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

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.

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.