Assessment of comorbidities, risk factors, and post tuberculosis lung disease in National Tuberculosis Guidelines: A scoping review

Abstract

Tuberculosis (TB) remains a major public health issue across the world and national TB guidelines are an important resource for diagnosis and treatment. This scoping review aimed to analyze how countries with the highest TB burdens approach the integration of comorbidity and risk factor screening, diagnosis and treatment, TB recurrence, and post-TB lung disease (PTLD) diagnosis and management, within their TB guidelines. We used the Arksey and O'Malley methodological framework to conduct a scoping review of TB guidelines among the WHO list of highest-TB burden countries. We identified drug-susceptible, drug-resistant, and consolidated guidelines through web searches and personal contacts within TB programs. We translated guidelines into English as needed and systematically extracted, recorded, and reviewed the guidelines to aggregate and describe our findings. Among the 49 countries with the highest TB burden, we successfully identified, translated, and analyzed 43 guidelines (24 drug-sensitive, 9 drug-resistance, and 10 consolidated) from 34 countries. Recommendations for screening varied by comorbidity or risk factor with the four most recommended being HIV/AIDS (100%), pregnancy (73%) and liver disease (59%) and mental health (59%). Recommendations for linkage to care were more infrequent and also varied with the top four being HIV (88%), liver disease (47%), diabetes (44%), and mental health (44%). Only 27 (79%) countries specified diagnostic tests to assess for TB recurrence among individuals presenting with symptoms post-TB treatment, with 25 recommending GeneXpert MTB/RIF. Notably, only 7 (21%) countries mentioned PTLD in their guidelines, with wide variations in their specific recommendations regarding screening, diagnosis, and management. Our findings highlight the lack of detailed guidance on how to properly diagnose and refer patients to appropriate care for various comorbidities or risk factors which may significantly impact microbiological and clinical TB treatment outcomes, including PTLD and ultimately point to an important opportunity for improvement in future guidelines.

Fig 1. PRISMA flow diagram.

Fig 2. Frequency of recommendation types by comorbidity or risk factor among TB guidelines for 34 countries.