Challenges in implementing tuberculosis infection control measures in health facilities, Uganda

Thesis summary

Background: Tuberculosis (TB) infection control (IC) is growing in importance because of the association of TB with HIV and the emergence of multidrug resistant TB and extensively drug-resistant TB. TB transmission in health facilities is a critical occupational risk for health care workers, causing substantial morbidity and mortality. However in the past, TB infection control in health-care facilities was a largely neglected practice of TB control, until multiple nosocomial TB outbreaks affecting HIV-infected patients and health care workers (HCWs) occurred in industrialized countries in the 1990s. This risk of transmission is greater in settings with high HIV prevalence due to the increased risk for TB infection and progression to disease in HIV positive people. The risk of transmission is high in the absence of infection control measures. The World Health Organization developed guidelines on TBIC in health-care facilities. In addition the Ministry of Health in Uganda released guidelines on TBIC. These guidelines recommend control measures like; promptly identifying patients with TB symptoms, separating infectious patients from others, promoting cough etiquette, use of masks and respirators, HIV and TB screening of health workers and improved ventilation. The cornerstone for TBIC is early and rapid diagnosis, and effective management of TB patients. However, no study in Uganda had evaluated the implementation of TBIC.

Objectives

The general objective of this thesis was to evaluate the implementation of TBIC measures in health facilities in Uganda. Specific objectives were: to assess community knowledge, attitudes and health-seeking behavior towards TB (study I); to explore patients’ acceptability of TBIC measures (study II), to assess TBIC practices and barriers to the implementation (study III); to assess utilization of HIV and TB services among HCWs (study IV) and to determine the delays in TB diagnosis and treatment initiation (study V).

Methods

Qualitative and quantitative data collection methods were used. Data were collected from communities and health facilities in Iganga, Mayuge, Mukono and Waksio districts. In a qualitative study in Iganga and Mayuge districts (study I), we assessed knowledge, attitudes and practices towards TB among community members. We also explored the acceptability of cough etiquette, wearing masks and separation by TB suspects and TB patients in Mukono and Wakiso districts in Uganda (study II). A mixed methods study assessed the implementation of TBIC measures in health facilities in Mukono and Wakiso districts (study III) including the utilization of HIV and TB services by health care workers (study IV). We also looked at timeliness in seeking TB care and in diagnosis i.e. patient and health system delay (study V). This was a quantitative study among new TB patients within three months on treatment.

Results

People in the Iganga-Mayuge district highlighted the varied perceived aetiologies for TB and the range of health-seeking options to which patients resort to and the reasons for their choices (paper I). Popular TB etiologies included sharing utensils, heavy labour, smoking, bewitchment and hereditary transmission. TB patients were perceived to seek care late or to avoid care. Combining care from traditional healers and the biomedical system was reported. Reasons for seeking care from traditional healers included: friendly services, proximity, poverty, fear of HIV testing and belief in expedited recovery. Stigma and avoidance of persons with TB due to fear of infecting others and an assumption of HIV co-infection was reported. People mistakenly assume that TB associated with HIV/AIDS cannot be cured.

In Mukono and Wakiso district health facilities, patients and health workers felt that physical separation was ideal, yet separation and masking were regarded as embarrassing to patients, emphasizing their potential infectiousness (paper II). Patients reported greater willingness to cover their mouth with a handkerchief than to wear a mask. Universal precautions were more acceptable than targeted ones. Lack of community awareness about airborne transmission of TB was identified as a barrier to accepting and adopting TB infection control measures. Good counseling and health education were suggested to improve patients’ adoption of separation and wearing masks.

Only 16 facilities (31%) had a TBIC plan (paper III).  Five (10%) facilities were screening patients for cough. Two facilities (4 %) reported providing masks to patients with cough. Ventilation in the waiting areas was inadequate for TBIC in 43 % (22/51) of the facilities.  No facility possessed N95 masks.  Elicited barriers for TBIC implementation included: under-staffing, lack of space for patient separation, lack of funds to purchase masks, and limited TBIC knowledge among HCWs.

Five percent (27/499) of the HCWs reported a history of TB in the past five years (paper IV). None reported routine screening for TB disease or infection.  Almost all HCWs (95%) reported previously testing for HIV; 34% outside their workplace, and 27% self-tested. Nearly half (45%) would prefer to receive HIV care outside their workplace. Hypothetical willingness to disclose HIV positive status to supervisors was moderate (63%) compared to willingness to disclose to sexual partners (94%). Older workers were more willing to disclose to a supervisor (adjusted prevalence ratio [APR] =1.51; CI=1.16-1.95). Being female (APR=0.78; CI=0.68-0.91), and working in the private sector (APR=0.81; CI=0.65-1.00) were independent predictors of unwillingness to disclose a positive HIV status to a supervisor. HCWs preferred having integrated occupational services, versus stand-alone HIV care.

The median patient delay was 4 (IQR 2-8) weeks (paper V). Prolonged patient delay was significantly associated with male sex [aPR] 1.57; 95% CI1.40-1.77).  The median reported health service delay was 10 (4-21) weeks. First visiting a public health facility was an independent predictor of no delay for health service (aPR 0.62; 0.47-0.83). The median total delay from onset of cough until start of anti-TB treatment was15 (8-30) weeks.  Health service delay was the greatest contributor (75%) to total delay.

In conclusion, the studies reported in this thesis show that the implementation of TBIC in health facilities is still poor in Uganda. Patient, community and health system factors are inhibiting the implementation. There is need to carry out TBIC advocacy among patients, the community and health workers, health system strengthening (i.e. improved financing, managerial support for TBIC, human resource, better ventilated facilities and training of health workers in TBIC), strengthen public-private partnership in TB control, and the introduction of rapid TB diagnostics.

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