Infection prevention and control for drug-resistant tuberculosis in South Africa in the era of decentralised care: a whole systems approach

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Infectious and Tropical Diseases

Abstract

Drug-resistant tuberculosis (DR-TB) is a major threat to global public health, causing one in four estimated worldwide deaths attributable to antimicrobial resistance. In South Africa, DR-TB transmission within clinics, particularly to HIV-positive people, is well-documented. Most TB transmission happens before people start TB treatment, but DR-TB transmission may continue after treatment is started, raising concern as DR-TB services in South Africa are decentralised from hospitals to primary care clinics. The extent to which exposure in clinics, as compared to other community settings, drives ongoing transmission of DR-TB requires better definition, to mobilise necessary resources to address this problem. Guidelines for clinics concerning infection prevention and control (IPC) measures to reduce DR-TB transmission are widely available. There is ample evidence that recommended measures are not put into practice, but limited understanding of the reasons. A comprehensive approach to understanding barriers to implementation is required to design effective IPC interventions for DR-TB.

Failure of IPC measures for DR-TB is often attributed to health care workers (HCW) failure to adhere to guidelines. Cognisant that HCW are part of a health system with specific organizational features, we examine how the health system as a whole supports IPC measures. We investigate the biological, environmental, infrastructural, and social dynamics of DR-TB transmission in clinics in two provinces in South Africa (KwaZulu-Natal and Western Cape). Our aim is to provide evidence for effective ways to improve IPC for DR-TB, addressing not only behavioural factors, but also the ways in which clinic space, infrastructure, work and patient flows are managed, and a rights-based occupational health ethos might be cultivated.

Our innovative approach brings together a team from several scientific disciplines.Taking a 'whole systems' approach, we will use methods from epidemiology, anthropology, and health systems research to understand the context, practice, and the potential for effective implementation of IPC for DR-TB. We will examine how South African policies on IPC for TB have evolved and been implemented. The epidemiological context will be defined by estimating how much DR-TB transmission happens in clinics compared to other community locations. We will estimate the risk of contact between people with infectious DR-TB and other clients within clinics, and separately estimate, among community members, the frequency of social contacts in clinics as compared to other settings where people meet.

We will use structured and in-depth qualitative methods to document IPC practice in health clinics: the role of clinic design, organisation of care, work practices, as well as HCW, manager, and patient ideas about risk and responsibility in IPC. In collaboration with key stakeholders, we will use health systems mapping and model-building exercises to visually document the environmental and organizational barriers and enablers to implementing optimal DR-TB IPC.

Synthesis of all these data will lead to development of a package of health systems interventions to reduce DR-TB transmission in clinics, adapted to the constraints and opportunities of the South African health system. We will use mathematical and economic modelling to project the potential impact of interrupting clinic-based transmission on community-wide TB incidence, and the consequent economic benefits for health systems and households.

In addition to significant academic, policy and programme-relevant outputs, the project will create an interdisciplinary platform for future implementation and evaluation of health systems strategies to improve IPC. It will stimulate discussion between researchers working on DR-TB and other drug-resistant infections, and foster greater public awareness of the importance of systems that minimize the risk of airborne infections in health facilities.

Planned Impact

This research aims to contribute to: 1) the development of evidence-based policies for the more effective reduction of nosocomial transmission of DR-TB in health facilities in high burden settings; and 2) a paradigm shift towards IPC measures for DR-TB in health facilities that are grounded in a whole systems approach. In order to achieve this impact, there are four key groups that are intended beneficiaries of this research.

Who will benefit, and how? Academic groups directly concerned with DR-TB infection and infection prevention and control (IPC) will benefit from the generation of new data around nosocomial DR-TB transmission in high burden settings and effective measures to implement IPC interventions; they may use the data for further analyses or to parameterise mathematical models. For academic researchers interested in the social, environmental, and economic implications of IPC, the research adopts a whole systems approach to address current knowledge gaps around context, processes, and pathways to strengthening the health system for improved IPC. This data is intended to directly inform the development of IPC intervention design and elements (see 'Academic Beneficiaries' for more details).

