Abstract
Background
Health care workers (HCWs) in low- and middle-income countries (LMICs) continue to have an unacceptably high prevalence and incidence of Mycobacterium tuberculosis infection due to high exposure to tuberculosis (TB) cases at health care facilities and often inadequate infection control measures. This can contribute to an increased risk of transmission not only to HCWs themselves but also to patients and the general population.
Aim
We assessed implementation of TB infection control measures in primary health centres (PHCs) in Bandung, Indonesia, and TB knowledge among HCWs.
Methods
A cross-sectional study was conducted between May and November 2017 amongst a stratified sample of the PHCs, and their HCWs, that manage TB patients in Bandung. Questionnaires were used to assess TB infection control measures plus HCW knowledge. Summary statistics, linear regression and the Kruskal–Wallis test were used for analysis.
Results
The median number of TB infection control measures implemented in 24 PHCs was 21 of 41 assessed. Only one of five management controls was implemented, 15 of 24 administrative controls, three of nine environmental controls and one of three personal respiratory protection controls. PHCs with TB laboratory facilities and high TB case numbers were more likely to implement TB infection control measures than other PHCs (p=0.003). In 398 HCWs, the median number of correct responses for knowledge was 10 (IQR 9–11) out of 11.
Discussion
HCWs had good TB knowledge. TB infection control measures were generally not implemented and need to be strengthened in PHCs to reduce M. tuberculosis transmission to HCWs, patients and visitors.
Keywords: Tuberculosis, infection control, knowledge, primary health
Background
Tuberculosis (TB) infection control consists of a combination of measures aimed at minimising the risk of Mycobacterium tuberculosis (M. tuberculosis) transmission within populations and is one of the key components of the End TB strategy (World Health Organization, 2009, 2015). Gaps in TB infection control implementation in health care facilities predispose health care workers (HCWs) to nosocomial M. tuberculosis transmission. HCWs in low- and middle-income countries (LMICs) continue to have an unacceptably high prevalence and incidence of M. tuberculosis infection due to high exposure to TB cases managed at health care facilities and inadequate implementation of TB infection control measures (Apriani et al., 2019; Joshi et al., 2006; Menzies et al., 2007). HCWs with limited knowledge about TB and infection control can also contribute to an increased risk of transmission not only to the HCWs themselves but also to patients and the general population (Aslesh et al., 2015; Schmidt et al., 2018; Woith et al., 2010). Despite education of HCWs being one of the World Health Organization (WHO) (2009) recommendations for effective TB infection control programmes, previous studies in other countries have reported varied levels of knowledge (Gizaw et al., 2015; Kanjee et al., 2011; Temesgen and Demissie, 2014; Tenna et al., 2013).
With a population of around 264 million people and a TB incidence rate of approximately 320 per 100 000 population, Indonesia has the third highest number of incident TB cases in the world (World Health Organization, 2018). There is an Indonesian national TB infection control policy (Ministry of Heath, Republic of Ministry of Health Republic of Indonesia, 2010) adapted from WHO guidelines on TB infection control in health care facilities (2009). This includes a comprehensive set of infection control measures in health care facilities comprising administrative, environmental and personal protection measures. Activities such as TB surveillance among HCWs, education and training for HCWs, periodic assessment of TB infection control in healthcare facilities and operational research are also recommended in the guidelines. Yet, there are no data on the implementation of these guidelines in health care facilities, including primary health centres (PHC). Screening for latent TB infection (LTBI) among HCWs is not included in the Indonesian guideline, but based on previous data from our randomised controlled trial of LTBI that involved HCWs from PHCs in Bandung, Indonesia, the prevalence might be around 60–65% (unpublished data). This highlighted the need to assess the implementation of the current guideline. Therefore, in this study, we aimed to assess the implementation of TB infection control measures in health care facilities that manage TB patients in Bandung, Indonesia, and HCW knowledge in relation to TB infection control.
