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Exploring the natural history and determinants of chronic respiratory disease in high-risk populations: perspectives from the UK and Malawi

Nightingale, Rebecca (2020) Exploring the natural history and determinants of chronic respiratory disease in high-risk populations: perspectives from the UK and Malawi, Thesis (Doctoral), Liverpool School of Tropical Medicine.

R Nightingale - PhD Thesis.pdf - Accepted Version

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Chronic respiratory disease affects over 500 million worldwide, with 251 million people suffering from Chronic Obstructive Pulmonary Disease (COPD) causing approximately 3 million deaths a year. In the global North tobacco smoke is known to be a risk factor for COPD, but little is known about the risks of other inhaled substances, such as heroin or the natural history of any respiratory disease associated with it. In the global South there is limited literature describing the burden of chronic respiratory disease or its natural history, with a particular lack of research amongst the more disadvantaged, harder to reach populations in sub-Saharan Africa. These populations have known high risk exposure including biomass use and a high burden of HIV and Tuberculosis. The gap in evidence provides an opportunity to explore the natural history and determinates of three potentially high-risk groups, the first heroin smokers in Liverpool UK, the second users of biomass fuel in rural Malawi, and thirdly those who have completed treatment for tuberculosis (TB) in urban Malawi.
The introduction chapter explains the rationale behind this thesis and highlights the key literature available in each population. The thesis then presents 5 papers, using different methods to explore chronic respiratory disease in these three populations. The data presented from Liverpool (Study 1: Screening heroin smokers attending community drug clinics for change in lung function: a cohort study) reports heroin users as being at significant risk of COPD. We found that forced expiratory volume in 1 second (FEV1) declined annually by 90ml (SD 190, p<0.001) which is significantly worse than you would expect in tobacco smokers. In the same population, study 2 (COPD in heroin smokers: a patient perspective) reports that accessing care and correct use of medication was a major problem that needs addressing. In a move from the global North to the global South, I report that the prevalence of chronic respiratory symptoms, spirometric obstruction and restriction in populations using biomass as their main fuel were 13·6% (95% CI:11.9-15.4), 8·7% (95% CI:7·0-10·7) and 34·8% (95% CI:31·7-38·0), respectively (Study 3: Noncommunicable respiratory disease and air pollution exposure in Malawi: a cross-sectional study). A systematic review and meta-analysis attempted to estimate the overall burden of chronic respiratory disease in Malawi but noted the heterogeneity of the available data. Airflow obstruction in adults varied between 2.3% and 20% and low FVC between 2.7% and 52.8%. (Study 4: Non-communicable respiratory disease in Malawi: a systematic review and meta-analysis). One possible cause of the high levels of abnormal spirometry and respiratory symptoms seen in Malawi could be Post-TB respiratory disease with study 5 (Respiratory symptoms and lung function in patients treated for pulmonary tuberculosis in Malawi: a prospective cohort study) highlighting that over a quarter of patients still have abnormal spirometry 3-years after TB-treatment completion. The proportions of participants with low FVC and obstruction changed from 57/285(20.0%) and 41/285(14.4%) at TB treatment completion to 34/272(12.5%) and 43/272(15.8%) at 3-years. All three populations presented in this thesis live with a significant burden of respiratory disease, often in disadvantaged situations where accessing optimal healthcare can be a challenge. Managing lung health in these populations requires careful planning with further research required into setting appropriate treatment options.

Item Type: Thesis (Doctoral)
Subjects: WA Public Health > WA 30 Socioeconomic factors in public health (General)
WF Respiratory System > WF 140 Diseases of the respiratory system (General)
WF Respiratory System > WF 20 Research (General)
Repository link:
Item titleItem URI
Exploring perspectives on chronic obstructive pulmonary disease in people who smoke heroin: a qualitative study
Noncommunicable Respiratory Disease and Air Pollution Exposure in Malawi (CAPS): A Cross-Sectional Study
Non-communicable respiratory disease in Malawi: a systematic review and meta-analysis
Faculty: Department: Clinical Sciences & International Health > Clinical Sciences Department
Depositing User: Lynn Roberts-Maloney
Date Deposited: 29 Mar 2021 12:13
Last Modified: 29 Mar 2022 01:02


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