Comparison of two area-level socioeconomic deprivation indices: Implications for public health research, practice, and policy.

OBJECTIVES: To compare 2 frequently used area-level socioeconomic deprivation indices: the Area Deprivation Index (ADI) and the Social Vulnerability Index (SVI). METHODS: Index agreement was assessed via pairwise correlations, decile score distribution and mean comparisons, and mapping. The 2019 ADI and 2018 SVI indices at the U.S. census tract-level were analyzed. RESULTS: Index correlation was modest (R = 0.51). Less than half (44.4%) of all tracts had good index agreement (0-1 decile difference). Among the 6.3% of tracts with poor index agreement (≥6 decile difference), nearly 1 in 5 were classified by high SVI and low ADI scores. Index items driving poor agreement, such as high rents, mortgages, and home values in urban areas with characteristics indicative of socioeconomic deprivation, were also identified. CONCLUSIONS: Differences in index dimensions and agreement indicated that ADI and SVI are not interchangeable measures of socioeconomic deprivation at the tract level. Careful consideration is necessary when selecting an area-level socioeconomic deprivation measure that appropriately defines deprivation relative to the context in which it will be used. How deprivation is operationalized affects interpretation by researchers as well as public health practitioners and policymakers making decisions about resource allocation and working to address health equity.

Making the invisible visible: the current face of tuberculosis in Detroit, Michigan, USA.

Objectives: The objective of this study was to describe the socioeconomic inequities among individuals with tuberculosis (TB) in metropolitan Detroit. Methods: We used data from the TB Social Survey to examine socioeconomic and demographic characteristics among individuals diagnosed with TB in one of three metropolitan Detroit health departments. We then examined mean levels of both economic disadvantage and socioeconomic instability across levels of race/ethnicity, nativity, and health department. Results: Sixty-seven percent of individuals with TB in Detroit City were non-Hispanic Black, compared to 27% and 25% in Oakland County and Wayne County (excluding Detroit), respectively. Non-Hispanic Blacks, U.S.-born individuals, and those living in Detroit City had higher mean levels of both economic disadvantage and socioeconomic instability compared to non-Hispanic Whites, foreign-born individuals and those living in Wayne (excluding Detroit City) or Oakland County. Conclusions: The findings from this study highlight the ways in which TB is distributed along lines of socioeconomic disadvantage. This suggests that enduring inequities in socioeconomic resources may be contributing to inequities in TB disease, a trend that is likely to continue with worsening socioeconomic disparities in the U.S.

A Geography of Risk: Structural Racism and Coronavirus Disease 2019 Mortality in the United States.

Coronavirus disease 2019 (COVID-19) is disproportionately burdening racial and ethnic minority groups in the United States. Higher risks of infection and mortality among racialized minorities are a consequence of structural racism, reflected in specific policies that date back centuries and persist today. Yet our surveillance activities do not reflect what we know about how racism structures risk. When measuring racial and ethnic disparities in deaths due to COVID-19, the Centers for Disease Control and Prevention statistically accounts for the geographic distribution of deaths throughout the United States to reflect the fact that deaths are concentrated in areas with different racial and ethnic distributions from those of the larger United States. In this commentary, we argue that such an approach misses an important driver of disparities in COVID-19 mortality, namely the historical forces that determine where individuals live, work, and play, and that consequently determine their risk of dying from COVID-19. We explain why controlling for geography downplays the disproportionate burden of COVID-19 on racialized minority groups in the United States. Finally, we offer recommendations for the analysis of surveillance data to estimate racial disparities, including shifting from distribution-based to risk-based measures, to help inform a more effective and equitable public health response to the pandemic.

Life Course Socioeconomic Disadvantage and the Aging Immune System: Findings From the Health and Retirement Study.

OBJECTIVES: Previous research has documented a consistent association between current socioeconomic status (SES) and cytomegalovirus (CMV). Early life is likely a critical period for CMV exposure and immune development, but less is known about early-life socioeconomic factors and CMV, particularly in older age populations. Using data from the Health and Retirement Study, we investigated the association between life course socioeconomic disadvantage and immune response to CMV among older adults. METHODS: Using ordered logit models, we estimated associations between several measures of socioeconomic disadvantage and the odds of being in a higher CMV Immunoglobulin G (IgG) response category in a sample of 8,168 respondents aged older than 50 years. RESULTS: We found a significant association between educational attainment and CMV IgG response. Those with less than a high school education had 2.00 (95% confidence interval [CI]: 1.67-2.40) times the odds of being in a higher CMV category compared to those with a college degree or greater. In addition, we also observed a significant association with parental education and CMV response. Individuals with parents having 8 years or less of schooling had 2.32 (95% CI: 2.00-2.70) times the odds of higher CMV response compared to those whose parents had greater than high school education. DISCUSSION: CMV IgG levels in older adults are associated with both early-life and adult SES. Life course socioeconomic disadvantage may contribute to disparities in immunological aging.

