Tuberculosis infection control practices in a high-burden metro in South Africa: A perpetual bane for efficient primary health care service delivery

Abstract

BackgroundTuberculosis (TB) prevention, including infection control, is a key element in the strategy to end the global TB epidemic. While effective infection control requires all health system components to function well, this is an area that has not received sufficient attention in South Africa despite the availability of policy and guidelines.AimTo describe the state of implementation of TB infection control measures in a high-burden metro in South Africa.SettingThe research was undertaken in a high TB- and HIV-burdened metropolitan area of South Africa. More specifically, the study sites were primary health care facilities (PHC), that among other services also diagnosed TB.MethodsA cross-sectional survey, focusing on the World Health Organization levels of infection control, which included structured interviews with nurses providing TB diagnosis and treatment services as well as observations, at all 41 PHC facilities in a high TB-burdened and HIV-burdened metro of South Africa.ResultsTuberculosis infection control was poorly implemented, with few facilities scoring 80% and above on compliance with infection control measures. Facility controls: 26 facilities (63.4%) had an infection control committee and 12 (29.3%) had a written infection control plan. Administrative controls: 26 facilities (63.4%) reported separating coughing and non-coughing patients, while observations revealed that only 11 facilities (26.8%) had separate waiting areas for (presumptive) TB patients. Environmental controls: most facilities used open windows for ventilation (n = 30; 73.2%); however, on the day of the visit, only 12 facilities (30.3%) had open windows in consulting rooms. Personal protective equipment: 9 facilities (22%) did not have any disposable respirators in stock and only 9 respondents (22%) had undergone fit testing. The most frequently reported barrier to implementing good TB infection control practices was lack of equipment (n = 22; 40%) such as masks and disposable respirators, as well as the structure or layout of the PHC facilities. The main recommendation to improve TB infection control was education for patients and health care workers (n = 18; 33.3%).ConclusionAll levels of the health care system should be engaged to address TB prevention and infection control in PHC facilities. Improved infection control will address the nosocomial spread of TB in health facilities and keep health care workers and patients safe from infection.

Barriers and facilitators of tuberculosis infection prevention and control in low- and middle-income countries from the perspective of healthcare workers: A systematic review

“…Poor funding and insufficient resources were the theme by far most frequently mentioned across all studies. Healthcare workers cited poor infrastructure, such as a lack of isolation space [ 17 , 24 ], poor clinic layout [ 28 ], windows opening in the wrong direction [ 29 ], and being unable to maintain equipment such as extractor fans as barriers to implementing isolation or environmental measures [ 17 , 19 , 26 , 27 , 30 ]. Because of insufficient funding to hire more staff, overstretched healthcare workers viewed cough screening, isolation and patient education as additional, non-essential tasks [ 14 , 17 , 19 , 22 , 30 , 31 ].…”

Tuberculosis infection prevention and control: why we need a whole systems approach

“…These gaps in understanding the health systems context relevant to TB IPC are evident in South Africa: nosocomial transmission featured prominently in the 2005 outbreak of extensively drug-resistant (XDR) TB in a hospital HIV outpatient service in KwaZulu-Natal and is likely to remain a key driver of Mtb transmission in the country [9,10]. South African TB IPC guidelines are in place [11], yet numerous studies report inadequate implementation in health facilities [8,12]. Studies tend to adopt cross-sectional designs and survey methods to assess HCW knowledge, attitudes, and practices, reflecting the focus on 'failed' IPC as poor adherence to guidelines rather than symptomatic of root systemic issues.…”

“…Though commonly referring to infection originating within hospitals, we apply the term more broadly to designate infection occurring within health facilities [5]. IPC measures to reduce airborne transmission of Mtb in health facilities, such as opening doors and windows, wearing protective respirators, and instituting cough triage, remain poorly implemented [6][7][8]; there are large gaps in understanding the barriers and enablers to implementing these measures in resourceconstrained health systems and specifically, within primary health clinics.…”

Exploring options for reprocessing of N95 Filtering Facepiece Respirators (N95-FFRs) amidst COVID-19 pandemic: A systematic review

“…airborne pathogens, such as Mycobacterium tuberculosis, against which their use is mandatory [39,40]. Finding a reprocessing method for FFRs will lead to provision of adequate respiratory protection for HCWs in such resource limited settings.…”