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Measuring TB Infection Control Progress: National Action Plan Indicators

This webinar introduces IPC indicators to measure progress towards NAP milestones in TB CARE II priority countries. It aims to define global indicators to measure IPC implementation and supplement them with country-specific ones. The speaker discusses operationalized measurements of IPC interventions and proposes a potential impact indicator. The NAP, launched in 2015, focuses on combating multidrug-resistant TB by strengthening capacity and collaboration, and accelerating research. TB CARE II supports NAP goals through IPC activities. The webinar addresses the challenges of measuring IPC interventions and the importance of using appropriate indicators. A pre-test question tests understanding of possible IPC measurements for administrative controls. It also covers choosing universal indicators, comparing country-level frameworks, and defining global indicators for monitoring progress. Examples of TB IPC indicators and impact indicators are discussed, emphasizing the importance of effective TB infection control measures. Next steps include working with NAP countries to improve occupational health services and validating impact indicators. Process indicators are tailored to facility protocols to inform local IPC implementation evaluation.

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Measuring TB Infection Control Progress: National Action Plan Indicators

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  1. WebinarPriority IPC Indicators TB CARE II 30-August 2019

  2. Introduction Measuring IPC Implementation

  3. Introduction and Purpose • To measure progress toward NAP Milestones 2.2.1 and 2.2.3 in the 10 NAP priority countries • To define global comparative indicators to measure IPC implementation • To supplement these global indicators with additional, country-specific indicators as requirements and resources allow • Understand the specific, operationalized measurements of certain IPC interventions and discuss a potential impact indicator for IPC

  4. The National Action Plan (NAP) • The U.S. Government released the National Action Plan for Combating Multidrug-Resistant Tuberculosis (NAP) in 2015. This is a five-year plan that builds on the U.S. Government’s domestic and global TB strategies, as well as the World Health Organization’s (WHO) END TB Strategy.

  5. The National Action Plan (NAP) • The goals of the National Action Plan are to: • Strengthen domestic capacity to combat MDR-TB; • Improve international capacity and collaboration to combat MDRTB; • Accelerate basic and applied research and development to combat MDR-TB.

  6. TB CARE II, NAP and IPC • TB CARE II supports the achievement of NAP milestones through its IPC activities and works to better define IPC measurements. The project currently works on the following within this domain: • Defining IPC indicators for improved measurement and comparability of IPC interventions in various settings • Providing technical support on IPC indicator development and IPC measurement planning

  7. Pre-Test • Which of the three is a possible IPC measurement for administrative controls: • Percentage of people who are started on effective therapy after a TB diagnosis through a molecular test within one day • Percentage of health care workers wearing N95 respirators • Percentage of facilities in the country with an up-to-date IPC plan • True or false, all countries can measure every IPC intervention through the same set of indicators?

  8. IPC Indicators Choosing “Universal” Indicators

  9. Methods • Define a detailed framework of IPC indicators • Within this framework, assess the current status of measuring IPC interventions in the NAP countries • Facilitated through the Global Consultation and Support for IPC Implementation in Manila, Philippines on August 6-7, 2018 • Compare the county-level frameworks to understand possibilities for comparative indicators • Define overall, global/comparative indicators to measure progress toward NAP milestones • Supplement these indicators with additional, country-specific indicators as necessary and feasible

  10. National Level M&E Indicator Survey Results Managerial Controls

  11. National Level M&E Indicator Survey Results Administrative Controls

  12. National Level M&E Indicator Survey Results Environmental Controls

  13. National Level M&E Indicator Survey Results Personal Protective Equipment

  14. National Level M&E Indicator Survey Results Healthcare Worker Screening

  15. ResultsStatus of IPC Measurement in 10 NAP Priority Countries

  16. Measuring TB IPC: Examples

  17. Measuring TB IPC: Impact Indicator Health care worker TB incidence compared to TB incidence in the general population • Inverse relationship between TB IPC and TB incidence in HCWs • Computationally straightforward • National level data • Synergy with NAP Milestone 2.2.3-D • WHO-endorsed

  18. “If effective TB infection control measures are in place, the relative risk of TB in health-care workers compared with the general adult population should be close to 1.” A guide to monitoring and evaluation for collaborative TB/HIV activities. WHO 2015

  19. Global TB Report. WHO 2017

  20. = NAP Countries Reporting = NAP Countries Not Reporting Global TB Report. WHO 2016

  21. China: WHO vs. Literature Review Prevalence rates from cross-sectional studies would roughly equal notification rates ranging from 154 - 285 cases / 100,000 HCWs and relative risks of TB for HCWs that are 2.7 to 4.9 times that of the general population.

  22. TB incidence in HCW – Limitations • At what level is the indicator useful? • National, longitudinal • Too much variability to be used for comparisons between countries over time • Sample sizes to small to be used at the facility/local level • Unsound assumption that the background risk of TB for health workers equals general population

  23. Next steps: TB IPC Impact Indicator • Work with NAP countries to strengthen occupational health services, especially TB screening and reporting • Consult with WHO to establish and promote universal definitions of terms and protocols for measurement, qualify confidence of measures (discounting of some terms) • Validate the impact indicator as a predictor of TB infection control

  24. Measuring TB IPC: Process Indicators • Informative evaluation of the implementation of IPC strategies at the local/facility level • Tailored to facility protocols and data sources • Avoids the variability of between-site comparisons • Can be reported on quarterly basis to relevant stakeholders

  25. FAST Process Indicators • Time to diagnosis • Time to treatment • Focused on two critical moments in the care cascade for patients with TB • Centered on decreasing the time of infectiousness • Relatively straightforward

  26. Time from hospitalization to TB diagnosis with drug susceptibility testing Definitions • Hospitalization: • Admission? Triage? • Depends on local protocols and data sources • TB diagnosis: • Date of first test with TB (smear, Xpert, others) versus first test with TB and drug susceptibility testing (Xpert, smear followed by LPA) • Requires strong laboratory data management

  27. Time from hospitalization to initiation of TB treatment Definitions • Initiation of TB treatment • Any • Indicated: according to DR-TB risk profile and diagnostic tests available (+/- DST) at time of treatment • Likely effective: informed by DST results (requires access to rapid molecular diagnostics)

  28. FAST indicators capture complex care cascades Le, et al. Process measure of FAST tuberculosis infection control demonstrates delay in likely effective treatment. IJTLD 2019

  29. Next steps – TB IPC process indicators • Work with select facilities in NAP countries to pilot the implementation of FAST and time to diagnosis and treatment indicators • Develop an administrative TB IPC process indicator focused on evaluating the proportion of patients in care who are screened for TB • Develop process indicators for environmental TB IPC

  30. Measuring TB IPC: Next Steps

  31. Review of Next Steps: TB IPC Indicators • Strengthen occupational health services, especially TB screening and reporting • Establish and promote universal definitions of terms and protocols for measurement • Validate indicators • Pilot implementation of indicators • Develop additional indicators for screening and for environmental controls

  32. ETTi implementation guide will recommend approaches to M&E of WHO IPC guidelines

  33. Next Steps: Necessary TA • TB Program Directors and M&E Managers: • Is TA needed? • What TA is most useful?

  34. Post-Test • Which of the three is a possible IPC measurement for administrative controls: • Percentage of people who are started on effective therapy after a TB diagnosis through a molecular test within one day • Percentage of health care workers wearing N95 respirators • Percentage of facilities in the country with an up-to-date IPC plan • True or false, all countries can measure every IPC intervention through the same set of indicators?

  35. Questions

  36. Thank You!

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