ARTÍCUL O ORIGINAL

Analysis of the operational management of the tuberculosis infection control plan in Santiago de Cali

Análisis de la gestión operativa del plan control de infecciones en tuberculosis en Santiago de Cali

Juan Santiago Serna-Trejos ^1,a, Claudia Marcela Castro-Osorio ^1,b, Mónica Espinosa Arana ^1,c, Lucy del Carmen Luna- Miranda ^2,d, Robinson Pacheco López ^3,a, Claudia Nathaly Rojas Zúñiga ^4,e, Gloria Mercedes Puerto Castro 1,f

¹ Instituto Nacional de Salud, Bogotá, Colombia.

²Secretaría Distrital de Salud Pública Santiago de Cali, Santiago

³ Grupo de Investigación Esculapio Universidad Libre, Santiago de Cali, Colombia.

⁴ Secretaría Distrital de Salud Pública Santiago de Cali, Santiago de Cali, Colombia.

^a Master in Epidemiology. b Master in Microbiology. c Master in Public Health. d Master in Public Policy.

^e Master in Psychosocial Intervention.

^f Doctor of Public Health.

Received: 18/09/24

Accepted: 27/12/25

Online: 06/01/25

ABSTRACT

Objective: To analyze the operational management of the infection control plan (ICP) for tuberculosis in hospital care settings in a city with a high burden of the disease. Methods. An analysis of operational management was conducted in 37 institutions providing health services in the city of Cali, by applying a tool to collect information on the implementation of administrative, environmental and respiratory protection control measures. Additionally, the program design evaluation was conducted. Results: Administrative control measures were not implemented in 65% of the institutions, primarily due to the absence of written infection control plans and a lack of risk assessment. 70% of institutions failed to comply with environmental measures, especially in the verification of air flows, while respiratory control was well implemented in 78. However, the absence of fit testing for N95 respirators was identified. An ICP model is proposed for health care service settings. Conclusion: Health service providers should strengthen the implementation of ICP in TB, prioritizing administrative and environmental control measures. It is essential to guarantee sufficient financial resources and to have trained personnel to ensure their proper implementation. Furthermore, continuous monitoring is essential to reduce TB transmission in health care settings.

Keywords: Evaluation of health programs; infection control; tuberculosis; Colombia (Source: MeSH - NLM).

RESUMEN

Objetivo. Analizar la gestión operativa del plan de control de infecciones (PCI) para tuberculosis en entornos de atención hospitalaria en una ciudad con alta carga de la enfermedad. Métodos. Se realizó un análisis de la gestión operativa en 37 instituciones prestadoras de servicios de salud de la ciudad de Cali a través de la aplicación de una herramienta para recabar información sobre la implementación de medidas de control administrativo, ambiental y de protección respiratoria, junto a la evaluación de diseño del programa. Resultados. Las medidas de control administrativo no se implementaron en el 65% de las instituciones, principalmente se evidenciaron falta de planes de control de infecciones por escrito y de evaluación del riesgo. Para las medidas ambientales en el 70% de las instituciones no hubo cumplimiento, especialmente en la verificación de flujos de aire, mientras que el control respiratorio estuvo bien implementado en el 78%, sin embargo, se identificó la ausencia de pruebas de ajuste para respiradores N95. Se hicieron recomendaciones para la implementación de PCI para entornos de prestación de servicios de salud. Conclusión. Las instituciones prestadoras de servicios de salud deben fortalecer la implementación del PCI en TB, priorizando las medidas de control administrativo y ambiental. Para ello, es fundamental garantizar recursos financieros suficientes y contar con personal capacitado que asegure su correcta aplicación. Además, el monitoreo continuo es esencial para reducir la transmisión de la TB en los entornos de atención en salud.

Palabras clave: Evaluación de Programas y Proyectos de Salud; Control de Infecciones; Tuberculosis; atención hospitalaria (Fuente: DeCS - BIREME).