Methods
Setting
In Indonesia, people with symptoms of TB can choose whether to seek diagnosis and treatment from a PHC or from a private medical practitioner, a private hospital or a public hospital. If a patient first seeks treatment in a PHC without sputum smear examination facilities, they are referred to a PHC that has a laboratory. In Bandung city, no PHCs have the facilities to undertake chest X-ray and patients are referred to a private radiology facility, district hospital or specific TB clinic. All PHCs have the facilities to carry out case treatment using Directly Observed Treatment, Short-course (DOTS) – which is undertaken by HCWs trained in the communicable disease programme – usually a doctor, nurse or laboratory personnel. Of 5204 pulmonary TB cases notified to the Bandung Municipal Health Office in 2017, 37% were diagnosed through a PHC.
Study design and population
We conducted a cross-sectional study between May and November 2017 of PHCs, plus all their HCWs, that manage TB patients in Bandung city. The number of HCWs and TB caseload at each PHC were identified from the Bandung Municipal Health Office database. A total of 73 PHCs provide general health services, including TB diagnosis and treatment; five have inpatient facilities and 30 have TB laboratory facilities for acid fast bacilli (AFB) smear examination. Twenty-four PHCs were selected from the 53 that manage more than five cases of TB per year, using stratified sampling, to yield 390 HCWs. The strata were determined by the following: (1) presence of a TB laboratory facility; and (2) TB caseload (classified as high, if their annual number of TB cases was greater than the median, or low). PHCs within each stratum were randomly selected with a greater preference to PHCs with a TB laboratory and higher TB caseload. Thirty of the 53 PHCs had a TB laboratory facility, with equal numbers in each caseload category. Of these, 11 with high and 5 with low TB caseload were randomly selected. Of the 23 PHCs with no laboratory facility, 10 had a high and 13 had a low TB caseload; 4 PHCs were randomly selected from each caseload group.
HCWs eligible for the study were any individual working in a PHC and providing health care services and/or support, including doctors, dentists, general nurses, TB nurses, midwives, laboratory personnel, pharmacists, nutritionists, environmental health officers, public health officers and support staff who have direct contact with patients through their work (clerical, pharmacy or anthropometric assessment).
Study procedures
An initial meeting was organised to inform the director of each PHC and seek permission to carry out the study, followed by meetings with HCWs to provide them with information about the study.
TB infection control measures
Following written informed consent, interviews were undertaken with the staff member responsible for infection control or senior administrator and director or head of each selected PHC. The questionnaire was developed by the WHO (Tuberculosis Coalition for Technical Assistance, 2009) and the Centers for Disease Control and Prevention (CDC) (2010) and was piloted locally before beginning the study. It covered four key components of TB infection control measures: (1) the implementation and availability of facility-level management, (2) administrative controls and management, (3) environmental controls and (4) personal respiratory protection. Most questions required a yes/no answer or a measurement with an option for additional information by free text if necessary. Trained research staff also made direct observations of infection control measures in the PHC.
Knowledge of TB infection control
For investigation of the knowledge of TB infection control in HCWs, we developed, piloted and implemented a questionnaire, informed by related scientific literature (Gizaw et al., 2015; Temesgen and Demissie, 2014). The questions required yes/no answers. Written informed consent was sought from all HCWs prior to undertaking the questionnaire. We collected data on the demographic and work characteristics of the HCWs, including age, gender, profession, current working unit, educational status, service years in the current or previous health facility, any experience (and years) of working in a TB clinic, formal and informal TB training, history of TB disease and any prior test for latent TB infection (either tuberculin skin test (TST) or interferon gamma release assay (IGRA).
Sample size considerations, data management and statistical analyses
A previous study conducted in public health facilities in Addis Ababa, Ethiopia, calculated a proportion of HCWs who had good knowledge about TB infection control to be 64%, using the mean as a cut-off (Gizaw et al., 2015). We conservatively assumed 75% in our study would have good knowledge. Assuming a design effect of 1.5 (Temesgen and Demissie, 2014), a non-response proportion of 10% and a finite population correction factor of 0.55, 390 HCWs would allow estimates of proportions with a margin of error of 5%.
All data were verified and entered into a database created in RedCap® (Harris et al., 2009) then transferred into Stata® for analysis (Version 14.2; Stata Corp LP, Texas, US).
