Challenges in respiratory medicine: the need for integrated tuberculosis and respiratory care in low-resource settings.

Abstract

Pulmonary tuberculosis (PTB) and chronic respiratory diseases (CRDs) are intricately linked. People with PTB and CRDs experience similar symptoms, including breathlessness, cough and chest pain. They may have similar risk factors for disease, including smoking and occupational exposures. PTB is also a direct cause of lung damage in the form of post-TB lung disease. However, despite the overlap in risk factors, symptoms and sequelae, public health and clinical care pathways for TB and CRDs remain almost entirely separate in many low- and middle-income countries (LMICs). Those with respiratory symptoms are directed to TB services as a first point of contact where they are known as 'people with presumptive TB', and pathways to respiratory diagnosis and care remain largely inadequate. In this opinion piece we describe opportunities for the integration of tuberculosis (TB) and respiratory care, as a means of improving patient outcomes in LMICs. Strategies may include upstream public health interventions to address shared risk factors, the use of shared diagnostic pathways, the provision of decentralised access to both TB and CRD care, and coordinated information provision about the risk factors and symptoms of both conditions. Health-related benefits may include more timely diagnosis of CRDs, improved CRD treatment and care, and reduced inappropriate empirical TB treatment or retreatment. We highlight the need for pilot models of integrated care, with robust design and evaluation, and we note that an integrated approach may be particularly timely given the increasing scarcity of global health donor funding.