# Concurrent disease burden from multiple infectious diseases and the influence of social determinants in the contiguous United States

## TL;DR

This study explores how social factors like poverty influence the spread of multiple infectious diseases across U.S. counties.

## Contribution

The study reveals how poverty affects the geographic clustering of diseases like HIV, TB, and COVID-19.

## Key findings

- Three counties showed consistent disease clusters in both adjusted and unadjusted analyses.
- Poverty-adjusted analysis showed a shift in disease burden from urban to rural areas.
- Social determinants significantly influence the co-occurrence of infectious diseases.

## Abstract

Social determinants of health are known to underly excessive burden from infectious diseases. However, it is unclear if social determinants are strong enough drivers to cause repeated infectious disease clusters in the same location. When infectious diseases are known to co-occur, such as in the co-occurrence of HIV and TB, it is also unknown how much social determinants of health can shift or intensify the co-occurrence. We collected available data on COVID-19, HIV, influenza, and TB by county in the United States from 2019–2022. We applied the Kulldorff scan statistic to examine the relative risk of each disease by year depending on the data available. Additional analyses using the percent of the county that is below the US poverty level as a covariate were conducted to examine how much clustering is associated with poverty levels. There were three counties identified at the centers of clusters in both the adjusted and unadjusted analysis. In the poverty-adjusted analysis, we found a general shift of infectious disease burden from urban to rural clusters.