Download WHO policy on TB infection control in health care

WHO policy on TB infection control
in health care facilities, congregate
settings and households.
Rose Pray
Stop TB, WHO
Why should we develop a policy on
TB infection control?
•To guide countries on what to do and why
•To provide an evidence base for the
recommendations.
1
Evidence base
•Systematic review on:
– TB transmission in health facilities and congregate settings
– Selected administrative and environmental controls and PPE.
•Managerial activities need to be evaluated.
•Results
– Higher incidence of TB in staff in HCFs and congregate settings.
– Combination of controls does work
– Administrative controls given priority.
Recommendation: Separate infectious cases
Population: Patients accessing health-care facilities and congregate settings
Intervention: Separation of infectious cases
Factor
Decision
Explanation
Quality of
Low
• The quality of the evidence available is low – only one study shows a
evidence
direct impact of physical separation as an individual intervention on
reduction of TB transmission
Benefits
• Early diagnosis and initiation of proper treatment
Strong
or desired
• Reduction of transmission among individuals attending health-care
(benefits
effects
facilities
outweigh
disadvantages)
• Reduction of transmission among health workers and close contacts
• People living with HIV (TB suspects) might be separated together with
Disadvantages
smear-positive TB patients
or undesired
effects
Values and
Strong
• Health workers will appreciate measures that reduce their exposure
preferences
• Communities will like measures that make health-care facilities safer
But …
• Increases workload for health workers
• May stigmatize people with chronic cough
Costs
Strong
Reduced by:
(may range
• averted diagnostic costs of suspected new cases acquired nosocomially
form minimal to
• patient being able to continue working
significant
• less transmission of TB – TB cases are averted
capital
• break in chain of transmission
investment in
Increased by:
infrastructure)
• staff training
• infrastructure (separated waiting area, isolation rooms…)
• additional AFB and CXR for positive TB triage
Feasibility
Conditional to
• Generally feasible in HIC
country setting
• Lack of human resources in MIC/LIC
• Lack of infrastructures in MIC/LIC
• Slow process to diagnose TB (slow turnaround time due to inadequate
laboratory capacity)
Overall ranking
STRONG RECOMMENDATION
Need
to
develop
and
assess
the effect of TB of different models of physical separation based o
Research gap
smear, HIV status and suspected or confirmed TB sensibility pattern
2
Pooled estimates (reference general population)
population
Outcome
Settings
Health care
workers
TB infection
Low income
9
5.77*
TB infection
High income
40
10.06
TB
Low income
37
5.71
TB
High income
15
1.99
TB infection
High income
5
2.74*
TB
High income
18
21.41*
21.41
TB infection & TB
Low income
7
1.73*
TB infection & TB
High income
15
3.19
Congregate
Household
Studies Risk Ratio
LMICs: Low- & Medium- Income countries (World Bank ranking)
HICs: High- Income countries (World Bank ranking)
*with outliers
2009 WHO TB infection control policy
•
Promotes a combination of controls
•
Addresses health facilities, congregate
settings, and households
•
Adds a managerial component at the
national level
•
Promotes the role of the civil society in
designing, implementing and evaluating
TB IC
•
Promotes minimizing time spent in a
health facility
•
Emphasizes community involvement in
raising awareness, promoting behavior
change, reducing stigma
•
Promotes integrating TB infection control
with other infection control activities
3
Managerial activities at national
and sub-national level
•Provides the managerial framework for the
implementation of TB IC in health care
facilities, congregate settings and
households
•Facilitates funding proposal development
•Enhances visibility
Managerial activities
• Identify or strengthen a coordinating body
• Develop a comprehensive and budgeted plan
• Ensure health facility design, construction or
renovation
• Conduct surveillance for TB disease among
HCWs
• Address advocacy, communication and social
mobilization
• Conduct monitoring and evaluation
• Enable operational research
4
Health care facilities
•
•
•
•
Health facility level managerial activities
Administrative controls
Environmental controls
Personal protective equipment
What are administrative controls?
