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Unit 4: Infection Control and
Prevention of Tuberculosis
Botswana National Tuberculosis Programme
Manual Training for Medical Officers
Objectives
At the end of this unit, participants will be able to:
• Identify the goals of infection prevention
• Identify 3 levels of prevention
• Identify infection control strategies to prevent
the transmission of TB in the healthcare setting
• Explain the importance of contact tracing
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-2
Levels of Prevention and Their Goals
Prevention efforts focus on the following three
goals:
• Primary prevention – preventing TB infection
• Secondary prevention – preventing TB disease
• Tertiary prevention – preventing TB morbidity and
mortality
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-3
The Transmission
of TB Knows No Boundaries
Patient to:
Worker
Visitor
Patient
Visitor to:
Worker
Visitor
Patient
Unit 4: Infection Control and Prevention of Tuberculosis
Worker to:
Worker
Visitor
Patient
Slide 4-4
Hierarchy of
Infection Prevention & Control
• Administrative controls
• Reduce risk of exposure, infection and disease
thru policy and practice
• Environmental (engineering) controls
• Reduce concentration of infectious bacilli in air in
areas where air contamination is likely
• Personal respiratory protection
• Protect personnel who must work in environments
with contaminated air
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-5
Activity
• Discuss the following in small groups:
• What infection control methods are being done
currently in your facilities?
• What are some things you could change?
• Are there any potential barriers to implementing
those changes?
• Report back to the larger group and other
groups should give feedback/discuss solutions
to any possible barriers identified
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-6
Administrative Controls
• Develop and implement written policies and
protocols to ensure:
• Rapid identification of TB cases (e.g., improving the turnaround time for obtaining sputum results)
• Isolation of patients with PTB
• Rapid diagnostic evaluation
• Rapid initiation treatment
• Educate, train, and counsel HCWs about TB
• To the extent possible, avoid mixing TB patients and
HIV patients in the hospital or clinic setting
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-7
Environmental Controls:
Ventilation and Air Flow
• Ventilation is the movement of air
• Should be done in a controlled manner
• Types
• Natural
• Local
• General
• Simple measures can be effective
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-8
Evidence from Peru
• Open windows and doors produced 6x greater air
exchanges than mechanical ventilation and 20x
great air changes per hour than with windows closed
• Natural ventilation in “old-style” hospitals and clinics
resulted in much better ventilation and much lower
calculated TB risk, despite similar patient crowding
• More likely to have larger, higher ceilings; larger
windows; windows on opposite walls allowing
through-flow of air
Unit 4: Infection Control and Prevention of Tuberculosis
Source: Escombe, et al. PLoS Medicine, 2007.
Slide 4-9
Estimated Risk of
Airborne TB Infection
• Naturally ventilated, windows closed - 97%
• Mechanically ventilated with neg pressure
(ACH 12) - 39%
• Naturally ventilation, windows and doors
fully open:
• Modern (1970-1990) 33%
• Old-fashioned (pre-1950) - 11%
Unit 4: Infection Control and Prevention of Tuberculosis
Source: Escombe, et al. PLoS Medicine, 2007.
Slide 4-10
Direction of Natural Ventilation and
Correct Working Locations (1)
Source: CDC, 2007
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-11
Direction of Natural Ventilation and
Correct Working Locations (2)
Unit 4: Infection Control and Prevention of Tuberculosis
Source: CDC, 2007
Slide 4-12
Direction of Natural Ventilation and
Correct Working Locations (3)
Unit 4: Infection Control and Prevention of Tuberculosis
Source: CDC, 2007
Slide 4-13
Direction of Natural Ventilation and
Correct Working Locations (4)
Source: CDC, 2007
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-14
Environmental Controls (2)
Ultraviolet Light
Source: iStockphoto, 2008.
Unit 4: Infection Control and Prevention of Tuberculosis
HEPA (high efficiency
particulate air) filters
Source: MedlinePlus, 2008.
Slide 4-15
Personal Respiratory Protection
• Respirators:
• Can protect HCWs
• Should be encouraged in high-risk settings
• May be unavailable in low-resource settings
• Face/surgical masks:
• Act as a barrier to prevent infectious patients from
expelling droplets
• Do not protect against inhalation of microscopic
TB particles
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-16
N95 Respirator Dos and Don’ts
Unit 4: Infection Control and Prevention of Tuberculosis
Source: CDC, 2007
Slide 4-17
Do
Be sure your
respirator is
properly fitted!
