1

Hospital infection control in selected facilities

managing drug-resistant tuberculosis in

Bangladesh: An explanatory mixed-methods study

Ateeb Ahmad Parray, MPH

BRAC James P Grant School of Public Health

2

• Introduction

•Justification

•Research Question

•Methodology

•Results

•Conclusion

•Recommendation

Outline of presentationGlobal context

Around half million people in the world have

drug-resistant tuberculosis

Source: WHO, 2018

Only 1 in 5 people needing treatment for drug-

resistant TB in 2016 actually received it

Only half of those who started the treatment were

cured

Each day 4700 people lose their lives and 28,500

people fall ill due to TB

3

Burden of drug-resistant TB in Bangladesh

Source: WHO, 2017; NTP, 2017

Bangladesh

DR-TB 1.3% (New), 28%

(Previous)

Estimated Cases

8500

Cases Detected 944

On Treatment 920

4

Justification II: Challenges in ‘infection control’

Difficult to Diagnose

•Laboratory testing which is inaccessible to patients

•Care seeking behavior of patients results in Delay

Difficult to Cure

•Longer treatment regimen i.e. 10-30 times extra cost

•One in ten patients is cured (16000 Pills Vs 750 pills)

Difficult to Prevent

•More safety measures than general TB

•Incidence is high among Relapse and Failure cases

Source: CDC, 2017

• What is the status of hospital infection control in selected

facilities managing drug resistant Tuberculosis in

Bangladesh?

• To what extent do the selected facilities, managing drug-

resistant Tuberculosis in Bangladesh, maintain infection

control standards?

• What are the barriers in the practice of infection control

standards in facilities managing drug-resistant Tuberculosis in

Bangladesh?

Research Question

5

Management of drug-resistant TB patients in Bangladesh

National Tuberculosis

reference laboratory

Regional Tuberculosis

reference laboratories

National Tuberculosis

Program

Govt. Chest diseases hospitals

Non-governmental organisation owned

facilities

National Institute of diseases of chest

and hospital

Non-governmental organisation owned

facilities

Study sites:

• Tangail

• Mymensingh

• Netrakona

National Institute of diseases of chest

and hospital

6

Methodology - I

Sequential mixed-methods explanatory design

Descriptive cross-sectional study

Non participatory observation (n=18)

Facilities managing drug-resistant TB

Document review (n=3)

Hospital records, TB register, Program records

Explanatory qualitative study

Key informant interview (n=9)

Programme personnel

In-depth interview (n=28)

Health care workers, patients

Telephonic interview (n=6)

Field staff

7

Ethics approval: IRB, James P Grant School of Public Health

Methodology - II

Non participatory observations

Frequency & proportion

Pooled data Triangulation

Document Reviews

InterviewsThematic Analysis

Data display matrix

Triangulation

Data analysis

8

Results : Socio-demographic characteristics

Characteristic Hospital 1 Hospital 2 Hospital 3

Health care

workers

10 11 10

Managers 3 3 3

Clinical 3 4 4

Support 2 2 1

Field 2 2 2

Age range 30-50 Years 30-45 Years 20-40 Years

Patients 4 4 4

Age range 20-35 Years 20-40 Years 20-30 YearsFigure: Example of physical

layout of the facilities

Type Tertiary Tertiary Tertiary

Upazilla

coverage (n)

27 12 35

Patients (n) 43 29 41

Attendants (n)

(Living on-site)

9 10 14

Variable Hospital 1 Hospital 2 Hospital 3

Fig: Example of

physical layout of the

facilities

9

Results : Quantitative assessment of infection control standards

StandardsPractice

H1 H2 H3

Separate budget for TB infection control

Focal person to monitor infection control

Training (Past 2 Years)

Screening - diagnosis delay is <1day

Diagnosis - treatment delay is <1day

Patient triage

Health education posters (in Bangla)

Cross ventilation

Separate wards for MDR+ and MDR-

Location of Sputum center (outside)

N-95 Mask (availability AND usage)

Health education sessions

Compliance

Non-compliance

10

Results : Reasons for non-compliance

Domain Standard Reasons

Managerial

controls

Separate budget

for TB activities

“there is not enough budget to arrange

training for so many workers” KII-7, Manager

Administrative

controls

Screening to

Diagnosis delay

“Suppose we test on Thursday, then they will

come back on Sunday Friday and Saturday

are off-days. This is the usual reason for

delay” PI-1, Field Worker

Health education

posters

Even we don’t understand the messages of the

posters (as they are in English). There are

patients who come from outside (Villages)” IDI-21, Health Worker

11

Results : Reasons for non-compliance (cont’d)

Personal

protective

equipment

N-95 Mask

“Actually, it (N-95 Mask) does not work

properly all the time. We must know how to

wear the mask. We need to know if the fitting

is 100% okay” IDI-11, Health Worker

Environmental

controls

Location of sputum

center“This structure is so old. We cannot change a

thing and we cannot modify the design”KII-7,

ManagerGuideline

compliant building

12

There is a need to improve infection control in the facilities managingDR-TB, by addressing challenges at all levels of health system

These include:

• Allocation of sufficient resources to the DR-TB program

• Implementation of the national policy on infection control

In programmatic settings, the implementation of the infection controlpolicy should be routinely assessed.

This study can serve as a baseline for future research

Conclusions

13

Setting up infection control committees

Display of health education posters in Bengali

Routine infection control trainings especially for N-95 mask

Adjustment of working roster to offer services on off-days

Building structures in facilities need urgent attention

Recommendations

14

Acknowledgements