All statistical analyses accounted for the stratified sampling and the numbers of PHCs. Sampling weights were used and were calculated from the selection probabilities of the PHCs in each group. For TB infection control measures in PHCs, the proportion of PHCs that reported implementation of each TB infection control measure was calculated, along with 95% confidence intervals (CI). The total number of TB infection control measures implemented was calculated in each PHC and presented as median and inter quartile range (IQR). The Kruskal–Wallis test was used to compare numbers of infection control measures implemented between the four PHC groups. The proportion of HCWs with correct knowledge responses was calculated; the total number of correct responses was calculated for each HCW and presented as the median with interquartile range (IQR). Linear regression was used to assess differences in the mean number of correct knowledge responses across job categories, with job category as a factor variable.
Ethics approval
Ethics approval was obtained from the University of Otago Ethics Committees, New Zealand (H16/139) and the Universitas Padjadjaran Ethics Committees, Bandung, Indonesia (No. 44/UN6.C1.3.2/KEPK/PN/2017).
Results
Description of the Primary Health Centres and implementation of TB infection control measures
Of the 24 participating PHCs, only two had inpatient facilities (8.3%). The median daily total of all patients and monthly TB cases were 120 (IQR 70–200) and 19 (IQR 10–40), respectively.
Facility-level management
A facility-based infection control officer was appointed in 21 PHCs (91.7%), yet only three (14.2%) had a written TB infection control plan (Table 1). No PHC had undertaken a TB infection control assessment in their PHC or participated in operational research to improve TB infection control measures. Staff training about TB infection control had occurred in only two PHCs (11.7%).
Table 1.
Implementation of tuberculosis infection control measures in 24 Primary Health Centres – four key components (proportion implementing the practice).
| Indicators | Frequency (n) | Proportion of PHC (weighted %, 95% CI) |
|---|---|---|
| 1. Facility level management measures (TB IC plan and capacity building) | ||
| a. Appointment of facility based IC officer | 21 | 91.7 (76.7–97.3) |
| b. Written TB IC plan | 3 | 14.2 (3.9–40.3) |
| c. TB IC assessment done | 0 | 0.0 † |
| d. Operational research to improve TB IC measures | 0 | 0.0 † |
| e. Training provided about TB IC capacity building | 2 | 11.7 (2.6–39.2) |
| 2. Administrative control measures (patient triage and management, patient education and awareness, sputum management, TB treatment and referral and staff protection) | ||
| a. Screening of patients for cough | 22 | 91.7 (66.0–98.4) |
| b. Availability of staff to screen patients for cough | 22 | 91.7 (66.0–98.4) |
| c. Separate area for patients with cough | 4 | 20.0 (6.9–45.9) |
| d. Prioritisation of patients with cough | 4 | 16.7 (5.0–43.1) |
| e. Availability of protection for patients with cough | 17 | 74.2 (50.3–89.1) |
| f. Availability of enclosed waste basket | 20 | 88.3 (72.4–95.6) |
| g. Symptom checklist to screen patients for TB | 0 | 0.0 † |
| h. Cough etiquette and respiratory hygiene advice given | 24 | 100.0 † |
| i. Information about TB signs and symptoms to patients | 23 | 97.5 (82.1–99.7) |
| j. Education on TB IC measures | 24 | 100.0 † |
| k. Families educated on TB IC measures | 23 | 94.2 (63.8–99.3) |
| l. TB patients given educational material | 21 | 89.2 (66.9–97.1) |
| m. Posters on cough etiquette and respiratory hygiene | 12 | 45 24.2–67.7) |
| n. Designated area for sputum specimen | 12 | 56.7 (37.1–74.4) |
| o. Advice on how to produce a good sputum specimen | 20 | 88.3 (72.4–95.6) |
| p. Register of presumptive TB | 20 | 83.3 (62.6–95.3) |
| q. Availability of specimen tracking system | 7 | 31.7 (14.1–56.7) |
| r. On-site TB treatment with DOTS | 24 | 100.0 † |
| s. Availability of system to ensure adherence | 18 | 82.5 (69.4–90.7) |
| t. TB patient register kept in the facility | 24 | 100.0 † |
| u. Staff members screened for TB | 0 | 0.0 a |
| v. Register of all staff who are diagnosed with TB disease | 0 | 0.0 † |
| w. Staff offered VCT for HIV | 10 | 48.3 (28.0–69.3) |
