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Background: Ensuring quality service provision is fundamental to ZAZIC''s voluntary medical male circumcision (VMMC) program in Zimbabwe. ZAZIC (a name created by merging partners┬┤ names) aims to create safe space to identify and manage adverse events (AEs); acknowledge surveillance weaknesses; and introduce quality improvement strategies. From October, 2014 -September, 2017, ZAZIC conducted 205,847 MCs. Passive surveillance recorded a moderate and severe AE rate of 0.2% and 95% follow-up visit adherence, suggesting program safety.
Description: To increase confidence in AE identification and improve reporting, ZAZIC implemented focused quality assurance (QA) at 6 conveniently-selected, high volume VMMC sites. ZAZIC Gold-Standard (GS) clinicians prospectively observed 100 post-VMMC follow-ups per site in tandem with facility-based providers to confirm and characterize AEs. Mentoring in AE recognition, reporting and management was conducted. GS clinicians also reviewed site-based routine VMMC data between Oct-Dec 2016, comparing recorded to reported AEs. Site leadership interviews noted strengths and weaknesses in AE-related issues.
Lessons learned: First, AEs identified using active prospective surveillance are considerably higher than passive surveillance: observations suggest AE rates from 1-5%. Most observed AEs were infections among clients under age 15. Second, facilities noted significant challenges in conducting VMMC follow-ups due to human resource and transport constraints. Although post-operative self-care appears to produce generally good results for adults, younger clients and guardians need additional attention to ensure quality care. Lastly, retrospective record review suggests discrepancies in AE documentation and reporting. Increased training in AE identification, management, and documentation matched with additional nurses and vehicles is needed. Evidence of missed severe AEs resulting in permanent impairment or morbidity was not found. This intensive QA activity required additional financial, transport, and human resources over routine program monitoring.
Conclusions/Next steps: Although results cannot be generalized, active surveillance suggests that AEs may be more frequent and follow-up lower than reported. Root causes for poor follow-up, poor documentation and/or poor reporting remain unclear and require further investigation. ZAZIC is responding with expanded active surveillance, accelerated refresher/retraining for clinical and data teams, improved post-operative counseling for younger clients, and creation of a Quality Assurance Task Force. ZAZIC will expand implementation of this QA effort.


SiteReported Passive Surveillance: Oct 2014-Sept 2017Observed Active Surveillance AE rate: Oct 2016-Dec 2016 (b)AEs Expected** Oct 2014-Sept 2017 (ab)
 AEs*MCs (a)AE Rate 
110147070.1%5%735
222138920.2%4%556
33081740.4%4%327
431179080.2%5%895
525112420.2%5%562
63967270.6%1%67
*Moderate and severe AEs; **AEs expected (ab) was calculated by multiplying the number of MCa reported over the passive surveillance period (a) by the observed active surveillance AE rate (b) to estimate the AEs that may have actually occurred over the past reporting period.
[Table 1: Comparison of retrospective AE data to AEs observed through routine QA]

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