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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
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• 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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Acknowledgements
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