Healthcare Associated Tuberculosis Infection Prevention Project in Zimbabwe (HATIPP-ZIM)

1.0 Background

The Healthcare Associated Tuberculosis Infection Prevention Project in Zimbabwe (HATIPP-ZIM) in the 2ndof its anticipated 5 year project period. HATIPP-ZIM is a co-agreement (October 2016 to September 2021) supported by CDC under the President’s Emergency Plan for AIDS Relief (PEPFAR) Grant No: NU2GGH001936-01-00. Its purpose is to support the Ministry of Health and Child Care (MOHCC) in preventing healthcare associated tuberculosis infection in Zimbabwe. This will be done by addressing three strategic objectives listed below:

Strategy 1 Strengthen existing IPC programmes & extending them to all HCF & into the    community  with  a focus on TBIC

Strategy 2 Develop a National HCW TB screening policy and strengthen HCW TB screening   activities linked to the National wellness programme

Strategy 3 Strengthen pre-service awareness of risks of TB transmission among HCWs    students during their training

The first year of the project was run by a Consortium led by Biomedical Research and Training Institute (BRTI) in partnership with the Infection Control Association of Zimbabwe (ICAZ) and The International Union against Tuberculosis and Lung Disease (The Union) in Zimbabwe. Within the consortium, BRTI and ICAZ led the implementation of strategic objectives 1 and 3 and strategic objective 2 was led by The Union. Because of the need to reduce costs at central level in Year 2 the roll-out of the HCW TB screening strategy was continued by the BRTI/ICAZ partnership with the local CDC office providing technical guidance on implementation and interpretation of PEPFAR policies and regulations to facilitate reporting. BRTI, the prime grantee was responsible for communications and reports to CDC and the focal department within the MOHCC, the Nursing Directorate. Though HATIPP-ZIM operates under the directorship and administratively within the policies and procedures of BRTI as a sustainability plan, the project also reported its activities to the National Infection Prevention and Control Committee (NIPCC) and its Technical Working Groups for implementation of HAI and TB reduction policies.

As with Year 1 the project has adopted a single M&E unit strategy coordinated by the HATIPP-ZIM M&E unit to cover all partner activities to ensure one project reporting system that complies with funder’s requirements.

2. Overview of Activities to implement each strategy

2.1. Implementation Activities for Strategy 1

Although in this revised strategy for Year 2 the main focus was put on Strategy 2 there were a few activities with a relatively small budget input that were continued in Strategy 1. These activities were considered important contributors to the reduction of risk of exposure to TB in health facilities and the Community and these included i) follow up visits to the meetings(to raise awareness of TB and TBIC issues and to support their community to access and adhere to treatment) that were held with Health Coordinators from Faith-based organisations  organised in collaboration with Zimbabwe Association of Church Hospitals (ZACH) in Year 1, ii) distribution and showing the TB community video at clinics and hospitals in order to educate patients on TBIC issues.

2.2. Implementation Activities for Strategy 2

In year 1, the project targeted the production of a Draft National HCW TB screening policy and implementation in 5 out of the 8 Provincial hospitals and in 3 Central hospitals. In Year 2, the HATIPP-ZIM team continued to move the policy through the MOHCC approval requirements and rolling out the policy framework. The roll-out process began by supporting the establishment of TB and Wellness screening sites and teams in the remaining 3 Provincial Hospitals and 1 Central Hospital (Ingutsheni – the largest psychiatric hospital in the country). Designated staff wellness clinics were equipped with basic starter packs (sputum specimen containers, thermometers, height-weight scales, glucometers, sphygmomanometers and laryngoscopes) to facilitate routine confidential screening for TB, diabetes and other NCDs. The establishment of the wellness clinics is expected to increase accessibility for HCWs to TB screening and NCD investigations by normalizing or de- stigmatizing TB screening of HCWs.

Training of link nurses was included under Strategy 2. It was considered essential to the support of the HCW TB screening program in the larger hospitals and was limited to Central and Provincial Hospitals. The smallest Central Hospital employs 720 HCWs and the largest, Parirenyatwa Hospital, over 3000 with the other 4 ranging from 1254- 2836. Provincial hospitals employ between 300 and 700 HCWs. The objective was to strengthen IPC at ward and department level and provide support for the overburdened IPC Focal Person. The responsibility of “link nurses” is not only to support and monitor adherence to good TBIC practices but to mobilise staff on the wards for HCW TB screening, thereby contributing to:

I. Adherence to the policy, strengthening the hospital HCW TB screening program and reducing risk of exposure to TB.

II. Strengthening recordkeeping for the HCW screening schedules at institutional levels (who has gone for screening, who is due for annual screening and send reminders).

III. Monitoring adherence to recommended TBIC practices such as opening of windows, cohorting and isolation of infectious patients, to reduce risk of transmission.

Cascading of the screening program for Healthcare Workers for Tuberculosis entailed HATIPP- ZIM  training and supporting Provincial HCW TB screening/wellness roll-out teams (Provincial IPC Training Team and members of the Provincial/Central Hospital wellness team) to capacitate District Hospital teams as well as Primary Healthcare (PHC) Teams at district levels. Each District PHC team comprised the District Medical Officer, District Nursing Officer, Senior Community Sister, Community nurse, Environmental Health Officer, TB Coordinator, Trainer of Village Health Workers Pharmacists/technicians, Laboratory Technician and a Wellness focal person. The PHC team is the implementer and supervisor of all health development programmes at district and rural health centre level in Zimbabwe. It had been recognised that the multidisciplinary PHC team would be best placed to roll-out the screening of HCWs for TB and NCDs and to establish services where none exist, conduct advocacy activities and mobilize staff to access the established TB screening services.  

Support and Monitoring visits to the Central and Provincial Hospitals were used to monitor progress in the establishment of the screening program and provide advice, assist in “troubleshooting” and interaction with facility management. The Provincial Hospital visits were conducted by HATIPP-ZIM accompanied by the Provincial wellness team (IPC Focal Person, Wellness coordinator, TB coordinator) in the first two quarters. The Central Hospitals visits were conducted together with an IPC focal person from other central hospitals.

HCWs in the Private Sector were also perceived as being at risk of exposure to TB and were known to refer patients diagnosed with TB into the Government system.  Outreach to this sector started in Year 1 with a meeting with a group of private healthcare managers and IPC coordinators and a two hour session with the Association of Occupational Nurses. Within Year 2 HATIPP-ZIM aimed to increase this coverage to make the private sector aware of the requirements of the HCW TB screening policy through meetings in the Northern and Southern region.

2.3. Strengthening pre-service awareness of risks of TB transmission among HCWs during their training
Strengthening pre-service awareness of the risks of TB transmission among student nurses and medical students on rural attachments continued using the risk assessment tools developed by HATIPP-ZIM in Year 1.The TBIC training modules and IEC materials developed in Year 1 were used for continued training of nursing and medical students and included in training of other health professionals to raise awareness among the students.

The nurse tutors were sensitized (Tutors and clinical instructors) in Year 1 and it was agreed that the Group Tutor assigned for each intake/cohort  would make sure that each student was screened annually. This exercise has been monitored by the M&E team. The system for screening medical students had not been established in Year 2 and discussions with the Dean of the College of Health Sciences at the University of Zimbabwe (UZ) and National University of Science Technology (NUST) will be held in Year 3 as to how this would be implemented.