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BACKGROUND: Analyzing surveillance data according to area-based poverty measures helps define populations at increased disease risk, an important step toward identifying, tracking, and reducing disparities. The extent to which socioeconomic disparities are associated with differential morbidity across many reportable infectious diseases is unknown. We described disparities across area-based poverty levels by systematically analyzing communicable disease incidence in New York City (NYC), an area with a population of over 8 million people and pronounced household income inequality.
METHODS: We identified cases of 53 diseases diagnosed during 2006-2013 and reported to the Bureau of Communicable Disease of the NYC Department of Health and Mental Hygiene. Cases were geocoded and categorized by census tract-based poverty level (<10% of residents below the federal poverty threshold, 10 to <20%, 20 to <30%, and ≥30%) according to the American Community Survey. Undomiciled individuals were assigned to the highest poverty level, and incarcerated individuals were excluded from analysis. For each disease, age-standardized incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated for the highest versus lowest poverty levels, following the guidance of the Public Health Disparities Geocoding Project.
RESULTS: Diseases strongly associated with high poverty included rickettsialpox (IRR=3.69, 95% CI: 2.29, 5.95), chronic hepatitis C (IRR for new reports=3.58, 95% CI: 3.50, 3.66), chronic hepatitis B (IRR for new reports=3.28, 95% CI: 3.20, 3.36), malaria (IRR=3.48, 95% CI: 2.97, 4.08), and invasive pneumococcal disease (IRR=2.61, 95% CI: 2.42, 2.81). Diseases strongly associated with low poverty included domestic vectorborne diseases such as human granulocytic anaplasmosis (IRR=0.08, 95% CI: 0.03, 0.19) and Lyme disease (IRR=0.34, 95% CI: 0.32, 0.36).
CONCLUSIONS: In NYC, residents of high poverty areas were disproportionately affected by chronic hepatitis C (for which the prevalence is very high, prevention programs are needed, and curative treatment is available), chronic hepatitis B and malaria (for which outreach activities to prevent infection and linkage to care programs can be targeted to the most affected immigrant communities), and rickettsialpox (which can be prevented by limiting exposure to mice). Residents of low poverty areas were disproportionately affected by vectorborne diseases predominantly acquired in the United States, likely reflecting a population wealthy enough to travel to areas outside of NYC where infected vectors are prevalent. To further understand disparities in infectious disease incidence and to support disease-specific targeted prevention measures, future work should clarify populations at greatest risk through subgroup analyses by pathogen subtype, patient demographics, and underlying medical conditions.