Operational research on implementation of tuberculosis guidelines in
Mozambique
Brouwer, M.A.
Publication date
2015
Document Version
Final published version
Link to publication
Citation for published version (APA):
Brouwer, M. A. (2015). Operational research on implementation of tuberculosis guidelines in
Mozambique.
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6. Implementation' of' tuberculosis' infection'
prevention' and' control' in' Mozambican' health'
care'facilities'
!
Miranda!Brouwer1,2,!Eliana!Coelho3,!Carla!das!Dores!Mosse4,!Frank!van!Leth5!
!
1!Health!Alliance!International,!Technical!Assistance!Unit,!Maputo,!Mozambique! 2!PHTB!Consult,!Tilburg,!The!Netherlands!
3!Ministry!of!Health,!Maputo,!Mozambique!!
4!Ministry!of!Health,!Provincial!Directorate,!Tete,!Mozambique!
5!Department! of! Global! Health,! Academic! Medical! Center,! University! of! Amsterdam,! Amsterdam,! The!
Netherlands!
!
Int!J!of!Tuberc!Lung!Dis!2015;!19!(1):!44<49.! “Reprinted!with!permission!of!the!International!Union!Against!Tuberculosis!and!Lung!Disease.!Copyright!©! The!Union.!“'!
! ! !Abstract' '
Setting:! District! and! urban! health! care! facilities! in! three! provinces! (Manica,! Sofala,! Tete)! in! central! Mozambique.!
Objective:!To!assess!the!level!of!implementation!of!selected!tuberculosis!infection!prevention!and!control! (TB<IPC)!measures.!
Design:! In! a! cross<sectional! study! of! TB<IPC! implementation! in! 29! health! care! facilities,! we! assessed! TB! clinics,! laboratories,! out<patient! departments! and! medical! and! TB! wards.! Assessment! included! selected! managerial,! administrative! and! environmental! measures! and! the! availability! and! use! of! respiratory! protective!equipment!(N95!respirators).!
Results:! Guidelines! for! diagnosis! and! treatment! of! (presumptive)! TB! patients! were! not! present! in! all! facilities.!Staff!instructed!patients!on!sputum!collection!in!91%,!but!only!4%!observed!it.!Using!a!pragmatic! ‘20%! rule’,! 52%! of! the! rooms! assessed! had! adequate! ventilation.! Potentially,! this! could! be! increased! to! 76%.!Three!quarters!of!the!health!care!workers!had!N95!respirators.!Only!36%!knew!how!to!use!it!correctly.! Conclusion:! Implementation! of! TB<IPC! measures! showed! wide! variations! within! health! care! facilities.! Relatively! simple! measures! to! improve! TB<IPC! include! the! availability! of! guidelines,! opening! doors! and! windows!to!improve!ventilation,!and!training!and!support!on!correct!N95!respirator!use.!However,!even! relatively!simple!measures!are!challenging!to!implement,!and!require!careful!attention!for!and!evaluation! of!in!the!implementation!process.!
!
Transmission!of!tuberculosis!(TB)!in!health!care!facilities!constitutes!a!serious!threat!to!health!care!workers! (HCWs)!and!other!facility!users.!Studies!have!shown!that!HCWs!have!a!much!higher!risk!of!developing!TB! than! the! general! population.1<3! TB! infection! prevention! and! control! (TB<IPC)! measures! are! aimed! at!
reducing!TB!transmission!risk!in!health!care!facilities.!Attention!to!the!implementation!of!TB<IPC!measures! in!health!care!facilities!has!increased!in!recent!years!due!to!the!spread!of!multidrug<resistant!(MDR<)!and! extensively!drug!resistant!(XDR<)!TB!in!hospitals.4!The!human!immunodeficiency!virus!(HIV)!epidemic!and!
integration! of! HIV! and! TB! services! have! further! contributed! to! renewed! attention! for! TB<IPC! implementation.5!
