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Disease Incidence and TB Mortality in High-Burden TB Countries

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Disease Incidence and TB Mortality in High-Burden TB Countries Georgia State University ScholarWorks @ Georgia State University Public Health Theses School of Public Health Fall 1-6-2017 Population Attributable Fraction of Smoking for Tuberculosis (TB) Disease Incidence and TB Mortality in High-Burden TB Countries Genet A. Amere MD Georgia State University Follow this and additional works at: https://scholarworks.gsu.edu/iph_theses Recommended Citation Amere, Genet A. MD, "Population Attributable Fraction of Smoking for Tuberculosis (TB) Disease Incidence and TB Mortality in High-Burden TB Countries." Thesis, Georgia State University, 2017. https://scholarworks.gsu.edu/iph_theses/506 This Thesis is brought to you for free and open access by the School of Public Health at ScholarWorks @ Georgia State University. It has been accepted for inclusion in Public Health Theses by an authorized administrator of ScholarWorks @ Georgia State University. For more information, please contact [email protected]. ABSTRACT POPULATION ATTRIBUTABLE FRACTION OF SMOKING FOR TUBERCULOSIS (TB) DISEASE INCIDENCE AND TB MORTALITY IN HIGH- BURDEN TB COUNTRIES by GENET AMERE _____________________ Background: Globally, there are 10 million new cases of tuberculosis (TB) disease annually and 95% of cases occur in low- and middle-income countries (LMIC). More than 1 billion people use tobacco, and 80% of tobacco users reside in LMIC. Smoking approximately doubles the risk of TB disease and is associated with excess mortality during TB treatment. We aimed to estimate the proportion of annual incident TB cases and TB mortality attributable to tobacco smoking in high burden TB countries. Methods: To estimate population attributable fractions (PAF), we obtained country specific estimates of TB incidence and TB mortality rates from the WHO 2015 Global TB Report. Country specific smoking prevalence was estimated from WHO 2015 tobacco surveillance reports and the Tobacco Atlas. Risk ratios for the effect of smoking on TB incidence and TB mortality were obtained from previously published meta-analyses. Country specific PAF of smoking for TB disease were age and sex adjusted. Results: In high burden countries during 2014, an estimated 4.5 million adults developed TB disease and 163,000 people died from TB. An estimated 740 million adult smokers lived in those high burden countries in 2014. We estimated that tobacco smoking was attributable for 17.7% (95% confidence interval [CI] 8.6-21.9%) of TB cases and 15.0% (95% CI 1.9-31.6%) of TB mortality. Of the high burden countries, Russia had the highest proportion of smoking attributable TB disease (31.8%, 95% CI 16.0-37.8%) and death (28.1%, 95% CI 3.8-51.3%). India had the greatest absolute number of TB cases (233,000) and TB deaths (7,400) attributable to smoking. Men (30.5%, 95% CI 14.9%-36.9%) had a greater proportion of TB cases attributable to smoking than women (4.7%, 95% CI 1.9%-6.2%). Conclusion: In high-burden TB countries, nearly one-sixth of all TB cases and TB deaths were attributable to smoking. Our findings highlight the need for tobacco control in high TB burden regions and specifically among patients with TB. Reaching key populations and integrating smoking cessation efforts into TB programs will be essential to achieve global TB control goals. POPULATION ATTRIBUTABLE FRACTION OF SMOKING FOR TUBERCULOSIS (TB) DISEASE INCIDENCE AND TB MORTALITY IN HIGH- BURDEN TB COUNTRIES BY GENET ASMAMAW AMERE M.D., ADDIS ABABA UNIVERSITY A Thesis Submitted to the Graduate Faculty of Georgia State University in Partial Fulfillment of the Requirements for the Degree MASTER OF PUBLIC HEALTH ATLANTA, GEORGIA 30303 i APPROVAL PAGE POPULATION ATTRIBUTABLE FRACTION OF SMOKING FOR TUBERCULOSIS (TB) DISEASE INCIDENCE AND TB MORTALITY IN HIGH- BURDEN TB COUNTRIES by GENET AMERE Approved: Matthew J. Magee, Ph.D, MPH Committee Chair Pratibha Nayak, Ph.D, MPH Committee Member Nov 29, 2016 Date ii ACKNOWLEDGEMENTS I am very grateful to Dr. Matthew Magee, my thesis committee chair, for his guidance and mentorship during my thesis project. I would also like to thank Dr. Pratibha Nayak, my thesis committee member, for her assistance and feedback during the thesis project. Last but not least, I would like to thank my husband for his love, support, and encouragement. iii Author’s Statement Page In presenting this thesis as a partial fulfillment of the requirements for an advanced degree from Georgia State University, I agree that the Library of the University shall make it available for inspection and circulation in accordance with its regulations governing materials of this type. I agree that permission to quote from, to copy from, or to publish this thesis may be granted by the