Changing the Paradigm: Using an Integrative Approach to Improve Understanding of Tuberculosis Control in Michigan.

Background. In the U.S., tuberculosis (TB) continues to disproportionately affect the poor, racial/ethnic minorities, and urban dwellers, yet traditional methods of TB control focus primarily on biomedical predictors for treatment and less on social factors that could direct prevention. Although characteristics of the social and physical environment increase vulnerability to TB, declining concern over those with disease and diminished resources have stunted understanding of risk and reduced the ability to respond. Methods. Using TB case surveillance data combined with genotypic testing of samples from the Michigan Department of Health and Human Service and a novel socio-demographic survey, this dissertation takes an integrative approach to understanding the patterns of TB incidence and transmission. Research has involved: 1. Analyzing risk factors for TB incidence in Michigan; 2. Evaluating which risk factors both at the individual- and neighborhood levels were associated with pathogen genotypic and temporal clustering; and 3. Analyzing social characteristics of TB cases diagnosed in Metro Detroit to better understand how social vulnerability and behavioral contacts augment risk. Results. From 2004 through 2012, the incidence of TB throughout Michigan declined by an average of 8% per year. However, significant disparities in the average incidence rate were observed by race and nativity. Overall, 22% of the foreign-born cases of TB were estimated to be resulting from recent transmission of TB compared to 52% of the U.S.-born cases. For the U.S.-born, recent transmission was predicted more by individual-level and neighborhood-level socio-demographic factors than by clinical risk factors. Preliminary results from the socio-demographic survey suggest that while individuals with TB in Metro Detroit may be employed and have access to stable housing, they still experience significant financial strain. Conclusions: The results of this dissertation highlight some of the ways in which TB incidence is socially patterned. Interventions aimed at reducing the incidence of TB in the foreign-born population should focus on reducing reactivation of latent TB infections. However, reducing the incidence of TB among the U.S.-born will require strategies that can reduce transmission of TB among socially disadvantaged groups, both at the individual- and neighborhood-level.PhDEpidemiological ScienceUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/120803/1/gnoppert_1.pd

The Modern Profile of Tuberculosis: Developing the TB Social Survey to understand contemporary social patterns in tuberculosis

Social disparities in tuberculosis have been documented for decades, yet to date there has not been a comprehensive study to examine the contemporary causes of these disparities. Local public health departments, and particularly public health nursing staff are charged with delivering directly observed therapy to individuals with tuberculosis disease. As a result of the frequency and duration of treatment, practitioners delivering therapy are often well‐acquainted with the lives and challenges of their constituents. Thus, through these practitioners there exists a deep repository of knowledge on the drivers of social disparities in tuberculosis disease. Partnering with local public health departments, we developed a survey instrument aimed at understanding the social profile of individuals with tuberculosis disease in metropolitan Detroit, Michigan. We discuss the development and implementation of the survey instrument as well as challenges in developing partnerships between academic researchers and local public health practitioners. This study can serve as a framework for both academic researchers and public health practitioners interested in addressing social disparities in infectious disease.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141046/1/phn12372_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/141046/2/phn12372-sup-0001-SupInfo.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/141046/3/phn12372.pd

Comparison of two area-level socioeconomic deprivation indices: Implications for public health research, practice, and policy.

ObjectivesTo compare 2 frequently used area-level socioeconomic deprivation indices: the Area Deprivation Index (ADI) and the Social Vulnerability Index (SVI).MethodsIndex agreement was assessed via pairwise correlations, decile score distribution and mean comparisons, and mapping. The 2019 ADI and 2018 SVI indices at the U.S. census tract-level were analyzed.ResultsIndex correlation was modest (R = 0.51). Less than half (44.4%) of all tracts had good index agreement (0-1 decile difference). Among the 6.3% of tracts with poor index agreement (≥6 decile difference), nearly 1 in 5 were classified by high SVI and low ADI scores. Index items driving poor agreement, such as high rents, mortgages, and home values in urban areas with characteristics indicative of socioeconomic deprivation, were also identified.ConclusionsDifferences in index dimensions and agreement indicated that ADI and SVI are not interchangeable measures of socioeconomic deprivation at the tract level. Careful consideration is necessary when selecting an area-level socioeconomic deprivation measure that appropriately defines deprivation relative to the context in which it will be used. How deprivation is operationalized affects interpretation by researchers as well as public health practitioners and policymakers making decisions about resource allocation and working to address health equity