The! World! Health! Organization! (WHO)! policy! on! TB<IPC! consists! of! a! set! of! measures! and! activities! for! different! levels! of! the! health! care! system.6! In! facilities,! managerial! activities! should! support! the!
implementation! of! administrative! and! environmental! measures,! and! the! use! of! respiratory! protection! equipment.!Administrative!measures!include!promptly!identifying!(presumptive)!TB!patients!and!separating! them!from!other!facility!users.!Environmental!measures!aim!to!reduce!the!concentration!of!bacilli!in!the! air,! for! example! through! the! use! of! natural! ventilation.! Respiratory! protective! equipment! refers! to! particulate!respirators!that!prevent!the!wearer!from!inhaling!TB!bacilli.!!
Assessment!tools!for!the!implementation!of!TB<IPC!measures!in!health!care!facilities!are!based!on!guidance! from! the! WHO6! and! the! US! Centers! for! Disease! Control! and! Prevention! (CDC).7! While! WHO! guidance!
applies!to!all!countries,!CDC!guidelines!target!the!United!States!health!care!system,!which!is!very!different! from!the!reality!in!sub<Saharan!Africa.!The!WHO!recommends!assessing!all!levels!of!the!health!care!system! for! TB<IPC! measures.! Interventions! and! studies! assessing! the! implementation! of! TB<IPC! measures! have! usually!targeted!tertiary!and!regional!referral!hospitals!first.8,9!However,!many,!if!not!most!presumptive!TB!
patients!attend!district!hospitals!and!urban!or!rural!health!care!facilities.!The!potential!for!TB!transmission! in!these!health!care!facilities!is!therefore!substantial.!Some!studies!recently!evaluated!the!implementation! of! TB<IPC! measures! in! district! hospitals! and! primary! health! care! facilities! in! sub<Saharan! Africa,! and! reported!limited!implementation.10<12!
The!implementation!of!TB<IPC!measures!has!received!more!attention!in!recent!years!in!Mozambique!with! the!development!of!national!guidelines!in!2009.13!Mozambique!is!among!the!22!high<burden!countries!(50!
827!TB!patients!in!201214)!and!has!an!increasing!estimated!TB!incidence.!TB!patients!are!mainly!notified!by!
district!hospitals!and!urban!health!care!facilities.!However,!little!is!known!about!the!implementation!of!TB< IPC! measures! in! district! and! urban! health! care! facilities.! We! therefore! addressed! the! following! research! question:! how! are! TB<IPC! measures! implemented! in! district! and! urban! health! care! facilities! in! central! Mozambique! in! terms! of! managerial! activities,! administrative! and! environmental! measures,! and! use! of! respiratory!protection!equipment?!
!
Methods'
We!assessed!the!implementation!of!TB<IPC!measures!in!all!TB!notifying!health!care!facilities!with!at!least! 150!TB!notifications!(all!forms)!in!2008!in!Manica,!Sofala!and!Tete!Provinces!in!central!Mozambique.!The! assessments! were! performed! in! September! and! October! 2010.! We! excluded! provincial! and! central! hospitals,!as!these!hospitals!have!no!separate!TB!department,!and!they!have!a!different!scope!and!scale!of! activities! compared! to! district! and! urban! facilities.! The! assessment! included! the! TB! clinic,! the! laboratory! and!the!out<patient!department!(OPD).!We!included!a!medical!ward!and!a!TB!ward!if!present.!
A!study!assessment!tool!based!on!the!Mozambican!Infection!Control!Guidelines!and!internationally!used! assessment! tools! was! developed! and! used.6,7,13! We! assessed! sputum! collection! and! separation! of!
(presumptive)!TB!patient!procedures!(administrative!measures)!through!observation!and!interviews!with!a! HCW! in! each! of! the! departments.! Among! the! environmental! measures,! we! assessed! ventilation! by! a! pragmatic!rule!of!thumb:!ventilation!was!adequate!if!the!surface!of!all!open!windows!and!doors!during!the! assessment!was!>20%!of!the!floor!surface!(the!20%!rule).12!This!rule!was!also!applied!to!the!surface!of!all!
windows!and!doors,!assuming!they!could!all!open,!to!assess!ventilation!potential.!In!addition,!we!assessed! through! observation! the! correct! use! of! the! N95! respirators! (3M! 1860;! 3M,! St! Paul,! MN,! USA).! Use! was! reported!as!correct!if!users!followed!the!manufacturer’s!instructions.!