Policy makers and public health programme managers are another group of beneficiaries. They will be engaged as stakeholders from the outset of the project to ensure that data generated by the primary research and the mathematical modelling will strengthen the evidence base around IPC interventions, and help policy makers to trace the policy-to-practice process, and prioritise investments.

We see the project as empowering health care workers to become effective agents of change and to foster a culture of local stewardship and effective use of information to prevent nosocomial transmission of DR-TB in health facilities and communities. The ethnographic research within the clinic itself can have transformative potential by using methods that are in-depth and centred on real-life experiences of health facility staff - as well as providing 'food for thought' through reflexive critical discussion around what works, and what doesn't work in IPC. Through our public engagement strategy, we also intend to strengthen the capacity of communities to become partners in the health system, and to hold government accountable for implementing effective IPC strategies. Interim outputs developed for different research stages, for example, the policy briefing, visual documentation, and case-based narratives may themselves have a direct impact as health promotion materials in raising awareness and motivating positive practices in DR-TB management in facilities and communities.

In addition to its impact on scholarship, policy, and practice, the project will stimulate further dialogue between TB and AMR researchers, while creating a strong international and interdisciplinary platform for future implementation and evaluation of health systems strategies to improve IPC for DR-TB.

Publications

10 25 50
 
Description Among adults attending primary healthcare clinics in KwaZulu-Natal, South Africa, 1% had TB in their sputum. Most of these people did not report classic symptoms of TB.
Exploitation Route The award is still active, and the outcomes are preliminary. However these results may have implications for policy on how to find people with TB earlier.
Sectors Healthcare

 
Description Our workshops engaging with policy makers and practitioners using group model building prompted participants to ask how to use similar methods in their work.
First Year Of Impact 2019
Sector Healthcare
Impact Types Policy & public services

 
Description Using system dynamics modelling for collaborative, evidence-based design of interventions to reduce tuberculosis transmission in South African health facilities
Amount £199,997 (GBP)
Funding ID CCF17-7779 
Organisation Bloomsbury Colleges 
Sector Academic/University
Country United Kingdom
Start 05/2019 
End 10/2020
 
Description Using system dynamics modelling for collaborative, evidence-based design of interventions to reduce tuberculosis transmission in South African health facilities 
Organisation London School of Economics and Political Science (University of London)
Country United Kingdom 
Sector Academic/University 
PI Contribution Developing and testing an approach that engages stakeholders in the development of SDM 'causal loop' models depicting system-wide factors influencing TB and DR-TB transmission in primary health clinics in South Africa. The first SDM workshop was completed in early August 2019; workshop turnout was high (9 policy-makers and 15 practitioners) and participation was enthusiastic.
Collaborator Contribution Reviewed the literature and synthesised evidence around how SDM systems modelling that may affect evidence use for informing health policy and related decision making. To explore and document current and 'routine' approaches to health policy-related debate and decision-making at provincial and national level. LSE are providing conceptual input to evidence-use and research uptake.
Impact SDM 1 August 2019 workshop - interviews with 11 policymakers and practitioners in August 2019 The first SDM workshop was completed in early August 2019; workshop turnout was high (9 policy-makers and 15 practitioners) and participation was enthusiastic 3 follow up drop in calls have been conducted with the workshop participants (Sep 2019, Nov 2019 and Feb 2020)
Start Year 2019
 
Description AHRI community advisory board presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Public/other audiences
Results and Impact Presentation of the study to the AHRI community advisory board
Year(s) Of Engagement Activity 2017
 
Description Africa Health Research Institute meeting with KwaZulu-Natal Department of Health 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact This was a meeting between the Africa Health Research Institute and the provincial Department of Health, where we presented preliminary findings of our clinic prevalence survey. . There was discussion of the implications of our findings for TB services.
Year(s) Of Engagement Activity 2019
 
Description Expert workshop on tuberculosis transmission in South African primary healthcare facilities. Perspectives of practice stakeholders 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The workshop's objective was to gather the perspectives of a range of practitioners involved in TB care and public health in South Africa concerning the drivers of TB and drug-resistant TB transmission in health facilities in order to understand challenges to policy implementation, and explore novel, feasible and sustainable solutions to this problem. The workshop facilitated participatory model-building exercises to generate ideas for interventions. The exercise was designed to that the experts' unique voices, experiences and recommendations were included in the development of interventions. The group loved the interactive model building exercise and reported they would use it in their own work contexts. Some asked for further advice on how to use the method. There was active engagement in the model building process and an interest to continue to be involved in the development of the intervention in forthcoming meetings.
Year(s) Of Engagement Activity 2019
 
