title: The epidemiological advantage of preferential targeting of tuberculosis control at the poor.
abstract: Tuberculosis (TB) remains disproportionately concentrated among the poor, yet known determinants of TB reactivation may fail to explain observed disparities in disease rates according to wealth. Reviewing data on TB disparities in India and the wealth distribution of known TB risk factors, we describe how social mixing patterns could be contributing to TB disparities. Wealth-assortative mixing, whereby individuals are more likely to be in contact with others from similar socio-economic backgrounds, amplifies smaller differences in risk of TB, resulting in large population-level disparities. As disparities and assortativeness increase, TB becomes more difficult to control, an effect that is obscured by looking at population averages of epidemiological parameters, such as case detection rates. We illustrate how TB control efforts may benefit from preferential targeting toward the poor. In India, an equivalent-scale intervention could have a substantially greater impact if targeted at those living below the poverty line than with a population-wide strategy. In addition to potential efficiencies in targeting higher-risk populations, TB control efforts would lead to a greater reduction in secondary TB cases per primary case diagnosed if they were preferentially targeted at the poor. We highlight the need to collect programmatic data on TB disparities and explicitly incorporate equity considerations into TB control plans.
authors: Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA.
authors: J R
authors: JR
authors: Andrews
authors: Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, USA.
authors: S
authors: S
authors: Basu
authors: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors: D W
authors: DW
authors: Dowdy
authors: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.
authors: M B
authors: MB
authors: Murray
mesh_terms: D054624:Health Status Disparities; D006801:Humans; D007194:India / Q000453:epidemiology; D011203:Poverty; D012959:Socioeconomic Factors; D014376:Tuberculosis / Q000453:epidemiology* / Q000517:prevention & control*