Effects of long-term ambient air pollution exposure on township-level pulmonary tuberculosis notification rates during 2005-2017 in Ningxia, China

Igor Popovic; Ricardo J Soares Magalhães; Yurong Yang; Shukun Yang; Boyi Yang; Guanghui Dong; Xiaolin Wei; Greg J Fox; Melanie S Hammer; Randall V Martin; Aaron van Donkelaar; Erjia Ge; Guy B Marks; Luke D Knibbs

doi:10.1016/j.envpol.2022.120718

Effects of long-term ambient air pollution exposure on township-level pulmonary tuberculosis notification rates during 2005-2017 in Ningxia, China

Environ Pollut. 2023 Jan 15:317:120718. doi: 10.1016/j.envpol.2022.120718. Epub 2022 Nov 23.

Authors

Igor Popovic¹, Ricardo J Soares Magalhães², Yurong Yang³, Shukun Yang⁴, Boyi Yang⁵, Guanghui Dong⁶, Xiaolin Wei⁷, Greg J Fox⁸, Melanie S Hammer⁹, Randall V Martin¹⁰, Aaron van Donkelaar¹⁰, Erjia Ge⁷, Guy B Marks¹¹, Luke D Knibbs¹²

Affiliations

¹ Faculty of Medicine, School of Public Health, University of Queensland, Herston, 4006, Australia; UQ Spatial Epidemiology Laboratory, School of Veterinary Science, University of Queensland, Gatton, 4343, Australia. Electronic address: i.popovic@uq.edu.au.
² UQ Spatial Epidemiology Laboratory, School of Veterinary Science, University of Queensland, Gatton, 4343, Australia; Children's Health and Environment Program, UQ Children's Health Research Center, The University of Queensland, South Brisbane, 4101, Australia.
³ Department of Pathogenic Biology & Medical Immunology, School of Basic Medical Science, Ningxia Medical University, Yinchuan, 750004, China.
⁴ Department of Radiology, The Second Affiliated Hospital of Ningxia Medical University, The First People's Hospital in Yinchuan, Yinchuan, 750004, China.
⁵ Guangdong Provincial Engineering Technology Research Center of Environmental Pollution and Health Risk Assessment, Department of Occupational and Environmental Health, School of Public Health, Sun Yat-sen University, Guangzhou, 510085, China.
⁶ Guangzhou Key Laboratory of Environmental Pollution and Health Risk Assessment, Department of Preventive Medicine, School of Public Health, Sun Yat-sen University, Guangzhou, 510085, China.
⁷ Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5S 1A1, Canada.
⁸ Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, NSW, 2006, Australia.
⁹ Department of Energy, Environmental, and Chemical Engineering, Washington University, St Louis, 63130, United States.
¹⁰ Department of Energy, Environmental, and Chemical Engineering, Washington University, St Louis, 63130, United States; Department of Physics and Atmospheric Science, Dalhousie University, Halifax, B3H 3J5, Canada.
¹¹ South Western Sydney Clinical School, University of New South Wales, Liverpool, 2170, Australia; Woolcock Institute of Medical Research, Glebe, 2037, Australia.
¹² Public Health Unit, Sydney Local Health District, Camperdown, 2050, Australia; Faculty of Medicine and Health, School of Public Health, The University of Sydney, Camperdown, 2006, Australia.

PMID: 36435281
DOI: 10.1016/j.envpol.2022.120718

Abstract

Studies examining long-term effects of ambient air pollution exposure, measured as annual averages, on pulmonary tuberculosis (TB) incidence are scarce, particularly in endemic, rural settings. We performed a small-area study in Ningxia Hui Autonomous Region (NHAR), a high TB-burden area in rural China, using township-level (n = 358 non-overlapping townships) annual TB notification data (2005-2017). We aimed to determine if annual average concentrations of ambient air pollution (particulate matter <2·5 μm [PM_2·5], nitrogen dioxide [NO₂] ozone [O₃]) were associated with TB notification rates (as a proxy for incidence). Air pollution effects on TB notification rates at township-level were estimated as incidence rate ratios (IRR), fitted using a generalised estimating equation (GEE) adjusted for covariates (age, sex, occupation, education, ethnicity, remoteness [urban or rural], household crowding and solid fuel use). A total of 38,942 TB notifications were reported in NHAR between 2005 and 2017. The mean annual TB notification rate was 67 (standard deviation [SD]; 7) per 100,000 people. Median concentrations of PM_2·5, NO₂, and O₃ were 42 μg/m³ (interquartile range [IQR]; 38-48 μg/m³), 15 ppb (IQR; 12-16 ppb), and 56 ppb (IQR; 56-57 ppb), respectively. In single pollutant models, adjusted for covariates, an interquartile range (IQR) increase (10 μg/m³) in PM_2·5 was significantly associated with higher TB notification rates (IRR: 1∙35; 95% CI: 1·25-1·48). Comparable effects on notifications of TB were observed for increases in NO₂ exposure (IRR: 1·20 per IQR (4 ppb) increase; 95% CI: 1·08-1·31). Ground-level ozone was not associated with TB notification rate in any models. The observed effects were consistent over time, in multi-pollutant models, and appeared robust to additional adjustment for indicators of household crowding, solid fuel use and remoteness. More rigorous study designs are needed to understand if improving air quality has population-level benefits on TB disease incidence in endemic settings.

Keywords: Ambient air pollution; Ground level ozone; Nitrogen dioxide; Particulate matter; TB; Tuberculosis.

MeSH terms

Air Pollutants* / analysis
Air Pollution* / analysis
China / epidemiology
Crowding
Environmental Exposure / analysis
Environmental Pollutants*
Family Characteristics
Humans
Nitrogen Dioxide / analysis
Ozone* / analysis
Particulate Matter / analysis
Tuberculosis, Pulmonary* / epidemiology

Substances

Air Pollutants
Nitrogen Dioxide
Particulate Matter
Ozone
Environmental Pollutants