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Original Research: COPD |

Prior TB, Smoking, and Airflow Obstruction: A Cross-Sectional Analysis of the Guangzhou Biobank Cohort Study FREE TO VIEW

Kin-bong Hubert Lam, PhD; Chao Qiang Jiang, MD; Rachel E. Jordan, PhD; Martin R. Miller, MD; Wei Sen Zhang, MD, PhD; Kar Keung Cheng, MBBS, PhD; Tai Hing Lam, MD; Peymané Adab, MD; Latin American Project for the Investigation of Obstructive Lung Disease (PLATINO) Team
Author and Funding Information

From the Institute of Occupational and Environmental Medicine (Dr K.-b. H. Lam), University of Birmingham, UK; Guangzhou Number 12 People’s Hospital (Drs Jiang and Zhang), Guangzhou, People’s Republic of China; Unit of Public Health, Epidemiology, and Biostatistics (Drs Jordan, Cheng, and Adab), University of Birmingham, UK; Department of Medicine (Dr Miller), University Hospital Birmingham NHS Trust, Birmingham, UK; and School of Public Health (Dr T. H. Lam), The University of Hong Kong, Pokfulam, Hong Kong.

Correspondence to: Tai Hing Lam, MD, Department of Community Medicine and School of Public Health, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong; e-mail: hrmrlth@hkucc.hku.hk


Funding/Support: The Guangzhou Biobank Cohort Study was funded by The University of Hong Kong Foundation for Educational Development and Research, the Guangzhou Public Health Bureau, the Guangzhou Science and Technology Bureau, and The University of Birmingham.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(3):593-600. doi:10.1378/chest.09-1435
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Background:  Prior pulmonary TB has been shown to be associated with a higher risk of airflow obstruction, which is the hallmark of COPD, but whether smoking modifies this relationship is unclear. We investigated the relationships between prior TB, smoking, and airflow obstruction in a Chinese population sample.

Methods:  Participants in the Guangzhou Biobank Cohort Study underwent spirometry, chest radiography, and a structured interview on lifestyle and exposures. Prior TB was defined as the presence of radiologic evidence suggestive of inactive TB. Airflow obstruction was based on spirometric criteria.

Results:  The prevalence of prior TB in this sample (N = 8,066, mean age: 61.9 years) was 24.2%. After controlling for sex, age, and smoking exposure, prior TB remained independently associated with an increased risk of airflow obstruction (odds ratio = 1.37; 95% CI, 1.13-1.67). Further adjustment for exposure to passive smoking, biomass fuel, and dust did not alter the relationship. Smoking did not modify the relationship between prior TB and airflow obstruction.

Conclusions:  Prior TB is an independent risk factor for airflow obstruction, which may partly explain the higher prevalence of COPD in China. Clinicians should be aware of this long-term risk in individuals with prior TB, irrespective of smoking status, particularly in patients from countries with a high TB burden.

Figures in this Article

Global efforts to control pulmonary TB are encouraging. The worldwide incidence per capita has been falling since 2003, and the treatment success rate is increasing.1 Nevertheless, those surviving TB are left with permanent changes in lung anatomy2 and are at higher risk of pulmonary sequelae and premature mortality.3

One such adverse outcome is the development of airflow obstruction, which is the hallmark of COPD, as suggested by early4-7 and more recent8-13 reports. Smoking is the major risk factor for airflow obstruction14 and is also associated with increased incidence of and mortality from TB,15,16 but studies attempting to clarify the effect of this potential confounder on the relationship between prior TB and airflow obstruction are limited and confined to patient samples.6,7,11

China is a country with a high burden of both TB and COPD17 and is the largest consumer of tobacco in the world.18 Information on the role of smoking on the development of airflow obstruction in individuals who had prior TB is essential but lacking. We sought to address the issue using data from a large study of older adults in Guangzhou, in southern China.

