Half of all tuberculosis survivors in Africa are left with permanent lung damage, yet TB and chronic respiratory disease are treated in separate, uncoordinated health systems. This matters because the two conditions are deeply linked. TB is both a cause and a consequence of lung disease, and patients with cough and breathlessness are routinely routed through TB services—only to find over half do not have TB. Without integrated care, TB survivors receive no respiratory support, while people with chronic lung disease are misdiagnosed and treated with repeated, ineffective courses of antibiotics and TB drugs. The absence of a practical model of care is the main barrier to change. Over four years, the researchers will develop a framework for integrated TB-respiratory care in Kenya, Tanzania, and Nigeria. They will map the true burden of non-TB lung disease among people referred for TB, co-create patient education tools, and design clinical pathways that link diagnosis to treatment. If successful, the framework and evaluation tools will be handed to policymakers to inform national guidelines. The ultimate goal is a multi-site trial testing whether integrated care improves outcomes for millions of people with damaged lungs across Africa.
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Background: The burden of tuberculosis (TB) and chronic respiratory disease (CRD) remains unacceptably high in low and middle income countries (LMICs), with 10.6 million incident cases of TB disease in 2021, and respiratory diseases amongst the leading causes of morbidity and mortality globally. TB and CRDs are closely linked in LMICs. Both are conditions of deprivation, with risk factors including smoking and occupational exposures. Both are highly stigmatised, and lead to long-term disability, health seeking, and loss of income. We have shown that TB is itself a direct cause of lung damage with up to half of pulmonary TB survivors left with residual post-TB lung disease (PTLD). The management of PTLD and CRDs require similar interventions including inhaled therapies and pulmonary rehabilitation. Patients present with similar symptoms of cough and breathlessness, and are largely routed through TB services as people with presumptive TB (PPTB), but after assessment over half will not have TB disease. Despite this close relationship, TB and CRD care are delivered separately in LMICs. TB is managed via well-resourced vertical National TB Programmes, whilst respiratory care is provided via less well defined and poorly resourced health systems. The absence of integrated TB-respiratory care means that TB patients receive inadequate respiratory support, and those with CRDs remain undiagnosed, and are incorrectly treated with recurrent courses of antibiotics and TB medication for ongoing symptoms. There are strong calls from TB patients and policy makers for integrated TB-respiratory care, and this is particularly important given the emerging burden of non-communicable diseases in LMICs. Our previous work shows that the absence of models of care remains a key barrier to implementation. Aims: In this four-year research programme we will develop a framework for the implementation and evaluation of integrated TB-respiratory care, for the diagnosis, prevention, and management of respiratory diseases across the TB care cascade in Kenya, Tanzania and Nigeria. This work is rooted in previous stakeholder engagement work, informed by MRC guidance for complex health intervention development, and builds on two previous NIHR grants (16/136/35 and 130307). Objectives: 1. WP1: To review the literature on TB-NCD and HIV-NCD care, and to develop a conceptual framework for integrated TB-respiratory care. 2. WP2: To describe the epidemiology of non-TB respiratory disease amongst PPTB, and to propose a respiratory diagnostic pathway for use within TB services. 3. WP3: To co-develop counselling and education tools around respiratory disease and exposures, in order to empower TB patients to manage their respiratory health. 4. WP4: To understand the existing context of respiratory care for those with presumptive or previous TB, and to propose pathways for linkage to care. 5. WP5: To synthesise findings from WP1-4 to develop frameworks for integrated TB-respiratory care, with accompanying tools for clinical, health system, and health economic evaluation. 6. WP6: To deliver sustainable research capacity strengthening in each site. Outcomes and Impact: The proposed framework and evaluation tools will be shared with policy makers to inform guideline development and operational research, and will lead to a funding application for a multi-site randomised control trial to evaluate the impact of integrated TB-respiratory care in Africa.
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