Unit 4. Managerial activities TB Infection Control Training for Managers at National and Subnational Level

1. Unit 4. Managerial activities TB Infection Control Training for Managers at National and Subnational Level

2. Objectives After this unit, participants will be able to: • Define managerial activities needed for infection control at the national and facility level. • Identify types of partner organizations for a national infection control (IC) coordinating body • Identify factors to consider in assessing the risk of TB transmission in a facility • Describe the elements that should go into a TB infection control plan

3. Outline Managerial activities at the national level 1. Coordinating body, plan 2. Health facility design and use 3. Surveillance and assessment 4. Advocacy, communication, social mobilization 5. Monitoring and evaluation • Operation research IC plan for national or facility level Managerial activities at the facility level

4. What are managerial activities? Activities used by program managers to support and facilitate the • implementation, • operation, maintenance and • evaluation of TB infection control at the national, sub-national and facility levels

5. Managerial activities at national and subnational levels (1) • Identify and strengthen a coordinating body, and develop an IC plan • Ensure health facility design, construction, renovation and use are appropriate • Conduct surveillance of TB disease among health care workers, and assessment of health and congregate settings at all levels

6. Managerial activities at national and subnational levels (2) • Address advocacy, communication and social mobilization (ACSM) • Conduct monitoring and evaluation of the set of IC measures • Enable and conduct operational research

7. 1. Identify a coordinating body to: • Adopt a national TB IC policy (after reviewing existing protocols and policies) • Assess the risk of TB transmission in health facilities and congregate settings • Develop a national TB infection control plan to include • A budget to reflect the costs of implementing the plan • Plans to develop human resource capacity

8. Think beyond the TB programme Is there an existing national infection control policy or group? • Such as for prevention of influenza, SARS, blood borne pathogens, hospital infections What organizations in your country care about infection control? How can (or did) you get them involved?

9. Potential stakeholders • Government agencies responsible for: • Health facilities (construction, licensing) • Medical services (hospitals, clinics, labs) • Prisons, Jails • Occupational Health, Labour, Finance • Standards, norms and codes • Civil society: professional associations, unions, NGO’s, patient groups, health sciences universities, HIV care providers • Private sector

10. Coordinating body • Establish or strengthen coordinating body • Identify members,including IC focal person in the national TB programme (NTP) • Include expertise in infection control, epidemiology, engineering, laboratory, occupational health, clinical medicine • Determine roles, terms of reference, budget • Responsibility and authority should be delegated to a specific person or leader of the coordinating body

11. 2. Health facility design, construction, renovation and use • Identify facilities conducive to TB transmission • Crowded TB, MDR-TB wards • Enclosed out-patient waiting areas with poor ventilation • Spaces reserved for high-risk aerosol generating procedures (sputum collection, bronchoscopy rooms, autopsy suites) • Consider redesign or reuse of space to decrease transmission

12. 3. Assess risk of TB transmission Where are people with infectious TB likely to expose others? • Health facilities • Other facilities where people come together (congregate): homeless shelters, prisons, refugee camps, dormitories, military barracks Identify facilities

13. Homeless shelter

14. Surveillance • Review TB epidemiology • TB prevalence • drug resistant TB • TB/HIV prevalence • Conduct surveillance of TB disease among health care workers • define responsibilities • establish a register

15. Assign higher priority to settings where: • TB is drug resistant (MDR, XDR) • A larger number of people are exposed (crowded) • There is failure to suspect TB • Exposure is of longer duration (length of stay in the facility, diagnostic delays) • Control measures are lacking • Exposed people are especially vulnerable (see next slide)

16. Groups especially vulnerable: • To developing TB disease if infected with M. tuberculosis • To dying, if develop TB Examples • People living with HIV • Young children

17. HIV prevalent settings • Health care facilities that provide chronic HIV care, such as ART clinics • Counselling and testing sites • Support clubs for people living with HIV/AIDS • Prisons and jails • Substance abuse treatment centres

18. Overcrowding in prisons

19. Examples of at risk settings • Vary by geography, climate, socio-economic status • Inner city • Urban slums • Specialty hospitals (MDR, XDR-TB facilities) • Nursing homes

20. High risk areas for TB transmission in health facilities • TB or Medical wards • Emergency rooms • Clinics to which people with known or suspected infectious TB are referred • Aerosol-generating procedures • Sputum collection • Bronchoscopy • Use of high speed devices during lung surgery or autopsy • Laboratories performing culture

21. Review information from facility assessments • How many infectious TB patients seen per year, by area of the facility? (MDR, HIV+) • Patient and specimen flow: how much time spent in each area? • Are high risk procedures performed? • Is there an infection control plan, coordinating body, responsible person? • Are administrative, environmental and respiratory protection controls in use?

