Amendment RFP_HE176-09-005-03.doc

1. Cover letter of the RFP, 1 page and SF-33, block 9, change the closing date as following:

CLOSING DATE:

Friday, May 8, 2009

CLOSING TIME:

5:00 pm, Almaty Time (or 7:00 am Eastern time)

2. add ATTACHMENT 24 ASSESSMENT OF THE PREVENTION OF TUBERCULOSIS INFECTION IN HEALTH CARE FACILITIES, WITH SPECIAL CONSIDERATION FOR TB FACILITIES IN KAZAKHSTAN AND KYRGYZSTAN

ASSESSMENT

OF THE PREVENTION OF TUBERCULOSIS INFECTION

IN HEALTH CARE FACILITIES, WITH SPECIAL CONSIDERATION FOR TB FACILITIES IN

KAZAKHSTAN AND KYRGYZSTAN

February- March, 2009

Almaty, Kazakhstan

Bishkek, Kyrgyzstan

USAID/ZdravPlus Project.

This is a very preliminary draft report. It should be noted that as data is still being collected and analyzed, findings, conclusions, and recommendations may be changed or enhanced.

EXECUTIVE SUMMARY

Country assessments on facility-level tuberculosis infection control (TB IC) were undertaken in Kazakhstan and Kyrgyzstan in February and March 2009. The country assessments were based on the conceptual framework outlined in the Health Systems Approach to TB Infection Control in Central Asia paper.

. The conceptual framework was built on desk research, a literature review, and key informant interviews. The global policies/strategies that support TBIC were used including Expanded Framework for TB; Interim Policy for TB/HIV; MDR; Global Strategy for HIV/AIDS; Occupational Health and Safety; Infection Control, Patient Safety. Available expertise was used to create a map of all conceptual reasons why or how the problems with infection prevention/control could contribute to increases in MDR-TB.

The assessment was implemented in response to the growing MDR/XDR-TB problem and high TB incidence among health care workers and in the Central Asia Region (CAR). There is international understanding that the best way to prevent TB spreading in health facilities is to use systemic strategy based on hierarchy of administrative control, environmental control, and personal protection measures.

The goal of the assessment was to collect and generate reliable data on the TB IC situation in Kazakhstan and Kyrgyzstan and inform decision makers on existing problem areas and a menu of options or possible interventions for future programming. The ultimate aim is to strengthen TB IC in the two countries and to prevent or minimize the transmission of TB in health care and congregate settings. The facility-level TB IC assessment attempted to identify the strengths and weaknesses of TB IC at the hospital and primary health care (PHC) level, including institutional capacity and every day practices, training of health care personnel, and the patient perspective with regards to access to prompt diagnoses and treatment. The main objectives of the country assessment were to answer the following questions:

· What is the state of infection control in TB facilities and in facilities where TB patients congregate?

· What are the obstacles for proper functioning of the infection control system at the facility level?

· What systemic barriers to facility-level infection control exist, and what are recommendations to address them?

Methodology The country assessment methodology included:

· Analysis of components of TB control program and general health care with emphasis on TBIC in TB and general health care facilities and also population at large.

· Review of reports provided by international organizations and external assessment reports;

· Review of international and national guidelines on infection control;

· Interviewing target groups, such as patients and health care providers (use of standardized data collection tools and checklists to obtain qualitative data and data not available at country level);

· Assessment of the TBIC program in health care facilities using standardized data collection tools and checklists;

· Site visits to selected health care facilities including TB facility diagnosing and treating TB and MDR/XDR-TB, general health care facility participating in TB case finding, diagnoses and follow-up of treatment, and a TB laboratory to assess the implementation of infection control components, and to observe organization and delivery of TB services. The facilities were selected randomly, but accessibility and representativeness of the sites were considered; the balance between urban and rural districts was considered.

