Global lung health: the colliding epidemics of tuberculosis, tobacco smoking, HIV and COPD

Abstract

Tuberculosis (TB), smoking, HIV and chronic obstructive pulmonary disease (COPD) are burgeoning epidemics in developing countries. The link between TB and HIV is well established. Less well recognised is the strong relationship between tobacco smoking and the development and natural history of TB. These associations are of considerable relevance to public health and disease outcomes in individuals with TB. Moreover, tobacco smoking, a modifiable risk factor, is associated with poorer outcomes in HIV-associated opportunistic infections, of which TB is the commonest in developing countries. It is now also becoming clear that TB, like tobacco smoke, besides its known consequences of bronchiectasis and other pulmonary morbidity, is also a significant risk factor for the development of COPD. Thus, there is a deleterious and synergistic interaction between TB, HIV, tobacco smoking and COPD in a large proportion of the world’s population. Further work, specifically mechanistic and epidemiological studies, is required to clarify the role of tobacco smoke on the progression of TB and HIV infection, and to assess the impact of smoking cessation interventions. These interactions deserve urgent attention and have major implications for coordinated public health planning and policy recommendations in the developing world.

South African tobacco smoking cessation clinical practice guideline

“…[65][66][67] In SA, with the added risk of HIV, the importance of smoking cessation to reduce the risk of TB, HIV-related diseases and COPD is unquestionable. [6,68] There are some data to show that integrating smoking cessation efforts (support plus NRT) with TB treatment is feasible, [69] improves quit rates (77% v. 8.7%, respectively) and completion of TB treatment (97.5% v. 84.8%, respectively). [70] It is unclear, however, whether stopping smoking during TB therapy will reduce the excess mortality associated with smoking and TB, [71] nor are there any efficacy data available on whether using bupropion or varenicline with concomitant anti-TB therapy may be of benefit.…”

“…[3,4] SA also has one of the highest burdens of tuberculosis (TB) and HIV, which are both risk factors for COPD and exacerbate the effects of smoking. [5,6] Tobacco smoking increases the risk for TB, cancer, pneumonia, ischaemic heart disease and stroke, which are all leading causes of death globally. [1] The mortality among current smokers in SA is nearly double that of nonor ex-smokers.…”

Symptom reporting among prevalent tuberculosis cases who smoke, are HIV-positive or have hyperglycaemia

“…[1][2][3][4] However, people who smoke, have diabetes or are HIV-positive may have symptoms that they attribute to these comorbidities and not recognise them as TB symptoms. 5 The World Health Organization (WHO) developed guidelines for TB screening specifically for HIV-positive individuals that are implemented in national TB programmes.…”

“…However, no such evidence-based guidelines for TB symptom screening exist for patients with DM or those who smoke. 1,6,7 To further investigate evidence for TB screening guidelines in other risk groups, our report aims to evaluate whether prevalent TB cases who smoke, have hyperglycaemia or who are HIV-positive are equally likely to report TB symptoms compared to prevalent TB cases without these comorbidities.…”

Chronic obstructive pulmonary disease in South Africa: Under-recognised and undertreated

“…SA is unique in many ways, having significant contributions from tuberculosis, HIV and biomass as well as mining exposure, creating 'colliding epidemics' , with resultant chronic lung disease. [9] Unfortunately, very little is known about the natural history or the response to therapy of these non-smoking forms of COPD, which are currently receiving due attention. For smoking-related COPD, it is critical that smokers cease smoking; the South African Clinical Practice Guideline is available to assist clinicians in helping their patients quit.…”