The Aftermath of Pulmonary Tuberculosis: Predictors of Severe Pulmonary Sequelae and Quality of Life of Patients Visiting a Tertiary Level of Care in Rwanda, East Africa

  

    
Risk factor Adjusted OR (95% CI) P value 
  
  

    
Gender 
    
 
    
 
  
  

    
Female
    
1
    
 
  
  

    
Male
    
0.59 (0.32-1.24)
    
0.212
  
  

    
HIV status 
    
 
    
 
  
  

    
Positive
    
1
    
 
  
  

    
Negative
    
2.98 (1.98-4.12)
    
0.011
  
  

    
Level of Education 
    
 
    
 
  
  

    
University
    
1
    
 
  
  

    
Secondary
    
2.11 (1.35-4.06)
    
 
  
  

    
Primary
    
3.77 (1.92-6.16)
    
 
  
  

    
None
    
4.13 (1.84-6.12)
    
0.002
  
  

    
History of tuberculosis 
    
 
    
 
  
  

    
Had TB once
    
1
    
 
  
  

    
Had TB twice
    
2.04 (1.11-4.09)
    
 
  
  

    
Had TB 3 times and above
    
3.91 (1.29-5.52)
    
0.0125
  

Table 2:  Risk factors for severe tuberculosis sequelae.

Focus Group Discussions

During focus group discussions, three themes were considered as most emergent

a. Disappointment of post TB therapy results

“When I completed my TB treatment, I was very happy, I had gained weight and I was no longer coughing, but one year later I restarted coughing and became breathless, unfortunately my doctor failed to find TB in sputum, he decided to restart anti TB drugs but I did not improve” (Patient P05, history of pulmonary tuberculosis).

Another one added: “Since I finished TB treatment I kept coughing and the doctor told me that my lungs are completely destroyed, I don’t understand why because I did not miss a single dose of my treatment, I am afraid I will die while sleeping at night” (P04, history of pulmonary tuberculosis).

Many participants to FGD expressed their non satisfaction after antiTB treatment because, as they explained, symptoms especially cough did not disappear and some other symptoms like shortness of breath and hemoptysis occurred shortly after the TB treatment.

b. Stigma

During Focus group discussion, participants revealed that they were stigmatized and were afraid to join and participate in activities organized by the community. A young lady declared that she was living home only for going to the hospital; she was avoiding to join other members of the community because she felt she was not going to be well received.

“I am coughing the whole day and people in the village are afraid of approaching me, they say that I may have resistant tuberculosis […] I gave several samples of sputum for TB screening but it was always negative, I prefer to stay home, I know people do not like my presence” (Patient P20, patient with TB sequelae).

Many others reported that they were not well accepted in the society because of symptoms related to pulmonary tuberculosis.

“I am coughing out blood since 3 years, doctors told me that I have scars on my lungs, no one can approach me in the village, even my husband left me for another woman, I know yourself cannot stay near someone who is coughing out blood” (P07, patient with TB sequelae).

Some participants reported that they were rejected by their families because they had frequent and abundant bad smelling expectorations sometimes mixed with blood, members of their families were afraid of being contaminated with TB. However, they explained that the level of stigma had reduced in some places due to regular visits of Community Health Workers to conduct educational sessions on tuberculosis.

c. Poor quality of life

Majority of participants in FGD highlighted that they were living in difficult conditions because they were not able to work and gain money.

“I am so breathless that I cannot even work 20 meters without sitting down, life is very hard, I am a widow and my children stopped to go to school, I cannot afford school fees, this disease has extremely impoverished my family” (P11, patient with history of MDR TB).

Others explained that it was even difficult for them to get money to come to the hospital; some patients revealed that they were treated for depression.

“I am always at the hospital, I have to pay a motorbike to go there, before this disease I had a small shop and could earn money for my family […] now I miss money for paying drugs, I spend sleepless nights despite all drugs given by the Mental Health doctor, I wish I could die and stop suffering” (P02, Patient with TB sequelae and heart failure).

