavin C K W
authors.initials: GC
authors.lastname: Koh
authors.forename: Gemma
authors.initials: G
authors.lastname: Hawthorne
authors.forename: Alice M
authors.initials: AM
authors.lastname: Turner
authors.forename: Heinke
authors.initials: H
authors.lastname: Kunst
authors.forename: Martin
authors.initials: M
authors.lastname: Dedicoat
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D017753:Ecosystem; D005260:Female; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D012621:Seasons; D013472:Sunlight; D013997:Time Factors; D014376:Tuberculosis / Q000453:epidemiology*; D006113:United Kingdom / Q000453:epidemiology; D055815:Young Adult