Challenge Cluster for Post-TB Lung Health in Children in sub-Sahara Africa.

In 2017, there were an estimated 10 million new cases of tuberculosis (TB) disease globally, and 1.6 million peoples died from TB. This makes TB the leading cause of death from a single infectious agent worldwide. However, the majority of the TB cases and deaths occur in low- and middle-income countries (LMICs), where difficulties in diagnosis and treatment contribute to poor outcomes in TB patients. While global TB reports are based on estimates of patients who die either before or during TB treatment, there is now a growing body of evidence suggesting that patients cured or successfully treated for TB have persistent health impairment, and a relatively higher morbidity and mortality after treatment, than the general population.

These evidence of potentially elevated risk of adverse health consequences after TB treatment in the published literature are exclusively derived from adult data. While pulmonary TB (PTB) accounts for at least 80% of the 1 million TB cases that occur in children aged less than 15 years, there are currently no published data about adverse health consequences and/or long-term impact of pulmonary TB, including changes in the lung function, in children and adolescents who have completed TB treatment in neither high- nor low-income countries, where the burden of TB disease is particularly high. Achieving the ambitious goals of the WHO End TB Strategy will require that attention is paid not only to poor outcomes before or during TB treatment, but also to morbidity and mortality after TB treatment. In this regard, "Life and Well-being after Tuberculosis" has now being adopted as one of the two overall priority themes in the strategic plan of the World TB Union's Lung Health Department.

With this Challenge Cluster proposal, we will bring together two multi-country collaborative projects, supported by MRC GCRF Foundation Awards, with specific expertise in childhood TB and in lung health in Africa, including the Reach for Kids Africa (R4KA) and Lung Health in Africa across the Life Course (LuLi). The GCRF-funded partners will additionally link with partners in national TB programs from across sub-Sahara Africa and members of the TB-affected communities, underpinned by key regional and international collaborative research networks, including the Pan African Thoracic Society (PATS), International Union Against TB and Lung Disease (The Union), West African Paediatric TB Network (WApTBNet) and TB PROOF - a leading TB advocacy organisation in South Africa. We will begin advocacy and research toward increasing the awareness of post-TB lung health with a focus on children among health care workers, TB-affected communities and policy makers from across sub-Sahara Africa. We will also develop the capacity and confidence of health care workers to evaluate lung function in children who have completed treatment for PTB, and begin to generate data that will accurately describe the prevalence of lung function impairment attributable to TB in children in sub-Sahara Africa.

Our proposal will deliver on the following specific objectives within 12 months of the project activities: (i) organise a workshop on post-TB lung health in children in LMICs for paediatricians drawn from our proposed pan-Africa GCRF Challenge Cluster collaborative partnerships; (ii) train paediatricians in sub-Sahara Africa on paediatric spirometry, in order to evaluate lung function in children who have completed TB treatment; (iii) organise a participatory workshop for former TB patients and TB-affected families in West Africa, using exploratory and descriptive qualitative research approaches, in relation to household-incurred costs and strategies adopted for coping with persistent health impairments due to TB; and (iv) set up a multi-site pan-African platform for the establishment of prospective cohorts in the future, for clinical, epidemiological and applied health research.

IMPACT SUMMARY: GCRF CHALLENGE CLUSTER FOR POST-TB LUNG HEALTH IN CHILDREN

This proposal will create a GCRF Challenge Cluster to address post TB lung health in children in sub-Saharan Africa, by bringing together and building upon two MRC GCRF Foundation Award-supported multi-country collaborative projects - "Reach for Kids Africa (R4KA)" and "Lung Health in Africa across the Life Course (LuLi)". The cluster aims to provide a multi-site and multi-disciplinary pan-African platform, underpinned by key regional and international collaborative research networks, with the strategic aim of increasing awareness of post-TB lung health in children among health practitioners, TB-affected communities and policy makers across sub-Sahara Africa, and to create the foundation for internationally competitive research proposals in the near future for the conduct of pan-African clinical, epidemiological and applied health research. It will benefit from underpinning support and strategic guidance from the Pan African Thoracic Society (PATS), The International Union against Tuberculosis and Lung Disease (The Union), West African Paediatric TB Network (WApTBNet) and TB PROOF - a leading TB advocacy organisation in South Africa.

The inclusion of investigators and research partnerships representing countries from West, East, Central and Southern Africa bring a variety of benefits to the proposal that will maximise its internal and external validity. These include bringing together Anglo-, Franco- and Lusophone settings. There will be pathways to beneficial impacts in individual countries included in the cluster, in the wider sub-Saharan African region and internationally:

- In individual participating countries, economic, societal and environmental impacts will be achieved predominantly though direct cluster-related activities, including formation of community-based advocacy groups of TB survivors, and the implementation of the guideline developed from this proposal on the methodology of post-TB lung health, including measurement of lung functions, in children.

- At regional level, health policy and commercial impacts will be achieved during the life of the grant by planned engagement with ministries of health, non-governmental organisations (NGO), and formation of TB advocacy groups together with facilitating the creation of partnerships between TB advocacy groups across sub-Sahara Africa. The preliminary data and guidelines will be of interest to business and industry sectors of healthcare, particularly the need to develop field-friendly spirometers that could be used in the investigation of lung functions of TB patients, particularly children, at the community level.

- At international level, the findings of this work will inform international policy through existing high-level engagement with national governments and international decision-making organisations, and international advocacy efforts.


MEASURES OF SUCCESS OF OUR IMPACT ACTIVITIES
The success of these impact activities will be assessed through community engagement discussion forums, feedback questionnaires at partnership events, stakeholder (public sector, business, third sector and other) surveys and website statistics. Impact on international policy will be assessed using conference and publication citations linking partnership findings to policy and public health decisions.