The!assessment!also!included!an!interview!with!the!facility’s!manager!to!assess!aspects!of!the!managerial! component.! The! interview! covered! attendance! of! adults,! children! and! HIV<infected! individuals! at! the! facility,!presence!of!a!written!TB<IPC!plan!and!an!open!question!about!the!presence!of!guidelines!for!the! diagnosis!and!treatment!of!TB!patients.!
Six!provincial!and!district!TB!supervisors!collected!the!data.!They!underwent!a!4<day!training!course!that! included! TB<IPC! theory,! practical! exercises! and! assessment! in! a! health! care! facility! not! selected! for! the! study.!The!last!day!of!the!course!comprised!an!assessment!under!supervision!in!one!of!the!study!facilities.! Data! were! entered! and! analysed! using! SPSS! Statistics! version! 20.0.0! (Statistical! Package! for! the! Social! Sciences,! Chicago,! IL,! USA).! The! data! were! cleaned! and! checked! for! completeness! and! consistency.! The! characteristics! of! the! health! care! facilities! were! summarised! descriptively! with! medians! and! ranges! for! continuous!variables.!For!categorical!variables,!frequencies!were!used.!
Ethics!!
The! National! Bio<ethics! Committee! of! the! Mozambican! Ministry! of! Health! approved! the! protocol.! The! relevant! health! care! authorities! of! the! provinces! approved! the! study! taking! place! in! the! selected! health! care! facilities.! For! Health! Alliance! International,! the! Institutional! Review! Board! of! the! University! of! Washington!in!Seattle,!WA,!USA!reviewed!the!protocol!and!waived!the!need!for!ethical!approval.! Results' We!assessed!29!health!care!facilities:!6!in!Manica!(3!urban),!14!in!Sofala!(6!urban)!and!9!in!Tete!Province!(4! urban).!The!three!provinces!notified!26%!of!the!country’s!TB!patients!in!2010!(source:!National!TB!Control! Programme!(NTP)!data).!The!participating!facilities!notified!87%!of!the!TB!patients!in!the!three!provinces!in! 2010.!All!facilities!had!a!TB!department!and!28!had!a!laboratory!with!smear!microscopy!services.!The!one! urban! facility! without! a! laboratory! took! samples! for! microscopy! to! the! nearest! facility! with! microscopy! services.!All!facilities!had!OPDs,!of!which!41!rooms!were!assessed.!All!district!hospitals!had!a!medical!ward! (n!=!12),!a!TB!ward!(n!=!3)!or!both!(n!=!5)!assessed.!One!urban!facility!had!a!TB!ward!that!was!solely!for!the! admission! of! patients! with! multidrug<resistant! TB! (MDR<TB).! Table! 6! provides! an! overview! of! the! key! characteristics!of!the!study!facilities.!
Managerial!Activities!!
Almost! half! (14! of! 29)! of! the! facilities! had! a! written! IC! plan,! and! when! present,! 79%! included! TB.! Most! facilities!(26/29)!provided!TB!education!for!their!workers,!58%!of!which!did!this!at!least!monthly.!
Facility!management!in!66%!(19/29)!of!the!facilities!said!they!had!written!guidelines!for!the!diagnosis!of! presumptive! TB! patients.! All! facilities! had! guidelines! for! the! treatment! of! diagnosed! TB! patients.! The! TB! staff!corroborated!these!figures.!Table!7!shows!the!available!guidelines.!
' Legend:!OPD!=!out<patient!department! ! Table&6&Characteristics&of&health&care&facilities& ! Administrative!measures!! Sputum!collection!is!the!first!step!in!the!laboratory!diagnosis!of!TB.!Table!8!shows!the!location!of!sputum! production,!and!whether!or!not!HCWs!provided!instructions!to!patients!on!sputum!sample!production;!50%! of!HCWs!said!that!sputum!was!produced!at!home.!Most!HCWs!(91%)!instructed!patients!on!sputum!sample! production,!and!4%observed!sputum!production.! In!11%!of!the!laboratories,!OPDs!and!medical!wards,!(presumptive)!TB!patients!were!separated!from!other! facility!users!while!waiting!for!care!or!while!admitted.!In!addition,!62%!of!these!departments!attended!to! presumptive!TB!patients!before!attending!to!other!patients.! ! Environmental!Measures!and!respiratory!protection! Of!the!98!waiting!rooms,!89!(91%)!were!open!spaces,!and!observed!ventilation!was!considered!adequate!in! 87!(98%)!of!these.!Table!9!shows!the!implementation!of!ventilation<related!measures!and!the!availability! and!use!of!respiratory!protective!equipment.! ! Characteristic! Facilities!/! departments! with! information!
