1. Webinar Priority IPC Indicators
TB CARE II
30-August 2019

2. Measuring IPC Implementation
Introduction
Measuring IPC Implementation

3. Introduction and Purpose
To measure progress toward NAP Milestones and 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

4. The National Action Plan (NAP)
The U.S. Government released the National Action Plan for Combating Multidrug-Resistant Tuberculosis (NAP) in 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.

5. 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.

6. 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

7. 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?

8. Choosing “Universal” Indicators
IPC Indicators
Choosing “Universal” Indicators

9. 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

10. 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

11. 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)

12. 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

13. 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

14. 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

15. 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

16. Measuring TB IPC: Examples

17. 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 D
WHO-endorsed

18. “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

22. Global TB Report. WHO 2017

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

24. 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
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 cases / 100,000 HCWs and relative risks of TB for HCWs that are 2.7 to 4.9 times that of the general population.

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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)

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

32. 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

33. Measuring TB IPC: Next Steps

34. 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

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

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

37. 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?

38. Questions

39. Thank You!