Cite as: Serna-Trejos JS, Castro Osorio CM, Espinosa Arana M, Luna-Miranda L, Pacheco López R, Rojas Zúñiga C, Puerto Castro GM. Analysis of the operational management of the tuberculosis infection control plan in Santiago de Cali. Rev Peru Cienc Salud. 2025; 7(1). doi: https://doi.org/10.37711/rpcs.2024.7.1.555

INTRODUCTION

Tuberculosis (TB) is a disease transmitted by aerosols and is considered a global public health problem. Healthcare workers are at a threefold higher risk of contracting TB compared to the general population ⁽¹⁾, a risk that increases in low- and middle-income countries where the burden of disease is high and infection control measures are limited ⁽²⁾.

In Colombia, there were 14,060 new TB cases reported in 2021, resulting in an incidence rate of 25.9 cases per 100,000 inhabitants. Among these, 233 cases were identified in healthcare personnel, despite the implementation of respiratory protection measures in healthcare institutions aimed at reducing the risk of COVID-19 transmission ⁽³⁾. Notably, Cali ranked as the second city in the country with the highest TB burden in 2021, reporting an incidence rate of 45.1 cases per 100,000 inhabitants, with 3% of these cases occurring among healthcare workers ⁽⁴⁾.

Between 2005 and 2016, TB was the third leading cause of death from communicable diseases in Cali, with a growing number of TB cases in healthcare personnel. In response to the increase in TB cases in healthcare workers, the Cali Public Health Secretariat (SSP, by its Spanish acronym) built the intervention plan for infection control in airborne diseases with emphasis on TB (ICP), based on the guidelines proposed by the Pan American Health Organization (PAHO), since at the time there were no national guidelines ⁽⁵⁾. These guidelines were implemented since 2016 in Health Service Providers (IPS, by its Spanish acronym) located in jurisdictions with a high incidence rate of TB ⁽⁶⁾.

ICP is essential in IPS as it reduces the risk of exposure and prevents the transmission of infections ⁽⁷⁾. This is part of the global strategy to end tuberculosis and is one of the pillars that allows the control of the transmission chains for any type of pathogen that is transmitted by air ⁽⁸⁾.

Evaluating the program enables a review of the public policies in place, allowing for adjustments based on results to better achieve objectives and goals ^(9-11). Assessing health plans facilitates informed judgments based on data and operational performance ⁽¹²⁾.

The objective of this study was to analyze the operational management of CP for TB in the hospital care setting of the city of Cali, Colombia.

METHODS

Type and area of study

This is a quantitative, descriptive, cross-sectional study. Evaluative process research was conducted to determine the implementation of the ICP comprising two stages. In the first stage, the design evaluation of the ICP was conducted based on the methodology proposed by CONEVAL which includes the identification, review and analysis of the documentation to identify the objectives of the program and the problem that was addressed in the construction. The review also covered technical, regulatory and contextual aspects (social, economic and cultural) in the formulation of the ICP ⁽¹¹⁾. The logical framework methodology was used to determine consistency in the causal chain and the alignment of objectives, activities, indicators and assumptions ⁽¹⁰⁾.

In the second stage, a methodology with a quantitative approach was developed, the operational management of the plan was explored by applying a survey that made it possible to assess the administrative-managerial, environmental and respiratory prevention control processes implemented in the participating IPS. The study was conducted in Cali, Colombia between July 2020 and August 2022.

Population and sample

The study population consisted of all 55 IPS in Cali that provided diagnosis, treatment, and follow-up services for TB patients and had implemented the Municipal Health Secretariat's ICP guidelines with a TB emphasis as of 2016. The inclusion criteria required that the IPS continued implementing the plan between 2019 and 2021 and had agreed to participate in the research. IPS that had been closed due to non-compliance with the conditions of authorization to provide services at the time of the invitation were excluded.

