Greenness exposure and all-cause mortality during multi-drug resistant tuberculosis treatment: A population-based cohort study

Erjia Ge; Jianhui Gao; Zhoupeng Ren; Xin Liu; Ming Luo; Jieming Zhong; Fangrong Fei; Bin Chen; Xiaomeng Wang; Xiaolin Wei; Ying Peng

doi:10.1016/j.scitotenv.2021.145422

Greenness exposure and all-cause mortality during multi-drug resistant tuberculosis treatment: A population-based cohort study

Sci Total Environ. 2021 Jun 1:771:145422. doi: 10.1016/j.scitotenv.2021.145422. Epub 2021 Jan 26.

Authors

Erjia Ge¹, Jianhui Gao², Zhoupeng Ren³, Xin Liu⁴, Ming Luo⁵, Jieming Zhong⁶, Fangrong Fei⁷, Bin Chen⁸, Xiaomeng Wang⁹, Xiaolin Wei¹⁰, Ying Peng¹¹

Affiliations

¹ Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Canada. Electronic address: erjia.ge@utoronto.ca.
² Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Canada. Electronic address: Jianhui.gao@mail.utoronto.ca.
³ State Key Laboratory of Resources and Environmental Information System (LREIS), Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing, China. Electronic address: renzp@lreis.ac.cn.
⁴ School of Geoscience and Technology, Southwest Petroleum University, Sichuan Province, China. Electronic address: liux@lreis.ac.cn.
⁵ Sechool of Geography and Planning, Sun Yat-Sen University, Guangdong Province, China. Electronic address: luom38@mail.sysu.edu.cn.
⁶ Division of Chronic Diseases, Zhejiang Provincial Centre for Disease Control and Prevention, Zhejiang Province, China. Electronic address: jmzhong@cdc.zj.cn.
⁷ Division of Chronic Diseases, Zhejiang Provincial Centre for Disease Control and Prevention, Zhejiang Province, China. Electronic address: frfei@cdc.zj.cn.
⁸ Division of Tuberculosis, Zhejiang Provincial Centre for Disease Control and Prevention, Zhejiang Province, China. Electronic address: bchen@cdc.zj.cn.
⁹ Division of Tuberculosis, Zhejiang Provincial Centre for Disease Control and Prevention, Zhejiang Province, China. Electronic address: xmwang@cdc.zj.cn.
¹⁰ Division of Clinic Public Health, Institute of Health Policy and Evaluation, Dalla Lana School of Public Health, University of Toronto, Canada.. Electronic address: xiaolin.wei@utoronto.ca.
¹¹ Division of Tuberculosis, Zhejiang Provincial Centre for Disease Control and Prevention, Zhejiang Province, China. Electronic address: ypeng@cdc.zj.cn.

PMID: 33548711
DOI: 10.1016/j.scitotenv.2021.145422

Abstract

Background: Living closer to greenness were thought to benefit various health outcomes. We aimed to assess the association between residential greenness and mortality among patients undergoing multidrug resistant tuberculosis (MDR-TB) treatment.

Methods: We enrolled all local MDR-TB patients reported in Zhejiang, China from 2009 to 2017 and followed them throughout the treatment. We calculated the contemporaneous normalized difference vegetation index (NDVI) in the 250 and 500 m radius around patient's residence. Cox proportional hazards regression models with time-varying NDVI were used to assess the impact of greenness exposure on all-cause mortality during MDR-TB treatment, adjusting for potential individual and contextual covariates.

Results: We ascertained 1,621 active MDR-TB cases, which contributed 3036 person-years at risk with an average follow-up of 684 days (s.d. 149 days) per patient. Among them, there were 163 deaths during follow-up, representing a crude mortality rate of 537 deaths per 10,000 person-years. Patients exposed to the second quintile (Q2) of greenness within the 500 m buffer had around 64% reduced mortality risk over the lowest quintile of greenness with hazard ratio (HR) = 0.364 (95% CI: 0.109-1.22). In lower nighttime light (NTL) areas, the hazard ratios (HR) per quintile increase in NDVI within the 500 m buffer were Q2: 0.35 (95% CI: 0.10-1.18), Q3: 0.24 (95% CI: 0.09-0.66), Q4: 0.26 (95% CI: 0.10-0.69), and Q5: 0.26 (95% CI: 0.10-0.71) relevant to the lowest quintile Q1, with a trend of p-value ≤0.01. Patients who were female, younger (<60 years), resided in urban areas, or had high PM_2.5 (i.e. particles with diagram ≤2.5 μm) exposure were more likely to benefit from greenness exposure. Associations were neither observed with NDVI in the 250 m buffer nor for patients living in higher NTL areas. There was a non-linear exposure-response relationship between greenness and deaths with p-value ≤0.05.

Conclusion: Increasing greenness exposure along with medical treatment reduces all-cause mortality among patients living in lower NTL areas.

Keywords: Air pollution; All-cause mortality; Greenness exposure; Multidrug resistant tuberculosis; Nighttime light; PM(2.5).

MeSH terms

China / epidemiology
Cohort Studies
Female
Humans
Research*
Tuberculosis, Multidrug-Resistant* / drug therapy
Tuberculosis, Multidrug-Resistant* / epidemiology