Long-term exposure to ambient air pollution and greenness in relation to pulmonary tuberculosis in China: A nationwide modelling study

Previous studies have attempted to clarify the relationship between the occurrence of pulmonary tuberculosis (PTB) and exposure to air pollutants. However, evidence from multi-centres, particularly at the national level, is scarce, and no study has examined the modifying effect of greenness on air pollution-TB associations. In this study, we examined the association between long-term exposure to ambient air pollutants (PM 10 p.m. 2.5 , and O 3 ) and monthly PTB or smear-positive pulmonary tuberculosis (SPPTB) incidence to further evaluate whether these associations were affected by greenness in mainland China using a two-stage analytic procedure. PM 2.5 was positively associated with both PTB and SPPTB incidence, with relative risk (RR) of 1.12 (95% confidence interval [CI]: 1.03, 1.22) and 1.08 (95% CI: 1.02, 1.10) per 10 μg/m 3 increase, respectively. Furthermore, PM 10 was positively associated with PTB incidence, with RR of 1.07 (95% CI: 1.01, 1.13). However, O 3 was not associated with the monthly incidence of PTB or SPPTB. The normalized difference vegetation index (NDVI) exhibited a modifying effect on the association between PM 2.5 exposure and SPPTB incidence in northern areas, with RR of 1.16 (95% CI: 1.03, 1.31) in lower mean annual NDVI areas than in the higher areas (RR = 0.98, 95% CI: 0.87, 1.09). This nationwide analysis indicated that NDVI could reduce the effect of air pollutants on TB incidence particularly in the northern areas. Long-term exposure to particulate matter (PM) may increase the occurrence of PTB or SPPTB in China, and further studies involving larger numbers of SPPTB cases are required to confirm the effects of PM exposure on SPPTB incidence in the future.