Race/Ethnic and Educational Disparities in the Association Between Pathogen Burden and a Laboratory-Based Cumulative Deficits Index.

BACKGROUND: Disparities in adult morbidity and mortality may be rooted in patterns of biological dysfunction in early life. We sought to examine the association between pathogen burden and a cumulative deficits index (CDI), conceptualized as a pre-clinical marker of an unhealthy biomarker profile, specifically focusing on patterns across levels of social disadvantage. METHODS: Using the data from the National Health and Nutrition Examination Survey 2003-2004 wave (aged 20-49 years), we examined the association of pathogen burden, composed of seven pathogens, with the CDI. The CDI comprised 28 biomarkers corresponding to available clinical laboratory measures. Models were stratified by race/ethnicity and education level. RESULTS: The CDI ranged from 0.04 to 0.78. Nearly half of Blacks were classified in the high burden pathogen class compared with 8% of Whites. Among both Mexican Americans and other Hispanic groups, the largest proportion of individuals were classified in the common pathogens class. Among educational classes, 19% of those with less than a high school education were classified in the high burden class compared with 7% of those with at least a college education. Blacks in the high burden pathogen class had a CDI 0.05 greater than those in the low burden class (P < 0.05). Whites in the high burden class had a CDI only 0.03 greater than those in the low burden class (P < 0.01). DISCUSSION: Our findings suggest there are significant social disparities in the distribution of pathogen burden across race/ethnic groups, and the effects of pathogen burden may be more significant for socially disadvantaged individuals.

Understanding the intersection of race and place: the case of tuberculosis in Michigan.

BACKGROUND: Race and place intersect to produce location-based variation in disease distributions. We analyzed the geographic distribution of tuberculosis (TB) incidence in Michigan, USA to better understand the complex interplay between race and place, comparing patterns in Detroit, Wayne County and the state of Michigan as a whole. METHODS: Using cross-sectional TB surveillance data from the Michigan Department of Health and Human Services, multivariable statistical models were developed to analyze the residence patterns of TB incidence from 2007 through 2012. Two-way interactions among the residence location and race of cases were assessed. RESULTS: Overall, Detroit residents experienced 58% greater TB incidence than residents of Wayne County or the state of Michigan. Racial inequalities were less pronounced in Detroit compared to both Wayne County and the state of Michigan. Blacks in Detroit had 2.01 times greater TB incidence than Whites, while this inequality was 3.62 times more in Wayne County and 8.72 greater in the state of Michigan. CONCLUSION: Our results highlight how race and place interact to influence patterns of TB disease, and the ways in which this interaction is context dependent. TB elimination in the U.S. will require strategies that address the local social environment, as much as the physical environment.

Contextualizing tuberculosis risk in time and space: comparing time-restricted genotypic case clusters and geospatial clusters to evaluate the relative contribution of recent transmission to incidence of TB using nine years of case data from Michigan, USA.

PURPOSE: Novel approaches must address the underlying factors sustaining the tuberculosis (TB) epidemic in the United States, specifically what maintains new Mycobacterium tuberculosis (Mtb) transmission. METHODS: Culture-confirmed TB cases reported to the Michigan Department of Health and Human Services (2004-2012) were analyzed for time-restricted genotypic and/or geospatial clustering. Cases with both types of clustering were used as a proxy for recent, local transmission. Modified, multivariate Poisson regression models were fit to estimate this prevalence in relation to various individual- and neighborhood-level demographic and socio-economic variables. RESULTS: Those individuals that were spatially clustered were 1.7 times as likely to also be time-restricted genotypically clustered. The prevalence of recent, local transmission was higher among U.S.-born cases, males, and non-Hispanic blacks. Moreover, people living in neighborhoods in the highest poverty quartile had 13.8 times the prevalence of recent, local transmission compared with those in the lowest poverty neighborhoods. CONCLUSIONS: Our results suggest geographic areas with high concentration of TB cases are likely driven by ongoing transmission, rather than enclaves of individuals who have reactivated a case of latent TB. Furthermore, efforts to continue reducing Mtb transmission in the United States, and other low-incidence settings, must better identify community-level sources of risk, manifested through the complex social interactions among people and their environments.

