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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