Author ORCID Identifier

0000-0002-2620-412X

Date of Award

1-10-2025

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Nursing

First Advisor

Blake T. McGee

Second Advisor

Maryam Haddad

Third Advisor

Terri Pigott

Abstract

Problem: In the United States, social inequities are concentrated in rural areas, potentially increasing the risk for recent transmission (RT) of tuberculosis (TB), a precursor of TB outbreaks. Most TB cases occur among non-U.S.–born patients; however, little is known about TB in rural areas. This dissertation examined characteristics associated with RT in rural areas.

Methods: TB cases with genotyping results reported to the National Tuberculosis Surveillance System during 2011–2021 were included if they occurred in areas classified as non-metropolitan (rural) by the National Center for Health Statistics. Community characteristics included county-level poverty (American Community Survey) and number of primary care physicians (PCP) per 100,000 (Health Resources and Services Administration). Hierarchical generalized linear models were constructed to estimate the relative association of individual and county characteristics with RT.

Results: During 2011–2021, 7,607 rural U.S. residents were diagnosed with TB. Patients lived in counties with a mean of 20% (SD=7.0) of the population below poverty and 49 (SD=27) PCPs per 100,000. Most patients were male (66.0%), U.S.-born (63.8%), and identified as a racial or ethnic minority (74.1%). TB was attributed to RT for 847 (15.0%) of 5,633 cases with an RT designation. Most patients with TB attributed to RT lived in the U.S. Census South Region (65.6%), followed by the West (27.2%), Midwest (6.4%), and Northeast (0.8%); nearly all were U.S.-born (90.3%). County and patient characteristics, except age, differed significantly by region. In hierarchical models, U.S. birth (odds ratio=5.05, 95% CI: 3.62–7.04), racial/ethnic minority identification (1.54, [1.13–2.11]), incarceration (0.46, [0.26–0.80]), age (0.97, [0.97–0.98]), and county PCP ratio (0.99, [0.98–1.00], p=.02) were associated with RT, whereas homelessness, substance misuse, comorbidities, and county-level poverty were not.

Conclusion: Unlike national epidemiology, most patients with TB in rural areas, and nearly all whose TB was attributed to RT, were U.S.-born. Healthcare providers in rural areas should consider TB as a potential diagnosis among symptomatic U.S.-born patients of racial or ethnic minority groups. More attention is needed to highlight the unique characteristics of patients with TB due to RT in rural areas.

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