Variable and data collection instruments

The survey instrument was designed based on the guidelines for the implementation of TB infection control in the Americas ⁽⁵⁾, the guide for the prevention of the transmission of Mycobacterium tuberculosis in health care settings of the Center for Control and Prevention of Diseases ⁽⁸⁾ and the ICP of Cali ⁽⁶⁾. The instrument was reviewed by six national and international infection control experts and piloted for relevance and clarity in an IPS outside the Cali health network. Nineteen questions removed from the initial instrument due to duplicity or lack of relevance. Finally, the survey consisted of four modules with a total of 106 items, 36 focused on the epidemiological context of the institution and administrative control measures, 55 on environmental measures and 15 on respiratory protection measures.

Data collection techniques and procedures

To verify that the measures implemented responded to ICP for TB and not to the pandemic, their application was investigated in 2019. The researchers were responsible for applying the survey in the IPS in the period from October 2021 to January 2022.

Data analysis

The data were analyzed using the Epiinfo 7.2.5 ® program, for the elaboration of descriptive statistics, the analysis of the information was univariate, the data were organized by distribution of frequencies and percentages, which were assessed on a 100 % compliance scale in a traffic light manner (≤ 59% red, between 60 and 79 % yellow and ≥ 80 % green) in accordance with the scale established in the ICP evaluation instruments in 2016 (6, 13).

Ethical aspects

This study was approved by the Research Ethics and Methodologies Committee of the National Institute of Health, Colombia. (CEMIN-10-2019). This research did not generate risks, because secondary information was used. The confidentiality of the information provided was maintained, as well as the identifiable data of the entity and the personnel responsible for responding to the survey, who signed the informed consent before the collection of the information.

RESULTS

ICP Design Evaluation

General description

Table 1 lists the objectives of the plan, along with the proposed monitoring indicators. The products offered for a period of five years (2016-2020) included: training for SSP personnel, managers, health personnel and engineers of the IPS and the evaluation of environmental control measures.

In the context of the implementation of the ICP, the incidence of TB in Cali went from 43,6 in 2015 to 53.1 cases per 100,000 inhabitants in 2019. The diagnosis of new cases of TB in health personnel was 3.07 % (n = 41) for 2019. For the year in which the ICP was designed, there were no specific binding regulations for the implementation of TB infection control in health institutions in Colombia. Since 2014, however, Colombia has recognized TB as an occupational risk disease. The Ministry of Health and Social Protection (MSPS, by its Spanish acronym) specifies, in the Plan Towards the End of TB, compliance with infection control in 100 % of territorial entities by 2025. Among the social determinants identified in the city were acute malnutrition in children under five years of age and chronic nutritional alterations in adults and barriers to access health services.

The proportion of the population with unsatisfied basic needs was 4.08 %, as identified by deficiencies in housing, health services, basic education and minimum income. The operation of the TB program in the IPS in Cali has been reported to have insufficient knowledge of health personnel, little university training in TB, high workload, and high staff turnover.

The problem tree and causality analysis were developed based on the evidence base. The main causes of the increase in TB transmission in health workers and users of IPS, and the lack of knowledge of infection control on the part of the working and user population, were identified as: deficiency in the implementation of the ICP in health establishments and in the implementation of administrative, managerial, environmental and respiratory protection control measures, as well as the absence of monitoring and evaluation. The logical framework matrix was built guaranteeing horizontal and vertical logic, and adjustments were proposed to the objectives, activities and indicators (Appendix 1).

Analysis of the operational management of the ICP

We did not receive a response from 18 of the IPS invited to participate, and two IPS were excluded for not providing services to TB patients at the time of the survey. Consequently, the analysis of ICP management included 37 IPS. Based on the level of care and service complexity, the study included 20 public IPS (17 at the primary level and three at the complementary level) and 17 private IPS (three at the primary level and fourteen at the complementary level).

One-third of the institutions implemented at least 80 % of the administrative and environmental control measures. while 78 % of the IPS complied with the respiratory control measures (see Table 2). For the administrative control measures, shortcomings were found in the evaluation of institutional risk, absence of a written infection control plan and lack of procedures to monitor the duration of care for patients with TB. It was also found that 48.7 % of the IPS do not have a TB surveillance program for healthcare workers, 39 % do not comply with the regulatory requirements for patient isolation rooms and only 54 % of the IPS have infection committees. (see Table 3).

