Municipality-Level Spatial Clustering and Socio- Environmental Determinants of Tuberculosis in Nepal, 2019- 2024

Municipality-Level Spatial Clustering and Socio- Environmental Determinants of Tuberculosis in Nepal, 2019- 2024 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Municipality-Level Spatial Clustering and Socio- Environmental Determinants of Tuberculosis in Nepal, 2019- 2024 Nabin Bisht, Chiranjivi Adhikari, Harikishor Yadav This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8515251/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 11 You are reading this latest preprint version Abstract Background Tuberculosis (TB) remains a major public health challenge in Nepal, marked by substantial geographic heterogeneity. Despite ongoing control efforts, spatial clustering patterns and socio-environmental determinants at the municipal level are not well understood. This study assessed spatial clustering of TB notification rates and their association with sociodemographic, housing, and environmental factors across all 753 municipalities of Nepal. Methods Data of notified TB cases were extracted from National Tuberculosis Control Centre from FY 2019/20 to FY 2023/24. Spatial autocorrelation and clustering were examined using Global Moran’s I, Getis-Ord Gi*, and Local Indicators of Spatial Association (LISA). Associations between TB notification rates and socio-demographic, housing, and environmental factors were evaluated using Ordinary Least Squares, Spatial Lag, and Spatial Error Models. Results A total of 172,155 TB cases were reported over the five-year period (FY 2019/20-2023/24), with national notification rates increasing from 92 to 139 per 100,000 population. Significant and persistent positive spatial autocorrelation was observed annually (Moran’s I: 0.42–0.53; p < 0.001). High-High clusters were consistently concentrated in the densely populated Terai municipalities of Madhesh and Lumbini Provinces, whereas Low-Low clusters dominated the remote mountain regions of Karnali and Sudurpashchim. The Spatial Error Model (SEM) provided the best fit (Pseudo-R² = 0.62), revealing that population density (β = 0.008, p < 0.001), liquefied petroleum gas use (β = 60.85, p < 0.001), and nighttime land surface temperature (β = 1.69, p < 0.05) were significantly associated with higher TB notification rates. Traditional housing materials (mud walls: β=-38.40, p < 0.001) and cow dung fuel use (β=-48.43, p < 0.05) showed negative associations, likely reflecting diagnostic access barriers rather than lower disease incidence. Conclusions Tuberculosis in Nepal demonstrates significant and persistent spatial clustering at the local municipal level, driven by population density, housing, energy access, and climatic conditions. These results emphasize the need for geographically targeted, municipality focused interventions to advance Nepal’s progress toward the End TB Strategy and Sustainable Development Goal 3.3 Tuberculosis Spatial analysis spatial autocorrelation LISA Ecological study GIS Environmental determinants Nepal Full Text Additional Declarations No competing interests reported. Tables 1 to 5 are available in the Supplementary Files section. Supplementary Files Table1.docx Table2.docx Table3.docx Table4.docx Table5.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 16 Mar, 2026 Reviews received at journal 22 Feb, 2026 Reviewers agreed at journal 31 Jan, 2026 Reviews received at journal 29 Jan, 2026 Reviewers agreed at journal 28 Jan, 2026 Reviewers agreed at journal 28 Jan, 2026 Reviewers invited by journal 22 Jan, 2026 Editor invited by journal 09 Jan, 2026 Editor assigned by journal 08 Jan, 2026 Submission checks completed at journal 08 Jan, 2026 First submitted to journal 04 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8515251","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":578714878,"identity":"6ec3ea91-a18b-4389-a001-2909164d651d","order_by":0,"name":"Nabin 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Nepal, 2019- 2024","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tuberculosis, Spatial analysis, spatial autocorrelation, LISA, Ecological study, GIS, Environmental determinants, Nepal","lastPublishedDoi":"10.21203/rs.3.rs-8515251/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8515251/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTuberculosis (TB) remains a major public health challenge in Nepal, marked by substantial geographic heterogeneity. Despite ongoing control efforts, spatial clustering patterns and socio-environmental determinants at the municipal level are not well understood. This study assessed spatial clustering of TB notification rates and their association with sociodemographic, housing, and environmental factors across all 753 municipalities of Nepal.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData of notified TB cases were extracted from National Tuberculosis Control Centre from FY 2019/20 to FY 2023/24. Spatial autocorrelation and clustering were examined using Global Moran\u0026rsquo;s I, Getis-Ord Gi*, and Local Indicators of Spatial Association (LISA). Associations between TB notification rates and socio-demographic, housing, and environmental factors were evaluated using Ordinary Least Squares, Spatial Lag, and Spatial Error Models.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 172,155 TB cases were reported over the five-year period (FY 2019/20-2023/24), with national notification rates increasing from 92 to 139 per 100,000 population. Significant and persistent positive spatial autocorrelation was observed annually (Moran\u0026rsquo;s I: 0.42\u0026ndash;0.53; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). High-High clusters were consistently concentrated in the densely populated Terai municipalities of Madhesh and Lumbini Provinces, whereas Low-Low clusters dominated the remote mountain regions of Karnali and Sudurpashchim. The Spatial Error Model (SEM) provided the best fit (Pseudo-R\u0026sup2; = 0.62), revealing that population density (β\u0026thinsp;=\u0026thinsp;0.008, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), liquefied petroleum gas use (β\u0026thinsp;=\u0026thinsp;60.85, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and nighttime land surface temperature (β\u0026thinsp;=\u0026thinsp;1.69, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were significantly associated with higher TB notification rates. Traditional housing materials (mud walls: β=-38.40, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and cow dung fuel use (β=-48.43, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) showed negative associations, likely reflecting diagnostic access barriers rather than lower disease incidence.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eTuberculosis in Nepal demonstrates significant and persistent spatial clustering at the local municipal level, driven by population density, housing, energy access, and climatic conditions. These results emphasize the need for geographically targeted, municipality focused interventions to advance Nepal\u0026rsquo;s progress toward the End TB Strategy and Sustainable Development Goal 3.3\u003c/p\u003e","manuscriptTitle":"Municipality-Level Spatial Clustering and Socio- Environmental Determinants of Tuberculosis in Nepal, 2019- 2024","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-27 18:04:42","doi":"10.21203/rs.3.rs-8515251/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-16T08:44:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-22T08:38:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181490991599180826720286697328268367920","date":"2026-02-01T01:44:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-30T02:08:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"148598626887410613982136837681300744887","date":"2026-01-29T04:19:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64775798511767612414922510825242767766","date":"2026-01-29T03:01:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-22T11:25:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-09T06:36:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-08T08:23:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-08T08:22:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2026-01-04T19:58:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"489f3cdf-d08f-4182-b9fc-c0e3514257a5","owner":[],"postedDate":"January 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T08:25:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-27 18:04:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8515251","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8515251","identity":"rs-8515251","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}