A systematic literature review and critical appraisal of epidemiological studies on outdoor air pollution and tuberculosis outcomes.

Ambient air pollution is the leading environmental risk factor for disease globally. Air pollutants can increase the risk of some respiratory infections, but their effects on tuberculosis (TB) are unclear. In this systematic literature review, we aimed to assess epidemiological studies on the association between outdoor air pollutants and TB incidence, hospital admissions and death (collectively referred to here as 'TB outcomes'). We sought to consolidate available evidence on this topic and propose recommendations for future studies. Following PRISMA guidelines, we searched PubMed, Web of Science, Google Scholar, and Scopus with no restrictions imposed on year of publication. A total of 11 epidemiological studies, performed in Asia, Europe and North America, met our inclusion criteria (combined sample size: 215,337 people). We extracted key study characteristics from each eligible publication, including design, exposure assessment, analytical approaches and effect estimates. The studies were assessed for overall quality and risk of bias using standard criteria. The pollutant most frequently associated with statistically significant effects on TB outcomes was fine particulate matter ( < 2.5 µm; PM2.5 ); 6/11 studies assessed PM2.5 , of which 4/6 demonstrated a significant association). There was some evidence of significant associations between PM10 ( < 10 µm), nitrogen dioxide (NO2 ) and sulfur dioxide (SO2 ) and TB outcomes, but these associations were inconsistent. The existing epidemiological evidence is limited and shows mixed results. However, it is plausible that exposure to air pollutants, particularly PM2.5 , may suppress important immune defence mechanisms, increasing an individual's susceptibility to development of active TB and TB-related mortality. Considering the small number of studies relative to the demonstrably large global health burdens of air pollution and TB, further research is required to corroborate the findings in the current literature. Based on a critical assessment of existing evidence, we conclude with methodological suggestions for future studies.