Participants

The Guangzhou Biobank Cohort Study, a collaboration between the Guangzhou Number 12 People’s Hospital and the Universities of Birmingham and Hong Kong, has been described in detail previously.19,20 Recruitment of participants drew from the Guangzhou Health and Happiness Association for the Respectable Elders, a community social and welfare association unofficially aligned with the municipal government whose membership is open to older persons for a monthly fee of 4 yuan (50 US cents). About 7% of permanent Guangzhou residents aged 50 years and older are members of the Guangzhou Health and Happiness Association for the Respectable Elders, of whom 11% (about 10,000 participants) enrolled in each of the two recruitment phases (2003-2004 and 2005-2006). Subjects were included if they were capable of consenting, ambulatory, and not receiving treatment modalities for any life-threatening conditions. Of those eligible, 90% of the men and 99% of the women participated. All participants underwent a half-day detailed assessment, including a structured interview on lifestyle and medical history, and a physical examination, including spirometry and chest radiography. The study was approved by the Medical Ethics Committee of the Guangzhou Medical Association. Written informed consent was obtained from all participants.

Prior TB

The presence of prior TB was primarily defined by suggestive changes on chest radiographs compatible with inactive TB. A posterio-anterior chest radiograph was obtained during deep inspiration in a standing position with an radiography unit (Toshiba KSO-15R; Otawara, Japan). The radiographs were reviewed by two experienced radiologists who were blinded to the details of the participants, using standard criteria for reporting of radiologic abnormalities.21,22 Discordant findings were resolved by discussion and consensus. Each radiograph was classified as either normal, suggestive of inactive TB, or suggestive of active TB (Table 1). To reduce the risk of reverse causation (ie, TB as the complication or consequence of airflow obstruction) those who had evidence of active TB were excluded from the analysis. Acceptable reliability (κ = 0.68) was found in a randomly selected sample of 300 chest radiographs assessed independently by the two radiologists. In addition, in order to be compatible with previous studies, we also examined self-reported TB, defined by a participant’s report of previous physician diagnosis of TB. However, there is much stigma associated with TB in this population,23 which is likely to lead to underreporting of the condition.

Table Graphic Jump Location
Table 1 —Radiograph Classifications
Airflow Obstruction

Details of lung function measurement have been described elsewhere.20 At least three maneuvers, without the use of a bronchodilator, were performed, and the best measures were recorded. Data quality was ascertained by a numerical algorithm and visual inspection of each individual flow-volume and volume-time loop. Predicted values and the lower limit of normal (LLN) of lung function parameters were derived from a Chinese population.24 As it has been suggested that the use of a fixed-ratio definition (FEV1/FVC < 0.70) would result in overdiagnosis of airflow obstruction in the elderly, we defined airflow obstruction by the statistically more appropriate FEV1/FVC < LLN.25

Smoking and Other Covariates

Based on the detailed smoking histories obtained, participants were classified as “ever-smokers” if they had smoked the equivalent of at least one cigarette per day for a minimum of 6 months and “never-smokers” if they did not smoke currently or in the past. Among ever-smokers, pack-years were calculated to quantify the exposure, where one pack-year is equivalent to smoking an average of 20 cigarettes per day for 1 year. Other reported important risk factors for airflow obstruction in this population were also assessed, including exposure to passive smoking at home or at work (yes/no), exposure to household biomass fuel (yes/no), and dust exposure during the longest held occupation (yes/no). The highest educational attainment was used as a proxy for socio-economic status.26 The presence of respiratory symptoms (chronic cough and phlegm, and dyspnea)20 and self-reported history of physician-diagnosed chronic bronchitis and/or emphysema (yes/no) were also obtained.

