“There is urgent need for wide-spread training that is comprehensive and integrates HIV and TB, but is inclusive of all aspects of care including psychosocial right down to occupational safety and how and when to put on an N95 mask,” Dr Krista Dong of iTeach told HATIP.
“Lack of education was our biggest barrier,” Robin Smith of MSF told HATIP. “We started by running DR-TB training sessions for all healthcare workers, now we are busy doing the same for all home-based carers, and after that we will move onto the general population.”
This is a big job because people need to produce TB IC training materials and methods that are appropriate to the language and culture of the nurses and other health staff.
Prof Mehtar emphasised that English is not the first language for many and that: “The method of instruction had to be more practical than theoretical...and the local culture of communication was verbal and relied on talking, workshops and discussion with visual evidence.”
These methods are time and labour-intensive.
PALSA PLUS has a wealth of experience using similar methods of training nurses who run primary care clinics in South Africa (published by the Knowledge Translation Unit at Cape Town University Lung Institute). According to Dr Ruth Cornick at the University of Cape Town Lung Institute, TB IC has been integrated into the TB section of this year's edition of PALSA PLUS, including how to take sputa safely, ventilation, and instructions on the appropriate use of facemasks and respirators.
“The guideline and training approach prioritises diagnosing and treating TB quickly and knowing the patient and health workers' HIV status which of course impact on the spread of TB. We also have several reminders about MDR and XDR TB where they would prompt appropriate action in the course of a clinical consultation,” she said.
Soon this course should reach most primary care nurses throughout South Africa.
Another issue is that training generally requires supervision to ensure implementation.
For instance, following recognition of the devastating impact of nosocomial TB on healthcare workers in Malawi, infection control guidelines were written and distributed to each hospital and staff were trained.4 The emphasis was on rapid diagnosis of patients with smear-positive pulmonary TB, administrative attempts to isolate infectious patients, and the education of patients on cough hygiene. Hospitals were requested to consider offering confidential counselling and HIV testing to their staff and to advise those who were HIV-positive against working on general wards and TB wards.
However, a survey three years later showed no significant improvement and staff only reported scattered implementation of the policy. “The introduction of guidelines for the control of TB infection is an important intervention for reducing nosocomial transmission…, but rigorous monitoring and follow-up are needed in order to ensure that they are implemented,” wrote Dr Anthony Harries and colleagues
Dr Corbett recently conducted a survey rating 50 African facilities in Ethiopia, Kenya, Malawi, Mozambique and Zimbabwe on their infection control practices — and found most were lacking.
Survey of reported TB IC practice at 50 African facilities:
At this facility |
Randomly selected facilities |
Best practice facilities |
P-value |
Is there a TB IC plan? |
40% |
65% |
0.08 |
Environmental measures in place: |
|
|
|
Outdoor TB clinics |
17% |
30% |
0.43 |
Policy of always keeping windows open |
50% |
90% |
0.003 |
Patients go outside to produce sputum |
40% |
55% |
0.30 |
Well ventilated areas for patients with TB/HIV |
50% |
80% |
0.032 |
Triage of coughing patients at OPD registration |
37% |
30 |
0.63 |
Separation of non/+coughing patients in ward |
50% |
53% |
0.87 |
Is there a “cough officer”/equivalent identifying patients with cough on the ward |
25% |
21% |
0.77 |
Do you routinely provide cloths to patients with cough to cover their mouths with |
13% |
40% |
0.03 |
Sputum pots in stock |
|
|
0.11 |
Either wards of OPD/lab out of stock |
40% |
35% |
|
Whole facility out of stock |
17% |
0% |
|
TB microscopy functioning |
50% |
80% |
0.028 |
Someone needs to be accountable, and empowered
So having a plan and putting it into practice are very different things.
Dr Francois Venter told HATIP that some of his facilities’ TB IC plans were all on paper: “We have patients coughing routinely in crowded waiting rooms. What’s holding up TB IC implementation? No central person is responsible. ID nurses see their role as TB notification and little else; ward nurses don’t really see it as a priority.” To change this, he would like to “make it someone’s responsibility, and give them the resources - and the power - to implement!”
Which is exactly what MSF has done in Khayelitsha by employing Robin Smith.
“One of our largest barriers was that TB infection control currently falls under the responsibility of the facility managers and Health & Safety reps, where it gets lost in the plethora of other things that they have to worry about, particularly if they are not educated about it. Having a full time Infection Control Practitioner for the Khayelitsha sub-district has allowed us to attack the problem more cohesively and I would recommend that other sub-districts do the same.”