Research Letter
Social profile of the highest tuberculosis incidence areas in Portugal
a Pulmonology Department, Hospital of Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
b Department of Clinical Epidemiology, Predictive Medicine and Public Health, Medical School, University of Porto, Porto, Portugal
c Occupational Health and Safety Department, Hospital of Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
d Department of Mathematics, Sciences School, University of Porto, Porto, Portugal
e Centre of Mathematics, University of Porto, Porto, Portugal
f EPI Unit, Institute of Public Health at University of Porto, Porto, Portugal
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"apellidos" => "Gaio" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "R." "apellidos" => "Duarte" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Pulmonology Department, Hospital of Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Clinical Epidemiology, Predictive Medicine and Public Health, Medical School, University of Porto, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Occupational Health and Safety Department, Hospital of Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Mathematics, Sciences School, University of Porto, Porto, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Centre of Mathematics, University of Porto, Porto, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "EPI Unit, Institute of Public Health at University of Porto, Porto, Portugal" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2198 "Ancho" => 1785 "Tamanyo" => 210132 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Variation of tuberculosis incidence rate, population density, proportion of people at working age and unemployment rate between 2002 and 2012, and proportion of immigrants between 2008 and 2012, in Greater Oporto, Greater Lisbon and Setúbal Peninsula.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">With a tuberculosis (TB) prevalence of over 20 cases per 100<span class="elsevierStyleHsp" style=""></span>000 individuals, Portugal is one of the countries with the highest TB burden in the European Union.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1–3</span></a> From 1999 to 2011, TB incidence in Portugal showed a consistent decrease of 4.3% per year, leading to a total decline of 52.1%<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> and to the disappearance of high incidence regions (≥50 cases/100<span class="elsevierStyleHsp" style=""></span>000 habitants).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Despite this progressive decline, the country's heterogeneity is remarkable and the districts of Oporto, Lisbon and Setubal still have an intermediate incidence of Tuberculosis (>20 cases/100<span class="elsevierStyleHsp" style=""></span>000 and <50 cases/100<span class="elsevierStyleHsp" style=""></span>000 population). Couceiro et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> showed that high risk of TB in some areas of Portugal was related to the high prevalence of HIV/AIDS, incarceration, nonstandard and/or crowded accommodation, unemployment and immigrant populations from countries with high TB incidence. A concentration of young adults might also contribute to the increase of the number of TB cases since the incidence is highest in individuals aged 25–44 years.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Realizing the importance of the social determinants in the control of TB, the authors wanted to characterize the profile of the Portuguese regions with higher incidence rates. The analyzed demographic and socio-economic factors included the population density, proportion of people at working age (15–64 years old), proportion of immigrants and unemployment rate and the TB incidence between 2002 and 2012 in Greater Oporto, Greater Lisbon and Setúbal Peninsula.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The territorial unit used was NUTS 3 (Nomenclatura das Unidades Territoriais para Fins Estatísticos). New TB cases were identified from the tuberculosis national surveillance system; unemployment rate values were obtained from the Employment and Vocational Training Institute reports and the remaining data were collected from National Statistics Institute database. The number of immigrants was only available from 2008 to 2012.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Greater Oporto presented the highest incidence of TB, followed by Greater Lisbon and Setúbal Peninsula. Until 2008, the decline of the incidence rate was higher in Oporto (81.16–37.69/100<span class="elsevierStyleHsp" style=""></span>000) than in Lisbon (63.82–35.10/100<span class="elsevierStyleHsp" style=""></span>000) and Setúbal (55.62–27.73/100<span class="elsevierStyleHsp" style=""></span>000). From that time onwards, the incidence curves became less pronounced and the three regions assumed closer values (34.39/100<span class="elsevierStyleHsp" style=""></span>000 in Setubal, 39.52/100<span class="elsevierStyleHsp" style=""></span>000 in Lisbon and 43.68/100<span class="elsevierStyleHsp" style=""></span>000 in Oporto) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Also, from 2008 onwards, the decline of people of working age started to accelerate and the unemployment rate, which had been decreasing since 2002, showed a trend variation and started to increase.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Regarding Oporto area, we can see that during the period studied the population density remained stable (1513.8–1522.5<span class="elsevierStyleHsp" style=""></span>population/km<span class="elsevierStyleSup">2</span>), and the proportion of people of working age (69.9–68.1%) and the proportion of immigrants (1.8–1.6%) decreased while the unemployment rate (7.0–13.4% of the labor force) increased. The Lisbon area presented the highest population density (1568.1–1625.4<span class="elsevierStyleHsp" style=""></span>population/km<span class="elsevierStyleSup">2</span>) with a definite increase over the years and the highest proportion of immigrants (8.8–8.4%). The proportion of people of working age (68.3–64.5%) and unemployment rate (5.5–8.8%) showed the lowest values for the three regions studied. The Setúbal area, although presenting the lowest population density (422.1–452.6<span class="elsevierStyleHsp" style=""></span>population/km<span class="elsevierStyleSup">2</span>), exhibited social and demographic characteristics very similar to those of Lisbon – the proportion of people of working age (69.3–65.4%) was quite close to that in Lisbon and the proportion of immigrants (6.0–5.2%) although not as high as in Lisbon was much higher than in Oporto. The unemployment rate (6.4–9.6%) however was higher than the one observed in Lisbon.</p><p id="par0030" class="elsevierStylePara elsevierViewall">It is well known that the TB burden is strongly linked to socio-economic factors. From 2008 to 2012 there has been a slowing down in the decrease in the Portuguese TB incidence rate, in which the European and the national economic crisis have had an important role. In order to reach long-term TB control targets, efforts to address TB risk factors and social determinants are needed.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6,7</span></a> When looking at the three areas with the highest incidence in Portugal – all urban centers – we can see that they have different social profiles. Despite being the second largest urban center of the country, Oporto presents a lower number of individuals from qualified socio-economic groups with higher education<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> and a higher unemployment rate than Lisbon. The latter is the main entry point for immigrants, many of them from sub-Saharan African countries with high TB incidence. Although less populated, Setúbal presents a considerable proportion of immigrants and a high unemployment rate due to its proximity to Lisbon. In these settings, TB control requires social, economic and environmental interventions that should be tailored according to each region profile: in Oporto the unemployed population must be addressed whereas in Lisbon and Setúbal the immigrant population is more relevant.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2198 "Ancho" => 1785 "Tamanyo" => 210132 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Variation of tuberculosis incidence rate, population density, proportion of people at working age and unemployment rate between 2002 and 2012, and proportion of immigrants between 2008 and 2012, in Greater Oporto, Greater Lisbon and Setúbal Peninsula.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary tuberculosis space–time clustering and spatial variation in temporal trends in Portugal, 2000–2010: an updated analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. 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