author or, in his/her absence, by the professor under whose direction it was written, or in his/her absence, by the Associate Dean, School of Public Health. Such quoting, copying, or publishing must be solely for scholarly purposes and will not involve potential financial gain. It is understood that any copying from or publication of this dissertation which involves potential financial gain will not be allowed without written permission of the author. Genet Amere Signature of Author iv Table of Contents ACKNOWLEDGEMENTS ......................................................................................ii List of Tables ........................................................................................................ v List of Figures .......................................................................................................vi CHAPTER I .......................................................................................................... 1 INTRODUCTION .................................................................................................. 1 1.1 Background ........................................................................................... 1 1.2 Gap and Purpose of Study ................................................................... 4 CHAPTER II ......................................................................................................... 5 REVIEW OF LITERATURE .................................................................................. 5 2.1 Epidemiology of TB and Smoking ....................................................... 5 2.2 The association between TB disease and smoking .......................... 6 2.3 The association betewwn TB mortality and smoking ...................... 10 2.4 Summary of literature review ............................................................. 13 CHAPTER III ...................................................................................................... 14 MANUSCRIPT .................................................................................................... 14 Introduction ................................................................................................... 14 Methods ......................................................................................................... 16 Results ........................................................................................................... 22 Discussion ..................................................................................................... 24 Conclusion ..................................................................................................... 27 THESIS REFERENCES ..................................................................................... 36 APPENDICES .................................................................................................... 46 v List of Tables Table 3.1. Country specific current tobacco smoking prevalence data………….29 Table 3.2. Estimated proportion of TB disease attributable to tobacco smoking among adults in 32 high burden TB countries……………………...…….30 Table 3.3. Estimated number and proportion of TB disease attributable to tobacco smoking by sex among adults in 32 high burden TB countries.................................................................................................31 Table 3.4. Estimated number and proportion of TB death attributable to tobacco smoking among adults in 32 high burden TB countries…………………32 Table 3.5. Sensitivity analysis for proportion of TB disease and deaths attributable to tobacco smoking based on smoking prevalence………..33 vi List of Figures Figure 3.1. Smoking prevalence data sources in order of priority………………..34 Figure 3.2. Population Attributable Fraction (PAF): definition and formula ……..35 CHAPTER I INTRODUCTION 1.1 Background Tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis (MTB), which is transmitted via droplet nuclei. According to World Health Organization (WHO), 10.4 million people developed TB disease and 1.8 million died from it in 2015. The majority of TB disease (87%) occurs in 30 high burden countries and 95% of cases occur in low- and middle-income countries (LMIC) (WHO, 2015a, 2016a). A third of the world population is infected with MTB but are asymptomatic and non-infectious. A small proportion of those infected will develop TB disease; the lifetime risk of developing TB disease is estimated at 10%. However, the risk of developing TB disease increases in immunocompromised people such as patients with HIV/AIDS, malnutrition, diabetes, and among individuals who use tobacco (WHO, 2015). Tobacco smoking is the most preventable cause of premature death and disease worldwide (CDC, March 15, 2016). The risk of diseases such as lung cancer, chronic obstructive pulmonary disease, and cardiovascular
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