Statistical Analysis

All analyses were performed using Stata 10.1 (StataCorp; College Station, TX). Logistic regression models were built to evaluate the relationship between prior TB and airflow obstruction. Potential confounders considered were age, sex, education level, smoking history and pack-years, and exposure to passive smoking, biomass fuel, and dust. The odds ratios (ORs) together with the 95% CIs were determined for three models. In Model 1, we adjusted for age (continuous), sex, and education level. In Model 2, we additionally adjusted for smoking history and pack-years (in tertiles: <10, 10-29, ≥ 30). Model 3 was the fully adjusted model, including adjustments for exposure to passive smoking, biomass fuel, and dust in addition to the aforementioned factors. We examined whether the relationship was consistent by sex and smoking status by assessing the heterogeneity of effect across strata, comparing the model fit with and without the interaction term. To further investigate the effect of smoking, we repeated the analyses, stratifying for smoking exposure (never; <10, 10-29, and ≥ 30 pack-years; and all ever-smokers). As airflow obstruction could be present in those who had a history of asthma or bronchiectasis and would potentially inflate the association, we also evaluated the relationship after excluding those who reported physician-diagnosed asthma or bronchiectasis. Finally, a sensitivity analysis was performed by redefining airflow obstruction as FEV1/FVC < 0.70, which was compatible with previous studies.11-13

Of the 20,431 participants, 8,145 had available information on relevant variables and valid spirometric data (Fig 1). Among them, 79 participants were removed because of radiologic evidence suggestive of active TB. Thus, the final study sample included 8,066 participants, of whom 5,933 (73.6%) were women and 2,133 (26.4%) were men, with an overall mean age of 61.9 years (SD 6.9). Participants who were included for analysis were similar to those who were excluded because of insufficient information and/or invalid spirometric data, except the final sample consisted of a slightly higher proportion of women (73.6% vs 69.9%) and fewer ever-smokers (22.7% vs 25.7%) compared with the excluded sample. The prevalence of prior TB, as defined by evidence of inactive TB on chest radiographs, was 24.2% (95% CI, 23.3-25.2; n = 1,954), while that based on self-report was much lower at 2.9% (95% CI, 2.5-3.2; n = 232). Individuals who had prior TB were more likely to be male, older, and ever-smokers, and were less likely to have been exposed to occupational dust. A higher prevalence of self-reported chronic bronchitis and/or emphysema history (7.6% vs 5.6%) and poorer lung function (FEV1 predicted 89.0% vs 92.0%) were found in those having radiologic evidence of inactive TB (Table 2).

Figure Jump LinkFigure 1. Flow diagram of the study sample.Grahic Jump Location
Table Graphic Jump Location
Table 2 —Characteristics of 8,066 Chinese Adults, Aged ≥ 50 Years, According to Prior TB and Sex

Data from the Guangzhou Biobank Cohort Study, 2003-2006.

Overall, the prevalence of airflow obstruction was 6.5% (95% CI, 5.9-7.0; n = 522), which was similar in men (6.4%) and in women (6.5%). A significantly higher prevalence was found in participants having prior TB on chest radiographs (8.6%) compared with those without (5.8%, crude OR 1.52; 95% CI, 1.25-1.84). Although prior TB was more common in men than in women (33.9% vs 20.8% for radiologic evidence, and 5.7% vs 2.4% for self-report), there was no evidence from the assessment of heterogeneity of effect across strata that the relationship between this and airflow obstruction varied with sex (data not shown). Results are therefore presented for men and women together. After controlling for age, sex, education, and smoking (Model 2), the OR for prior TB on chest radiographs was reduced to 1.37 (95% CI, 1.13-1.67). Exposure to passive smoking, biomass fuel, or occupational dust did not alter the association (OR = 1.37; 95% CI, 1.13-1.67). On the other hand, there was no significant association between airflow obstruction and self-reported TB (adjusted OR = 1.35; 95% CI, 0.83-2.20) (Table 3). The higher risk of airflow obstruction among those with prior TB was seen across all ranges of severity (data not shown). In addition, among those with relevant clinical respiratory symptoms, a higher proportion of those with prior TB (12.8%) compared with those without (7.4%) had airflow obstruction.

