Rehabilitation after Recovery: Addressing the Long-Term Pulmonary Sequelae of Tuberculosis

Tuberculosis (TB), along with drug-resistant tuberculosis (DRTB), continues to be a major global public health risk threatening to reverse the efforts to end TB by 2035.[1] An estimated 10.8 million cases were identified in 2023, and 400,000 multidrug-resistant tuberculosis (MDR-TB)/rifampicin-resistant tuberculosis (RR-TB) cases were estimated globally in 2023.[1] In 2023 only two in five people with DRTB accessed treatment, with 1.25 million reported deaths of whom 150,000 were RR/DRTB. Post-TB lung disease (PTLD) is a heterogeneous entity, encompassing any chronic respiratory abnormality attributable in whole or part to previous tuberculosis. Globally, an estimated 155 million TB survivors are currently living; with an estimated prevalence of 59% PTLD, there would be approximately 91 million people with PTLD globally.[2] In India, PTLD has been recognized since 2009,[3,4] although not named as such. However, since then, there have been no concentrated efforts to assess the burden in the country. Studies have shown that post-treatment pulmonary TB (PTB) is associated with irreversible changes to bronchial and parenchymal structures leading to bronchiectasis, emphysema, and fibrosis. Lung functions show a predominantly restrictive pattern; an obstructive and mixed pattern is also observed in clinical practice and has been associated with adverse patient outcomes. Chronic obstructive pulmonary disease (COPD) due to any cause reduces the health-related quality of life (HRQOL) due to physical and psychological morbidity. This affects the individual’s earning capacity and social interaction. Introduction of newer drugs and shorter regimens in the management of DRTB cases has improved the outcomes in recent times. There is evidence that post-infectious sequelae of tuberculosis are common even after effective therapy and have long-term consequences.[5] These include lung function impairment, either obstructive or restrictive and many a times, mixed pattern;[6] impaired quality of life;[7] and reduced performance status.[5] The first International Post-Tuberculosis Symposium has highlighted the physical, psychological, and socio-economic suffering that continues long after treatment completion.[8] Clinical standards for managing PTLD have only recently been published.[9] Pharmacological interventions have a limited impact in controlling the effects of lung impairment. Non-pharmacological interventions such as pulmonary rehabilitation (PR) and other interventions may help in improving the overall quality of life.[8-11] PR aims to restore patients to an independent, productive, satisfying life with a view to integrating them into social and vocational activities[12] and preventing further clinical deterioration to the maximum extent compatible with the stage of the disease. This goal may be accomplished, without materially improving lung function, by helping the patients to become aware of their disease, actively involved in their own healthcare, and independent in performing daily care activities, attempting to reverse the disability. This is achieved by supervised exercise, chest/breathing exercises, airway clearance techniques, smoking cessation therapy, along with psychological and nutritional support which will help improve quality of life and slow the progression to frailty. PR is thus crucial in the management of cured TB cases and especially DRTB patients, as many have lasting pulmonary impairments and reduced quality of life.[6,7] Existing literature suggests PR can reduce the debilitating effects of post-tuberculosis pulmonary sequelae, including COPD and exercise intolerance.[10,13] Therefore, care after cure of PTB cases should be an essential part of TB programs. The extent of lung damage may play a significant role in the success of PR. Thus, preventing respiratory disability by identifying cases early and initiating appropriate treatment on time is essential to maintain the HRQOL of cases. Also, host-directed therapies during treatment of tuberculosis, shown to help preserve lung function and reduce the severity of DRTB,[14,15] should be further evaluated. There is evidence that PR has a positive impact on the neuropsychiatric performance of individuals.[16] Counseling, especially on psychosocial issues and nutrition, over a prolonged period, should be an important component of PR. Vocational rehabilitation, which includes job retraining and occupational therapy to enable individuals to return to their previous jobs or take up new work-related activities based on the progress from exercise training, is an important aspect of PR.[12] Despite promising results, challenges remain in implementing PR universally.[17] Resource constraints, including access to trained personnel, equipment, and ongoing support, pose barriers to scaling up PR programs in settings with high TB and DRTB prevalence and in low and middle-income countries (LMICs) where access to comprehensive healthcare remains limited.[8] Furthermore, variability in patient response and adherence underscores the need for tailored rehabilitation strategies that consider individual clinical profiles and socio-economic factors. Long distances to commute to the center, the high cost of transportation, and respiratory disabilities are some important barriers to access.[17] This underscores the need to locate PR facilities closer to patients’ homes to mitigate these challenges and ensure long-term follow-up. Another critical issue is the lack of awareness about PR and its role in managing chronic respiratory illnesses among both medical professionals[18] and the broader community. This lack of awareness significantly hinders uptake of these services. Most public sector hospitals already have physiotherapy units staffed with trained physiotherapists. These units could serve as viable settings for PR, thereby eliminating the need for costly stand-alone rehabilitation centers. Integration of PR into the general health system could alleviate future concerns about sustainability and accessibility. There is a growing body of evidence supporting PR as a valuable adjunct therapy for DRTB. Future research should focus on longitudinal outcomes, cost-effectiveness, and strategies to optimize PR delivery in diverse healthcare settings. In conclusion, there is evidence of the beneficial impact of PR on improving functional capacity and quality of life in individuals recovered from tuberculosis, demonstrating its potential as a vital component of post-tuberculosis care. Concerted efforts are needed to address logistical and resource challenges to ensure equitable access to PR, particularly in resource-constrained settings, by fostering collaboration between healthcare providers, policymakers, and community stakeholders, thus maximizing the benefits of PR and enhancing long-term health prospects of TB survivors worldwide. Data availability statement No data was generated Author contribution YD: conceptualization, literature search and writing of the manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.