Communicable and non-communicable co-morbidities and the presentation of COVID-19 in an African setting of high HIV-1 and tuberculosis prevalence

Abstract

Objectives To describe the presentation and outcome of SARS–CoV2 infection in an African setting of high non–communicable co–morbidity and also HIV–1 and tuberculosis prevalence. Design Case control analysis with cases stratified by HIV–1 and tuberculosis status. Setting A single–centre observational case–control study of adults admitted to a South African hospital with proven SARS–CoV–2 infection or alternative diagnosis. Participants 104 adults with RT–PCR–proven SARS–CoV2 infection of which 55 (52.9%) were male and 31 (29.8%) HIV–1 co–infected. 40 adults (35.7% male, 30.9% HIV–1 co–infected) admitted during the same period with no RT–PCR or serological evidence of SARS–CoV2 infection and assigned alternative diagnoses. Additional in vitro data from prior studies of 72 healthy controls and 118 HIV–1 uninfected and infected persons participants enrolled to a prior study with either immune evidence of tuberculosis sensitization but no symptoms or microbiologically confirmed pulmonary tuberculosis. Results Two or more co–morbidities were present in 57.7% of 104 RT–PCR proven COVID–19 presentations, the commonest being hypertension (48%), type 2 diabetes mellitus (39%), obesity (31%) but also HIV–1 (30%) and active tuberculosis (14%). Amongst patients dually infected by tuberculosis and SARS–CoV–2, clinical features could be dominated by either SARS–CoV–2 or tuberculosis: lymphopenia was exacerbated, and some markers of inflammation (D–dimer and ferritin) elevated in singly SARS–CoV–2 infected patients were even further elevated (p less than 0.05). HIV–1 and SARS–CoV2 co–infection resulted in lower absolute number and proportion of CD4 lymphocytes, with those in the lowest peripheral CD4 percentage strata exhibiting absent or lower antibody responses against SARS–CoV2. Death occurred in 30/104 (29%) of all COVID–19 patients and in 6/15 (40%) of patients with coincident SARS–CoV–2 and tuberculosis. Conclusions In this South African setting, HIV–1 and tuberculosis are common co–morbidities in patients presenting with COVID–19. In environments in which tuberculosis is common, SARS–CoV–2 and tuberculosis may co–exist with clinical presentation being typical of either disease. Clinical suspicion of exacerbation of co–existent tuberculosis accompanying SARS–CoV–2 should be high.

The association of SARS-CoV-2 infection and tuberculosis disease with unfavorable treatment outcomes: A systematic review

“…Three studies (38%) recruited participants in 2021 [ 14 , 17 , 19 ]. One study focused on children [ 16 ], while the remainder involved adults [ 13 – 15 , 17 – 19 , 23 ]. Participants were predominantly male, driven mostly by one study consisting of 5409 participants of whom 66% were male ( Table 1 ) [ 19 ].…”

“…Participants were predominantly male, driven mostly by one study consisting of 5409 participants of whom 66% were male ( Table 1 ) [ 19 ]. Among the eight studies in this review, corticosteroids or other immunomodulating treatments were not used in five studies, use was unknown in two studies [ 14 , 17 , 19 ], and were used by 8/15 (53%) of participants with TB and SARS-CoV-2 infection in one study [ 23 ].…”

“…In most studies, there was no significant difference in all-cause mortality between persons treated for TB with vs. without SARS-CoV-2 coinfection. With respect to in-hospital mortality, deaths only occurred in the group with SARS-CoV-2 coinfection in the two studies reporting this outcome [ 18 , 23 ]. Loss to follow-up and treatment failure were relatively uncommon across studies, with no trends to suggest these differed systematically between groups ( Table F and Table G in S1 Text ) [ 13 – 17 ].…”

The incidence and mortality of COVID-19 related TB disease in Sub-Saharan Africa: A systematic review and meta-analysis

“…The median study duration was 15 months (ranging, from 4 months to 45 years) and the study period ranged from 2020 to 2021. Eleven studies used retrospective case identification [13, 26-33, 36, 39], six prospective case identification [16-20, 35], and three were case series [20, 37, 38], three Cross-sectional studies [22-24], one cross-sectional and retrospective cohort study [34] and one case-control study [25] ( Supplementary material Table 1 ).…”

“…All the studies analysed clinical characteristics and co-morbidities of COVID-19 patients in SSA. Among them, twenty studies included the incidence proportion of COVID-19 associated with PTB [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35], and nine studies included the case fatality rate of COVID-19 associated with TB [13,16,26,29,34,[36][37][38][39].…”