Post-tuberculosis pulmonary hypertension: a case of global disparity in health care

Tuberculosis is a disease of poverty, disproportionately affecting the most vulnerable populations. Nicolas Menzies and colleagues (December, 2021)1Menzies NA Quaife M Allwood BW et al.Lifetime burden of disease due to incident tuberculosis: a global reappraisal including post-tuberculosis sequelae.Lancet Glob Health. 2021; 9: e1679-e1687Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar highlight the persistence of inequity in tuberculosis follow-up care. Post-tuberculosis sequelae are associated with significant morbidity and an estimated reduction of more than 16 life-years in WHO high burden countries. Post-tuberculosis sequelae, most often occurring in the lungs following the destruction of lung tissue caused by M tuberculosis, include diseases such as chronic obstructive lung disease, pulmonary hypertension, bronchiectasis, and secondary non-tuberculosis infections, all of which require appropriate screening and diagnosis to guide subsequent therapies. Pulmonary hypertension remains an understudied post-tuberculosis lung sequela because of several diagnostic challenges. Pulmonary hypertension is defined by a resting mean pulmonary artery pressure of more than 20 mm Hg, which requires invasive right heart catheterisation to diagnose.2Simonneau G Montani D Celermajer DS et al.Haemodynamic definitions and updated clinical classification of pulmonary hypertension.Eur Respir J. 2019; 531801913Crossref Scopus (1506) Google Scholar Specialised equipment is needed for this procedure, as well as trained staff for medication administration and haemodynamic monitoring, which are not readily available in resource-limited settings. The management of pulmonary hypertension is subsequently dictated by measures of cardiopulmonary haemodynamics. Approximately 80% of people with pulmonary hypertension live in low-income and middle-income countries, and the disease mainly affects people younger than 65 years.3Hoeper MM Humbert M Souza R et al.A global view of pulmonary hypertension.Lancet Respir Med. 2016; 4: 306-322Summary Full Text Full Text PDF PubMed Scopus (299) Google Scholar While the prevalence of pulmonary hypertension among tuberculosis survivors is unknown, some data from echocardiography suggest it can manifest in up to 47% of tuberculosis survivors who experience dyspnoea after tuberculosis therapy.4Ahmed AEH Ibrahim AS Elshafie SM Pulmonary hypertension in patients with treated pulmonary tuberculosis: analysis of 14 consecutive cases.Clin Med Insights Circ Respir Pulm Med. 2011; 5: 1-5Crossref PubMed Scopus (25) Google Scholar The mean survival in patients with pulmonary hypertension from respiratory causes is only 4 years.5Strange G Playford D Stewart S et al.Pulmonary hypertension: prevalence and mortality in the Armadale echocardiography cohort.Heart. 2012; 98: 1805-1811Crossref PubMed Scopus (173) Google Scholar Because right heart catheterisation is such a technically demanding diagnostic procedure, millions of tuberculosis survivors at risk of pulmonary hypertension will likely never be identified. As a result, many will not be treated, exacerbating tuberculosis-related morbidity. As the world advances towards eliminating tuberculosis, it is crucial not to forget the tuberculosis survivors who still face a significant burden of disease from chronic lung destruction, particularly in regard to the diagnosis of post-tuberculosis pulmonary hypertension. Improved, less expensive, and less invasive diagnostic methods are needed. Now is the time to revisit and apply approaches such as echocardiography, and other more easily accessible assessments to address the global disparities in tuberculosis follow-up care. JKL reports funding from the National Institute of Health, National Heart, Lung, and Blood Institute grant number 1F32HL156614-01. KFW reports funding from the Weill Cornell Medicine Physician-Scientist Academy, Burroughs Wellcome Fund, grant number 53270584. The authors declare no competing interests. KFW and JKL contributed equally to this work. Lifetime burden of disease due to incident tuberculosis: a global reappraisal including post-tuberculosis sequelaePost-tuberculosis sequelae add substantially to the overall disease burden caused by tuberculosis. This hitherto unquantified burden has been omitted from most previous policy analyses. Future policy analyses and burden estimates should take better account of post-tuberculosis, to avoid the potential misallocation of funding, political attention, and research effort resulting from continued neglect of this issue. Full-Text PDF Open Access