· The review focused on the civilian sector

MAIN FINDINGS

It was found during the assessment that there are many similarities but also differences in the TBIC in Kazakhstan and Kyrgyzstan. The implementation of TBIC measures in Kazakhstan and Kyrgyzstan is weak. Both countries are guided by the SES regulations on IC, which need to be revised in-line with international recommendations, such as the 1999 and 2006 WHO guidelines and also the CDC 2005 guidelines and other relevant documents. There is little understanding among health care workers and administration of the ways of transmission of an airborne disease such as TB and, therefore, health care workers tend to disregard the risk of infection and limit themselves to removing visible dirt and dust from surfaces.

Strengths

· The existing MOH/SES regulations on IC include many useful recommendations on preventing transmission of TB in health care facilities.

· The National TB Programs (NTPs) in both countries undertake efforts to strengthen early case finding and prompt treatment of TB cases to stop the spread of infection.

· Both countries have applied to the GFATM in order to strengthen implementation of TB activities, including IC measures

· Cooperation between MOH and SES in TB IC is ongoing in both countries and the revision of the current standards on IC is underway in Kazakhstan.

· The persons responsible for IC in health care facilities are appointed

· There is some knowledge of modern approaches in TB IC among health care staff.

· Training of the health care staff (specifically personnel in TB facilities) on IC is planned in both countries

· Refurbishment considering appropriate IC measures is underway in both countries

· Rapid responses for MDR-TB cases are planned to be implemented in both countries during 2010-2011.

· In both countries there are referral or tertiary level TB facilities with appropriate IC measures (Almaty City TB Dispensary MDR-TB Department in Kazakhstan and TB departments in colony 31 and 27 in the penitentiary system in Kyrgyzstan, less so in the TB Institute in Kyrgyzstan)

· In some places appropriate respirators are used

Weaknesses

· The current MOH/SES regulations on TB IC need to be revised in-line with international recommendations

· There are significant budget constraints in TB control, including a lack of funds necessary to implement IC measures

· The existing IC regulations contain many useful points on isolation measures, triage of patients, UVGI, ventilation etc, however, these regulations are not followed partly due to the lack of training but mainly due to the lack of funding.

· Virtually all TB patients are hospitalized for intensive phase of treatment, which in conditions of weak IC increasing the risk of nosocomial infection (every fifth never previously treated patient and every second previously treated patient suffer MDR-TB)

· The IC measures are weak overall in TB laboratories

· Safe working conditions are disregarded while carrying out procedures that will probably generate infectious aerosols (e.g., bronchoscopy, sputum induction, endotracheal intubation, suctioning, irrigating TB abscesses, aerosol treatments, autopsies on cadavers with untreated TB disease)

· IC measures are weak in the surgery and intensive care units

· TB diagnoses and treatment is sometimes delayed and patients are defaulting while being infectious

· Health care staff have not received sufficient training in TB IC

MAIN RECOMMENDATIONS

· Revise with partners (NTP, SES, international organizations) the existing standards and guidelines for TB IC in order to ensure that they are in-line with international recommendations

· Ensure there is sufficient funding to implement IC measures in health care facilities, particularly in specialized TB facilities.

· Strengthen early TB case finding and decrease the default rate to decrease TB infection in society and health care facilities

· Implement rapid laboratory techniques to quickly diagnose MDR-TB in order to decrease risk of nosocomial MDR/XDR-TB infection

· Strengthen administrative TB IC measures, such as conduct TB IC risk assessment in health facilities; develop written TB infection control plans; implement effective work practices for the management of patients with suspected or confirmed active TB disease, including separation of patients according to their potential infectiousness and ensuring safe working conditions while carrying out procedures that generate infectious aerosols; and testing, evaluating, and educating health care workers.

· Avoid hospitalizing TB patients and performing aerosol producing procedures in case TB IC measures are not implemented

· Implement environmental TB IC measures maximizing natural ventilation and controlling the direction of airflow. Although many environmental control measures (negative pressure rooms, high efficiency particulate air (HEPA) filters) require resources that are not available in many situations, some inexpensive environmental control measures (e.g., opening windows to increase natural ventilation and use of fans to control the direction of air flow) can be implemented in all settings.