Description Group model building workshop to gather the perspectives of policymakers in South Africa concerning the drivers of TB and drug-resistant TB transmission in health facilities 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact We held a workshop for South African provincial and national policy makers to do a group model building exercise concerning TB transmission in primary healthcare facilities. This will inform our subsequent prioritisation of interventions for TB (and drug-resistant TB) infection prevention and control which we will subsequently use in system dynamics, mathematical and economic modelling. This will lead to recommendations for policy in South Africa and elsewhere. We held three follow-up calls with participants to get further input as the models are refined. This activity also raises awareness of our research among policy makers.
Year(s) Of Engagement Activity 2019
 
Description Participatory workshop on patient flow and waiting times 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact To bring together experts in measurement and modification of waiting time, physical space, person movement, primary health care policy, primary health clinic operations, and infection prevention & control to share knowledge and perspectives around measuring and modifying patient flow in South African primary health clinics and to develop methods to assess and improve flow in these settings. Objectives were
1. to facilitate discussion for exchange of ideas and create a 'reference group' for future similar discussions/publications.
2. to design rapid assessment tool/s to assess waiting times, flow, and crowding in South African primary health clinics (PHCs)
3. to devise simple short- and long-term strategies to reduce crowding/improve flow in PHCs
Participants were very interested in the methods used in our project and requested further follow up meetings to hear more about the project as it evolves, and to contribute their views on the emerging findings.
Year(s) Of Engagement Activity 2019
 
Description Presentation at KwaZulu-Natal TB Advisory Group meeting 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact Presentation of results of clinic TB prevalence survey to the provincial TB advisory group, comprising staff from the Kwa-Zulu-Natal Department of Health, TB programme managers and clinical staff from the province, and researchers. Participants were very interested in the results which seeks to identify how much transmission occurs in health care facilities and to identify interventions to reduce this. The meeting ensures that research is used to inform policy and practice.
Year(s) Of Engagement Activity 2019
 
Description Presentation to South Africa TB Think Tank working group on TB prevention 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Presentation on issues affecting implementation of TB infection prevention and control guidelines in South African primary healthcare facilities.
Year(s) Of Engagement Activity 2020
 
Description Presentation to the KwaZulu-Natal Department of Health 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact Presentation of early results from our clinic TB prevalence survey to senior staff from the KwaZulu-Natal Department of Health.
Year(s) Of Engagement Activity 2018
 
Description Public health responses symposium: combatting infectious disease and AMR - Bloomsbury SET 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other audiences
Results and Impact Invited presentation: "Using system dynamics modelling for collaborative, evidence-based design of interventions to reduce tuberculosis transmission in South African health facilities". Interest from and links made with the group at LSE running the LEAD project (Dr Cristin Fergus & Prof Tim Allen), Dr Nina Zhu (Imperial and PHE) who does system dynamics modelling work, and with Kevin Queenan (does food sustainability work in South Africa and is looking to use similar methods).
Year(s) Of Engagement Activity 2020
URL https://www.eventbrite.co.uk/e/public-health-responses-symposium-combatting-infectious-disease-amr-b...
 
Description Stakeholder meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact A meeting for key policymakers (representing the South African National Department of Health and the two provincial departments of health where the research will be undertaken) and researchers to discuss our research plans, and get their advice and input. This drew out attention to aspects of infection control policy that we were not aware of. We also sought advice on where to undertake the research.
Year(s) Of Engagement Activity 2017
URL https://www.ahri.org/kick-off-meeting-innovative-project-tackle-tb-kzn-western-cape/
 
Description Talk at TB2018 (AIDS2018) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Project described as part of an invited talk on TB /HIV service integration at the TB2018 conference.
Year(s) Of Engagement Activity 2018
URL http://www.tb2018.org/Portals/7/File/tb2/TB_2018__Programme.pdf?ver=2018-06-11-180832-347