Table Graphic Jump Location
Table 3 —Adjusted Associations of Airflow Obstruction With Prior TB in 8,066 Chinese Adults Aged > 50 Years

Data from the Guangzhou Biobank Cohort Study, 2003-2006. Airflow obstruction defined as FEV1/FVC < LLN. LLN = lower limit of normal; OR = odds ratio.

a 

Adjustments for age, sex and, education.

b 

Model 1 adjustments plus smoking history and pack-years.

c 

Models 1 and 2 adjustments plus exposure to passive smoking, biomass fuel, and dust.

Exclusion of those who had a previous diagnosis of asthma or bronchiectasis (n = 152) did not alter the association between prior TB on chest radiographs and airflow obstruction. The fully adjusted OR (Model 3) was 1.35 (95% CI, 1.10-1.66). Both radiologic evidence and self-report of prior TB were significantly associated with airflow obstruction if the latter was redefined as FEV1/FVC < 0.70, the OR (Model 3) being 1.43 (95% CI, 1.22-1.69) and 1.63 (1.13-2.35), respectively.

Prior TB based on radiologic evidence remained independently associated with increased risk of airflow obstruction in both ever-smokers (OR = 1.47; 95% CI, 1.04-2.08) and never-smokers (OR = 1.30; 95% CI, 1.02-1.66), although the relationship was slightly weaker in the latter (Table 4). Despite the sex difference in smoking history, the OR estimates in male (OR = 1.50; 95% CI, 1.01-2.22) and female smokers (OR = 1.38; 95% CI, 0.67-2.82) were essentially the same (P = .84 by z test). Among smokers, there was no evidence of a dose-response relationship between increasing pack-years of exposure and airflow obstruction (see Table 4). The likelihood ratio test showed no evidence of effect modification by smoking on the association between airflow obstruction and radiologic evidence of prior TB (P = .27) or self-reported TB (P = .87). The same conclusion was reached when airflow obstruction was redefined as FEV1/FVC < 0.70 (P = .40 and P = .78, respectively).

Table Graphic Jump Location
Table 4 —Adjusteda Associations of Airflow Obstructionb With Prior TBc Stratified by Smoking Status in 8,066 Chinese Adults Aged ≥ 50 Years

Data from the Guangzhou Biobank Cohort Study, 2003-2006. See Table 3 for expansion of the abbreviation.

a 

Adjustments for age, sex, education, and exposure to passive smoking, biomass fuel, and dust.

b 

Airflow obstruction defined as FEV1/FVC < LLN.

c 

Prior TB defined by radiologic evidence suggestive of inactive TB.

In a sample of older people from a TB-prevalent region in Asia, we found that radiologic evidence suggestive of inactive TB was associated with a higher risk of airflow obstruction. Furthermore, we did not find evidence to suggest the relationship was modified by smoking.

Our finding is in accordance with a previous study conducted in TB patients6 and two small-scale case-control studies.7,11 Snider and colleagues6 found that heavy smoking (≥20 cigarettes per day) and more severe TB (roentgenographic score ≥ 9) independently increased the prevalence of airflow obstruction (defined as FEV1/FVC< 0.70 and vital capacity > 80% predicted) by approximately twofold, while the effect was additive but not synergistic in the simultaneous presence of the two factors. In one of the case-control studies, individuals who had been treated for TB had significantly lower FEV1 than the matched healthy controls.7 In the other study, the risk of pulmonary impairment (comprising obstructive and restrictive abnormalities) was significantly higher in patients with TB who were on directly observed therapy than in individuals with latent TB infection (OR = 5.37; 95% CI, 2.98-9.68).11 Both studies made some adjustments for smoking, but were not able to examine the relationship in smokers and nonsmokers separately.