Biological expressions of early life trauma in the immune system of older adults

Background Poor immune function is associated with increased risk for a number of age-related diseases, however, little is known about the impact of early life trauma on immune function in late-life. Methods Using nationally representative data from the Health and Retirement Study (n = 5,823), we examined the association between experiencing parental/caregiver death or separation before age 16 and four indicators of immune function in late-life: C-reactive Protein (CRP), Interleukin-6 (IL-6), soluble Tumor Necrosis Factor (sTNFR), and Immunoglobulin G (IgG) response to cytomegalovirus (CMV). We also examined racial/ethnic differences. Findings Individuals that identified as racial/ethnic minorities were more likely to experience parental/caregiver loss and parental separation in early life compared to Non-Hispanic Whites, and had poorer immune function in late-life. We found consistent associations between experiencing parental/caregiver loss and separation and poor immune function measured by CMV IgG levels and IL-6 across all racial/ethnic subgroups. For example, among Non-Hispanic Blacks, those that experienced parental/caregiver death before age 16 had a 26% increase in CMV IgG antibodies in late-life (β = 1.26; 95% CI: 1.17, 1.34) compared to a 3% increase in CMV antibodies among Non-Hispanic Whites (β = 1.03; 95% CI: 0.99, 1.07) controlling for age, gender, and parental education. Interpretation Our results suggest a durable association between experiencing early life trauma and immune health in late-life, and that structural forces may shape the ways in which these relationships unfold over the life course

The Modern Profile of Tuberculosis: Developing the TB Social Survey to understand contemporary social patterns in tuberculosis

Social disparities in tuberculosis have been documented for decades, yet to date there has not been a comprehensive study to examine the contemporary causes of these disparities. Local public health departments, and particularly public health nursing staff are charged with delivering directly observed therapy to individuals with tuberculosis disease. As a result of the frequency and duration of treatment, practitioners delivering therapy are often well‐acquainted with the lives and challenges of their constituents. Thus, through these practitioners there exists a deep repository of knowledge on the drivers of social disparities in tuberculosis disease. Partnering with local public health departments, we developed a survey instrument aimed at understanding the social profile of individuals with tuberculosis disease in metropolitan Detroit, Michigan. We discuss the development and implementation of the survey instrument as well as challenges in developing partnerships between academic researchers and local public health practitioners. This study can serve as a framework for both academic researchers and public health practitioners interested in addressing social disparities in infectious disease.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141046/1/phn12372_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/141046/2/phn12372-sup-0001-SupInfo.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/141046/3/phn12372.pd

Understanding the intersection of race and place: the case of tuberculosis in Michigan

Abstract Background Race and place intersect to produce location-based variation in disease distributions. We analyzed the geographic distribution of tuberculosis (TB) incidence in Michigan, USA to better understand the complex interplay between race and place, comparing patterns in Detroit, Wayne County and the state of Michigan as a whole. Methods Using cross-sectional TB surveillance data from the Michigan Department of Health and Human Services, multivariable statistical models were developed to analyze the residence patterns of TB incidence from 2007 through 2012. Two-way interactions among the residence location and race of cases were assessed. Results Overall, Detroit residents experienced 58% greater TB incidence than residents of Wayne County or the state of Michigan. Racial inequalities were less pronounced in Detroit compared to both Wayne County and the state of Michigan. Blacks in Detroit had 2.01 times greater TB incidence than Whites, while this inequality was 3.62 times more in Wayne County and 8.72 greater in the state of Michigan. Conclusion Our results highlight how race and place interact to influence patterns of TB disease, and the ways in which this interaction is context dependent. TB elimination in the U.S. will require strategies that address the local social environment, as much as the physical environment.http://deepblue.lib.umich.edu/bitstream/2027.42/173474/1/12889_2019_Article_8036.pd

