Addressing TBMM

Tuberculosis (TB) is a chronic infectious disease. Every year, approximately 10 million people fall ill with TB and 1.6 million die from it. TB often coexists with other chronic diseases including chronic non-infectious conditions (e.g. lung disease and diabetes), mental health conditions (e.g. depression), and chronic infectious diseases (e.g. HIV/AIDS). This coexistence (or 'multimorbidity') is common because these illnesses share similar risk factors. For example, smoking can lead to both chronic lung disease and TB. Having one condition also increases the risk of another; for example, people with diabetes have poor defences against infections making them vulnerable to developing TB. Coexisting conditions also interact adversely with each other, worsening health, quality of life and survival for each, compared with having just one condition alone.

Healthcare services for people with TB should, therefore, offer prevention, detection and treatment of other coexisting chronic illnesses. Traditionally, however, services, including TB programmes, typically focus only on a single condition. Our overall goal is to support TB programmes in low- and middle-income countries to improve the prevention, screening, and management of the most common and most devastating chronic illnesses that coexist in people with TB. This approach may improve quality of life and survival for individuals and also help control the rapidly increasing epidemics of chronic conditions.

We focus on conditions coexisting with TB due to their common occurrence and their significant negative health consequences. We think that there may be opportunities to integrate care for multimorbidity within relatively well-resourced and functioning TB programmes (compared with other parts of the health system). Knowledge gained about managing multimorbidity could also be transferable to other services.

Multimorbidity can manifest in many patterns or combinations of conditions (clusters). In this 'seed-funding' project, we will first estimate how common are the various co-existing illnesses, and identify the clusters that contribute the greatest burden in terms of shortening life expectancy, causing ill health and incurring healthcare costs for people with TB. We will then explore potential interventions for these conditions.

To do this, we will review published academic literature on coexisting chronic conditions in people with TB and analyse data from a large world health survey. This will allow us to estimate how common is multimorbidity and how it affects the health, quality of life and life expectancy of people with TB. It will also help to identify the clusters of conditions that cause the most burden for patients, and to understand the sorts of interventions that are effective for these target conditions, which may be feasible to deliver integrated within TB programmes. We will also look for other sources of information on multimorbidity in people with TB, collected in study countries.

We will establish a global TB Multimorbidity Network of people and organisations that can contribute expertise in the topic, support efforts to spread our findings to a wide audience, help identify additional countries to improve generalisability of, and support the next stage of research. We will also grow capacity in research methods, leadership and management of research funding, required for a low- and middle income partner organisation to take a lead role in a future programme.

We build this proposal on previous work in TB, mental health, chronic diseases and HIV, and expertise in health systems and policy. Our team has established collaborations in global mental and physical health and TB and lung health in South Asia and Africa.

This preliminary work will inform plans for a future research programme, in which we will develop and test a package of interventions to prevent, detect and manage chronic conditions in people with TB in 'real world' settings.

Background: TB often coexists with other conditions, including mental disorders and chronic communicable and non-communicable diseases, e.g. HIV/AIDS, diabetes and depression. This 'TB multimorbidity' can be explained by a clustering of common social and behavioural determinants, impaired immunity and drug interactions. The bi-directional, adverse interactions between TB and other conditions worsen treatment adherence and patient outcomes. However, healthcare services, including TB programmes, typically focus on single conditions, missing opportunities to integrate prevention, screening and management of multimorbid disorders and thereby to improve outcomes and efficiency of healthcare.

Aims: Our long-term goal is to improve life expectancy, health outcomes and quality of life in people with TB multimorbidity, and generate learning that could be used to improve the care of multimorbidity more widely.

Methods: We will define clusters of conditions contributing to disease burden associated with TB multimorbidity and identify candidate interventions to address them. In a future programme, we will develop and evaluate an integrated package of care that can help prevent, screen and manage multimorbid chronic conditions in people with TB.

In this first (seed-funding) stage, we will conduct literature reviews and secondary analysis of World Health Survey data to identify TB multimorbidity clusters, risk factors, outcomes and candidate interventions to prevent, screen and treat these conditions. We will also explore other data sources on TB multimorbidity. A global Network will help agree the target clusters, share knowledge of data sources, help collate interventions for a TB multimorbidity intervention package and support dissemination. We will grow capacity in research, leadership and finance governance. We build on previous work in TB, HIV, mental health and NCD and established collaborations in mental and physical multimorbidity and TB and lung health.

We envisage the following impact from this SEED-FUNDING proposal:

1) Increased global awareness of the importance of TB multimorbidity: The current single-disease structures and funding mechanisms (through governments, bi- and multilateral donors) of many health systems result in many missed opportunities for addressing multiple morbidities. Our activities in this seed-funding phase will raise the profile of these multimorbidities and their common risk factors, triggering donors and global policymakers to strengthen their response. Our success in increasing awareness will be evidenced by our expanding TB Multimorbidity Network, the emergence of multimorbidity streams within relevant conferences and journals and greater social media outputs addressing this topic.
2) A step-change in our three partner countries in support of a multimorbidity approach: The concept of a multimorbidity approach within TB services is new. Our growing Network and Research-Policy Forums will provide the catalyst for policymakers and those commissioning services in government and disease/condition-specific institutes to consider how multimorbidity could be addressed. This will also increase the demand for epidemiological evidence and identification of effective/cost-effective interventions that can feasibly be implemented within TB programmes. The extent of this step-change will be evidenced by the level of engagement in the national networks and meetings.
3) A clear plan and partnership for future research: By the end of this phase we will have a strong team ready to implement a programme of research in Africa and Asia to develop and evaluate the effectiveness and cost-effectiveness of an intervention package to address TB multimorbidity. This includes close collaborations with decision-makers, a strong multidisciplinary team with trained early career researchers able to conduct the multiple methods required, and LMIC partners with increased capability to lead future research. This will be evidenced by at least one collaborative proposal for further research funding from the Network.


From a FUTURE longer-term programme of work, we expect the following impact:

4) Extend and improve the quality of life of people during and after they recover from TB: We aim to identify effective and cost-effective interventions that can be implemented at scale within national TB programmes. Such interventions will result in improvements in chronic disease screening, diagnosis and management, improving case detection and health outcomes, quality of life and life expectancy.
5) Health, Health System, Social and Economic gains beyond TB: TB multimorbidity packages can potentially help patients to manage their diabetes, CVD or mental health beyond the end of their TB treatment. Given the challenges facing health systems in responding to long-term chronic conditions, interventions that can address multiple conditions through an integrated package bring significant economies. The social and economic impacts of these improvements in health will be felt beyond the individual level, bringing positive benefits to families and communities. TB alone has been estimated to reduce GDP by 1% in many Asian and African countries. There will be considerable synergistic benefits on economic and social development by addressing TB multimorbidity.