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

Abstract

BackgroundLiving 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. MethodsWe 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. ResultsWe 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 PM2.5 (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. ConclusionIncreasing greenness exposure along with medical treatment reduces all-cause mortality among patients living in lower NTL areas.