Tuberculosis, tobacco and COPD: Colliding Epidemics

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1 Tuberculosis, tobacco and COPD: Colliding Epidemics Gonzalo G. Alvarez MD, MPH, FRCPC Assistant Professor of Medicine University of Ottawa at The Ottawa Hospital Division of Respirology and Infectious Diseases Ottawa Hospital Research Institute

2 Conflicts of Interest None

3 TOBACCO TB COPD

4 Smoking epidemic Edwards et al 2004 BMJ

5 Mathers et al 2006 PLos Medicine

6 MPOWER WHO 2008

7 TOBACCO TB COPD

8 BOLD study Burden of obstructive lung disease study Measure worldwide prevalence of COPD and to investigate variation in prevalence across all levels of economic development by age, gender and smoking status 12 countries, 9425 participants Buist AS et al Lancet 2007

9 BOLD study Surveyed population based samples of men and women over 40 years Standardized definitions - GOLD Buist AS et al Lancet 2007

10 BOLD study - Results Overall prevalence of COPD was 10.1% (SE 4.8%) Highest rates of COPD in South Africa Lowest rates of COPD in Sweden and Germany (developed countries) GOLD 2 postbronchodilator FEV1/FVC < 0.7 and FEV1 < 80% predicted

11 BOLD The burden of obstructive lung disease study Lancet 2007 Drs. Tan and Wang

12 BOLD study Increasing age and increased smoking rates resulted in higher rates of COPD (widely known) Significant heterogeneity in COPD rates

13 BOLD study Cape Town had very high reported rates of prior TB and occupation exposures in addition to high smoking rates Key: other factors also contribute to the development of COPD

14 A traditional home in Kwazulu Natal, South Africa (Picture from Nigel Bruce) Wood, crop residues, Animal dung and charcoal AND Coal used for cooking And heating

15 Adjusted for housing, crowding, age, gender, residence, education, caste or tribe and geographic region

16 TOBACCO TB COPD BIOMASS FUELS

17 Complete cessation of smoking and solid fuel use by 2033 would reduce the annual TB incidence by 14-52%

18 TOBACCO TB COPD

19

20 Financial support The Union Against TB and Lung disease WHO Health Canada Several prominent Canadian TB researchers: D.Enarson, A.Fanning, M.Pai

21 TB and Tobacco First study published in years of data!!!!!!!!!!

22 Systematic review 50 studies included Scored on the strength of evidence Quality based on study pop, assessment of exposure to tobacco, passive smoking, TB outcome, study design and analysis and presentation of data

23 WHO systematic review Passive and active exposure to tobacco smoke is associated with TB disease (strong evidence) Active smoking significantly increased the risk of infection, mortality (limited evidence) and recurrent TB (moderate evidence)

24

25 Smoking and TB mortality Half a million adults from Taiwan Followed prospectively since 1994 Smokers were 9X more likely to die of TB compared to never smokers (HR 8.6 ( )) Once the smokers quit, the risk of TB mortality decreased to a rate similar to never smokers Smoking cessation resulted in a 65% reduction in TB mortality Analysis adjusted for age, gender, education, alcohol, BMI, and diabetes

26 Passive smoking and TB 15,000 females between years living with their husbands in Hong Kong Multicentered, enrolled prospectively for 3 years Culture confirmed TB in non smoking women living with smokers compared to those not living with smokers RR 1.70 ( ) p=0.04) Analysis adjusted for age, Cantonese, education, alcohol, diabetes, COPD, Hypertension, heart disease, cerebrovascular disease (overcrowding?)

27 TOBACCO POVERTY? TB COPD

28 Confounded by poverty? No Doll et al 1954, studied a cohort of male doctors, risk of death from TB 4x greater in smokers vs non smokers Many studies have since supported this theory and it is widely believed that smoking is independently associated with TB outcomes (6 studies*) *Adjusted for socioeconomic status

29 Other confounders Alcohol (10 studies) association remained significant after adjustment Gender, may have an effect due to the global differences in smoking

30 TOBACCO TB COPD

31 COPD and risk of TB COPD is 2 nd most common co morbid condition seen in TB patients 2 nd only to diabetes Difficult to control for cigarette smoking thus challenging to make a direct link between COPD and TB Aktogu et al 1996, Didilescu et al 2000, Wang et al 2005, Liu et al 2005

32 TB and airflow obstruction Several studies demonstrating that patients with TB have increased risk of post disease obstruction (six studies) Repeated episodes of TB results in incremental worsening of lung function Hnizdo et al 2000 Thorax

33

34 Prevalence of daily smokers > 15 years old in Canada was 14% in 2006

35 Rate of TB in Canada in / 100,000 Rate of TB in Nunavut in / 100,000

36 TOBACCO TB COPD

37 It took 20 years to cut the smoking prevalence by half in Canada

38 TOBACCO TB COPD

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