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.affiliation: División de Enfermedades Infecciosas y Medicina Geográfica, Facultad de Medicina, Universidad de Stanford, California, Estados Unidos de América, jandr@stanford.edu.
authors.forename: J R
authors.initials: JR
authors.lastname: Andrews
authors.affiliation: Centro de Investigación en Prevención de Stanford, Facultad de Medicina, Universidad de Stanford, Stanford, California, Estados Unidos de América.
authors.forename: S
authors.initials: S
authors.lastname: Basu
authors.affiliation: Departamento de Epidemiología, Escuela de Salud Pública Bloomberg, Universidad Johns Hopkins, Baltimore, Maryland, Estados Unidos de América.
authors.forename: D W
authors.initials: DW
authors.lastname: Dowdy
authors.affiliation: Departamento de Salud Mundial y Medicina Social, Escuela de Medicina de Harvard, Boston, Massachusetts, Estados Unidos de América.
authors.forename: M B
authors.initials: MB
authors.lastname: Murray
mesh_terms: D006801:Humans; D007194:India / Q000453:epidemiology; D014376:Tuberculosis / Q000175:diagnosis / Q000453:epidemiology*