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426 A Systematic Evaluation of Infection Control at M(X)DR-TB Hospitals in South Africa

Saturday, March 20, 2010
Grand Hall (Hyatt Regency Atlanta)
Jason E. Farley, PhD, MPH, NP , Johns Hopkins University, Baltimore, MD
Carrie Tudor, MPH, RN , Johns Hopkins University, Baltimore, MD
Kara Franz, MPH, CRNP , Johns Hopkins University, Baltimore, MD
Matsie Mphahlele, MPH , Medical Research Council of South Africa, Pretoria, South Africa
Nancy Perrin, PhD , Center for Health Research, Kaiser Permanente Foundation, Portland, OR
Susan Dorman, MD , Johns Hopkins University, Baltimore, MD
Martie van der Walt, PhD , Medical Research Council of South Africa, Pretoria, South Africa
Background: Outbreaks of drug resistant Mycobacterium tuberculosis (TB) in South Africa have demonstrated the clear and urgent need to evaluate infection control (IC) in TB care settings. This is the first country-wide evaluation of multi-drug (MDR) and extensively-drug (XDR) resistant TB facilities in SA.

Objective: To systematically evaluate the IC infrastructure of M(X)DR-TB facilities; and to complete an evaluation of healthcare workers (HCW) IC knowledge, attitudes and practices (KAP) to determine factors associated with each.

Methods: A cross-sectional descriptive study was conducted from June to September 2009. All M(X)DR-TB facilities were eligible. A 78-item structured interview was completed with key personnel from IC, occupational health and hospital administration. HCWs in M(X)DR-TB wards were asked to complete an 83-item anonymous KAP survey. Analysis of variance was used to test for differences in KAP by current training and recent TB training.  Multilevel modeling was used to examine the relationship between center and HCW level variables as HCW were nested within centers.  

Results: Twenty four M(X)DR-TB facilities (100%) were enrolled. We identified the following infrastructure: 19 (79%) facilities had an IC nurse; 13 (54%) had a written TBIC plan; 14 (58%) had ultra-violet light; 2 (0.08%) had a UV maintenance plan; 23 (96%) had N-95 respirators, none offered fit testing; 15 (63%) windows open appropriately; 11 (46%) reassigned HIV positive staff. We enrolled 499 HCWs in the KAP evaluation; 42 (8.4%) physicians; 176 (35%) registered nurses; 125 (25%) enrolled nurses; 85 (17%) nurses aids; 72 (14%) other.  Higher level of clinical training was associated with greater IC knowledge (p<0.001) and less time spent with coughing patients (p<0.001). Prior IC training had no impact on KAP for any level of non-physician staff. Among physicians, attending a recent facility-based IC training was associated with lower knowledge (p=.01). The presence (p=NS) or time dedicated to IC (p=NS) by an IC nurse was not associated with greater knowledge unless the IC nurse also had patient care duties (p=.05). IC attitudes were highly varied, with 32% believing it was OK to collect sputum samples in wards; 38% reported not wearing an N-95 in wards; 43% felt a financial incentive would improve their IC practices. Higher level of clinical training was associated with more appropriate IC attitudes (p<0.001) in this setting.      

Conclusions: IC infrastructure was highly varied. The lack of association between knowledge and the presence of an IC nurse is likely related to poor IC training and limited experience. Clinical mentoring by experienced IC nurses is essential. Overall, higher levels of clinical training were associated with greater knowledge and more appropriate attitudes, but less time with coughing patients. This suggests that HCW IC training should focus on those with less clinical training and those with more direct patient contact.