Median! Minimum! Maximum!
!! n! ! ! ! Adult!attendees/month! 25! 3,686! 535! 18,164! Child!(<!5!yrs)!attendees!/month! 25! 1,385! 177! 7,156! Attendees!HIV<clinic/month! 24! 715! 33! 2,081! Total!TB!patients/month! 29! 28! 8! 70! TB!patients!with!positive!sputum/month! 29! 11! 1! 33! Smears!performed!at!laboratory/month! 27! 184! 24! 537! Positive!smears/month! 27! 17! 2! 56! Attendees!at!OPD/month! 41! 2,274! 39! 7,020! Attendees!with!cough!at!OPD/month! 41! 533! 17! 2,080! Admissions/month!in!medical!ward! 12! 73! 3! 138! Admissions!with!respiratory!illness/month!in! medical!ward! 11! 8! 1! 19! Admissions!with!TB/month!in!medical!ward! 11! 1! 0.2! 6!
Table& 7& Guidelines& available& in& health& care& facilities& according& to& facility& managers& (n=29)& and& TB& staff& (n=29)&
!
Discussion'
The! level! of! implementation! of! TB! infection! prevention! and! control! measures! in! health! care! facilities! in! central! Mozambique! shows! great! variation! in! managerial! TB<IPC! activities,! administrative! and! environmental! measures,! and! the! use! of! respiratory! protection! equipment.! All! facilities! implemented! measures!such!as!the!presence!of!guidance!about!the!treatment!of!TB!patients,!whereas!implementation!of! separation!of!(presumptive)!TB!patients!only!reached!11%.! !
!
Legend:!HF!=!health!care!facility;!OPD!=!out<patient!department;!HCW!=!health!care!worker;!NA!=!not!available! ! Table&8&Sputum&collection&by&department& ! Guidance!material! Guidelines!for!identification!of! presumptive!TB!patients!available! Guidelines!for!treatment!of!diagnosed! TB!patients!available!Facility!managers! TB!staff*! Facility!managers! TB!staff!
None! 10! 11! ! ! NTP!manual! 12! 10! 19! 22! Leaflets!and!Information! Education!and!Communication! (IEC)!material! 4! 5! 8! 7! TB!treatment!dosage!table! 4! 3! 18! 21! Other/Unknown! 4! 6! 2! ! Legend:!*!Most!facilities!had!only!one!TB!staff!member.!If!a!facility!had!more!than!one!TB!staff!member,!the!head!of!department!provided!the! information.! !
Sputum!collection! TB!clinic!(n=29)! Laboratory!(n=28)! OPD!(n=41)! Medical!ward!!(n=12)!
!! n!(%)! n!(%)! n!(%)! n!(%)! Location!sputum!collection! ! ! ! ! !!!At!the!laboratory! 0!(0)! 0!(0)! 12!(29)! 1!(8)! !!!At!a!ventilated!space!in!HF! 12!(41)! 4!(14)! 8!(20)! 0!(0)! !!!At!home! 12!(41)! 22!(79)! 20!(49)! 1!(8)! !!!In!the!bathroom!of!HF! 3!(10)! 2!(7)! 1!(2)! 0!(0)! !!!Other/Unknown! 2!(&)! 0!(0)! 0!(0)! 10!(83)! HCW!gives!instruction!on!how!to!collect! sputum!sample!(yes)! NA! 28!(100)! 41!(100)! 11!(92)! HCW!observes!production!of!sputum!sample! (yes)! NA! 1!(4)! 0!(0)! 2!(17)!
