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

分散护理时代南非耐药结核病的感染预防和控制：全系统方法

• 批准号: ES/P008011/1
• 负责人: Alison Grant
• 金额: $ 221.71万
• 依托单位: London School of Hygiene & Tropical Medicine
• 依托单位国家: 英国
• 项目类别: Research Grant
• 财政年份: 2017
• 资助国家: 英国
• 起止时间: 2017 至 无数据
• 项目状态: 已结题
• 来源: https://gtr.ukri.org/projects?ref=ES%2FP008011%2F1
• 关键词: Infection; prevention; control; drug; resistant

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.

耐药结核病（DR-TB）是对全球公共卫生的一个主要威胁，全世界估计有四分之一的死亡是由抗菌素耐药性造成的。在南非，耐药结核病在诊所内的传播，特别是对艾滋病毒阳性患者的传播是有据可查的。大多数结核病传播发生在人们开始结核病治疗之前，但耐药结核病可能在开始治疗后继续传播，这引起了关注，因为南非的耐药结核病服务从医院分散到初级保健诊所。与其他社区环境相比，诊所暴露在多大程度上推动了耐药结核病的持续传播，需要更好地定义，以调动必要的资源来解决这一问题。为减少耐药结核病传播而采取的感染预防和控制措施的诊所指南已广泛提供。有充分的证据表明，建议的措施没有付诸实施，但对原因的理解有限。为设计针对耐药结核病的有效IPC干预措施，需要采取全面的方法来了解实施障碍。耐药结核病IPC措施的失败通常归因于卫生保健工作者未能遵守指南。认识到卫生保健是具有特定组织特征的卫生系统的一部分，我们研究卫生系统作为一个整体如何支持IPC措施。我们调查了南非两个省（夸祖鲁-纳塔尔省和西开普省）诊所耐药结核病传播的生物、环境、基础设施和社会动态。我们的目标是为改善耐药结核病IPC的有效方法提供证据，不仅解决行为因素，而且还解决诊所空间、基础设施、工作和病人流动的管理方式，以及可能培养的基于权利的职业卫生精神。我们的创新方法汇集了来自多个科学学科的团队。我们将采取“整个系统”方法，利用流行病学、人类学和卫生系统研究的方法，了解有效实施耐药结核病IPC的背景、做法和潜力。我们将审查南非的结核病IPC政策是如何演变和实施的。将通过估计与其他社区地点相比，在诊所发生多少耐药结核病传播来确定流行病学背景。我们将估计传染性耐药结核病患者与诊所内其他客户之间接触的风险，并单独估计社区成员在诊所中与人们见面的其他场所进行社会接触的频率。我们将使用结构化和深入的定性方法来记录卫生诊所的IPC实践：诊所设计的作用，护理组织，工作实践，以及HCW，经理和患者对IPC风险和责任的看法。我们将与主要利益攸关方合作，利用卫生系统制图和模型构建活动，直观地记录环境和组织障碍以及实施最佳耐药结核病IPC的推动因素。综合所有这些数据将导致制定一揽子卫生系统干预措施，以减少耐药结核病在诊所的传播，适应南非卫生系统的限制和机会。我们将使用数学和经济模型来预测阻断基于诊所的传播对全社区结核病发病率的潜在影响，以及由此给卫生系统和家庭带来的经济效益。除了重要的学术、政策和规划相关产出外，该项目还将创建一个跨学科平台，用于今后实施和评价卫生系统改善IPC的战略。它将促进研究耐药结核病和其他耐药感染的研究人员之间的讨论，并促进公众更好地认识到在卫生设施中尽量减少空气传播感染风险的系统的重要性。

项目成果

Optimising Vaccine Dose in Inoculation against SARS-CoV-2, a Multi-Factor Optimisation Modelling Study to Maximise Vaccine Safety and Efficacy.

优化 SARS-CoV-2 接种中的疫苗剂量，一项旨在最大限度提高疫苗安全性和功效的多因素优化建模研究。

• DOI: 10.3390/vaccines9020078
• 发表时间: 2021-01-22
• 期刊: Vaccines
• 影响因子: 7.8
• 作者: Benest J;Rhodes S;Quaife M;Evans TG;White RG
• 通讯作者: White RG

Using system dynamics modelling to estimate the costs of relaxing health system constraints: a case study of tuberculosis prevention and control interventions in South Africa.

• DOI: 10.1093/heapol/czab155
• 发表时间: 2022-03-04
• 期刊: Health policy and planning
• 影响因子: 3.2
• 作者: Bozzani FM;Diaconu K;Gomez GB;Karat AS;Kielmann K;Grant AD;Vassall A
• 通讯作者: Vassall A

The Correlated Beta Dose Optimisation Approach: Optimal Vaccine Dosing Using Mathematical Modelling and Adaptive Trial Design.

• DOI: 10.3390/vaccines10111838
• 发表时间: 2022-10-30
• 期刊: Vaccines
• 影响因子: 7.8
• 作者: Benest J;Rhodes S;Evans TG;White RG
• 通讯作者: White RG

Beyond checklists: Using clinic ethnography to assess the enabling environment for tuberculosis infection prevention control in South Africa.

• DOI: 10.1371/journal.pgph.0000964
• 发表时间: 2022
• 期刊: PLOS global public health
• 作者: Arakelyan, Stella;MacGregor, Hayley;Voce, Anna S;Seeley, Janet;Grant, Alison D;Kielmann, Karina
• 通讯作者: Kielmann, Karina

Cost-effectiveness of tuberculosis infection prevention and control interventions in South African clinics: a model-based economic evaluation informed by complexity science methods.

• DOI: 10.1136/bmjgh-2022-010306
• 发表时间: 2023-02
• 期刊: BMJ GLOBAL HEALTH
• 影响因子: 8.1
• 作者: Bozzani, Fiammetta Maria;McCreesh, Nicky;Diaconu, Karin;Govender, Indira;White, Richard G.;Kielmann, Karina;Grant, Alison D.;Vassall, Anna
• 通讯作者: Vassall, Anna