Discussion

The objective of this study was to determine the predictors of severe post TB sequelae among patients consulting a tertiary level of care in Rwanda and understand their quality of life using a questionnaire and through focus group discussions. To our knowledge, this is the first study in the country which focuses on the daily life of patients with tuberculosis sequelae.

Cough, hemoptysis and dyspnea were among the main symptoms presented by patients in our study, other authors [7-9] have also described similar symptoms in patients with TB sequelae. Different etiologies can explain those symptoms, cough and dyspnoea may result from extended parenchymal destruction leading to a poor pulmonary compliance but also endobronchial involvement which can cause localized or even generalized bronchial obstruction [10,11]. Bronchiectasies, aspergillomas and other parenchymal, airway and vascular lesions are potential sources of hemoptysis [12-15].

10.4% of participants had a chest x-ray showing emphysematous bullae mainly in both lung apexes. All those patients had a history of heavy smoking, though no spirometry was performed, we concluded to coexistence with Chronic Obstructive Lung Disease (COPD). Different authors had discussed the role of tobacco smoking not only in the genesis but also in the clinical presentation and healing process of pulmonary tuberculosis [16,17]. In their study done in India, Agarwal et al. [18] concluded that tobacco smoking was an important risk factor for developing pulmonary tuberculosis; it plays a role in the severity of the disease and can increase risk of relapse. Authors argued that there is impairment of the innate defense of the lungs caused by nicotine, destruction of tight junctions that form the epithelium barrier, reduced lysozymes activity and decreased CD4, thus, easy invasion of the lungs by mycobacterium tuberculosis [18,19].

Fibrosis is a common finding in tubercular sequelae, there is often atelectasis of the upper lobe and retraction of the hilum, compensatory lower lobe hyperinflation, and a mediastinal shift toward the fibrotic lung [10].

In this study, patients infected with HIV presented with less severe sequelae lesions compared to those who were immunocompetent, this is linked with the poor inflammatory response found in HIV patients. It was expected to find severe tuberculosis sequelae among patients with already a history of tuberculosis, despite chemotherapy TB healing can be associated with important lung destruction and extensive fibrosis [20].

Discussions with patients in the current study revealed that they were victims of stigma in their families and villages. Different authors [21-23] showed that patients with tuberculosis are often experiencing rejection and social isolation. Our patients did not have active TB but presented TB-like symptoms and were suspected by their neighbors as potential TB carriers. Lack of knowledge on TB transmission and the perceived contagiousness of the disease are among the main causes of stigmatization. Frequent co-infection between TB and HIV is another factor which can increase the level of stigmatization. Some authors noted that patients with TB-like symptoms tend to hide them fearing discrimination and/or isolation and end up in a self-exclusion which is dangerous regarding continuation of care [24,25].

Participants in this study did not directly associate TB with poverty but argued that TB is a cause of poverty because of the length of the treatment and post treatment complications which do not allow any remunerated activity. The WHO showed that there is a symbiotic relationship between TB and poverty and made estimates that the average TB patient loses three to four months of work-time each year and experiences a loss of up to 30% in yearly household earnings [2].

The main limitation of this study is that majority of participants were coming from one region mainly rural and were farmers with low level of schooling, comparison with other groups (Eg. Urban/rural) could give additional information.

Conclusion

HIV status, level of education and history of pulmonary tuberculosis were the main predictors of severe tuberculosis sequelae. Stigma and poverty were the principal factors undermining the quality of life of patient with tuberculosis sequelae.