Socioeconomic and race/ethnic differences in immunosenescence: evidence from the Health and Retirement Study

Background The COVID-19 pandemic has highlighted the urgent need to understand variation in immunosenescence at the population-level. Thus far, population patterns of immunosenescence have not well described. Methods We characterized measures of immunosenescence from the 2016 Venous Blood Study from the nationally representative U.S Health and Retirement Study (HRS) of individuals ages 50 years and older. Results Median values of the CD8+:CD4+, EMRA:Naïve CD4+ and EMRA:Naïve CD8+ ratios were higher among older participants and were lower in those with additional educational attainment. Generally, minoritized race and ethnic groups had immune markers suggestive of a more aged immune profile: Hispanics had a CD8+:CD4+ median value of 0.37 (95 % CI: 0.35, 0.39) compared to 0.30 in non-Hispanic Whites (95 % CI: 0.29, 0.31). Non-Hispanic Blacks had the highest median value of the EMRA:Naïve CD4+ ratio (0.08; 95 % CI: 0.07, 0.09) compared to non-Hispanic Whites (0.03; 95 % CI: 0.028, 0.033). In regression analyses, race/ethnicity and education were associated with large differences in the immune ratio measures after adjustment for age and sex. Conclusions Lower educational attainment and minoritized racial ethnic status were associated with higher levels of immunosenescence. This population variation may have important implications for both risk of age-related disease and vulnerability to emerging pathogens (e.g., SARS-CoV-2)

Life course socioeconomic disadvantage and the aging immune system: findings from the health and retirement study

Objectives Previous research has documented a consistent association between current socioeconomic status (SES) and cytomegalovirus (CMV). Early life is likely a critical period for CMV exposure and immune development, but less is known about early-life socioeconomic factors and CMV, particularly in older age populations. Using data from the Health and Retirement Study, we investigated the association between life course socioeconomic disadvantage and immune response to CMV among older adults. Methods Using ordered logit models, we estimated associations between several measures of socioeconomic disadvantage and the odds of being in a higher CMV Immunoglobulin G (IgG) response category in a sample of 8,168 respondents aged older than 50 years. Results We found a significant association between educational attainment and CMV IgG response. Those with less than a high school education had 2.00 (95% confidence interval [CI]: 1.67–2.40) times the odds of being in a higher CMV category compared to those with a college degree or greater. In addition, we also observed a significant association with parental education and CMV response. Individuals with parents having 8 years or less of schooling had 2.32 (95% CI: 2.00–2.70) times the odds of higher CMV response compared to those whose parents had greater than high school education. Discussion CMV IgG levels in older adults are associated with both early-life and adult SES. Life course socioeconomic disadvantage may contribute to disparities in immunological aging

Biological expressions of early life trauma in the immune system of older adults

Background Poor immune function is associated with increased risk for a number of age-related diseases, however, little is known about the impact of early life trauma on immune function in late-life. Methods Using nationally representative data from the Health and Retirement Study (n = 5,823), we examined the association between experiencing parental/caregiver death or separation before age 16 and four indicators of immune function in late-life: C-reactive Protein (CRP), Interleukin-6 (IL-6), soluble Tumor Necrosis Factor (sTNFR), and Immunoglobulin G (IgG) response to cytomegalovirus (CMV). We also examined racial/ethnic differences. Findings Individuals that identified as racial/ethnic minorities were more likely to experience parental/caregiver loss and parental separation in early life compared to Non-Hispanic Whites, and had poorer immune function in late-life. We found consistent associations between experiencing parental/caregiver loss and separation and poor immune function measured by CMV IgG levels and IL-6 across all racial/ethnic subgroups. For example, among Non-Hispanic Blacks, those that experienced parental/caregiver death before age 16 had a 26% increase in CMV IgG antibodies in late-life (β = 1.26; 95% CI: 1.17, 1.34) compared to a 3% increase in CMV antibodies among Non-Hispanic Whites (β = 1.03; 95% CI: 0.99, 1.07) controlling for age, gender, and parental education. Interpretation Our results suggest a durable association between experiencing early life trauma and immune health in late-life, and that structural forces may shape the ways in which these relationships unfold over the life course