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Title: Post-TB lung damage amongst Malawian adults
Author: Meghji, Jamilah
ISNI:       0000 0004 7964 318X
Awarding Body: Liverpool School of Tropical Medicine
Current Institution: Liverpool School of Tropical Medicine
Date of Award: 2019
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INTRODUCTION: Pulmonary tuberculosis (PTB) remains an important risk factor for chronic lung disease (CLD) in sub-Saharan Africa (sSA), but our understanding of the nature of post-TB lung damage, its evolution over time, and the associated morbidity remains limited. This information is needed to inform clinical care and health system approaches to the management of those surviving PTB disease. METHODS: A general review of the literature on CLDs in sSA, TB disease and epidemiology, and post-TB lung damage and its associated morbidity were completed, followed by a systematic review of the prevalence and pattern of post-TB structural lung pathology. Primary data presented in this thesis were drawn from two studies based in urban Blantyre, Malawi. The first was a cross-sectional survey of respiratory abnormalities amongst adults in the community which was completed as part of the Burden of Obstructive Lung Disease (BOLD) initiative. The second was a prospective cohort study of HIV-positive and negative adults completing treatment for PTB which aimed to describe a) the prevalence of respiratory pathology at TB treatment completion using symptoms, quality of life scores, spirometry and high-resolution CT imaging, and b) the relationships between post-TB lung damage at treatment completion and adverse outcomes over 1-year of followup. RESULTS: The systematic review identified 39 studies of variable quality describing post-TB structural lung damage. A lack of prospective data, and data from sSA and HIV-positive groups was noted. Few studies related structural damage to symptoms, spirometry, or morbidity. The BOLD data estimated a high burden of respiratory symptoms and abnormal spirometry amongst adults aged ≥18 years in urban Blantyre: 11.8% reported ≥1 symptom, and 4.8% had airway obstruction. The prevalence of the low-FVC pattern of abnormal spirometry varied according to the reference range used for standardisation, from 9.0% (local reference range) to 38.6% (NHANES III reference range). A considerable burden of residual lung pathology was seen amongst 405 adults completing treatment for PTB in Blantyre: 60.7% had ongoing weekly/monthly respiratory symptoms, and 34.2% of participants had abnormal spirometry at PTB treatment completion. Participants had a median of 1.4 lobes of abnormal parenchyma on CT imaging. Moderate-severe bronchiectasis was seen in 44%, and 9.6% had ≥1 'destroyed' lobe. The burden of pathology was lower in HIV-positive vs. HIV-negative adults, but patterns of abnormality were similar. The odds of ongoing respiratory symptoms or an impaired quality of life at 1-year were over three-fold higher amongst those with both extensive structural damage and abnormal spirometry at PTB treatment completion. CONCLUSION: Post-TB lung damage is a common but neglected form of CLD amongst both HIV-positive and negative adults in Malawi, and occurs against a high background prevalence of respiratory symptoms and abnormal spirometry in the community. Severe forms are associated with considerable ongoing morbidity including persistent symptoms and reduced quality of life. Further work is required to understand the range of patterns of post-TB lung damage, and their relationship with long-term outcomes such as respiratory exacerbations and mortality. However, this is a neglected population and interventions to maximise their health following PTB treatment completion are required.
Supervisor: Squire, Bertie ; Mortimer, Kevin ; Corbett, Liz Sponsor: Wellcome Trust
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: WA 395 Health in developing countries ; WF 200 Tuberculosis (General) ; WF 215 Pathology ; WF 300 Pulmonary tuberculosis