Our! findings! are! in! line! with! other! studies! on! the! implementation! of! TB<IPC! measures! in! health! care! facilities!in!similar!settings.10,12!However,!there!is!little!evidence!on!the!relevance!of!the!implementation!of!
certain! measures! on! the! practice! of! TB<IPC.! For! example,! a! measure! emphasised! in! international! TB! infection!prevention!and!control!guidelines!is!that!all!facilities!should!have!a!TB!infection!prevention!and! control!plan.!However,!a!knowledge,!attitudes!and!practices!study!looking!at!MDR<TB!facilities!found!no! relation! between! the! presence! of! a! plan! and! actual! TB<IPC! practices.15! This! raises! the! question! as! to!
whether!the!emphasis!on!having!such!a!plan!is!justified!and!how!valid!the!inclusion!of!such!a!measure!in! TB<IPC! assessment! tools! might! be.! A! South! African! study! investigating! the! relationship! between! TB<IPC! assessment! scores! and! TB! in! HCWs! found! no! relation! between! the! scores! and! the! incidence! of! TB! in! HCWs.11!The!study!suggested!developing!and!testing!TB!infection!prevention!and!control!assessment!tools!
locally!in!different!settings.!This!may!also!apply!to!the!different!levels!of!the!health!care!system.!
Administrative! measures! aiming! to! diagnose,! isolate! and! treat! (presumptive)! TB! patients! promptly! are! considered!basic!measures!applicable!to!all!facilities.!However,!some!studies!identified!several!gaps!in!the! diagnostic!and!treatment!initiation!process.!HCWs!do!not!necessarily!test!for!TB!in!individuals!presenting! with!respiratory!symptoms.16!(Presumptive)!TB!patients!are!often!not!separated!from!other!patients!(only!
11%! in! our! study).! When! tests! confirm! TB! diagnosis,! treatment! is! not! always! initiated! promptly.17! As!
adequate! treatment! renders! patients! less! infectious! in! a! short! time,18! prompt! diagnosis! and! treatment!
initiation! is! crucial! as! a! TB<IPC! measure! to! reduce! transmission.! An! obstacle! to! adequate! diagnosis! and! treatment!may!be!the!lack!of!NTP!guidelines.!In!our!study,!some!managers!and!TB!staff!even!referred!to! patient! education! material! as! their! guidelines! for! TB! diagnosis! and! treatment.! Although! this! material! is! highly!relevant!for!patients,!HCWs!require!different!guidelines.!
Sputum! collection! is! part! of! the! TB! diagnostic! process.! The! TB! manual! indicates! that! presumptive! TB! patients!should!produce!the!first!sample!following!consultation!in!the!facility.19!In!our!study,!50%!of!HCWs!
stated! that! sputum! was! produced! at! home.! Although! production! at! home! reduces! the! possibility! of! TB! transmission!in!the!facility,!patients!may!not!return!to!submit!their!samples!and!remain!undiagnosed,!in! which! case! they! may! spread! disease! for! a! prolonged! period.! There! is! a! need! for! places! in! health! care! facilities!where!sputum!production!can!take!place!safely!for!patients,!HCWs!and!other!users,!particularly!if! HCWs!are!to!observe!sputum!production.!!
Separation! of! (presumptive)! TB! patients! reduces! the! time! during! which! these! patients! share! the! same! waiting!room!or!ward!with!other!facility!users.!This!measure!therefore!reduces!the!risk!of!TB!transmission.! The!OPDs!in!our!study!generally!had!only!one!waiting!room,!which!made!separation!difficult.!It!therefore! recommended!that!patients!with!(presumptive)!TB!be!prioritised!for!attention!before!other!patients.!This! reduces! the! time! (presumptive)! TB! patients! spend! in! the! facility,! which! is! considered! an! important! TB! infection!prevention!and!control!measure.6!