For environmental control measures, the greatest non-compliance was due to the lack of verification of air flow in the offices where TB patients are treated with 43.2 %. The main strength was the existence of a cleaning and disinfection program for areas and surfaces in most IPS institutions (see Table 3). Natural ventilation was prevalent in medical offices caring for TB patients and waiting rooms in 67.6 % and 75.5 % respectively, and in isolation rooms, 56.7 % had mechanical ventilation. Although 64.5 % of the IPS had an isolation room for airborne infections, only 21,6 % complied with the necessary six air changes per hour (R.A.H) and 78,4 % did not have negative pressure and/or filters HEPA. It was found that in 10.8 % of the IPS, the air extracted from the isolation room was recirculated inside the building in areas with circulation of patients and visitors.

16.2 % of the IPS institutions lacked a designated person responsible for the installation, maintenance and evaluation of environmental controls or the verification of air flows, and in 51.6 % of the IPS, there was no coordination between the Infection Control Committee and the technical area responsible for the operation and maintenance of the ventilation systems.

For respiratory control measures, N95 respirators were used by health personnel in outpatient consultations, respiratory procedures, care for patients in isolation and emergencies. N95 respirators were used for 48 hours in 91.9 % of the IPS and, in 73 % of IPS, storage was in paper bags. Verification of the correct use of N95 respirators by health personnel was conducted in 62.2 % of the IPS, through observation and field notes. The main shortcoming identified was the failure to perform fit tests on N95 respirators in 30 % of the IPS (see Table 3).

DISCUSSION

This is the first study to evaluate the design and operational management of the ICP implemented in Cali in 2016, prior to the issuance of national guidelines by the MSPSP in February 2020, which outlined the measures to be adopted by the IPS ⁽¹⁴⁾.

A ICP monitoring model is proposed based on the logical framework methodology ^(15,16) that can be a useful tool for each IPS to continuously monitor the implementation of the ICP, considering the characteristics of the user census, the demographic, socioeconomic and cultural characteristics of the environment. Such a tool enables the IPS to make the necessary adjustments in the operation of the ICP, with a view to achieving a decrease in the transmission of TB in their health personnel, generating an impact on public health ^(10,16).

In our study, we observed the low implementation of administrative and environmental control measures in the evaluated IPS in Cali. Studies conducted by Muñoz et al. ⁽⁷⁾ in Bogotá, Colombia, identified deficiencies in the implementation of ICP especially to environmental control measures, with greater progress in the establishment of the administrative and personal protection (30 - 60%) ⁽¹⁷⁾. The literature reports that the lack of an infection control plan within health institutions negatively affects the transmission of M. tuberculosis in the hospital environment, while its implementation impacts the reduction of the number of cases of intramural transmission ⁽¹⁸⁾.

The findings of this study support recommendations aligned with current regulations, highlighting significant deficiencies in administrative and environmental control adherence in over half of the evaluated healthcare institutions ^(5,6,14).

For administrative control measures: managers of IPS must guarantee the creation and maintenance of an infection control committee with a designated person who is responsible for TB infection control. The Infection Control Committee must prepare in writing the institutional ICP that includes all administrative, environmental and respiratory control measures, including the evaluation of risk management ⁽⁶⁾, and the monitoring and evaluation of the ICP on an annual basis. The Committee must also guarantee the existence of one isolation room for patients with infectious diseases for every 20 hospital beds in the institution ⁽¹⁹⁾.

Senior management in IPS ensures the existence of collaborative work between the area in charge of purchasing, occupational health and the infection control committee for the provision of personal protective elements for health workers and patients with TB. The infection control committee must guarantee that within each institution there is a surveillance system for TB among health workers: the study of TB infection among its workers with the application of the PPD test at the time of admission to the institution and repeat periodically according to the annual risk assessment ⁽²⁰⁾.

