Comment
The social drivers of tuberculosis, reconfirmed
“As long as there are crowds of poor people living in poor houses 5 years, who are usually less infectious. These findings
and who are food insecure and unable to access health services highlight the need for ruling out (or confirming)
of a certain level of quality, we will continue to have TB for a
long while to come.” tuberculosis disease with chest radiographs in contacts
of all ages—including children younger than 5 years—
Flickr - Frontierofficial
Prof Chakaya Muhwa, Liverpool School of Tropical Medicine
before starting tuberculosis preventive treatment,
Tuberculosis, the number one infectious killer, affects given the high prevalence of co-prevalent tuberculosis
mostly people on low incomes. All 30 countries with a in young children. Importantly, the risk in older children
high burden of tuberculosis, which comprise 87% of all and young adults remained high for the entire follow- Lancet Infect Dis 2023
new tuberculosis cases, are low-income and middle- up period, up to 15 years, which suggests ongoing Published Online
August 14, 2023
income countries (LMICs).1 Within these countries, tuberculosis transmission, whether in the household or https://doi.org/10.1016/
people living in urban slums have 3-fold higher odds more likely in the community. Tuberculosis incidence S1473-3099(23)00390-0
See Online/Articles
of smear-positive tuberculosis than the general was also higher among the lowest income households
https://doi.org/10.1016/
population.2 Other individual and environmental (ie, Black and Pardo contacts, less educated, and living S1473-3099(23)00371-7
factors increase the odds of tuberculosis infection in poor housing conditions). Due to the observational
and progression to tuberculosis disease. Household design of the study and of the variables available for
contacts of people living with tuberculosis have a high analyses in the databanks, the authors were not able
risk of tuberculosis infection,3 particularly in low income to confirm the well-known reduced risk by tuberculosis
households, due to crowding,4,5 poor house ventilation,5 preventive treatment or by other individual-level
and increased transmission in the same community as interventions. Delayed diagnosis was arguably
the index patient.6,7 Additionally, risk of progression suggested in cities with lower quality tuberculosis
to disease after infection is increased among contacts primary care service indicators.
with HIV infection, diabetes, and malnutrition—all As concluded by the authors, better tuberculosis
more prevalent among those with low income, as well services, with active case and infection finding,
as children younger than 5 years.6,8 Last but not least, followed by appropriate treatment are indeed
tuberculosis causes further impoverishment, as people necessary to improve tuberculosis indicators. However,
living with tuberculosis often incur catastrophic costs9 more is needed. Previous studies have shown that
and have long-term disabilities.10 coverage by the Brazilian Family Health Strategy
In The Lancet Infectious Diseases, Priscila Pinto and reduces unsuccessful tuberculosis outcomes, as does
colleagues shed light on the substantial vulnerability of the Cash Transfer Program Bolsa Família.12 A recent
young Brazilian children from low income households randomised clinical trial in India found that a monthly
exposed to tuberculosis.11 A large cohort of cohabitants food supplement (750 calories, 23 g of protein per day
of people on low incomes living with any form of with micronutrients) reduced the risk of tuberculosis
tuberculosis registered to the social benefit database incidence in household contacts of people living
CadÚnico was evaluated for co-prevalent and incident with tuberculosis by 39% (52% for microbiologically
tuberculosis. Using validated linkage techniques confirmed tuberculosis) over 2 years.13
of CadÚnico with the tuberculosis notification To advance towards tuberculosis elimination, social
information system, the authors confirmed the high protection is crucial not only for people living with
risk of tuberculosis in this cohort, at 16-fold higher than tuberculosis but for all their family members. WHO
non-cohabitants, especially in children younger than has congratulated the Brazilian Federal Government
5 years, in whom the risk was 62-fold higher. As in a for the decree number 11 494 of April 17, 2023, that
previous systematic review,8 the risk was higher in the created an inter-ministerial committee, composed of
first 6 months, suggesting that these young children representatives of nine different ministries, to work
were possibly a secondary case in the household (co- together for the elimination of tuberculosis and other
prevalent tuberculosis). Surprisingly, the risk was also socially determined diseases in the country.14 The
higher when the index patient was a child younger than study by Pinto and colleagues corroborates the need
www.thelancet.com/infection Published online August 14, 2023 https://doi.org/10.1016/S1473-3099(23)00390-0 1
Comment
for urgent social interventions in Brazil—the inter- 7 Crawford FW, Marx FM, Zelner J, Cohen T. Transmission modeling with
regression adjustment for analyzing household-based studies of infectious
ministerial committee needs to act now. Other LMIC disease: application to tuberculosis. Epidemiology 2020; 31: 238–47.
