||Correlations of pulmonary tuberculosis with air pollutants and other environmental factors in Taiwan
||Institute of Environmental and Occupational Health
結果與討論：從2004年到2011年的健保資料庫百萬抽樣歸人檔中，總共有6,770名結核病患者，其中一線用藥與二線用藥的病人各占了6,477人及293人，並選取33,346名樣本作為對照組。在共病症方面，三組人不管在糖尿病、氣喘、肺阻塞、愛滋病及塵肺症皆有統計上的顯著差異(P<0.001)。本研究將空氣污染指標依據四分法進行分組，使用logistic regression 評估空氣污染指標PM10，NO2，O3和CO與肺結核治療成效的相關性，在調整了年齡、性別、都市化程度、共病症等干擾因子後，發現空氣污染的濃度指標會影響肺結核患病情形。
Objective: Tuberculosis (TB) is a major infectious disease that causes illness and death worldwide. It has been reported one third of the world’s population is infected with Mycobacterium tuberculosis. The incidence and the mortality of tuberculosis has been decreased recent year in Taiwan. However, compared to other developed countries, the incidence and mortality rates are higher. Its incidence is associated with the region's lifestyle, habits, population density, and social-economic status. However, it is unclear whether the treatment outcome is also related to environmental factors. Therefore, this study evaluated the associations between anti-TB treatment outcome and potential environmental factors.
Methods: We conducted a retrospective cohort study using data from the Longitudinal Health Insurance Database 2000 of Taiwan between 2004 and 2011 to identify pulmonary tuberculosis cases. According to anti-TB treatment, the patients were divided into two groups: first-line treatment and second-line treatment. We estimated individual exposure to air pollution using data from air quality monitoring stations established by the Environmental Protection Administration, Taiwan. We stratified air pollutant concentrations into quartiles and applied logistic regression models to evaluate their association with TB outcome while adjustments were made for age, sex, urbanization, and comorbidity.
Results: There were 6,770 patients diagnosed with tuberculosis between 2004 and 2011; 6,477 received first-line treatment only, and 293 received second-line treatment. A total of 33,346 individuals were selected as the control group. As to comorbidity, diffenences in the prevalence rates of diabetes mellitus, asthma, chronic obstructive pulmonary disease, AIDS and pneumoconiosis between the two patient groups were statistically significant (P<0.001). After adjusting for cofounders, our cohort study provided evidence supporting that fine particle pollution and traffic-related air pollution might be associated with an increased risk of TB.
Keywords: Tuberculosis; treatment outcome; Spatial Analysis
Chapter 1 Introduction 1
1.1 Background and motivation 1
1.2 Research question 2
Chapter 2 Literature review 3
2.1 The epidemiology of tuberculosis 3
2.2 The ambient air pollution and tuberculosis 3
2.3 The effectiveness of the anti-tuberculosis treatment 4
Chapter 3 Significance 5
3.1 Objective 5
3.2 Significance 5
Chapter 4 Materials and Methods 6
4.1 Study structure and study design 6
4.2 Study cohort 6
4.3 Outcome of interest 6
4.4 Exposure assessment 7
4.5 Covariates 7
4.6 Statistical analysis 8
Chapter 5 Results 10
5.1 Description of sample 10
5.2 Air pollution 10
5.3 The risk of tuberculosis 11
5.3.1 The 3-month Models 11
5.3.2 The 6-month Models 12
5.3.3 The 12-month Models 14
Chapter 6 Discussion 15
6.1 Past literatures 15
6.2 Tuberculosis and air pollution 15
6.3 Tuberculosis and other risk factor 16
6.4 Strength and limitation 16
Chapter 7 Conclusion 18
TABLE 1 The frequency distributions among gender in patients with anti-tuberculosis treatment and control group stratified by age. 23