The!availability!of!N95!respirators!was!better!in!the!TB!clinics!(90%)!than!in!OPDs!(59%).!Although!this!was! better! than! in! other! reports,11,12!! anecdotal! evidence! from! Mozambique! reveals! that! the! supply! of!
respirators! is! irregular.! Even! more! worrisome! is! that! only! 36%! of! observed! staff! used! the! respirators! correctly.!A!rapid!assessment!of!the!implementation!of!TB<IPC!measures!in!Mozambique!found!that!in!75%! of!the!health!care!facilities!assessed,!at!least!one!HCW!was!seen!using!the!N95!respirator!incorrectly!(Samu! Gudo,!et!al.!Report!of!a!rapid!assessment:!tuberculosis!transmission!risk!and!infection!control!compliance! in!Mozambican!health!care!settings.!Unpublished).!Incorrect!use!of!respirators!reduces!the!protection!of! the!wearer!and!may!lead!to!inhalation!of!TB!bacilli.! !
!
Legend:!*In!the!laboratories!this!was!when!processing!the!sputum!samples.!OPD!=!out<patient!department;!HCW!=!health!care!worker!
!
Table&9&Environmental&measures&and&respiratory&protection&by&department&
!
In! Mozambique,! as! many! other! resource<limited! settings,! N95! respirators! are! used! more! than! once.! Keeping!the!respirator!in!good!condition!between!uses!in!an!adequate!place!and!maintaining!the!shape!of! the!respirator!is!therefore!crucial.!This!was!difficult!for!many!HCWs,!who!kept!the!respirator!between!uses! in!their!coat!pockets,!where!it!loses!its!shape,!or!on!their!desk!where!the!respirator!may!collect!dust!and! become! less! functional.! These! findings! show! that! HCWs! need! more! support! in! the! correct! use! and! maintenance!of!respirators.!
!! TB!clinic!(n=29)! Laboratory!(n=28)! (n=41)!OPD! Medical!ward!! (n=12)! TB!ward!! (n=9)! !! n!(%)! n!(%)! n!(%)! n!(%)! n!(%)! Environmental!measures! Staff!work!with!door!open! 29!(100)! 15!(54)! 14!(34)! 10!(83)! 9!(100)! Staff!work!with!window!open! 29!(100)! 21!(75)! 39!(95)! 11!(92)! 9!(100)! Staff!work!with!door!and!window!open! 29!(100)! 13!(46)! 12!(29)! 9!(75)! 9!(100)! Ventilation!adequate!at!time!of!assessment!(“20%! rule”)!! 12!(41)! 13!(46)! 22!(54)! 8!(67)! 7!(78)! Ventilation!potentially!adequate”!if!all!openings! open!(“20%!rule”)! 20!(69)! 15!(54)! 36!(88)! 12!(100)! 8!(89)! Personal!Protective!Equipment! N95!respirators!available!(yes)! 26!(90)! 24!(86)! 24!(59)! 9!(75)! 8!(89)! When!do!you!use!N95!respirators! ! ! ! ! !!!Attending!patients! 25!(96)! 1!(4)! 12!(50)! 5!(56)! 7!(88)! !!!Attending!patients!with!cough! 1!(4)! 1!(4)! 10!(42)! 2!(22)! 1!(13)! !!!Other*! 0!(0)! 22!(92)! 2!(8)! 2!(22)! 0!(0)! Where!do!HCW!keep!N95!respirator!in<between!use?! ! ! !!!Drawer/cupboard! 17!(65)! 13!(54)! 20!(83)! 5!(56)! 5!(63)! !!!On!desk! 3!(12)! 1!(4)! 0!(0)! 0!(0)! 0!(0)! !!!Pocket!of!coat! 2!(8)! 0!(0)! 2!(8)! 1!(11)! 1!(13)! !!!Other/unknown! 4!(15)! 10!(42)! 2!(8)! 3!(33)! 2!(25)! HCW!uses!N95!correctly! 10!(38)! 4!(17)! 9!(38)! 4!(44)! 6!(75)! Observed!incorrect!use! ! ! ! ! ! !!!Crossed!elastics! 5!(31)! 8!(40)! 6!(40)! 1!(20)! 0!(0)! !!!Touched!inside! 5!(31)! 1!(5)! 0!(0)! 0!(0)! 1!(50)! !!!Crossed!elastics!and!touched!inside! 3!(19)! 4!(20)! 3!(20)! 2!(40)! 1!(50)! !!!Other! 3!(19)! 7!(35)! 6!(40)! 2!(40)! 0!(0)!