It should fit snugly
at nose and chin
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-18
Source: CDC, 2007
Note poor fit at the
bridge of nose
Note poor fit at the
chin
Respirator should
cover chin and
create a seal
Unit 4: Infection Control and Prevention of Tuberculosis
Source: CDC, 2007
Slide 4-19
Don’t Forget to WEAR It!
Unit 4: Infection Control and Prevention of Tuberculosis
Source: CDC, 2007
Slide 4-20
TB Prevention & Control
in the Community: MO Role
•
•
•
•
Begin TB treatment as soon as possible
Screen other people in the household
Ensure that TB patients complete treatment
Minimise crowding in congregate settings
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-21
TB Prevention & Control in the
Community: Community Role
Teach members of the community to:
• Recognize the early symptoms of TB
• Minimise crowded living conditions
• Allow natural light into buildings and rooms as
ultra-violet rays quickly kill TB bacilli
• Open windows to air out rooms to dilute the
load of infectious TB bacilli
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-22
TB Prevention & Control in the
Community: Patient Role
• Patient should maintain a well-balanced diet to
keep the immune system strong
• Patient should TB patient to stop smoking and
minimize intake of alcohol
• Patient should hold a cloth or handkerchief
over mouth when coughing
• Patient should not spit on the floor but in a
container (preferably disposable) and dispose
of properly
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-23
TB Prevention & Control Among
HIV+ Patients and HCWs
• Immunosuppressed persons are much more
susceptible to TB and therefore should not be
housed with inpatients who have undiagnosed
cough or untreated TB
• Encourage patients and HCWs to know their
HIV status so they can reduce their exposure
to TB infection
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-24
Infection Prevention &
Control in the Workplace
• Provide a well-ventilated, sun-lit environment
• Educate all staff on TB transmission &
prevention
• Implement HIV/AIDS workplace policy
• Link with health facilities for treatment &
support
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-25
TB Prevention in Special Settings
Prisons and Police Holding Cells
• Screen all prisoners
• Treat & isolate
• Implement strict DOT during entire
treatment
• Refer all released prisoners under
treatment to nearest healthcare facility
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-26
TB Prevention in Special Settings
Barracks
• Educate all personnel
• Screen all recruits
• Start treatment & organise workplace
DOT
• Identify & screen all close contacts
• Advise TB patients to have an HIV test
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-27
Contact Tracing
What is it? How does it work? Why is it
important? What are some strategies?
Contact Tracing (1)
The identification and diagnosis of persons
who may have come into contact with an
infected person
An important element to infection prevention
and control
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-29
Contact Tracing (2)
• Identify and evaluate contacts of persons with smear
positive pulmonary TB within 3 days of new case
discovery
• All close contacts should be evaluated
• Particular attention give to children under 5
• If index case is a child, source of disease will be a person
with PTB
• If source unknown, ask household contacts for symptoms
and investigate any contact with symptoms of PTB
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-30
Contact Tracing (3)
• Generally done by FWE or nurse
• Not necessary for smear-negative PTB or
EPTB, unless index case is a child
• Contact examination form completed for each
confirmed case’s contacts
• Suspects should be entered into the “Suspect
and Sputum Dispatch Register” and evaluate
appropriately
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-31
Contact Tracing: Children
• Nurses can give INH to child contacts <5 who
have been screened and are asymptomatic
• Treatment lasts 6 months, but a monthly
supply is handed out
• Pyridoxine is not routinely indicated for
children
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-32
TB Screening Among Contacts
• Basic screening for TB done in home by FWE
or nurse
• Refer the following individuals to clinic for
further evaluation and follow-up (evaluation for
active TB and evaluation for INH prophylaxis
or IPT):
• Children in household < 5 years old
• Persons in household who are HIV+
• Persons in household who are ill
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-33
Large Group Discussion
• Who here works in a facility that does contact
tracing?
• Why is it important?
• What are some strategies you use at your
facility to make contact tracing successful?
• What are some challenges/barriers you have
encountered in the process?
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-34
Key Points
• Prevention efforts should focus on primary,
secondary, and tertiary prevention
• Attention to the potential spread of infection
and disease among special populations,
including among those who are HIV+ is crucial
• Contact tracing is an important component of
TB control in the community
Unit 4: Infection Control and Prevention of Tuberculosis
Slide 4-35