1. TB IC PROGRAM AT UMGUNGUNDLOVU HEALTH DISTRICT : PRESENTED BY : KUMBUZILE KHUMALO

2. DISTRICT CONTEXT  2 nd Largest District in KZN  Population in excess of 1 Million souls  84,3% of Population considered indigent and totally dependent on state service delivery  Comprises of 7 Municipalities  Provides services to clients that drain from surrounding Districts

3. UMgungundlovu Health District

4. SERVICE DELIVERY PLATFORM  PRIMARY HEALTH CARE: - 51 Fixed PHC Clinics - 17 Mobile PHC Clinics - 23 School Health Teams - 14 PHC Family Health Teams  COMMUNITY HEALTH CENTRES: 3  HOSPITAL SERVICES: 9 HOSPITALS - 1Tertiary, 1Regional, 2District & 2Specialized TB and 3 Specialized Psych Hospitals.

5. DISTRICT TB STATUS INDICATORTARGET2013/142014/15COMMENT TB Incidence200/100 000 750/100 000627/100 000Reduction noted although far from achieving the target TB Suspicion index 5%3%4% Facilities to  TB screening to pts visiting Facilities Treatment success rate 85%83%85%Improvement noted. Target achieved Defaulter rate>5%6%4,7%Reduction noted. Target achieved Death Rate>2%5%3%Reduction noted although target not achieved yet Smear conversion 85%83%88%Good Performance TB/ Coinfection68%Strict TB IC measures needed

6. DISTRICT STRATEGIES FOR TB IC  Engaging TB Patients and the Community in Advocacy campaigns to prevent infections  To Develop TB IPC Plan for the District and in all healthcare facilities.  Ensure safe sputum collection  Promote cough etiquette and cough hygiene  Triage TB suspects for fast track care or separation  Assure rapid diagnosis and initiation of TB treatment  Improve room air ventilation  Protect healthcare workers  Build capacity to prevent infections  To monitor infection control practices

7. TB IC STATUS AT UMGUNGUNDLOVU HEALTH DISTRICT ADMINISTRATIVE CONTROLS BEFORE SPECIFIC INTERVENTIONS INTERVENTIONSCURRENT STATUS No functional IPC Committees - Establishment of functional IPC Committees in all healthcare facilities All hospitals and CHCs have functional IPC Committees No IPC Focal Persons- PHC - Appointment of IPC Champions in all PHC Facilities and provided training All facilities have IPC Focal staff. PHC Champions are on the ongoing training & Development No TB IPC Risk Assessments - Conducted TB IPC Risk Assessments in all Healthcare Facilities(annually according to DQPR) Progress noted on number of facilities conducting TB Risk assessments.

8. TB IC STATUS AT UMGUNGUNDLOVU HEALTH DISTRICT ADMINISTRATIVE CONTROLS PERFORMANCE BEFORE INTERVENTION INTERVENTIONSCURRENT STATUS No District TB IC Plan- Development of the District Plan through assistance by CSIR District TB IC plan was developed and distributed to all facilities to base their plans on. No Facility Specific TB IPC Policies - Redistribute Policies, ProtocolsAll relevant policies were distributed are available. Poor screening, Triaging, separation and Fast tracking system - Allocation of screening nurse, distribution of screening tools Most facilities have allocated TB screening nurses. No standardized TB screening Tool - Liaise with TB ComponentScreening books have been distributed to all facilities

9. TB IC STATUS AT UMGUNGUNDLOVU HEALTH DISTRICT ADMINISTRATIVE CONTROLS PERFORMANCE BEFORE INTERVENTION INTERVENTIONSCURRENT STATUS Lack of Training Plans that include TB IC - Facilitated development & implementation of training plans that include TB Infection Control All facilities include TB in their annual training plans Lack of evidence for Patient Education on TB IC -Distribute training material -Facilities to record evidence on patient education Posters and pamphlets are available and patient education record books available. Lack of masks and tissues available for coughing patients -Recommendations given to have these in all patient care areas Most facilities provide these for clients.

10. TB IC STATUS AT UMGUNGUNDLOVU HEALTH DISTRICT ADMINISTRATIVE CONTROLS PERFORMANCE BEFORE INTERVENTION INTERVENTIONSCURRENT STATUS No Medical evaluations for staff - The District OHS communicated guidelines in all healthcare facilities. Facilitated implementation thereof. Still a challenge with PHC Facilities No standardized TB reporting to IPC Added section in IPC month end reporting template DQPR indicators now includes TB IC indicators New template developed and distributed Quarterly reporting by facilities

11. BEST PRACTICES TB Risk Assessments are conducted Patient and Staff Educational Material displayed in all strategic areas All facilities have IPC Files with Policies and Protocols and Guidelines

12. Guidelines and Tools have been distributed across the District

13. Community awareness campaigns related to IPC and TB.

14. COMMUNITY AWARENESS CAMPAIGNS

15. TB IC STATUS AT UMGUNGUNDLOVU HEALTH DISTRICT ENVIRONMENTAL CONTROLS PERFORMANCE BEFORE INTERVENTION INTERVENTIONSCURRENT STATUS No designated area for sputum collection in most facilities Identified, and created ventilated area that ensures privacy, observe sputum collection Facilities have identified designated areas. Poor ventilation practicesDeveloped and implemented ventilation checklist, staff and patient training on importance of ventilation Training\Ventilation Check List.doc Training\Ventilation Check List.doc Some improvement in ventilation Overcrowded healthcare facilities Designate/ create outside seating waiting area Most facilities are compliant now.