• Measures to significantly reduce the risk of
TB transmission by preventing the
generation of droplet nuclei or reducing
exposure to droplet nuclei
• Administrative controls will specify the
appropriate work practices for a particular
setting
5
Administrative controls
Strategies to promptly identify potentially
infectious cases (triage), separate them,
control the spread of pathogens (cough
etiquette) and minimize time in health care
settings
1) Triage
2) Separation
3) Cough etiquette
4) Minimize time in health care settings
Separation
Separate infectious patients from noninfectious patients
• Identify patients with potential TB with the
use of a screening questionnaire
• Move them to the front of the line for
treatment
• Place them in separate waiting area away
from susceptible patients
• Give them specific times for follow-up
appointments
6
Cough etiquette
• Promote cough etiquette among
symptomatic patients
– Patient education
– Posters
– Cough officer
– Use of tissues, surgical mask, hands, elbow to
cover mouth when coughing or sneezing
Time in health settings
• Minimize time in HCF
– Prioritize care
– Ensure rapid laboratory time around time
– Emphasize ambulatory treatment, where
possible
• Minimize time in hospital ward
• Utilize community treatment models
• Attention to TB IC in the home and
community
7
Protection of HCWS
• Encourage TB diagnostic investigation
when signs and symptoms suggestive of
TB occur or when exposed to smearpositive and culture-positive TB patients
• Encourage HIV testing
• If HIV-positive, make available a package
of care, including IPT, ART, if needed, job
relocation, and screen for TB
Environmental controls &
personal protective equipment
Environmental controls
10. Use ventilation systems.
11. Use ultraviolet germicidal irradiation (UVGI) fixtures, at least when adequate
ventilation cannot be achieved.
Personal protective equipment
12. Use particulate respirators.
8
Ventilation systems
• In existing health-care facilities that have natural
ventilation, when possible, effective ventilation
should be achieved by proper operation and
maintenance on a regular schedule.
• Simple natural ventilation may be optimised by
maximising the size of the opening of windows
and locating them on opposing walls.
• Well-designed, maintained mechanical
ventilation systems can help to obtain adequate
dilution when natural ventilation alone cannot
provide sufficient ventilation rates
Personal protective equipment
• Use of particulate respirators is recommended
for health workers when caring for patients or
suspects with infectious TB
• In particular, health workers should use
respirators:
– during high-risk aerosol-generating procedures
associated with high risk of TB transmission
(e.g. bronchoscopy, intubation, sputum induction
procedures, aspiration of respiratory secretions, and
autopsy or lung surgery with high-speed devices)
– when providing care to infectious MDR-TB and XDRTB patients or people suspected of having infectious
MDR-TB and XDR-TB.
9
Prioritization of TB IC measures
• Evidence based
• Choice of controls or a combination of
controls should be based on a
comprehensive TB IC assessment
• Epidemiological, climatic, socioeconomic
conditions, and cost considerations.
• Specific recommendations for high HIV
prevalent settings and for MDR-TB and
XDR-TB.
Congregate settings
• Prisons, jails, military barracks, homeless
shelters, refugee camps, dormitories and
nursing homes.
• Each facility differs in type of population
and duration of stay of the dwellers.
10
Congregate settings
Avoid overcrowding
Focus on DOT in prisons.
Be part of the national planning and assessment of
facilities.
Recommendations are less specific than those for HCF.
Recommendations on medical services as per HCF.
Long-term stay (prisons) and short term stay (jails)
Household
Importance of early case detection and TB contact
investigation
Emphasis on behaviour-change campaigns for patients
and families of smear/culture positive patients
Focus on cough etiquette and respiratory hygiene and to
spend as much time as possible outside
Use of respirators by HWs in specific situations
Renovation of houses for MDR and XDR TB
11
Conclusions
• Implementation of TB IC involves multiple
stakeholders.
• TB IC truly cuts across the disciplines
• TB programme unable to implement all aspects.
• HIV prompted TB programmes to collaborate
with HIV counterpart. TB IC should prompt TB
programmes to collaborate with other airborne
disease control programmes efforts and
contribute to health systems strengthening.
12