TABLE 2 Distribution of estimated air pollution concentration based on monitoring stations. 25
TABLE 3 Correlations between different pollutants 26
TABLE 4 Crude odds ratios (OR) and associated 95 % confidence intervals (CI) for tuberculosis treatment from univariate model. 27
TABLE 5 Crude and adjusted odds ratios (OR) and associated 95 % confidence intervals (CI) for tuberculosis from quartile air pollutant (3-month) model. 28
TABLE 6 Crude and adjusted odds ratios (OR) and associated 95 % confidence intervals (CI) for tuberculosis from quartile air pollutant (6-month) model. 30
TABLE 7 Crude and adjusted odds ratios (OR) and associated 95 % confidence intervals (CI) for tuberculosis from quartile air pollutant (12-month) model. 32
FIGURE 1. Study flow chart 34
FIGURE 2. The monthly variation of air pollutants level over the study years... 35
FIGURE 3. The Taiwanese town scale concentration of particulate matter less than 10 m in diameter in main Taiwan island 37
FIGURE 4. The Taiwanese town scale concentration of nitrogen dioxide in main Taiwan island 41
FIGURE 5. The Taiwanese town scale concentration of ozone in main Taiwan island 45
FIGURE 6. The Taiwanese town scale concentration of carbon monoxide in main Taiwan island 49
American Thoracic Society. Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis. 1986; 134:355-363.
Byrd RB, Horn BR, Solomon DA, Griggs GA: Toxic effects of isoniazid in tuberculosis chemoprophylaxis – role of biochemical monitoring in 1,000 patients. JAMA 1979 241:1239-1124.
Dash LA, Comstock GW, Flynn JPG: Isoniazid preventive therapy – retrospect and prospect. Am Rev Respir Dis. 1980 121:1039-1044.
Durand F, Bernuau J, Pessayre D, Samuel D, Belaiche J, Degott C, Bismuth H, Belghiti J, Erlinger S, Rueff B, et al. Deleterious influence of pyrazinamide on the outcome of patients with fulminant or subful- minant liver failure during antituberculous treatment including isoniazid. Hepatology. 1995; 21:929-932.
Furin JJ, Johnson JL. Recent advances in the diagnosis and management of tuberculosis. Curr Opin Pulm Med. 2005; 11:189-94.
Fielder JF, Chaulk CP, Dalvi M, Gachuhi R, Comstock GW, Sterling TR. A high tuberculosis case-fatality rate in a setting of effective tuberculosis control: implications for acceptable treatment success rates. Int J Tuberc Lung Dis. 2002; 6:1114-7.
Franks AL, Binkin NJ, Snider DE, Rokaw WM, Becker S. Isoniazid hepatitis among pregnant and postpartum hispanic patients. Public Health Rep. 1989; 104:151-155.
Froggatt K. Tuberculosis: spatial and demographic incidence in Bradford, 1980-2. J Epidemiol Community Health. 1985; 39:20-6.
Hiramatsu K, Saito Y, Sakakibara K, et al. The effects of inhalation of diesel exhaust on murine mycobacterial infection. Exp Lung Res. 2015; 31:405-15.
Jong BC1, Israelski DM, Corbett EL, Small PM. Clinical management of tuberculosis in the context of HIV infection. Annu Rev Med. 2004; 55:283-301.
Kopanoff DE, Snider DE, Caras GJ. Isoniazid-related hepatitis. Am Rev Respir Dis 1978; 117:991-1001.
Lin HH, Ezzati M, Murray M. Tobacco smoke, indoor air pollution and tuberculosis: a systematic review and meta-analysis. Plos Med. 2007; 4:173-89.
Leung CC, Lam TH, Ho KS, et al. Passive smoking and tuberculosis. Arch Intern Med. 2010 ;170:287-92.
Lin HH, Suk CW, Lo HL, et al. Indoor air pollution from solid fuel and tuberculosis: a systematic review and meta-analysis. Int J Tuberc Lung Dis. 2014; 18:613-21.
Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012; 380:2224-60.