The! implementation! of! several! TB<IPC! measures! seems! relatively! easy.! Examples! of! apparently! easy! to! implement! measures! are! prioritisation! of! presumptive! TB! patients! and! opening! doors! and! windows! to! increase!ventilation.!However,!as!simple!as!it!may!seem,!prioritisation!requires!a!person!to!identify!those! patients!who!need!to!be!attended!to!first.!In!a!setting!like!Mozambique,!where!human!resources!for!health! care! are! scarce,! this! is! a! real! challenge.! Furthermore,! working! with! open! doors! and! windows! has! its! challenges.!HCWs!keep!doors!closed!for!patient!privacy;!windows!cannot!always!open,!as!other!studies!also! found;12! and! weather! conditions! and! security! are! also! relevant! considerations! when! working! with! open!
doors!and!windows.!Nevertheless,!natural!ventilation!has!good!potential!to!reduce!airborne!transmission! at!little!cost.20!The!use!of!wind<driven!roof!turbines!is!a!relatively!cheap!intervention!in!situations!where!
privacy!requires!closed!doors!and!ventilation!is!inadequate.21!
Most!of!our!findings!showed!that!the!implementation!of!TB<IPC!measures!was!inadequate!due!to!the!lack! of!guidelines!or!insufficient!implementation!of!available!guidelines.!A!study!from!South!Africa!showed!that! informing! HCWs! about! TB<IPC! measures! is! not! sufficient! for! HCWs! to! incorporate! them! into! their! daily! practice.22!Motivation!of!HCWs!as!well!as!social!support!from!colleagues!and!superiors!is!very!important!for! the!implementation!of!and!adherence!to!guidelines.!Increasing!motivation!and!social!support!require!on< going!attention!to!improve!the!implementation!of!TB<IPC!measures.! The!implementation!of!TB<IPC!measures!is!not!a!goal!in!itself.!The!measures!aim!to!reduce!TB!transmission! in!health!care!facilities.!In!addition!to!assessing!the!implementation!of!TB<IPC!measures,!HCWs!should!be! monitored!for!TB.! ! Limitations! We!obtained!information!on!TB<IPC!in!the!facilities!using!a!questionnaire,!but!did!not!confirm!all!answers! through! observation.! Several! studies! have! shown! gaps! between! knowledge! or! information! given! and! practice.23!This!means!that!the!actual!situation!regarding!TB<IPC!could!be!worse!or!unknowingly!better!than!
we! describe! here.! In! addition,! the! results! of! our! study! are! context<specific,! which! limits! their! generalisability.!However,!given!that!our!findings!and!those!of!a!rapid!assessment!done!at!the!same!time!in! Mozambique!(Samu!Gudo,!et!al.!Report!of!a!rapid!assessment:!tuberculosis!transmission!risk!and!infection! control! compliance! in! Mozambican! health! care! settings.! Unpublished)! were! similar! indicates! that! our! results!are!probably!accurate!in!presenting!the!TB<IPC!situation!in!Mozambican!health!care!facilities.!Our! findings!are!also!similar!to!other!studies!in!sub<Saharan!Africa.!
!
Conclusions'
The! implementation! of! TB<IPC! measures! at! lower! level! health! care! facilities! varies! from! complete! implementation!of!some!and!almost!no!implementation!of!other!TB<IPC!measures.!We!also!conclude!that!it! remains! a! considerable! challenge! to! translate! guidelines! or! research! findings! into! applicable! actions! or! interventions!in!practice.!Implementation!science!looks!into!theories!or!models!of!how!to!obtain!successful! outcomes! and! how! to! assess! the! success! of! implementation.24! However,! research! efforts! in! TB<IPC! have! seldom! included! these! aspects,! leaving! many! implementers! to! learn! how! to! implement! measures! for! themselves!instead!of!being!able!to!use!best!practice!experiences!of!other!implementers.!
We!recommend!that!future!research!looks!into!the!relevance!of!international!recommended!guidelines!in! certain!settings!and!pay!more!attention!to!aspects!related!to!the!implementation!of!guidelines.!
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