| x. HIV-infected staff offered ART | 6 | 28.3 (12.0–53.5) |
| y. IPT available for HIV-infected staff | 3 | 14.2 (3.9–40.3) |
| 3. Environmental control measures | ||
| a. Natural ventilation: adequate ‡ | 15 | 70.8 (54.9–82.9) |
| Type of natural ventilation | ||
| - Open windows on opposite walls, unrestricted airflow | 15 | 70.8 (54.9–82.9) |
| High ceiling height (>3m) | 11 | 57.5 (39.8–73.5) |
| Standard ceiling height (minimum 2.5 m) | 13 | 42.5 (26.5–60.2) |
| Windows on one wall, restricted airflow | 5 | 14.2 (6.1–22.5) |
| Closed windows, doors always open | 6 | 20.8 (9.2–40.7) |
| b. Windows kept open during the day | 21 | 89.2 (65.4–97.3) |
| c. Doors kept open during the day | 24 | 100.0 † |
| d. Mechanical ventilation: adequate § | 13 | 50.0 (28.5–71.5) |
| Type of mechanical ventilation | ||
| Enclosed room with re-circulating air conditioner | 2 | 11.7 (2.6–39.2) |
| Propeller fan | 13 | 42.5 (26.5–60.2) |
| Exhaust ventilation system | 0 | 0.0 † |
| e. Air-cleaning methods used | 2 | 11.7 (2.6–39.2) |
| Ultraviolet germicidal irradiation | 0 | 0.0 † |
| HEPA filtration | 2 | 11.7 (2.6–39.2) |
| f. Natural and/or mechanical airflow monitored daily | 0 | 0.0 † |
| g. Signage for doors and windows | 2 | 11.7 (2.6–39.2) |
| h. Access to an engineer or professional assistance | 6 | 28.3 (12.1–53.1) |
| i. Environmental controls maintained | 4 | 16.7 (5.2–42.1) |
| 4. Personal respiratory protection | ||
| a. Written respiratory protection plan in the PHC | 7 | 37.7 (39.8–80.8) |
| b. Availability of certified respirators for staff to use | 15 | 65.8 (41.7–83.8) |
| c. Staff members trained on proper fit of respiratory protection | 3 | 14.2 (3.9–40.3) |
ART = antiretroviral therapy, CI = confidence interval, DOTS = directly observed treatment short-course, HEPA = high efficiency particulate air, HIV = human immunodeficiency virus, IC = infection control, IPT = Isoniazid preventive treatment, PHC = primary health centre, TB = tuberculosis, VCT = voluntary counseling and testing.
†Survey 95% CIs were not available if the proportion was 0 or 1
‡Natural ventilation adequate: has open windows on opposite walls, unrestricted airflow with high or standard ceiling height.
§Mechanical ventilation adequate: use exhaust ventilation system or propeller fans with air should flow from low concentration of infectious particles, towards a high concentration. The health care workers (HCWs) should always be ‘upwind’ of the patient – that is, clean air should flow from behind the HCW towards the patient.
Administrative controls
The majority of PHCs (91.7%) had implemented screening of patients for cough (Table 1) and had a staff member available who screened patients for prolonged cough (longer than two weeks). Only four (20.0%) PHCs had a separate area in the waiting room for patients with cough. Of the remaining PHCs with no separate area, only four (16.6%) reported a practice of prioritising patients with cough to minimise the time spent in the waiting room. None of the PHCs had a symptom checklist to screen patients for TB. All PHCs reported that patients with cough were given advice on cough etiquette and respiratory hygiene, and TB patients were educated on TB infection control measures. Less than half (45.0%) had posters displaying cough etiquette and respiratory hygiene. Just over half (56.7%) had a designated area for patients to produce a sputum specimen. The majority of PHCs (88.3%) had a staff member to advise patients on how to produce a good sputum specimen and 83.3% had a register for those presumed to have TB. No PHCs had screened their staff members for TB, yet 10 (48.3%) PHCs reported that staff members were offered confidential voluntary HIV counselling and testing and management.
Environmental controls
The majority of the PHCs relied on their adequate natural ventilation (70.8%), with windows (89.2%) and doors (100%) kept open during the day (Table 1). Two PHCs (11.7%) used high-efficiency particulate air (HEPA) filtration for air-cleaning methods. None of the PHCs reported the monitoring of natural and mechanical airflow, and only four PHCs (16.7%) reported that environmental controls were periodically maintained with results recorded in a register.
