Webinar Priority IPC Indicators TB CARE II 30-August 2019

Measuring IPC Implementation Introduction Measuring IPC Implementation

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

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.

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.

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

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?

Choosing “Universal” Indicators IPC Indicators Choosing “Universal” Indicators

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

National Level M&E Indicator Survey Results Managerial Controls Country Total Selected indicators Indonesia Kazakhstan Nigeria Pakistan Philippines South Africa Ukraine 2.2.3.C: Has this country improved the implementation of infection control practices in facilities responsible for diagnosis and treatment for MDR-TB? Managerial Controls   National TB infection control guideline scorecard Yes No Yes (Checklist) Yes (TB DOTS Certification) 3 Proportion of health care facilities (small, medium, larger) with an updated (past 10 years) IPC Plan/SOP that includes TB IPC measures 4 Proportion of health care facilities in the district/state with an active infection control committee responsible for implementing the written infection control plan that includes airborne infection control Proportion of health care workers trained in infection prevention and control. 5 Proportion of tertiary health care facilities in the district/state that have been subjected to facility risk assessment for airborne infection control 1

National Level M&E Indicator Survey Results Administrative Controls Country Total Selected indicators Indonesia Kazakhstan Nigeria Pakistan Philippines South Africa Ukraine 2.2.3.C: Has this country improved the implementation of infection control practices in facilities responsible for diagnosis and treatment for MDR-TB? Administrative Controls   Proportion of facilities w/ > 90% of hospitalized patients screened for active TB No Yes 2 Proportion of facilities w/ > 90% patients with presumptive TB tested with Xpert 4 Proportion of facilities w/ > 90% patients with presumptive TB tested with Xpert within one day of admission 1 Proportion of facilities w/ > 90% patients with presumptive TB initiating effective treatment Propose to Collect in 2019 Proportion of TB patient perform HIV test ; 50% (2018), 60% (2019), 75% (2020) Proportion of PLWH perform TB screened ; 100% Proportion of IPT child; 100% Proportion of IPT in PLWH; 40% (2018); 50%(2019)

National Level M&E Indicator Survey Results Environmental Controls Country Total Selected indicators Indonesia Kazakhstan Nigeria Pakistan Philippines South Africa Ukraine 2.2.3.C: Has this country improved the implementation of infection control practices in facilities responsible for diagnosis and treatment for MDR-TB? Environmental Controls   Proportion of facilities w/ airborne infection control risk assessment No Yes Proposed for 2019 3 Proportion of facilities which have outside or well ventilated waiting areas Yes in DR-TB Centers 1 Proportion of health facilities with a designated sputum collection area Proportion of health facilities which meeting ventilation requirements Proportion of facilities with high TB risk equipped with effective GUV

National Level M&E Indicator Survey Results Personal Protective Equipment Country Total Selected indicators Indonesia Kazakhstan Nigeria Pakistan Philippines South Africa Ukraine 2.2.3.C: Has this country improved the implementation of infection control practices in facilities responsible for diagnosis and treatment for MDR-TB? Personal Protective Equipment   Proportion of facilities with surgical masks available for patients identified with a cough No No, but data available Yes in DR-TB Centers Proposed for 2019 Yes 5 Proportion of facilities w/ N95 availability Proportion of health facilities which provide respirators to staff members based on their risk profile 1 Proportion of health facilitiies w/ appropriate N95 utilization 2

National Level M&E Indicator Survey Results Healthcare Worker Screening Country Total Selected indicators Indonesia Kazakhstan Nigeria Pakistan Philippines South Africa Ukraine 2.2.3.D: Has this country introduced and/or improved healthcare worker surveillance and screening in facilities responsible for diagnosis and treatment for MDR-TB  Health Care Worker Surveillance Proportion of HCWs screened for active TB disease No Yes 3 Proportion of HCWs screened for TB infection Proposed for 2019 (IGRA pilot) 4 Proportion of HCWs diagnosed with TB disease Proportion of facilities w/ adequate score on HCW screening program evaluation 2 OUTCOME/IMPACT: Risk of TB (disease) among health care workers relative to the general population, adjusted for age and sex 1

Results Status of IPC Measurement in 10 NAP Priority Countries Selected indicators Country Indonesia Kazakhstan Nigeria Pakistan Philippines South Africa Ukraine Summary 2.2.3.C: Has this country improved the implementation of infection control practices in facilities responsible for diagnosis and treatment for MDR-TB? Managerial Controls Number of indicators currently in place 3 5 1 Total indicators for this domain by 2019 Administrative Controls 4 Environmental Controls 2 Personal Protective Equipment 2.2.3.D: Has this country introduced and/or improved healthcare worker surveillance and screening in facilities responsible for diagnosis and treatment for MDR-TB? Health Care Worker Surveillance   Total all IPC Indicators by 2019 7 12 9 8 11 10

Measuring TB IPC: Examples

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

“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

Global TB Report. WHO 2017

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

China: WHO vs. Literature Review Author (Year) Region Methods # TB Cases Total HCW HCW TB per 100,000 Lower 95% CI Per 100,000 Upper 95% CI per 100,000 Is WHO data in CI? He et.al. (2010) Henan Province 127 TB centers with TB clinics; Symptom check and chest X-ray 20 3,746 534 326 823 No Du et. al. (2017) 31 geographically diverse provinces, municipalities and autonomous regions 2010 – 203 facilities: all TB hospitals/depts. w/ at least 30 beds; confirmed and clinically diagnosed cases 186 18,899 984 853 1,135 Wang et.al. (2018) 4 Eastern, 4 Central, and 4 Western provinces 2014 - 212 facilities that treat TB at some level; TB prevalence sample survey 71 9,663 735 574 926 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.

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

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

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

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

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

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)

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

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

Measuring TB IPC: Next Steps

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

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

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

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?

Questions

Thank You!