Unlike previous studies in which prior TB was based on medical records6,7,11,13 or self-report,12 we defined prior TB primarily according to chest radiograph findings suggestive of inactive TB. While the magnitude of the ORs for airflow obstruction (defined by the LLN criteria) was similar in those with radiologic evidence of prior TB (1.37) and those with self-reported TB (1.35), the latter did not reach statistical significance. When airflow obstruction was defined as FEV1/FVC < 0.70, the association between self-reported TB and airflow obstruction became statistically significant. This is consistent with a report from a population-based sample from five cities in Latin America,12 although the association was stronger (adjusted OR = 2.33) in that study compared with ours (1.63).

The mechanisms of airflow obstruction following prior TB remain largely speculative. Bronchostenosis due to inflammation and lesions has been shown as a result of endobronchial involvement of TB, as well as secondary to tuberculous lymphadenopathy.27 Extensive parenchymal lung destruction through the dysregulation of matrix metalloproteinases by TB has been demonstrated.28 It is possible that a combination of the damage in the airways and the lung parenchyma results in abnormalities in ventilation that lead to impairment of lung function and the development of airflow obstruction.

Based on a sample of over 8,000 relatively healthy community-dwelling older adults in a TB-prevalent region in Asia, our findings provide more reliable data than the earlier studies in much smaller patient samples. We have controlled for and ruled out major confounding factors related to other important known risk factors of airflow obstruction. By using radiologic data, we also have an objective measure of prior TB.

There are a number of potential limitations that deserve mention. First, although our sample is not totally representative of the older population in China, our findings remain valid unless we have systematically missed those who had a specific relation between prior TB, smoking, and airflow obstruction. In this regard, the prevalence rates of smoking29 and airflow obstruction30 were similar to those reported in recent surveys using national samples of Chinese. However, we could not exclude the possibility that heavy smokers with prior TB died of or with airflow obstruction more quickly than never-smokers or light smokers, which might have reduced the statistical power to detect the effect modification by smoking.

Second, the prevalence of prior TB based on self-reports (2.9%), although similar to another report from China (3.3% [59/1,765]),31 was significantly lower than that defined by radiologic evidence (24.2%). The radiographic-based prevalence estimate was, however, similar to that reported in a recent study from Hong Kong (31.4%), in which older residents from homes for the aged (mean age ± SD: 82.3 ± 8.1 y) were recruited.32 Up-to-date results from a representative nationwide sample suggested that tuberculin-purified protein derivative reactivity ranged from 40% to 50% in the older population.33 Also, extrapulmonary TB accounts for around 10% of all TB cases in China.34 Thus, it could be expected that the prevalence of exposure to TB is likely to be in the region of 35% to 45%. However, there are no ationally representative data on the prevalence of prior pulmonary TB with associated radiologic changes. The prevalence of self-reported TB is likely to be underestimated because of the social stigma associated with a diagnosis of TB in that population.23 Hence, our definition of radiologic evidence of inactive TB is likely to provide the most objective and reliable estimate of pulmonary TB. We acknowledge that this definition results in relatively low sensitivity for detecting inactive TB,35 but it is likely to be highly specific, with few people being misclassified as having prior TB. In a TB-prevalent region such as China, the presence of fibrotic scars or calcified nodules in the upper lobe is usually secondary to healed TB infection.36 It is important to note that our findings relate only to prior TB defined by radiologic changes on chest radiographs. Whether persons with milder pulmonary TB with no associated radiologic abnormalities are also affected by airflow obstruction is not known.

Third, because of the cross-sectional nature, a temporal sequence could not be inferred in the relationship between prior TB, smoking, and present airflow obstruction. In this regard, although the age at which TB infection occurred was unknown, the peak incidence of TB is usually in early adulthood,37 whereas airflow obstruction is relatively uncommon before the fifth decade of life.38 Therefore, the association observed in our study is unlikely to be to the result of reverse causation.

