Effects of conditional cash transfers on tuberculosis incidence and mortality according to race, ethnicity and socioeconomic factors in the 100 Million Brazilian Cohort

Abstract

Conditional cash transfer (CCT) programs have been implemented globally to alleviate poverty. Although tuberculosis (TB) is closely linked to poverty, the effects of CCT on TB outcomes among populations facing social and economic vulnerabilities remain uncertain. Here we estimated the associations between participation in the world's largest CCT program, the Brazilian Bolsa Família Program (BFP), and the reduction of TB incidence, mortality and case-fatality rates using the nationwide 100 Million Brazilian Cohort between 2004 and 2015. We also evaluated these relationships according to race, ethnicity, wealth levels, sex and age. Exposure to the BFP was associated with a large reduction in TB incidence (adjusted rate ratio (aRR): 0.59; 95% confidence interval (CI): 0.58-0.60) and mortality (aRR: 0.69; 95% CI: 0.65-0.73). The strongest BFP association was observed in individuals of Indigenous ethnicity both for TB incidence (aRR: 0.37; 95% CI: 0.32-0.42) and mortality (aRR: 0.35; 95% CI: 0.20-0.62), and in individuals of Black and Pardo ethnicity (incidence-aRR: 0.58; 95% CI: 0.57-0.59; mortality-aRR: 0.69; 95% CI: 0.64-0.73). BFP associations were considerably stronger among individuals living in extreme poverty both for TB incidence (aRR: 0.49; 95% CI: 0.49-0.50) and mortality (aRR: 0.60; 95% CI: 0.55-0.65). CCT can strongly reduce TB incidence and mortality in individuals living in extreme poverty, and of Indigenous, Black and Pardo ethnicity, and could significantly contribute to achieving the End TB Strategy targets and TB-related Sustainable Development Goals.