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TB Infection Control within the palliative care context Kath Defilippi Patient Care Portfolio Manager Hospice Palliative Care Association of South Africa (HPCA) 1 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 2 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 4 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 6 “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%) 7 1. Decreasing the reservoir • Screening and referral for further investigation of TB: • all new patients admitted to the pall care programme • 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 8 Contacts who are at risk of contracting TB in the home care setting where 99% of palliative care patients are to be found • 9 Health Care Workers Neighbours Family* Person with infectious TB * Especially children under 5 years 9 Indicators of probable TB disease in severely immune-suppressed patients According to studies done by Hardman and Ong the most important indicators are: • • • • 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 10 HPCA TB Screening Tool • • • All newly admitted patients to IPU and HBC programmes Visitors and family members All new staff /annual screening 11 1.1 Decreasing the reservoir iro of patients/families • 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 • Promoting the relevant rights and responsibilities from the Patients Charter for Tuberculosis Care (p15 HPCA Guidelines) • Advocating for all HIV+ patients with TB to commence with ART asap, including those on TB treatment 12 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 13 1.2 Decreasing the reservoir iro staff and volunteers • Staff wellness programme to promote and maintain optimal immune status • Mandatory training on TB including infection control, for all categories of staff and volunteers • Creating an organisational environment conducive to disclosure of HIV and TB status • INH preventive therapy for HIV+ staff without signs of active TB 14 Training community caregivers on infection control Photo St Bernard’s Hospice, East London 15 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 16 2.1 Infection control linked to place of exit • Policies in place regarding criteria for admission of TB patients to palliative care programmes (HPCA Draft Guidelines p 12-14) • 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 • 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 • Safe sputum collection (HPCA Draft Guidelines p 23) 17 3.1 Prevention of transmission • 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 • This effective mixture increases the dilution of infectious particles 18 3.2 Promote good natural ventilation to prevent airborne transmission of MTB • Keep doors and windows open especially in areas where people congregate inside a building • 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 19 5.1 Susceptible children • • • 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 20 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 • Filter >95% of infectious droplets (N95) • Fit-testing required • Valuable during aerosol-producing procedures • May be re-used if handled properly 21 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 • Covering any breaks in the skin • Effective disposal of all potentially contaminated waste • Safe disposal of sharps 22 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 • No children under 5 years in the household • If possible no elderly relatives in the household Monitor response to second line treatment and liaise with MDR unit re management of side effects 23 5.1 Protection of susceptible health care workers in palliative care teams • Provide effective facial masks and monitor their use • 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 • Promote disclosure of HIV and TB status • INH preventive therapy • Care for the caregiver programmes 24 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 25 5.3 Infection Control Plan • Designated responsibility reflected on job description/s • Includes assessment of TB infection control risks • Written policies and procedures • In-service training for all categories of staff /volunteers • Forms part of Risk Management Programme which is evaluated annually 26 5.6 Staff Training • Each staff person should understand the importance of infection control & their role in implementing infection control • Job descriptions should include specific infection control duties • Infection control should be included as part of staff orientation and in-service training, and include those not directly involved in patient care 27 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 28 29 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 30 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 31