title: Strengthening TB infection control in specialized health facilities in Romania--using a participatory approach.
abstract: BACKGROUND
  In 2012, the tuberculosis (TB) notification rate among Romanian TB facility doctors and nurses was 7.2 times higher than in the general population. This indicates that transmission is ongoing inside TB facilities and that TB infection control measures are insufficient. To help prevent nosocomial TB transmission a project was implemented that aimed at providing nationwide tailor-made technical assistance in TB infection control (TB-IC) in TB treatment facilities, including the development of TB infection control plans. The objective of the present article is to describe the implementation of the project and to discuss successes and challenges.
  
  
  METHODS
  The project was an implementation study using two methods of evaluation: (1) a cross sectional questionnaire study; and (2) collection of information, during the training, on challenges related to infection control and to the project implementation.
  
  
  METHODS
  The project team developed a TB facility infection control (TB-IC) plan template, together with the Romanian experts. The template was discussed and agreed upon with the experts at a meeting and thereafter distributed by email to all TB facilities. Afterwards, a training of trainers (TOT) seminar was organized which included the provision of information about different training methods, as well as information about TB-IC. The TOT was followed by training for key TB-IC providers. Information about use of the TB-IC template was gathered through a self-administered questionnaire sent to all participants of the expert meeting and the training (42 people). Additionally, non-systematized discussions were held on broader challenges in TB-IC implementation during the training.
  
  
  RESULTS
  Within the project 42 key TB-IC service providers were trained in TB-IC, including 9 who were trained at a TOT seminar. The trainees were specialists working at the national level, such as country TB coordinators, or at the TB facility level: TB doctors, epidemiologists, laboratory specialists and maintenance engineers. Out of 42 key TB-IC service providers who were trained, only eighteen responded to the questionnaire (no reminders were sent). Out of these, 14 had used the TB-IC plan template after the project team disseminated it to them by email. The remaining four TB-IC service providers indicated that they were planning to use the template to develop or update their facility TB-IC plans. Related to the use of TB-IC plan template, the following broader challenges in TB-IC were identified: a lack of authority of the individuals responsible for TB-IC to implement the TB-IC measures, lack of training among facility epidemiologists on TB, underdeveloped system for reporting TB in healthcare workers, difficulties with triage of the TB suspects, and poor facility infrastructure hampering implementation of TB-IC measures.
  
  
  CONCLUSIONS
  Implementing TB-IC plans in Romanian health care facilities proved to be challenging, mainly due to the fact that the national infection control plan for TB was not yet adopted at the time of project implementation, and therefore there was neither a regulatory framework to support TB facility-IC planning nor any related budget allocations for the implementation of the facilities' TB-IC plans. Nonetheless, most respondents who answered the questionnaire (18 of 42 responded) indicated that they had started using the TB-IC plan template, which represents a full package of infection control measures that, when implemented effectively and in its entirety, may be expected to reduce nosocomial transmission. The study's limitations are: very low survey response rate, thus there is a likelihood of responder bias.
authors.affiliation: International Public Health Consultant, Romania.
authors.forename: N
authors.initials: N
authors.lastname: Turusbekova
authors.affiliation: National Institute of Pulmonology "Marius Nasta", Romania.
authors.forename: C
authors.initials: C
authors.lastname: Popa
authors.affiliation: Pneumophitisiology Hospital Baia Mare, Romania.
authors.forename: M
authors.initials: M
authors.lastname: Dragos
authors.affiliation: European Centre for Disease Prevention and Control, Sweden.
authors.forename: M J
authors.initials: MJ
authors.lastname: van der Werf
authors.affiliation: European Centre for Disease Prevention and Control, Sweden. Electronic address: irina.dinca@ecdc.europa.eu.
authors.forename: I
authors.initials: I
authors.lastname: Dinca
mesh_terms: D003428:Cross Infection / Q000517:prevention & control*; D003430:Cross-Sectional Studies; D006268:Health Facilities; D006282:Health Personnel; D006801:Humans; D017053:Infection Control / Q000379:methods*; D012383:Romania; D011795:Surveys and Questionnaires; D014376:Tuberculosis / Q000517:prevention & control*
keywords: Airborne infection control; Facility plan; Staff training; Tuberculosis