Personal respiratory protection
Only seven PHCs (37.7%) had a written respiratory protection plan in their facility. Availability of certified particulate respirators was reported in 15 PHCs (65.8%), and only three (14.2%) had training on the proper fit of the mask.
Implementation of infection control measures
Overall, in the 24 participating PHCs, the median number of TB infection control measures implemented was 21 out of 41 assessed. Of the four key components: only one of the five facility level management measures was implemented, 15 of a possible 24 administrative controls, three of nine environmental controls and one of three personal respiratory protection measures (Table 2). The median number of TB infection control measures implemented varied significantly between the groups of PHCs (p = 0.003); notably PHCs with TB laboratory facilities and high caseload had a higher median number of TB infection control measures implemented than the other PHC groups.
Table 2.
Implementation of tuberculosis infection control measures in 24 Primary Health Centres – median number of correct items.
| Item | Median number of correct items – weighted (IQR) | Maximum |
|---|---|---|
| All measures | 21.0 (18.0–25.0) | 41 |
| Key components | ||
| 1. Facility level management measures | 1.0 (1.0–2.0) | 5 |
| 2. Administrative control measures | 15.0 (13.0–17.0) | 24 |
| 3. Environmental control measures | 3.0 (3.0–4.5) | 9 |
| 4. Personal respiratory protection measures | 1.0 (0.0–2.0) | 3 |
IQR = inter quartile range.
Characteristics and TB infection control knowledge of HCWs
A total of 433 HCWs were employed in the 24 PHCs within the study period from which 398 (92.8%) were recruited, 31 were absent at the time of the scheduled visit and four refused to participate. The median age was 34.4 (IQR 27.4–48.1), and 347 (87.1%) were female. Of the 10 different types of professionals recruited, a greater proportion were midwives (n=102, 25.6%) or general nurses (n=89, 22.4%) (Table 3). Overall, HCWs had a good knowledge about TB infection control except about the use of a surgical mask (57.8%) or of fans to reduce M. tuberculosis transmission (35.3%) (Table 4). The median number of correct responses was 10 out of 11. From the regression analysis, TB nurses had the highest median number of correct responses for knowledge of TB infection control, compared to other job categories (Figure 1). In a regression model, the differences between job categories were statistically significant (p<0.0001).
Table 3.
Characteristics of study participants in 24 Primary Health Centres (N=398).
| Variable | Characteristics | Frequency | Percentage or median (IQR) | Weighted percentage or median (IQR) |
|---|---|---|---|---|
| Age | Median, IQR – years | — | 36.9 (28.2–48.6) | 34.4 (27.4–48.1) |
| Gender | Male | 51 | 12.8 | 12.9 |
| Female | 347 | 87.2 | 87.1 | |
| Profession | Doctor | 38 | 9.6 | 8.9 |
| Dentist | 27 | 6.8 | 6.8 | |
| General nurse | 89 | 22.4 | 21.1 | |
| TB nurse | 16 | 4.0 | 4.3 | |
| Midwife | 102 | 25.6 | 27.4 | |
| Laboratory personnel | 14 | 3.5 | 3.8 | |
| Pharmacist | 30 | 7.5 | 7.9 | |
| Nutritionist | 24 | 6.0 | 5.6 | |
| Environmental health officer | 23 | 5.8 | 5.3 | |
| Public health officer | 26 | 6.5 | 6.5 | |
| Support staff | 9 | 2.3 | 2.3 | |
| Current work site | Outpatient department | 146 | 36.7 | 35.6 |
| TB clinic | 27 | 6.8 | 6.7 | |
| Maternity/paediatric | 104 | 26.1 | 28.0 | |
| Laboratory | 18 | 4.5 | 4.6 | |
| Pharmacy | 31 | 7.8 | 8.1 | |
| Nutrition room | 23 | 5.8 | 5.4 | |
| Administrative office/other | 49 | 12.3 | 11.6 | |
| Educational status | High school | 41 | 10.3 | 9.1 |
| Diploma | 200 | 50.3 | 51.9 | |
| First degree | 142 | 35.7 | 35.0 | |
| Second degree and above | 15 | 3.8 | 4.0 | |
| Years working in health facility | Median, IQR – years | — | 5.0 (0.7–9.0) | 4.5 (0.5–9.0) |
| Current work in a TB clinic | Yes | 40 | 10.1 | 9.5 |
| No | 358 | 89.9 | 90.5 | |
| Years working in TB clinic † | Median, IQR – years | — | 6.0 (3.5–9.0) | 6.0 (3.0–9.0) |
| Years working in previous health facility | Median, IQR – years | — | 7.0 (2.0–18.0) | 5.5 (2.0–17.0) |
| Previous TB clinic work experience | Yes | 27 | 6.8 | 6.1 |
| No | 371 | 93.2 | 93.9 | |
| Previous TB clinic work experience ‡ | Median, IQR – years | — | 6.0 (3.0–14.0) | 6.0 (2.0–14.0) |
| Formal TB training | Yes | 80 | 20.1 | 17.2 |
| No | 318 | 79.9 | 82.8 | |
| Informal TB training | Yes | 83 | 20.9 | 19.7 |
| No | 315 | 79.2 | 80.3 | |
| History of TB treatment | Yes | 14 | 3.5 | 3.3 |
| No | 384 | 96.5 | 96.7 |
IQR = inter quartile range, TB = tuberculosis.
