|Year : 2022 | Volume
| Issue : 2 | Page : 139-144
Post tuberculosis chronic lung disease in tuberculosis HIV coinfected and non-HIV individuals in Sub-Saharan Africa: A systematic review and meta-analysis
Violet Dismas Kajogoo1, Calleb Twebaze2, Bibie Said3, Hanna Amanuel Tesfahunei4, Loveness Charlie5, Emnet Getachew6
1 Mafia District Hospital, Mafia Islands, Tanzania
2 Department of Research, MCT- Clinical Research Organisation, Kampala, Uganda
3 Department of Research, Kibong'oto National Tuberculosis Hospital, Kilimanjaro, Tanzania
4 Disease Control and Prevention Division, Africa CDC, Endemic and NTDs African Union, Ethiopia
5 Center for Innovative Drug Development and Therapeutic Trials for Africa, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
6 Department of Public Health, Arsi University, Ethiopia
|Date of Submission||04-Apr-2022|
|Date of Decision||04-May-2022|
|Date of Acceptance||17-May-2022|
|Date of Web Publication||14-Jun-2022|
|Date of Print Publicaton||14-Jun-2022|
Violet Dismas Kajogoo
Mafia District Hospital, Mafia Islands
Source of Support: None, Conflict of Interest: None
Background: Post tuberculosis (TB) sequelae are faced by many individuals who survive TB. The most common of all is post-TB chronic lung disease (CLD) and pulmonary impairment. We reviewed studies that estimated the prevalence of post-TB CLD in patients with TB only and those with TB-HIV coinfection. Methods: Searched Google scholar, PubMed, African journals online, Embase, and Cochrane Central Register of Clinical Trials from the year 2000 to 01 March 2022 for all designs of studies that examined the impact of post on lung impairment or damage. The protocol was registered in PROSPERO, ID: chronic respiratory disease 42022304628. Results: Three hundred and thirty-six studies were identified and five studies were identified through other sources, four were finally in the meta-analysis with a total of 4382 enrolled participants. All the studies had a low risk of bias; The prevalence of CLD between the TB HIV coinfection and those with TB only was of no statistical significance between the three of the four studies – new statement: the prevalence of CLD in the TB-HIV coinfected group when compared to the group of participants with TB only was not statistically significant in the study. This was seen in three of the four studies. One study was in favor of the high prevalence of CLD in HIV coinfection participants (relative risk [RR] = 0.75 [0.61–0.89] with 95% confidence interval [0.61–0.89]). Conclusions: Post-TB lung disease is still a burden that needs advocation and an increase of awareness is necessary from the health-care level to the communities and societies, especially in regions of high prevalence. Development of guidelines for health-care workers to aid the management of individuals, multi-disciplinary advocacy is necessary for those whom prevention is not too late.
Keywords: HIV, post-TB chronic lung disease, pulmonary impairment after TB, tuberculosis
|How to cite this article:|
Kajogoo VD, Twebaze C, Said B, Tesfahunei HA, Charlie L, Getachew E. Post tuberculosis chronic lung disease in tuberculosis HIV coinfected and non-HIV individuals in Sub-Saharan Africa: A systematic review and meta-analysis. Int J Mycobacteriol 2022;11:139-44
|How to cite this URL:|
Kajogoo VD, Twebaze C, Said B, Tesfahunei HA, Charlie L, Getachew E. Post tuberculosis chronic lung disease in tuberculosis HIV coinfected and non-HIV individuals in Sub-Saharan Africa: A systematic review and meta-analysis. Int J Mycobacteriol [serial online] 2022 [cited 2022 Aug 15];11:139-44. Available from: https://www.ijmyco.org/text.asp?2022/11/2/139/347524
| Background|| |
A third of the world's population is infected with Mycobacterium tuberculosis. It is one of the top 10 causes of mortality., An estimated 10 million incident cases of tuberculosis (TB) disease occurred globally in 2018, one-quarter of which occurred in Africa where 29% of patients were HIV coinfected.,
The term post-TB describes the range of pathological conditions experienced by TB survivors. Pulmonary TB, the most common disease presentation, causes progressive destruction of lung tissue, and this damage might not fully resolve after treatment.,, In 2016, scholars called for better linkages between TB control programs and respiratory medicine services as well as a better understanding of the burden of respiratory disability at the end of anti-TB treatment to improve quality of life (QoL)., Many patients with pulmonary TB (PT) undergo anatomical changes secondary to the illness, such as parenchymal structural damage including bronchovascular distortion, bronchiectasis, emphysematous and fibrotic band formations, and other well-described histologic and anatomic changes., Furthermore, treated TB patients appear to contribute substantially to the growing worldwide burden of chronic obstructive pulmonary disease (COPD).,
Individuals with COPD experience lower QoL, higher health-care use, and reduced economic productivity compared with healthy individuals.,, The burgeoning prevalence of chronic respiratory disease (CRD) is fueled by an aging population, the combination of respiratory infections such as TB with human immunodeficiency virus, tobacco smoking, household air pollution, and nutritional impairment., To date, much of the evidence about adverse health consequences post-TB treatment has come from countries with a relatively low burden of TB. In Africa, the problem may be worse; permanent extensive lung damage after PTB is common and is associated with delayed diagnosis, multidrug resistance, and nonadherence to treatment., Pulmonary impairment after TB, which is presumably a result of these anatomical changes, has been shown to be common in patients who have completed at least 20 weeks of TB treatment. Evaluation is only recommended for patients in whom recurrence or relapse is suspected, not for surveillance for chronic sequelae related to TB.
