Download Infection Control for palliative care workers and families

TB Infection Control within the
palliative care context
Kath Defilippi
Patient Care Portfolio Manager
Hospice Palliative Care Association of South Africa (HPCA)
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During this presentation:
•
TB infection control will be discussed in relation to the
disease transmission cycle
•
Additional interventions implemented by HPCA will be
shared
•
Although drug resistant TB will be specifically
mentioned, the focus is on general infection control iro
TB in the palliative care context and includes both
adults and children
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Disease Transmission Cycle
MYCOBACTERIIUM
TB
Disease-producing agent
1. RESERVOIR
5.SUSCEPTIBLE
HOST
Person who can become infected
4.
PLACE
OF
ENTRY
Place where the agent lives
2. PLACE OF
EXIT
Where the agent leaves the host
Where the agent enters the next host
3. METHOD OF
TRANSMISSION
How the agent moves from place-to-place or person-to-person
Adapted from JHPIEGO,
2003
The agent – mycobacterium tuberculosis
•
Has been active in humans for hundreds of years
•
Acid fast slightly curved rod shaped bacillus 0.2-0.5 microns in
diameter; 2-4 microns in length
•
Thick lipid cell wall
•
Multiplies slowly (every 18-24 hours)
•
Aerobic – pulmonary TB most common variety
•
One cough can release 3,000 droplet nuclei – one sneeze can
release tens of thousands
•
Initial infection – can remain dormant for decades as latent TB
Infection (LTBI)
CDC Training, Pretoria University, August, 2010
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Granuloma
COURSE OF INFECTION
Control of replication
fibrosis
inadequate control
of replication
Latent TB
Immunosuppression
Bacterial replication
REACTIVATION
ACTIVE TB
G Kaplan, CDC Training, University of Pretoria, Aug, 2010
No disease
(control of replication)
Conditions that promote progression of LTBI to
active TB disease
•
•
•
•
•
Overcrowding
Malnutrition
Age very young – immature immune system
very old – deteriorating immune system
HIV infection – immune suppression
- A healthy person with a strong immune system has a
10% chance per lifetime of developing TB disease
- An HIV+ person has a 10% chance per year of
developing TB
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“Everywhere in the world, whenever a new case of
infectious tuberculosis emerges, the diagnosis and
commencement of treatment are usually only made
after that case has already infected one or more other
persons”. JD Klausner, CDC Training , Pretoria University, August , 2010
Given the HIV/TB co-infection rate, statistics
collected from HPCA member organizations
suggest that there are a large number of
undiagnosed TB patients already on palliative care
programmes in South Africa.
In Sept 2010 out of a total of 31,685 HIV+ patients
there were only 4,831 diagnosed with TB (15.2%)
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1. Decreasing the reservoir
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Screening and referral for further investigation of TB:
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all new patients admitted to the pall care programme
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all existing patients who develop any of the signs and
symptoms on TB screening tool
•
all staff and volunteers on appointment and thereafter at
least annually
•
all staff and volunteers developing any of the signs and
symptoms listed on TB screening tool
NB for palliative care programmes to liaise with DOH partners
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Contacts who are at risk of contracting TB in the
home care setting where 99% of palliative care
patients are to be found
•
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Health
Care
Workers
Neighbours
Family*
Person
with
infectious
TB
* Especially children under 5 years
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Indicators of probable TB disease in severely
immune-suppressed patients
According to studies done by Hardman and Ong the most important indicators are:
•
•
•
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Significant recent weight loss
Persistent low grade fever
Night sweats
Cough
Only 60% of patients had a cough in Ong study
CK Ong et al Tuberculosis -HIV Coinfection: The relationship between manifestation of tuberculosis and the degree of immune-suppression le JSME: 2(2): 17-21
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HPCA TB
Screening Tool
•
•
•
All newly admitted
patients to IPU and
HBC programmes
Visitors and family
members
All new staff
/annual screening
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1.1 Decreasing the reservoir iro of patients/families
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Information regarding TB disease included in the health
education given to all HIV+ patients and their families
•
A person-centred approach to the provision of treatment
adherence support and the management of side effects of
TB drugs
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Promoting the relevant rights and responsibilities from the
Patients Charter for Tuberculosis Care (p15 HPCA Guidelines)
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Advocating for all HIV+ patients with TB to commence with
ART asap, including those on TB treatment
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Challenging environment in
which infection control is
implemented in HBC setting
Photo South Coast Hospice
Kwa-ZuluNatal
Open air support group
Photo St Bernard’s Hospice E Cape
Photo Msunduzi Hospice KZN
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1.2 Decreasing the reservoir iro staff and volunteers
•
Staff wellness programme to promote and maintain optimal
immune status
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Mandatory training on TB including infection control, for all
categories of staff and volunteers
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Creating an organisational environment conducive to
disclosure of HIV and TB status
•
INH preventive therapy for HIV+ staff without signs of
active TB
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Training community caregivers on infection control
Photo St Bernard’s Hospice, East London
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2.0 Infection control linked to place of exit of MTB
COUGH HYGIENE! COUGH HYGIENE!