Finally, although airflow obstruction is a manifestation of several pulmonary conditions, evidence from previous studies tends to suggest that chronic airflow obstruction, otherwise labeled as COPD, was mainly responsible for the association with prior TB.11-13 In our sample, exclusion of those who reported physician-diagnosed asthma or bronchiectasis did not alter the direction and the magnitude of the OR estimate. The association was unlikely to be confounded by the commonly reported risk factors for airflow obstruction adjusted for in our analyses, as there was no material difference between the ORs obtained with or without these variables included in the regression model.

Our findings have important public health implications. The burden of COPD is increasing in China,17,30 both among men, for whom smoking is prevalent, and among the predominantly nonsmoking women.18 Our finding that radiologic evidence of prior TB is associated with a higher risk of airflow obstruction (most likely due to COPD) in both smokers and never-smokers may provide a partial explanation, for this in a TB-prevalent region. Despite the heavy burden, COPD is currently largely underdiagnosed in China, and the use of spirometry is relatively uncommon.30 In fact, in our study population, 76.9% of those with relevant clinical symptoms and evidence of airflow obstruction on spirometric examination did not report a physician diagnosis of COPD. On the other hand, chest radiograph examination is routine, partly because of the TB epidemic. Thus, identification of inactive TB on chest radiographs should prompt a case finding for COPD by clinicians, which would likely remain undetected otherwise. At present, prior TB is not recognized as a risk factor for COPD in most countries.14 Improved treatment and survival, together with increasing international migration, mean that a larger number of individuals with prior TB will be settling in more developed countries, where the awareness of TB-induced lung damage is low. Clinicians need to be aware of this association, and clinical guidelines such as those from the National Institute for Health and Clinical Excellence39 that recommend case finding should reflect this (ie, that radiologic evidence of inactive TB is one of the relevant risk factors for considering spirometry). While conventional treatment of COPD should be offered to those who are diagnosed this way, prospective studies are needed to examine and compare the natural history of TB-induced airflow obstruction with that due to other traditional risk factors such as smoking.

In summary, radiologic evidence suggestive of inactive TB is associated with an increased risk of airflow obstruction, and this is likely to be an important contributor to the burden of COPD in TB-prevalent regions. Clinicians should be aware of the long-term risk of developing airflow obstruction in individuals with prior TB, irrespective of smoking status.

Author contributions:Dr K.-b. H. Lam: contributed to the quality control of spirometry data in the Guangzhou Biobank Cohort Study, conceived the idea for the paper and developed the approach, analyzed the data, drafted the paper, contributed to the development of the paper, and commented on and approved the final version.

Dr Jiang: helped to conceive the Guangzhou Biobank Cohort Study, contributed to the development of the paper, and commented on and approved the final version.

Dr Jordan: contributed to the development of the paper, and commented on and approved the final version.

Dr Miller: contributed to the quality control of spirometry data in the Guangzhou Biobank Cohort Study, contributed to the development of the paper, and commented on and approved the final version.

Dr Zhang: contributed to the development of the paper, and commented on and approved the final version.

Dr Cheng: helped to conceive the Guangzhou Biobank Cohort Study, contributed to the development of the paper, and commented on and approved the final version.

Dr T. H. Lam: helped to conceive the Guangzhou Biobank Cohort Study, contributed to the development of the paper, and commented on and approved the final version.

Dr Adab: conceived the idea for the paper and developed the approach, drafted the paper, contributed to the development of the paper, and commented on and approved the final version.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: We thank the Guangzhou Health and Happiness Association for the Respectable Elders for recruiting the participants.