The Modern Profile of Tuberculosis: Developing the TB Social Survey to understand contemporary social patterns in tuberculosis.

Social disparities in tuberculosis have been documented for decades, yet to date there has not been a comprehensive study to examine the contemporary causes of these disparities. Local public health departments, and particularly public health nursing staff are charged with delivering directly observed therapy to individuals with tuberculosis disease. As a result of the frequency and duration of treatment, practitioners delivering therapy are often well-acquainted with the lives and challenges of their constituents. Thus, through these practitioners there exists a deep repository of knowledge on the drivers of social disparities in tuberculosis disease. Partnering with local public health departments, we developed a survey instrument aimed at understanding the social profile of individuals with tuberculosis disease in metropolitan Detroit, Michigan. We discuss the development and implementation of the survey instrument as well as challenges in developing partnerships between academic researchers and local public health practitioners. This study can serve as a framework for both academic researchers and public health practitioners interested in addressing social disparities in infectious disease.

Individual- and neighborhood-level contextual factors are associated with Mycobacterium tuberculosis transmission: genotypic clustering of cases in Michigan, 2004-2012.

PURPOSE: Using genotyping data of Mycobacterium tuberculosis isolates from new cases reported to the tuberculosis (TB) surveillance program, we evaluated risk factors for recent TB transmission at both the individual- and neighborhood- levels among U.S.-born and foreign-born populations. METHODS: TB cases (N = 1236) reported in Michigan during 2004 to 2012 were analyzed using multivariable Poisson regression models to examine risk factors for recent transmission cross-sectionally for U.S.-born and foreign-born populations separately. Recent transmission was defined based on spoligotype and 12-locus-mycobacterial interspersed repetitive unit-variable number tandem repeat typing matches of bacteria from cases that were diagnosed within 1 year of each other. Four classes of predictor variables were examined: demographic factors, known TB risk factors, clinical characteristics, and neighborhood-level factors. RESULTS: Overall, 22% of the foreign-born cases resulted from recent transmission. Among the foreign-born, race and being a contact of an infectious TB case were significant predictors of recent transmission. More than half (52%) of U.S.-born cases resulted from recent transmission. Among the U.S.-born, recent transmission was predicted by both individual- and neighborhood-level sociodemographic characteristics. CONCLUSIONS: Interventions aimed at reducing TB incidence among foreign-born should focus on reducing reactivation of latent infection. However, reducing TB incidence among the U.S.-born will require decreasing transmission among socially disadvantaged groups at the individual- and neighborhood- levels. This report fills an important knowledge gap regarding the contemporary social context of TB in the United States, thereby providing a foundation for future studies of public health policies that can lead to the development of more targeted, effective TB control.

Race and nativity are major determinants of tuberculosis in the U.S.: evidence of health disparities in tuberculosis incidence in Michigan, 2004-2012.

BACKGROUND: The incidence of TB in Michigan was 1.5 per 100,000 people in 2012, roughly half the U.S. incidence. Despite successes in TB control, disparities in TB still exist in Michigan, particularly by race, age, and nativity. A major challenge in understanding disparities in TB burden is distinguishing between TB cases resulting from recent transmission and those resulting from reactivation of latent TB infection, information critical to tailoring control strategies. We examined nine-year trends in tuberculosis (TB) incidence patterns for the entire population of Michigan, and within demographic subgroups. METHODS: Using a cross-sectional study of TB surveillance data, we analyzed 1254 TB cases reported in Michigan during 2004-2012. Cases included were those for whom both spoligotyping and 12-locus-MIRU-VNTR results were available. Using a combination of the genotyping information and time of diagnosis, we then classified cases as resulting from either recent transmission or reactivation of latent TB infection. We used multivariable negative binomial regression models to study trends in the TB incidence rate for the entire population and by race, nativity, gender, and age. RESULTS: Overall, the incidence rate of TB declined by an average of 8% per year-11% among recently transmitted cases, and 9% among reactivation cases. For recently transmitted disease, Blacks had an average incidence rate 25 times greater than Whites, after controlling for nativity, gender, and age. For disease resulting from latent TB infection Asians had an average incidence rate 24 times greater than Whites, after controlling for nativity, gender, and age. CONCLUSIONS: Disparities in incidence persist despite ongoing TB control efforts. Greater disparities were observed by race and nativity demonstrating some of the ways that TB incidence is socially patterned. Reducing these disparities will require a multi-faceted approach encompassing the social and environmental contexts of high-risk populations.