COUGH HYGIENE!
Picture – G Kaplan, CDC Training, Pretoria University, August, 2010
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2.1 Infection control linked to place of exit
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Policies in place regarding criteria for admission of TB patients
to palliative care programmes (HPCA Draft Guidelines p 12-14)
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Generally patients with TB in the lungs or larynx should be
considered infectious until they have:
• Completed 2 wks of TB treatment and show improvement in
clinical symptoms
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In the case of MDRTB:
• Had two consecutive negative sputum smears on two
different days. At least one specimen should be an early
morning specimen
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Safe sputum collection (HPCA Draft Guidelines p 23)
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3.1 Prevention of transmission
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Good ventilation can help reduce the risk of infection
by diluting and/or removing infectious particles in the
air
•
A well-ventilated space has air constantly entering and
leaving, allowing an effective mixture of air
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This effective mixture increases the dilution of
infectious particles
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3.2 Promote good natural ventilation to prevent
airborne transmission of MTB
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Keep doors and windows open especially in areas where
people congregate inside a building
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Where electricity is available, use fans to blow air out of the
room
•
Hold support groups in the open air whenever the weather
permits
•
Encourage patients and family members to sit outside in the
sun
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5.1 Susceptible children
•
•
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All children who have been exposed to an adult with
infectious TB must be referred for investigation
- they should then either receive first or second line
treatment or be given INH preventive therapy (IPT)
Young children with TB are usually not a risk to other
children or adults
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4.0 Infection Control linked to place of entry airborne mycobacterium tuberculosis
Personal Controls
•
•
Surgical masks
• No protection against infectious
droplets
• May limit distribution of large
particles
• Consider for coughing patients
Respirators for caregivers
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Filter >95% of infectious droplets (N95)
• Fit-testing required
• Valuable during aerosol-producing
procedures
• May be re-used if handled properly
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4.1 Implement universal precautions linked to the
prevention of HIV infection
•
Hand washing and the wearing of gloves whenever
there is contact with bodily secretions
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Covering any breaks in the skin
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Effective disposal of all potentially contaminated waste
•
Safe disposal of sharps
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5.0 Protection of susceptible family members
In the case of MDR TB
• Assess home prior to admission of patient, prepare and
capacitate family to implement the necessary infection
control measures
•
•
Ensure that there are separate sleeping arrangements
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No children under 5 years in the household
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If possible no elderly relatives in the household
Monitor response to second line treatment and liaise with
MDR unit re management of side effects
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5.1 Protection of susceptible health care
workers in palliative care teams
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Provide effective facial masks and monitor their use
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As far as is possible do not allow immune
compromised staff and volunteers to have direct
contact very ill AIDS patients who could have
undiagnosed TB or with MDR TB patients
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Promote disclosure of HIV and TB status
•
INH preventive therapy
•
Care for the caregiver programmes
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5.2 Personal Protective Equipment
In order for facial masks to be effective:
-Must be large enough to fully cover the nose, lower face,
jaw, and facial hair
-Must be made of fluid-resistant materials
All staff/volunteers caring for patients must be
given gloves and have access to aprons
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5.3 Infection Control Plan
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Designated responsibility reflected on job description/s
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Includes assessment of TB infection control risks
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Written policies and procedures
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In-service training for all categories of staff /volunteers
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Forms part of Risk Management Programme which is
evaluated annually
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5.6 Staff Training
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Each staff person should understand the importance of
infection control & their role in implementing infection
control
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Job descriptions should include specific infection
control duties
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Infection control should be included as part of staff
orientation and in-service training, and include those
not directly involved in patient care
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Additional interventions adopted by HPCA
2nd edition of the Hospice Palliative Care Standards include criteria on:
• Screening for TB as part of initial and ongoing assessments
• TB infection control and training
• Inclusion of TB in risk management and quality improvement
programmes
Surveys are conducted to assess compliance with the standards on a
regular basis
Infection control guidelines distributed to all members
• Implementation of infection control monitored via audit tool
Development of Guidelines for providing palliative care to patients with TB
Development of a specific 5-day training course for TB in the palliative care
setting
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Topics included in TB master training course
Global, national and provincial overview
SA National TB programme (4 I’s)
Diagnosis and investigations (pulmonary
and extra-pulmonary TB) adults and
children
Palliative care principles within the
context of TB
Prevention and Infection Control – adults
and children
TB as part of risk management
History of TB
Epidemiology
Treatment adherence support
Patient and family education
Communication
Drug resistant TB
Integration of TB and HIV
IRIS – implications for palliative care
programmes
Collaboration, referrals and networking
Special paediatric considerations
IPT
Monitoring evaluation and reporting
Providing care for TB patients, including
end of life care
Loss, grief and bereavement
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Sincere thanks to:
HPCA TB Task Team and the reference group of TB
experts - in particular Prof David Cameron
Open Society Institute
Worldwide Palliative Care Alliance
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