Article Text

Original research
Patient outcomes associated with post-tuberculosis lung damage in Malawi: a prospective cohort study
  1. Jamilah Meghji1,2,
  2. Maia Lesosky3,
  3. Elizabeth Joekes4,
  4. Peter Banda5,
  5. Jamie Rylance1,2,
  6. Stephen Gordon1,2,
  7. Joseph Jacob6,7,
  8. Harmien Zonderland8,
  9. Peter MacPherson1,2,9,
  10. Elizabeth L Corbett2,10,
  11. Kevin Mortimer1,
  12. Stephen Bertel Squire1,2
  1. 1 Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
  2. 2 Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
  3. 3 Division of Epidemiology and Biostatistics, University of Cape Town, Rondebosch, Western Cape, South Africa
  4. 4 Department of Radiology, Royal Liverpool University Hospital, Liverpool, UK
  5. 5 Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Southern Region, Malawi
  6. 6 Centre for Medical Imaging and Computing, University College London, London, UK
  7. 7 Department of Respiratory Medicine, University College London, London, UK
  8. 8 Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
  9. 9 Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
  10. 10 Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Dr Jamilah Meghji, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK; jamilah.meghji{at}


Background Post-tuberculosis lung damage (PTLD) is a recognised consequence of pulmonary TB (pTB). However, little is known about its prevalence, patterns and associated outcomes, especially in sub-Saharan Africa and HIV-positive adults.

Methods Adult (≥15 years) survivors of a first episode of pTB in Blantyre, Malawi, completed the St George’s Respiratory Questionnaire, 6-minute walk test, spirometry and high-resolution CT (HRCT) chest imaging at TB treatment completion. Symptom, spirometry, health seeking, TB-retreatment and mortality data were collected prospectively to 1 year. Risk factors for persistent symptoms, pulmonary function decline and respiratory-related health-seeking were identified through multivariable regression modelling.

Results Between February 2016 and April 2017, 405 participants were recruited. Median age was 35 years (IQR: 28 to 41), 77.3% (313/405) had had microbiologically proven pTB, and 60.3% (244/403) were HIV-positive. At pTB treatment completion, 60.7% (246/405) reported respiratory symptoms, 34.2% (125/365) had abnormal spirometry, 44.2% (170/385) had bronchiectasis ≥1 lobe and 9.4% (36/385) had ≥1 destroyed lobe on HRCT imaging. At 1 year, 30.7% (113/368) reported respiratory symptoms, 19.3% (59/305) and 14.1% (43/305) of patients had experienced declines in FEV1 or FVC of ≥100 mL, 16.3% (62/380) had reported ≥1 acute respiratory event and 12.2% (45/368) had symptoms affecting their ability to work.

Conclusions PTLD is a common and under-recognised consequence of pTB that is disabling for patients and associated with adverse outcomes beyond pTB treatment completion. Increased efforts to prevent PTLD and guidelines for management of established disease are urgently needed. Low-cost clinical interventions to improve patient outcomes must be evaluated.

  • tuberculosis
  • bronchiectasis
  • clinical epidemiology
  • respiratory infection

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  • KM and SBS are joint senior authors.

  • Contributors JM, SBS and KM were responsible for study conceptualisation and design. JM performed data collection. JM, PB and JR provided clinical oversight of the cohort. SBG, ELC and SBS provided institutional support in Malawi. JM, EJ, JJ and HZ developed image reporting systems and performed image reading. JM, ML, PM and KM analysed and interpreted data. JM was the lead author, with input from all co-authors. JM had final responsibility for the decision to submit for publication.

  • Funding Funded by a Wellcome Trust PhD Training Fellowship to JM (106065/Z/14/A). Additional support from The Wellcome Trust (Clinical Career Development Fellowship to PM (206575/Z/17/Z), Clinical Career Development Fellowship to JJ (209553/Z/17/Z), Senior Research Fellowship to ELC (200901/Z/16/Z), Malawi-Liverpool-Wellcome Trust Core Award to SG (206545/Z/17/Z)), an EDCTP2 Senior Fellowship (TMA2017SF-1959) and Academy of Medical Sciences Newton Advanced Fellowship (NAF\R2\180681) to ML and support to ML, BS and KM from the NIHR Global Health Research Unit on Lung Health and TB in Africa at the Liverpool School of Tropical Medicine (16/136/35). The funders had no role in study design, data analysis and interpretation or writing of this manuscript.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval was obtained from the Liverpool School of Tropical Medicine (15.040RS) and Malawi College of Medicine Research Ethics (P.10/15/1813) Committees.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Individual deidentified participant data that underlie the results reported in this article will be available, together with the study protocol, beginning 12 months after article publication. Data will be made available by the corresponding author to researchers with a methodologically sound protocol, and independent review committee approval for data use, upon reasonable request.

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