· Where limited funding is available, it is recommended to develop a priority list of environmental IC measures to be implemented. Environmental controls are most important in areas where the risk of exposure is high due to high bacillary loads in air, e.g., wards with infectious TB patients, sputum induction areas, bronchoscopy suites, laboratories performing culture and susceptibility testing, surgery suites, intensive care units, and autopsy rooms.

· Consider obtaining technical assistance in developing the layout of TB facilities (local or international engineers knowledgeable in TB IC measures). An engineer will be helpful in planning the direction of the air flow and the number and location of the UVGI in the health acre facilities.

· Implement personal protection measures, such as:

· Respiratory hygiene and cough etiquette for patients

· Appropriate respirators for health care workers. Ensure that all persons coming into contact with an infectious TB patient are wearing an appropriate respirator at all times. Develop, implement and maintain a respiratory protection program (training of health care workers, selection of respirators, and fit testing).

· Implement TB IC measures in TB laboratories based on international recommendations

5. PROJECT NO.

CODE

7. ADMINISTERED BY

2. AMENDMENT/MODIFICATION NO.

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NO.

3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NO.

9B. DATED

PAGE OF PAGES

10A. MODIFICATION OF CONTRACT/ORDER NO.

10B. DATED

BPA NO.

1. CONTRACT ID CODE

FACILITY CODE

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR AC-

KNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 10-83)

is required to sign this document and return ___________ copies to the issuing office.

is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES

SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER

BY

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED STATES OF AMERICA

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER

16A. NAME AND TITLE OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30

STANDARD FORM 30

(Type or print)

(Type or print)

(Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(No., street, county, State and ZIP Code)

(If other than Item 6)

(Specify type of modification and authority)

(such as changes in paying office, appropriation date, etc.)

(If required)

(If applicable)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

(X)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign)

(Signature of Contracting Officer)

04/17/2009

USAID/CAR/AA

7030 Almaty place

Department of State

Washington DC 20521-7030

To all Offerors/Bidders

HE176-09-005

03-19-2009

X

The purposes of amendment #3 for RFP HE176-05-009 are to:

extend the closing date to Friday, 8 May 2009, 5:00 pm, Almaty Time (or 7:00 am Eastern time);

release an Executive Summary of the Assessment of the Prevention of Tuberculosis Infection in Health Care Facilities, With Special Consideration for TB Facilities in Kazakhstan and Kyrgyzstan, ATTACHMENT 24. The entire report will be released by o/a April 22, 2009;

post ATTACHMENT 16, Conceptual Paper: A Health Systems Approach to TB Control in Central Asia (available as a separate document).

[Continued on Page 2]

Casey-Lynn Finnerty

Contracting Officer

04-17-2009

� Borowitz M, O’Dougherty S, Muratov S, Turgunbaev M, Jafarov A, Maddix J, Pickett J. USAID ZdravPlus Project: A Health Systems Approach to TB Infection Control in Central Asia, December 2008 Almaty, Kazakhstan

� Guidelines for the Prevention of Tuberculosis in Health Care Facilities in Resource-Limited Settings, 1999, World Health Organization, WHO/CDS/TB/99.269

� Tuberculosis Infection Control in the Era of Expanding HIV Care and Treatment. Addendum to WHO Guidelines for the Prevention of Tuberculosis in Health Care Facilities in Resource-Limited Settings, 2006, WHO_TB_99.269_ADD_eng

�Centers for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacerium Tuberculosis in Health Care Settings, 2005. MMWR 2005; 54 (RR17).

� FFP2 or FFP3 filter mask (Standard: EN149:2001 FFP3)

� Laboratory Biosafety Manual Third Edition, 2004, World Health Organization, WHO/CDS/CSR/LYO/2004.11