22. 4. Advocacy, communication and social mobilization (ACSM)

23. Why enlist civil society and other stakeholders? • Leverage resources, enlist expertise and perspectives of affected communities • Increase sense of urgency and ownership • Build a stake in implementing and sustaining effective measures • Create demand for safe health facilities to expedite implementation

24. ACSM plans should include: • Strategies for behaviour change targeting multiple target audiences • Policy makers • Donors • Health care workers • Patients • Families • Patient-centred messages, balancing the interests of individuals and the wider community

25. 5. Monitoring and evaluation • Develop IC performance indicators • Establish a system for monitoring and evaluation • Use the indicators during supervisory visits • What’s going well and should be reinforced and replicated elsewhere? • What needs improvement and how can the gaps be addressed? • Collaborate across programmes

26. Examples of IC indicators • Number and percent of clinics with written procedures for identifying and separating coughing patients • Number and percent of health care workers that developed TB during a given period

27. 6. Operational research • Can help evaluate effectiveness of specific IC measures or combinations • Can assess impact (for example, by detecting TB infection or disease in health care workers) • Can identify problem areas to be addressed • Needs to be planned, prioritised and budgeted within a national plan

28. Infection control plan development • Assign responsibility • Base plan on surveillance, epidemiological data, and risk assessment results • Prioritize TB infection control measures based on epidemiology and risk assessment • Draft the plan

29. Prioritization of TB IC interventions Base the set of measures on degree of risk: give highest priority to interventions with most impact and lowest cost Low- and medium-risk settings: administrative controls and selected environmental controls High-risk settings: administrative controls, enhanced environmental controls, and respiratory protection 29

30. Draft the plan Make plan specific to the country situation Base plan on level of risk Put plan and procedures in writing, easy to understand and accessible Make the plan Practical, Affordable, Comprehensive and Creative 30

31. Elements of a TB IC plan—national or facility Responsible authority List highest risk settings and how defined Recommended set of IC measures Policies Human resource development Advocacy, communication, social mobilization Monitoring and evaluation indicators Budget 31

32. Evaluating the TB IC Plan Develop IC performance indicators Establish a system for monitoring and evaluation, including supervision Repeat risk assessment Evaluate compliance with the plan Seek input from staff Identify impediments to implementation Monitor status of implementation of control measures 32

33. Revise TB IC plan as needed Enlist input from health care workers (HCW) Verify resources available Evaluate any changes in risk Evaluate changes in function or need Deal with problems encountered Re-educate HCW (and continue education of patients and visitors) 33

34. Lifecycle of IC plan Develop Implement Monitor, evaluate Revise 34

35. Lifecycle of IC plan Develop Educate Implement Educate Educate Monitor, evaluate Revise Educate 35

36. Managerial activities at the facility level • Identify and strengthen local IC coordinating bodies, develop a facility plan • Rethink the use of available spaces • Conduct on-site surveillance of TB among health workers, assess the facility • Address ACSM • Monitor and evaluate the set of TB IC measures • Participate in research efforts

37. Set of measures for TB infection control at the facility level • Managerial • Administrative • Environmental • Personal protective equipment

38. Summary (1) • Managerial activities support and facilitate TB infection control at the national and facility levels • Potential stakeholders to involve in IC include civil society and the private sector, in addition to government organizations • Factors to consider in assessing the risk of TB transmission include the frequency of TB, drug resistant TB and HIV in the community and in the facility; implementation of IC measures; whether aerosol generating procedures are performed; and the occurrence of TB cases in employees

39. Summary (2) • Infection control plans should be based on a risk assessment • For low and medium risk areas, the plan should focus on administrative controls and selected environmental controls • High risk areas will require administrative controls, enhanced environmental controls, and respiratory protection