16. TB IC STATUS AT UMGUNGUNDLOVU HEALTH DISTRICT ENVIRONMENTAL CONTROLS PERFORMANCE BEFORE INTERVENTION INTERVENTIONSCURRENT STATUS Poor maintenance of extractor fans and whirly birds Facilitated development and implementation of maintenance plans Still a challenge, no clear way forward Inadequate use of ceiling fans - Education for both staff and patients on role of ceiling fans Some facilities are compliant Lack of knowledge of air- flow resulting in poor arrangement of consultation rooms -Education about air flow direction, use of air flow direction posters -Arrangement of furniture/ seating placement to promote adequate ventilation/ environmental controls Some facilities have started. More training needed

17. TB IC STATUS AT UMGUNGUNDLOVU HEALTH DISTRICT ENVIRONMENTAL CONTROLS PERFORMANCE BEFORE INTERVENTION INTERVENTIONSCURRENT STATUS Infrastructural problems-non compliance to TB IPC Protocols/ No consultation from IPC by Infrastructural component - Enhance collaboration on TB IPC specifications regarding infrastructure Remains a huge challenge

18. BEST PRACTICES

19. Air Flow Direction Patient Doctor/ Nurse

20. OUTSIDE SEATING IS ENCOURAGED

22. TB IC STATUS AT UMGUNGUNDLOVU HEALTH DISTRICT RESPIRATORY CONTROLS PERFORMANCE BEFORE INTERVENTIONSCURRENT STATUS No effective respiratory protection programme Development of the Respiratory Protection Programme that includes Some facilities have developed and implemented the programme. Training was conducted on Fit Test and Fit Check Fit Testing/ Fit CheckProcurement of fit test kits and training. Some Fit Test Kits donated by CSIR Most facilities have conducted Fit Tests and others have opted for Fit Check process. Different inappropriate N95 respirators in various facilities Created awareness to staff on standardized N95 Respirators that are on the Provincial Contract All facilities are using Kimberly Clark appropriate masks- Provincial tender

23. BEST PRACTICES ON RESPIRATORY PROTECTION PROGRAMME

24. N95 Respirators for Staff and Surgical Masks for Patients available at all entrances in Critical Areas

26. CHALLENGES & LESSONS EMANATED FROM PROCESS  Resistance to change/staff attitude  Lack of managerial support to IPC Programme  Lack of collaboration and integration in Programmes  Staff turn over for PHC IPC Champions due to resignations  High patient-staff ratios  Infrastructural challenges  Programme conflicts with TB IC/NCS Vs (Ideal Clinic)

27. IDEAL CLINIC VS NCS 51) There is a staff member who is assigned infection prevention and control role in a facility Ideal Clinic NCS

28. IDEAL CLINIC VS NCS Old measureSignificance of change and guidance 2.6.2.2.1 The health establishment`s rooms to be used for confirmed infectious TB patients are separated by means of adequate physical barriers from non-TB patients (extreme) The requirement for segregating in-patients with contagious respiratory conditions remains however it has been contextualized specifically to the type of Health Establishment as follows  Hospitals: The health establishment`s rooms to be used for confirmed infectious patients with respiratory illnesses are separated from other patients (guidance Separated means being located away from non infected patients, especially areas with paediatric or immune-compromised patients)  Clinics have no requirement for rooms 3 streams of services created (acute/minor ailments, chronic, MCWH)

29. ESSENTIAL ELEMENTS OF EFFECTIVE TB IC AT FACILITY & DISTRICT LEVEL  Comprehensive District IC Plan which outlines the Controls for TB IC  Effective Maintenance Department  Capacity Building  Enhance collaboration between TB/IPC/HIV/CDC/MCWH Programmes

30. TB IC FUNCTION/ COLLABORATION WITH OTHER PROGRAMS DISTRICT TB/ HAST PROGRAMME IPC PROGRAMME OHS QUALITY ASSURANCE HOSPITALS IPC COORDINATORS TB COMPONENT OHS PHC FACILITIES TB FOCAL NURSE IPC CHAMPIONS OUTREACH TEAMS SCHOOL HEALTH FAMILY HEALTH TEAMS TB ASOs CCGS DISTRICT SUPPORTING PARTNERS

31. OUR PLAN TO CONTINUE QUALITY CONTROL IN TB IPC  Ensuring Managerial support for improving TB IPC Practices  Arranging continuous training sessions in TB Infection Control  Monitoring the functioning of IPC Committees and their roles in TB.  Ensuring the establishment of baseline patterns of client movement and air flow in facilities  To ensure special waiting areas for patients  Ensuring TB Infection Control at reception areas in facilities  Effective management of all suspects and TB clients  Ensuring an adequate respiration protection Programme is available in all facilities  Monitoring provision for personal protective equipment  Development of risk assessments  Ensuring adherence to quality(NCS)  Ensuring effective screening process

32. CONCLUSION TB IPC should not be viewed as an isolated intervention rather, it is a part of general infection prevention and control and an important part of a TB prevention and treatment package along with IPT, ICF, TB treatment and access to early ART.

33. THANK YOU FOR LISTENING! KUMBUZILE KHUMALO Kumbuzile.khumalo@kznhealth.gov.za 033 897 1000