†Data available for participants who had experience working in a TB clinic (N=39).
‡Data available for participants who had experience working in a TB clinic in previous health facility, missing 1 (N=26).
Table 4.
Knowledge of tuberculosis infection control infection in health care workers in 24 Primary Health Centres (N=398) – proportion with correct responses.
| Knowledge item | Frequency of correct responses | Proportion with correct responses (weighted %) | 95% CI |
|---|---|---|---|
| 1. Every facility should establish an IC committee | 373 | 93.9 | 90.9–95.9 |
| 2. Every facility should establish a guideline for TB IC | 389 | 98.1 | 96.1–99.0 |
| 3. The windows of a room should be left open whenever a patient suspected or confirmed to have TB is in the room | 329 | 82.8 | 78.5–86.4 |
| 4. Patients suspected or confirmed to have TB should be kept separately from the rest of the patients while in the health facility | 376 | 95.1 | 92.5–96.9 |
| 5. HCWs should try to minimise the time a TB patient spends in health facility | 300 | 76.1 | 71.5–80.3 |
| 6. Surgical masks cannot protect the HCWs from TB | 223 | 57.8 | 52.7–62.9 |
| 7. Respirator can protect the HCWs from TB | 377 | 95.0 | 92.2–96.8 |
| 8. TB patients have to be educated to cover their mouth with a handkerchief or scarf | 384 | 97.0 | 94.7–98.3 |
| 9. Fans can be used to reduce TB transmission in a TB ward | 150 | 35.3 | 30.6–40.4 |
| 10. Regular screening of HCWs for TB is one of the TB infection control measures | 305 | 76.6 | 72.0–80.8 |
| 11. Patients suspected or confirmed to have TB should be prioritised to see a nurse or doctor | 341 | 85.7 | 81.7–89.0 |
| Median number of correct answer (weighted) | 10 | IQR 9–11 | Maximum 11 |
BCG = Bacille Calmette-Guerin, CI = confidence interval, HCWs = health care workers, IC = infection control, IQR= inter quartile range, LTBI = latent tuberculosis infection, TB = Tuberculosis.
Figure 1.
Knowledge of tuberculosis infection control in health care workers by job type. Lab. = Laboratory, Env. = Environmental. Gray indicates the distribution of correct answer in health care workers and black indicates the median number of correct answers.
Discussion
In this study, we found that no PHCs had implemented a full programme of TB infection control measures, yet HCWs themselves had good knowledge of TB infection control. The median number of TB infection control measures implemented was only 21 out of 43. PHCs with TB laboratory facilities and high TB case numbers were more likely to implement TB infection control measures. For HCWs, the median number of correctly answered questions of knowledge about TB infection control was high, although it differed by job category, with TB nurses having the best knowledge. This is likely due to their greater exposure to TB training and workshops held by the Bandung Municipal Health Office and other organisations.
