BACKGROUND Despite an overall decline in tuberculosis incidence and mortality in the USA in the past two decades, racial and ethnic disparities in tuberculosis outcomes persist. We aimed to examine the extent to which inequalities in health and neighbourhood-level social vulnerability mediate these disparities. METHODS We extracted data from the US National Tuberculosis Surveillance System on individuals with tuberculosis during 2011-19. Individuals with multidrug-resistant tuberculosis or missing data on race and ethnicity were excluded. We examined potential disparities in tuberculosis outcomes among US-born and non-US-born individuals and conducted a mediation analysis for groups with a higher risk of treatment incompletion (a summary outcome comprising diagnosis after death, treatment discontinuation, or death during treatment). We used sequential multiple mediation to evaluate eight potential mediators: three comorbid conditions (HIV, end-stage renal disease, and diabetes), homelessness, and four census tract-level measures (poverty, unemployment, insurance coverage, and racialised economic segregation [measured by Index of Concentration at the ExtremesRace-Income]). We estimated the marginal contribution of each mediator using Shapley values. FINDINGS During 2011-19, 27 788 US-born individuals and 57 225 non-US-born individuals were diagnosed with active tuberculosis, of whom 27 605 and 56 253 individuals, respectively, met eligibility criteria for our analyses. We did not observe evidence of disparities in tuberculosis outcomes for non-US-born individuals by race and ethnicity. Therefore, subsequent analyses were restricted to US-born individuals. Relative to White individuals, Black and Hispanic individuals had a higher risk of not completing tuberculosis treatment (adjusted relative risk 1·27, 95% CI 1·19-1·35; 1·22, 1·11-1·33, respectively). In multiple mediator analysis, the eight measured mediators explained 67% of the disparity for Black individuals and 65% for Hispanic individuals. The biggest contributors to these disparities for Black individuals and Hispanic individuals were concomitant end-stage renal disease, concomitant HIV, census tract-level racialised economic segregation, and census tract-level poverty. INTERPRETATION Our findings underscore the need for initiatives to reduce disparities in tuberculosis outcomes among US-born individuals, particularly in highly racially and economically polarised neighbourhoods. Mitigating the structural and environmental factors that lead to disparities in the prevalence of comorbidities and their case management should be a priority. FUNDING US Centers for Disease Control and Prevention National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention Epidemiologic and Economic Modeling Agreement.

中文翻译：

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结核病诊断和治疗结果中种族和民族差异的危险因素，2011-19：国家监测数据的多重中介分析。


背景尽管过去二十年美国结核病发病率和死亡率总体下降，但结核病结果的种族和民族差异仍然存在。我们的目的是研究健康不平等和社区层面的社会脆弱性在多大程度上调节这些差异。方法 我们从美国国家结核病监测系统中提取了 2011-19 年间结核病患者的数据。患有耐多药结核病或缺少种族和民族数据的个体被排除在外。我们检查了美国出生和非美国出生的个体之间结核病结果的潜在差异，并对治疗未完成风险较高的群体进行了中介分析（总结结果包括死亡后诊断、治疗中断或治疗期间死亡）。我们使用序贯多重中介来评估八个潜在中介：三个共病（艾滋病毒、终末期肾病和糖尿病）、无家可归和四个人口普查区域层面的衡量指标（贫困、失业、保险覆盖率和种族化经济隔离[测量]通过极端种族收入集中指数]）。我们使用 Shapley 值估计每个中介的边际贡献。调查结果 2011-19 年期间，27 788 名美国出生的人和 57 225 名非美国出生的人被诊断患有活动性结核病，其中分别有 27 605 人和 56 253 人符合我们分析的资格标准。我们没有观察到非美国出生的人的结核病结果因种族和民族而存在差异的证据。因此，随后的分析仅限于美国出生的个体。 相对于白人，黑人和西班牙裔个体未完成结核病治疗的风险较高（调整后相对风险分别为 1·27、95% CI 1·19-1·35；1·22、1·11-1·33） ）。在多中介分析中，八个测量中介解释了黑人个体 67% 的差异和西班牙裔个体 65% 的差异。造成黑人和西班牙裔个体差异的最大因素是伴随的终末期肾病、伴随的艾滋病毒、人口普查区层面的种族经济隔离以及人口普查区层面的贫困。解释 我们的研究结果强调需要采取举措减少美国出生的个体结核病结果的差异，特别是在种族和经济高度两极分化的社区。减轻导致合并症患病率及其病例管理差异的结构性和环境因素应成为优先事项。资助美国疾病控制和预防中心国家艾滋病毒、病毒性肝炎、性病和结核病预防流行病学和经济模型协议中心。