Towards elimination of TB in Europe: Successive interventions on social determinants and vulnerable groups

Objectives. Elimination strategies for tuberculosis (TB) in Europe are composed of a number of program components. However, discrepancies between countries in TB prevalence rates and social inequalities call for a differentiated approach. We examined the correlation between TB rates and distribution of wealth in the EU in order to further inform TB control and elimination strategies.

Methods. To compute correlations a public wealth index (PWI) was developed taking into account both GDP per capita and income distribution. This metric takes the national level of wealth into account while controlling for its distribution, thus more accurately reflecting the European setting than GDP alone.

Results. GDP, Gini and the Eurostat income distribution ratio were poorly correlated with TB prevalence. However, a regression model of log-transformed PWI and TB prevalence yielded a strong inverse relationship between the PWI and TB rates (correlation coefficient of R2 = 0.67). With increasing PWI, TB rates dropped, but the proportion of foreign-born TB cases increased.

Conclusions: High prevalence countries should initially focus on population-based, social determinants interventions to help reduce societal inequalities and TB rates. However, eventually with decreasing TB rates this strategy suffers from diminishing returns and fails to reach foreign-born cases that are particularly vulnerable to TB. In fact, these vulnerable groups concentrate a number of fundamental risk factors associated with their position in society. If TB were to be eliminated in low prevalence counties these vulnerabilities must be collectively targeted with comprehensive interventions in these populations.