Socioeconomic dynamics and tuberculosis mortality in São Paulo: a population-level analysis using spatial modeling.

Background: Tuberculosis remains a major cause of preventable mortality in Brazil, marked by pronounced social and territorial inequalities. Evidence remains limited on how socioeconomic conditions and health system characteristics are associated with tuberculosis mortality across age groups in high-burden settings such as São Paulo state. This study aimed to examine the spatial and temporal associations of these factors with tuberculosis mortality across municipalities in the State of São Paulo, Brazil. Methods: We conducted a population-based ecological study in São Paulo, Brazil. All TB deaths reported to the Mortality Information System from 2020 to 2024 were included. Socioeconomic, demographic and health system factors were selected based on a conceptual framework. Variables associated with TB mortality were assessed using Generalized Additive Models for Location, Scale, and Shape, with spatial smoothing. Findings: The analysis included 38,700 municipality-month observations. In the final spatial GAMLSS model, proportions of household crowding (>2 residents/bedroom) and elderly population (>59 years) were associated with 3.25% and 5.92% increases in expected TB mortality for each one percentage-point increase, respectively. In contrast, each one percentage-point increase in primary health care coverage was associated with a 0.30% decrease in expected TB mortality. The fitted spatial effect indicated higher expected TB mortality along coastal and central regions, and lower expected mortality in the northwestern region. Interpretation: Tuberculosis mortality in São Paulo is shaped by persistent socioeconomic and territorial inequalities, with distinct patterns across age groups. These findings highlight the need for strategies that address structural vulnerability and strengthen primary health care to reduce avoidable tuberculosis-related deaths. Funding: This work was supported by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-Brasil and São Paulo State Research Foundation (FAPESP).