The causal links between long-term exposure to major PM2.5 components and the burden of tuberculosis in China

Background: We aimed to estimate the causal impacts of long-term exposure to major PM2.5 components - including black carbon, organic matter, sulfate, nitrate, and ammonium - on the incidence and mortality of tuberculosis in China.Methods: We collected annual and provincial-level tuberculosis incidence and mortality, concentrations of PM2.5 components, and socioeconomic indicators from between 2004 and 2018 in mainland China. We used the difference-indifferences (DID) causal inference approach with a generalized weighted quantile sum (gWQS) regression model to estimate the long-term effects and relative contributions of PM2.5 components' exposure on tuberculosis incidence and mortality. Results: We found that long-term multi-components exposure was significantly associated with tuberculosis incidence (WQS index IR%:8.34 %, 95 % CI:4.54 %-12.27 %) and mortality (WQS index IR%:19.49 %, 95 % CI: 9.72 %-30.13 %). Primary pollutants, black carbon and organic matter, contributed most of the overall mixture effect (over 85 %). Nitrate showed a critical role in tuberculosis burden in not-aging provinces and in regions at the Q3 stratum (i.e., the 3rd quartile) of GDP per capita and urbanization rate. Meanwhile the contribution of sulfate to tuberculosis burden in regions at the Q1 stratum of GDP per capita and urbanization rate was the largest among the effect of secondary pollutants (i.e., sulfate, nitrate, and ammonium).Conclusion: The mitigation of black carbon and organic matter pollution may significantly reduce the tuberculosis burden in China. Controlling nitrate emissions and increasing clean energy (i.e., energy sources with limited pollution emissions, such as natural gas and clean coal) may also be effective in certain regions.