Historically, post-TB has not been a major focus of the TB control agenda. However, the healthcare needs of TB survivors are drawing increasing attention, and there is increasing awareness of the severe and potentially life-threatening adverse health consequences of TB after completion of treatment. Current guidelines for the management of TB cases do not recommend screening for chronic lung diseases (CLDs) following treatment. HIV infection itself can lead to respiratory disorders., A recent meta-analysis showed a high prevalence of COPD in the global population with HIV. It is probable that the high prevalence of TB and HIV in Africa leads to an increased prevalence of lung function impairment, particularly post-TB; however, this situation is poorly documented. HIV coinfection is also associated with TB retreatment, and may contribute to additional chronic respiratory debility and overall mortality.
In this systematic review and meta-analysis, we aimed at analyzing post TB CLD in patients with HIV and those without HIV in Sub-Saharan where the prevalence of HIV is higher.
| Methods|| |
The protocol for the review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database, ID: CRD42022304628. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.,
The PICOS format was used to identify the studies that were eligible for the review. We included all study designs, apart from case studies and case series. The studies had to evaluate post-TB CLD in TB-HIV coinfected and those without HIV.
People who had previously suffered from PT, regardless of age, sex, and HIV status.
The participants in the study must have received cure of TB as per the standard guidelines of the particular nation.
We compared participants who had the previous history of PT without HIV and those with TB-HIV coinfection.
The outcome measure was post-TB CLD or pulmonary impairment.
Studies selected were from Sub-Saharan Africa, with human participants.
Electronic database search was done from Pubmed, google scholar, African Journals Online, and Cochrane. We selected studies with human participants, peer reviewed, and published in English. The studies were published from the year 2000 to March 2022.
For Pubmed MeSH terms were used, that included the following: “post TB chroncic lung disease” (MeSH Terms) OR “post TB CRD” (MeSH Terms) OR “pulmonary impairement after TB” (MeSH Terms) OR “COPD” AND “HIV” (MeSH Terms) OR “human immunodeficiency” (MeSH Terms) OR “AIDS” (MeSH Terms) OR “immunocompromised” (MeSH Terms) AND “TB” (MeSH Terms) OR “Pulmonary TB” (MeSH Terms) OR “miliary TB” (MeSH Terms) OR “Mycobacterium TB” (Medical Subject Headings (MeSH Terms)) AND 'Sub-Sahara Africa' (MeSH Terms) OR “Africa” (MeSH Terms) OR “South Africa” (MeSH Terms) AND “TB-HIV coinfection”(MeSH Terms) OR “cormobidity” (MeSH Terms) OR “coinfection” (Medical Subject Headings (MeSH Terms)).
Study selection, data collection, and data analysis.
Mendeley software and Stata 14 software were used for managing data and analysis. Two authors independently selected studies and reviewed results. misunderstanding between authors was resolved through discussion and reaching an agreement. In case of missing data or clarification, the authors of the study were contacted for details.
Data extraction and management.
Two authors independently screened titles and abstracts that were retrieved from the databases, excluded case studies and case series and those that were not of the English language. Information collected included author and year of publication, country, study design, year of data collection, participants, and treatment outcomes of CLD, which was extracted by using a data extraction tool adapted from Cochrane. The number of participants in each treatment group with the outcome measure was also captured. The dichotomous outcomes of the number of events and the total number of participants in each group were documented. The extraction and management of data were done independently by two authors and any disagreements were resolved by discussion.
Assessment of risk of bias in included studies/quality assessment
Assessment of the quality of the studies was done using the Newcastle–Ottawa scale. The scale has the following characteristics: standardized methods of diagnosis confirmation, large enough sample size, multicenter study, appropriate statistical methods that report outcomes, accounting for confounders (demographics, socioeconomic status, previous treatment history), and clear methodology for the selection of participants. The risks were also grouped into high, unclear, and low.