leaders should also commit to eliminating tuberculosis 8 Martinez L, Cords O, Horsburgh CR, Andrews JR, Pediatric TB. The risk of
tuberculosis in children after close exposure: a systematic review and
through better patient-centred tuberculosis care and individual-participant meta-analysis. Lancet 2020; 395: 973–84.
social protection, including food and cash incentives for 9 Ghazy RM, El Saeh HM, Abdulaziz S, et al. A systematic review and meta-
analysis of the catastrophic costs incurred by tuberculosis patients. Sci Rep
the entire household. 2022; 12: 558.
I declare no competing interests. 10 Nightingale R, Carlin F, Meghji J, et al. Post-TB health and wellbeing.
Int J Tuberc Lung Dis 2023; 27: 248–83.
Anete Trajman 11 Pinto PFPS, Teixeira CSS, Ichihara MY, et al. Incidence and risk factors of
[email protected] tuberculosis among 420 854 household contacts of patients with
tuberculosis in the 100 Million Brazilian Cohort (2004–18): a cohort study.
Federal University of Rio de Janeiro, Rio de Janeiro 21941-617, Brazil; McGill Lancet Infect Dis 2023; published online Aug 14. https://doi.org/10.1016/
University, Montreal, QC, Canada S1473-3099(23)00371-7.
1 WHO. Global tuberculosis report 2022. Geneva: World Health Organization, 12 Durovni B, Saraceni V, Puppin MS, et al. The impact of the Brazilian Family
2022. Health Strategy and the conditional cash transfer on tuberculosis
treatment outcomes in Rio de Janeiro: an individual-level analysis of
2 Noykhovich E, Mookherji S, Roess A. The risk of tuberculosis among
secondary data. J Public Health 2018; 40: e359–66.
populations living in slum settings: a systematic review and meta-analysis.
J Urban Health 2019; 96: 262–75. 13 Bhargava A, Bhargava M, Meher A, et al. Nutritional supplementation to
prevent TB incidence in household-contacts of patients with pulmonary
3 Fox GJ, Barry SE, Britton WJ, Marks GB. Contact investigation for
tuberculosis: results from the RATIONS, a field-based open-label cluster-
tuberculosis: a systematic review and meta-analysis. Eur Respir J 2013;
randomized controlled trial in Jharkhand, India. SSRN 2023; published
41: 140–56.
online May 19. https://papers.ssrn.com/sol3/papers.cfm?abstract_
4 Lienhardt C, Sillah J, Fielding K, et al. Risk factors for tuberculosis infection id=4452011 (preprint).
in children in contact with infectious tuberculosis cases in The Gambia,
14 WHO. WHO applauds Brazil’s leadership in advancing multisectoral
West Africa. Pediatrics 2003; 111: e608–14.
engagement towards ending TB. April 21, 2023. https://www.who.int/
5 Saunders MJ, Wingfield T, Tovar MA, et al. A score to predict and stratify risk news/item/21-04-2023-who-applauds-brazil-s-leadership-in-advancing-
of tuberculosis in adult contacts of tuberculosis index cases: a prospective multisectoral-engagement-towards-ending-tb (accessed June 9, 2023).
derivation and external validation cohort study. Lancet Infect Dis 2017;
17: 1190–99.
6 McIntosh AI, Jenkins HE, Horsburgh CR, et al. Partitioning the risk of
tuberculosis transmission in household contact studies. PLoS One 2019;
14: e0223966.
2 www.thelancet.com/infection Published online August 14, 2023 https://doi.org/10.1016/S1473-3099(23)00390-0
