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

耐药结核病(DR-TB)是对全球公共卫生的重大威胁，据估计，全世界四分之一的死亡可归因于抗菌素耐药性。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者的传播，是有充分记录的。大多数结核病传播发生在人们开始治疗结核病之前，但DR-TB传播可能在治疗开始后继续，这引发了人们的担忧，因为南非的DR-TB服务从医院分散到初级保健诊所。与其他社区环境相比，诊所的暴露在多大程度上推动了耐药结核病的持续传播，需要更好的定义，以调动必要的资源来解决这一问题。关于减少耐药结核病传播的感染预防和控制(IPC)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。需要一种全面的方法来了解执行障碍，以便为耐药结核病设计有效的IPC干预措施。治疗耐药结核病的IPC措施的失败通常被归因于卫生保健工作者(HCW)未能遵守指南。认识到卫生保健工作者是具有特定组织特征的卫生系统的一部分，我们审查了卫生系统作为一个整体如何支持IPC措施。我们在南非两个省(夸祖鲁-纳塔尔和西开普省)的诊所调查了DR-TB传播的生物学、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综合防治的有效方法提供证据，不仅涉及行为因素，而且还包括诊所空间、基础设施、工作和病人流动的管理方式，以及可能培养基于权利的职业健康风气。我们的创新方法汇集了来自几个科学学科的团队。我们将采用流行病学、人类学和卫生系统研究的方法，从流行病学、人类学和卫生系统研究的方法来了解有效实施综合防治的背景、实践和潜力。我们将研究南非结核病综合防治政策是如何演变和实施的。流行病学背景将通过估计与其他社区地点相比在诊所发生的耐药结核病传播程度来确定。我们将评估传染性DR-TB患者与诊所内其他客户之间的接触风险，并分别估计社区成员在诊所与其他人们见面环境中的社会接触频率。我们将使用结构化和深入的定性方法来记录医疗诊所中的IPC实践：诊所设计、护理组织、工作实践的角色，以及HCW、管理者和患者对IPC中风险和责任的看法。我们将与主要利益攸关方合作，利用卫生系统测绘和模型建立活动，直观地记录实施最佳耐药结核病国际规划的环境和组织障碍和推动因素。综合所有这些数据，将导致制定一套卫生系统干预措施，以减少耐药结核病在诊所的传播，以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以诊所为基础的传播对整个社区结核病发病率的潜在影响，以及由此为卫生系统和家庭带来的经济利益。除了与学术、政策和方案相关的重大成果外，该项目还将为未来实施和评估卫生系统战略以改善IPC创造一个跨学科的平台。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，并促进公众更多地认识到将卫生设施中空气传播感染的风险降至最低的系统的重要性。

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.