The frequent lack of a written TB infection control plan reflects a poorly established system for routine infection control. None of the PHCs had an audit of TB infection control performed and there was little in the way of training activities about TB infection control for staff members, similar to that found in previously published studies (Buregyeya et al., 2013; Kuyinu et al., 2016; Lin and Harries 2015). Screening of patients for cough and the availability of a staff member to do so were implemented in most of the PHCs, although none had a symptom checklist for screening. Few had a separated area for patients with cough or provided an expedited priority service to minimise the length of patient stay. Patient education and awareness were implemented well, except for a lack of posters displaying cough etiquette and respiratory hygiene. Posters are strongly recommended by the WHO because they have the potential to increase knowledge and are low cost (World Health Organization, 2009). A similar lack of posters was also reported in another study in Pakistan, and addressing this lack of poster supplies may be a relatively simple means of increasing TB awareness and cough etiquette in health care settings (Waheed et al., 2017). The lack of a designated area for a patient to produce a sputum specimen was similar to studies conducted in China (Chen et al., 2016) and Uganda (Buregyeya et al., 2013).
Regarding environmental control measures, more than half of the PHC buildings were first built 30 years ago and, at that time, no one considered the need for integration of infection control measures into their design. Over the last 20 years, some of the buildings have been rebuilt as TB clinics were incorporated. We found that natural ventilation was adequate in the majority of PHCs. Even though windows and doors were open during the day in most of the PHCs, few had signage to ensure that they were kept open. None reported that they had a staff member monitoring natural or mechanical airflow, to reduce the concentration of droplet nuclei in the air inhaled by staff and visitors (Jensen et al., 2005; World Health Organization, 2009).
Although the use of N95 respirators among HCWs in our study was better than that reported in studies in other countries such as Uganda (Buregyeya et al., 2013) and South Africa (Naidoo et al., 2012; Claassens et al., 2013), few PHCs had training on their proper use. Undertaking audits for TB infection control appears to be poorly done nationally, with no report or data found, to date, in Indonesia. This is similar to other countries, such as South Africa where only seven out of 121 PHCs studied had an audit of TB infection control (Claassens et al., 2013).
To our knowledge, this is the first report assessing TB infection control in any health care setting in Indonesia. We interviewed two key personnel and undertook observation in each site. Furthermore, the response rate was high, and we used statistical methods for survey data to account for the sampling process. We were unable to differentiate quality and implementation of all infection control measures at the assessed sites. For the environmental control measures, due to unavailability of anemometer and other equipment, we did not measure air change per hour (ACH) to assess natural or mechanical ventilation adequacy (World Health Organization, 2009). Our study was conducted before updated guidelines were published by the WHO in 2019 (World Health Organization, 2019), although it remains in line with them. Finally, our study was restricted to Bandung city, the capital of West Java Province, so our results may be not be generalisable to all of Indonesia.
Given the findings of this study, it is important for protection of HCWs to implement measures to reduce their risk. Some implications for practice include a written TB infection control plan, training for staff members, separation of patients suspected of having TB, symptom checklists to screen patients for TB, regular monitoring of infection control measures and training on proper fit of respirator masks should be strengthened. Moreover, future investigations should consider measuring the effectiveness of implementation of infection control measures through monitoring and routine reporting of the number of HCWs who develop TB disease and M. tuberculosis infection each year in the facilities.
Our findings suggest that while HCWs had good knowledge of TB infection control measures, these were generally not well implemented in PHCs in Bandung. This study highlights the importance of strengthening effective TB infection control measures to reduce M. tuberculosis transmission not only to HCWs but also to other patients and visitors.
Acknowledgements
The authors thank the Head of the Bandung Municipal Health Office for facilitating the study, the Head of selected PHCs and HCWs for participating in the study and the research staff (Ita Aprianti, Elly Aprilianti, Novianty and Andini Cahya Nurani) for collecting data.
Footnotes
Author contributions: LA, DM, KS, SM and PCH designed the study. LA, HN and IA undertook the data collection. LA undertook the statistical analysis on advice from KS. LA, SM, KS, RR, BA, DM and PCH interpreted the data. LA drafted the manuscript. All authors read, revised and approved the final manuscript.
Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research cost was sponsored by the Centre for International Health with donations from Mercy Hospital Charitable Trust Dunedin, New Zealand.
ORCID iD
Susan McAllister https://orcid.org/0000-0001-7881-6622
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