Maciel EL1, Pan W, Dietze R, Peres RL, Vinhas SA, Ribeiro FK, Palaci M, Lonnroth K, Jaramillo E, Williams BG, et al. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Soc Sci Med. 2009; 68:2240-6.
Nolan CM, GOLDBERG SG, BUSKIN SE: Hepatotoxicity associated with isoniazid preventive therapy – a 7-year survey from a public health tuberculosis clinic. JAMA (1999) 281:1014-1018.
Nunes C: Tuberculosis incidence in Portugal: spatio-temporal clustering. Int J Health Geogr. 2007; 6:30.
Onozuka D, Hagihara A: Geographic prediction of tuberculosis clusters in Fukuoka, Japan using the space-time scan statistic. BMC Infectious Diseases. 2007; 7:26.
Ormerod LP, Horsfield N. Frequency and type of reactions to antituberculosis drugs: observations in routine treatment. Tuber Lung Dis. 1996; 77:37-42.
Rodrigues RR, Zandonade E, Golub JE. Spatial patterns of pulmonary tuberculosis incidence and their relationship to socio-economic status in Vitoria, Brazil. Int J Tuberc Lung Dis. 2010; 14:1395-1402.
Rieder HL. Epidemiologic basis of tuberculosis control. Int J Tuberc Lung Dis. 1999; 1:63-118.
Rodrigues AL Jr1, Ruffino-Netto A, de Castilho EA. Spatial distribution of M. tuberculosis-HIV coinfection in São Paulo State, Brazil, 1991-2001. Rev Saude Publica. 2006; 40:265-70.
Roger J. Marshall A review of methods for the statistical analysis of spatial patterns of disease. Royal statistical society. 1991.
Stead WM, TO T, HARRISON RW, ABRAHAM JH: Benefit-risk considerations in preventive treatment for tuberculosis in elderly persons. Ann. Int. Med. 1987; 107:843-845.
Schaberg T, Rebhan K, Lode H. Risk factors for side-effects of isoniazid, rifampin and pyrazinamide in patients hospitalized for pulmonary tuberculosis. Eur Respir J. 1996; 9:2026-2030.
Smith GS, Schoenbach VJ, Richardson DB, et al. Particulate air pollution and susceptibility to the development of pulmonary tuberculosis disease in North Carolina: an ecological study. Int J Environ Heal R. 2013; 24:103-12.
Sarkar S, Song Y, Kipen HM, et al. Suppression of the NF-kappaB pathway by diesel exhaust particles impairs human antimycobacterial immunity. J Immunol. 2012; 188:2778-93.
Tremblay GA. Historical statistics support a hypothesis linking tuberculosis and air pollution caused by coal. Int J Tuberc Lung Dis. 2007; 11:722-32.
Tan WC, Ong CK, Lo Kang SC, et al. Two years review of cutaneous adverse drug reaction from first line anti-tuberculous drugs. Med J Mlaysia. 2007; 62:143-6.
Thompson NJ: Efficacy of various durations of isoniazid preventive therapy for tuberculosis: five years of follow-up in the IUAT trial. Bull. Wld. Hlth. Org. 1982; 60:555-564.
Van den Brande P, Steenbergen WV, Verdoot G, Demedts M. Aging and hepatoxicity of isoniazid and rifampin in pulmonary tuberculosis. Am J Respir Crit Care Med. 1995; 152:1705-1708.
Vendramini SH, Santos NS, Santos Mde L, Chiaravalloti-Neto F, Ponce MA, Gazetta CE, Villa TC, Netto AR. Spatial analysis of tuberculosis/HIV coinfection: its relation with socioeconomic levels in a city in south-eastern Brazil. Rev Soc Bras Med
Trop. 2010; 43:536-41.
World Health Organization. Burden of disease from Ambient Air Pollution for 2012. World Health Organization, 2014.
World Health Organization. Global Tuberculosis Report 2014. World Health Organization, 2014.