Measures of treatment effect
The outcome measure of the review was the development of post-TB CLD. The risk ratio was used to present the results of the dichotomous outcomes that were combined, with a 95% confidence interval (CI). In the forest plot, the upper and the bottom tips of the diamond (the center of the diamond) represents point estimate and the left and right tips of the diamond represent the confidence interval.
Assessment of heterogeneity
Forest plots were used to assess for heterogeneity, using Chi-Square and I2. the results were reported and possible cause of heterogeneity was explored and explained.
For easy interpretations, studies were identified by the first authors and year of publication. Forests plot was drawn; random-effects model was used in studies with a common effect estimate. Two researchers independently synthesized the data.
The studies that were included had a low risk of bias.
| Results|| |
A total of 336 studies were identified through database search and five other studies were identified through other sources of backward citation referencing. Ten studies remained after the removal of duplicates by the Mendeley reference manager, screening of titles and abstracts. Full-text review of the 10 studies was done, and four studies remained for qualitative and quantitative synthesis [Figure 1].
[Table 1] summarizes the characteristic of studies that included cross-sectional, cohorts, and retrospective reviews. There were a total of 4382 participants, all adults. – new statement: There was a total of 4382 adult participants.
The risk of bias and methodological quality
[Table 2] is the summary of the risk of bias according to the authors' judgment using the new castle Ottawa scale. All four studies had a low risk of bias and were found to have one bias of not being multicenter studies.
|Table 2: Risk of bias summary according to the author's judgments about each risk of bias item for the included studies|
Click here to view
Prevalence of CLD
The prevalence of CLD between the TB-HIV coinfection and those with TB only was of no statistical significance between the three of the four studies. One study was in favor of the high prevalence of CLD in HIV coinfection participants [Figure 2].
|Figure 2: Prevalence of CLD in TB-HIV coinfected and those with TB only. CLD: Chronic lung disease, TB: Tuberculosis|
Click here to view
| Discussion|| |
The main purpose of the review was to determine the prevalence of post-TB CLD between those with TB only and those with TB-HIV coinfection. Four studies were included in the meta-analysis. This is the first meta-analysis of the kind comparing CLD post-TB in adult individuals with or without HIV in Sub-Saharan Africa. The main findings suggest that there is no statistical significance of post-TB CLD in patients with or without HIV. Three studies show no statistical significance between prevalence of CLD post-TB in those with or without HIV, and one study shows a higher prevalence in those with HIV. The heterogeneity in the studies was moderate.
In a study done in low-incidence US population, the TB recurrence rate was low, but CLD and HIV were independent risk factors for recurrence. Another study revealed that previous TB is an independent risk factor for obstructive lung disease, even if the lesion is minimal and TB can be an important cause of obstructive lung disease in never smokers. Another study on MDR TB patients showed that after the completion of treatment the significant number of cured MDR-TB patients are left with residual symptoms, abnormal X-ray chest, and impairment of lung functions. Furthermore, a study had results that HIV status, level of education, and history of PT were the main predictors of severe TB sequelae. Data collected from a particular study suggested that the clinical severity and the radiographic pattern of HlV associated PT are strongly related to the degree of progression of HIV infection.
A study also concluded that a history of TB was associated with both airflow obstruction and spirometric restriction, and should be considered as a potentially important cause of obstructive disease and low lung function, particularly where TB is common. In a prospective study of retreatment TB survivors from a high-HIV burden country, we found a high prevalence of residual respiratory symptoms, functional deficits, and radiographic abnormalities, with approximately one in seven demonstrating frank CLD and one in 10 experiencing major depression. Although 35% of the population analyzed were HIV negative, the rate of death among retreatment TB patients was six-fold that of the general HIV-positive Zimbabwe referent population.
| Conclusions|| |
Post-TB lung disease is still a burden that needs to be advocated and increase of awareness is necessary from the health-care level to the communities and societies, especially in regions of high prevalence. Development of guidelines for health-care workers to aid the management of individuals, multi-disciplinary advocacy is necessary for those for whom prevention is not too late. This will reduce morbidity by improving QoL, reducing suffering, and probably prolonging life. Appropriate treatment and regular follow-up, research to understand baseline risk factors that predict long-term lung damage is also necessary, especially in regions with the high burden.
The limitations of the study include the moderate heterogeneity found in the forest plots. The study was also limited to sub-saharan Africa settings, which could be a strength in that it is the endemic region for TB and HIV but also a limitation as we could address our research question with studies from elsewhere.
Availability of data and materials
All relevant data are within the manuscript and its supporting files.
We would like to express our gratitude to Mafia District Hospital for providing a conducive environment for supporting the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
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