References

1. Aaron L, Saadoun D, Calatroni I, Launay O, Mémain N, Vincent V, et al. Tuberculosis in HIV-infected patients: a comprehensive review. Clin Microbiol Infect. 2004; 10: 388-398.
2. WHO. Tuberculosis, Global tuberculosis report. 2015.
3. WHO. Global tuberculosis report. 2012.
4. Rwanda Biomedical Center. 2015.
5. Nasehi M, Hassanzadeh J, Rezaianzadeh A, Zeigami B, Tabatabaee H, Ghaderi E. Diagnosis delay in smear positive tuberculosis patients. J Res Med Sci. 2012; 17: 1001-1004.
6. Falk A, O'Connor JB, Pratt PC. Classification of pulmonary tuberculosis. Falk A, O'Connor JB, Pratt PC, Webb JA, Wier JA, Wolinsky E, editors. In: Diagnostic Standards and Classification of Tuberculosis. New York. National Tuberculosis and Respiratory Disease Association. 1969; 68-76.
7. Winer-Muram HT, Rubin SA. Thoracic complications of tuberculosis. J Thorac Imaging. 1990; 5: 46-63.
8. Hopewell PC1. A clinical view of tuberculosis. Radiol Clin North Am. 1995; 33: 641-653.
9. Kim HY, Song KS, Goo JM, Lee JS, Lee KS, Lim TH. Thoracic sequelae and complications of tuberculosis. Radiographics. 2001; 21: 839-858.
10. Verma SK, Kumar S, Narayan KV, Sodhi R. Post Tubercular Obstructive Airway Impairment. Indian J Allergy Asthma Immunol. 2009; 23: 95-99.
11. Godoy MD, Mello FC, Lopes AJ, Costa W, Guimarães FS, Pacheco AG, et al. The functional assessment of patients with pulmonary multidrug-resistant tuberculosis. Respir Care. 2012; 57: 1949-1954.
12. Proaño A, Rudgard W, Gayoso O. The cost of tuberculosis sequelae. Eur Respir J. 2014; 44: 822-824.
13. Ding WY, Chan T, Yadavilli RK, McWilliams R. Aspergilloma and massive haemoptysis. BMJ Case Rep. 2014; 2014.
14. Lopez-Pastorini A, Plönes T, Ludwig C, Stoelben E. Intrapulmonary aspergilloma in an old tuberculous cavity with access to the bronchial system. Eur J Cardiothorac Surg. 2014; 46: 144.
15. Madansein R, Parida S, Padayatchi N, Singh N, Master I, Naidu K, et al. Surgical treatment of complications of pulmonary tuberculosis, including drug-resistant tuberculosis. Int J Infect Dis. 2015; 32: 61-67.
16. Bam TS, Aditama TY, Chiang CY, Rubaeah R, Suhaemi A. Smoking cessation and smokefree environments for tuberculosis patients in Indonesia-a cohort study. BMC Public Health. 2015; 15: 604.
17. Biswajit Chakrabarti, Peter MA Calverley, Peter DO. Tuberculosis and its incidence, special nature, and relationship with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2007; 2: 263-272.
18. Agarwal A, Agrawal VK. Impact of tobacco smoke on tuberculosis: A case control study. National Journal of Integrated Research in Medicine. 2011; 2: 38-42.
19. Dogar OF, Pillai N, Safdar N, Shah SK, Zahid R, Siddiqi K. Second-hand smoke and the risk of tuberculosis: a systematic review and a meta-analysis. Epidemiol Infect. 2015.
20. Dheda K, Booth H, Huggett JF, Johnson MA, Zumla A, Rook GA. Lung remodeling in pulmonary tuberculosis. J Infect Dis. 2005; 192: 1201-1209.
21. Atre S, Kudale A, Morankar S, Gosoniu D, Weiss MG. Gender and community views of stigma and tuberculosis in rural Maharashtra, India. Glob Public Health. 2011; 6: 56-71.
22. Cremers AL, de Laat MM, Kapata N, Gerrets R, Klipstein-Grobusch K, Grobusch MP. Assessing the consequences of stigma for tuberculosis patients in urban Zambia. PLoS One. 2015; 10: e0119861.
23. Mathew AS, Takalkar AM. Living with tuberculosis: the myths and the stigma from the Indian perspective. Clin Infect Dis. 2007; 45: 1247.
24. Courtwright A, Turner AN. Tuberculosis and stigmatization: pathways and interventions. Public Health Rep. 2010; 125 Suppl 4: 34-42.
25. Baral SC, Karki DK, Newell JN. Causes of stigma and discrimination associated with tuberculosis in Nepal: a qualitative study. BMC Public Health. 2007; 7: 211.