Each IPS must have a TB program coordinator responsible for the design and publication, where required, of information on TB transmission and cough hygiene. Managers must ensure the evaluation of the architectural design of the facilities where TB patients will be cared for and make the necessary improvements to comply with regulations. They must also create a flow map of TB patients within the institution that is known by patients and by all the staff who work in the institution with special emphasis on people presenting with respiratory symptoms upon admission. Administrative-managerial control measures are without a doubt the most relevant pillar when it comes to TB control, since they focus on those conducted by senior management which are of an administrative nature, to reduce the risk of exposure to anyone who may have the disease.

Environmental control measures aim to prevent the spread, dispersion, and reduce the concentration of infectious droplet nuclei containing M. tuberculosis in the air. These controls focus on the use of local ventilation to achieve the elimination of contaminated air ⁽¹⁴⁾. In some developing countries, an increase in transmission in waiting areas has been observed, since patients and visitors tend to congregate or remain for a long time in hallways and common areas in health centers ⁽⁵⁾.

Senior management must ensure that air exchanges in natural ventilation are changed, using the PAHO document “Natural ventilation for infection control in health care environments” as a guide ⁽²¹⁾. Institutions where hospitalization is conducted must have an isolation room with negative pressure and an air filtration system with HEPA filters of at least 6 to 12 R.A.H. It is advisable to use some method of air cleaning in the offices. Ideally, they should have an engineer responsible for the correct operation of air flows in the different areas of the institution, the maintenance of environmental control devices and all the required documentation ⁽⁵⁾.

It is necessary for ICP to include a respiratory protection section, which guides the use and control of the operation of N95 respirators and surgical masks, considering that these are aimed at reducing the number of people exposed to infection. Fox and collaborators indicated that the implementation of respiratory control measures reduces TB infection by 14.8 % and tuberculosis disease by 0.5 to 28.9 % ⁽¹⁸⁾.

Some limitations of this study include that the surveys were conducted during the period of health restrictions due to the pandemic, which may have influenced the lack of participation of the IPS in the study, the respiratory control measures such as use of N95 masks and infection control training were implemented in IPS due to the Covid-19 pandemic and not as part of the ICP for TB. In many cases, the epidemiology coordinator or infection control committee coordinator was solely responsible for responding. However, many engineering aspects related to environmental control may have been inadequately addressed due to lack of experience or the absence of in-house engineering staff. The IPS needs to consider including engineering experts to ensure airflow and negative pressure were required.

One of the strengths of this study is its collaboration with the local health authority, as the program's evaluation will enable adjustments to the ICP based on the results and in accordance with the guidelines issued by Colombia’s national TB program. We hope that improvements in its implementation will contribute to reducing TB transmission in health care settings, a situation that can be determined through an impact evaluation that attributes change in the decrease in cases to the intervention conducted.

Conclusions

In conclusion, there was evidence of low compliance in the implementation of the ICP for TB in the IPS in Cali, which was influenced by the lack of resources for investment in personnel and infrastructure, and the lack of specific regulation given in the period evaluated. To ensure correct operational management, financial and human resources must allow for effective implementation and continuous monitoring, leading to reduced TB transmission in healthcare settings such as IPS. Compliance with the control measures included in the ICP could be improved by being included within the institutional authorization standards monitored by the health control authorities.

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Authorship contribution

JSS-T: formal analysis, research, methodology, and review.

CMC-O: conceptualization, writing, original draft, formal analysis, research, methodology, supervision, writing: review and editing.

GMPC: conceptualization, writing, original draft, formal analysis, research, methodology, supervision, writing: review and editing.

MEA: formal analysis, research, methodology, and review.

RPL: formal analysis, research, methodology, and review.

CNRZ: formal analysis, research, methodology, and review.

LCL-M: formal analysis, research, methodology, supervision, and review.

Funding sources

The research was funded by the Ministry of Science, Technology, and Innovation of Colombia. Project code 210484467820.

Conﬂict of interest statement

The authors declare no conflicts of interest.