LLN

lower limit of normal

OR

odds ratio

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National Technical Steering Group of the Epidemiological Sampling Survey for TuberculosisNational Technical Steering Group of the Epidemiological Sampling Survey for Tuberculosis Report on nationwide random survey for the epidemiology of tuberculosis in 2000. Journal of the Chinese Anti-Tuberculosis Association. 2002;242:56-108
 
Huang J, Shen M, Sun Y. Epidemiological analysis of extrapulmonary tuberculosis in Shanghai. Zhonghua Jie He He Hu Xi Za Zhi. 2000;2310:606-608. [PubMed]
 
Harries A.Frieden T. What are the relative merits of chest radiography and sputum examination (smear microscopy and culture) in case detection among new outpatients with prolonged chest symptoms? Toman’s Tuberculosis: Case Detection, Treatment, and Monitoring: Questions and Answers. 2004; Geneva World Health Organization:61-65
 
Van Dyck P, Vanhoenacker FM, Van den Brande P, De Schepper AM. Imaging of pulmonary tuberculosis. Eur Radiol. 2003;138:1771-1785. [CrossRef] [PubMed]
 
Tocque K, Bellis MA, Tam CM, et al. Long-term trends in tuberculosis. Comparison of age-cohort data between Hong Kong and England and Wales. Am J Respir Crit Care Med. 1998;1582:484-488. [PubMed]
 
Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med. 2000;16011:1683-1689. [CrossRef] [PubMed]
 
National Collaborating Centre for Chronic ConditionsNational Collaborating Centre for Chronic Conditions Chronic obstructive pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax. 2004;59Suppl 1:1-232
 

Figures

Figure Jump LinkFigure 1. Flow diagram of the study sample.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Radiograph Classifications
Table Graphic Jump Location
Table 2 —Characteristics of 8,066 Chinese Adults, Aged ≥ 50 Years, According to Prior TB and Sex

Data from the Guangzhou Biobank Cohort Study, 2003-2006.

Table Graphic Jump Location
Table 3 —Adjusted Associations of Airflow Obstruction With Prior TB in 8,066 Chinese Adults Aged > 50 Years

Data from the Guangzhou Biobank Cohort Study, 2003-2006. Airflow obstruction defined as FEV1/FVC < LLN. LLN = lower limit of normal; OR = odds ratio.

a 

Adjustments for age, sex and, education.

b 

Model 1 adjustments plus smoking history and pack-years.

c 

Models 1 and 2 adjustments plus exposure to passive smoking, biomass fuel, and dust.

Table Graphic Jump Location
Table 4 —Adjusteda Associations of Airflow Obstructionb With Prior TBc Stratified by Smoking Status in 8,066 Chinese Adults Aged ≥ 50 Years

Data from the Guangzhou Biobank Cohort Study, 2003-2006. See Table 3 for expansion of the abbreviation.

a 

Adjustments for age, sex, education, and exposure to passive smoking, biomass fuel, and dust.

b 

Airflow obstruction defined as FEV1/FVC < LLN.

c 

Prior TB defined by radiologic evidence suggestive of inactive TB.

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Huang J, Shen M, Sun Y. Epidemiological analysis of extrapulmonary tuberculosis in Shanghai. Zhonghua Jie He He Hu Xi Za Zhi. 2000;2310:606-608. [PubMed]
 
Harries A.Frieden T. What are the relative merits of chest radiography and sputum examination (smear microscopy and culture) in case detection among new outpatients with prolonged chest symptoms? Toman’s Tuberculosis: Case Detection, Treatment, and Monitoring: Questions and Answers. 2004; Geneva World Health Organization:61-65
 
Van Dyck P, Vanhoenacker FM, Van den Brande P, De Schepper AM. Imaging of pulmonary tuberculosis. Eur Radiol. 2003;138:1771-1785. [CrossRef] [PubMed]
 
Tocque K, Bellis MA, Tam CM, et al. Long-term trends in tuberculosis. Comparison of age-cohort data between Hong Kong and England and Wales. Am J Respir Crit Care Med. 1998;1582:484-488. [PubMed]
 
Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med. 2000;16011:1683-1689. [CrossRef] [PubMed]
 
National Collaborating Centre for Chronic ConditionsNational Collaborating Centre for Chronic Conditions Chronic obstructive pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax. 2004;59Suppl 1:1-232
 
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