1. Unit 4: Infection Control and Prevention of Tuberculosis
Botswana National Tuberculosis Programme Manual Training for Medical Officers

2. 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

3. 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
All three of these goals are important in the prevention of TB. Use the following examples to explain the levels of prevention
Primary prevention:
Using infection control measures in healthcare settings can prevent TB among patients and staff – i.e., wearing masks, appropriate ventilation
Offering INH-preventive therapy to infants living with adults with infectious TB
Secondary prevention
INH is used to prevent the progression to TB disease
Persons who benefit the most from secondary prevention are those most likely to develop severe forms of active TB (such as contacts less than 5 years old and immunosuppresed persons)
Early diagnosis and treatment
Tertiary prevention
BCG vaccination does not prevent infection with TB but it does prevent severe forms of childhood TB and thus can be considered tertiary prevention
The more commonly used interpretation of tertiary prevention is the early diagnosis of TB before complications have developed and that will be discussed in subsequent units

4. The Transmission of TB Knows No Boundaries
Worker to:
Worker
Visitor
Patient
Patient to:
Worker
Visitor
Patient
Visitor to:
Worker
Visitor
Patient
Emphasise that transmission is not one-way and does not discriminate!
Patients can transmit to workers, visitors and other patients and vice versa. Any infectious person puts everyone in his/her immediate surroundings at risk!
Infection prevention and control is the PREVENTION of transmission from individual to individual (as above) through administrative, environmental, and personal protection equipment

5. 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
Infection control is divided into three different control measures
First two levels are the most important
Use of personal respiratory protection cannot compensate fully for missing administrative and environmental controls

6. 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
Have the participants break into small groups and discuss the questions, 3 minutes for each question. They should then report back as a large group quickly
After the small groups have discussed as a large group, present slides 7-27 to summarize what participants have just discussed and add some additional information

7. Administrative Controls
Develop and implement written policies and protocols to ensure:
Rapid identification of TB cases (e.g., improving the turn-around 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
Administrative controls refer to policies and procedures that reduce the risk of exposing uninfected persons to infectious TB
Ask participants what administrative measures they can think of to accomplish this goal
Ask participants to discuss specific advice for HIV+ healthcare workers

8. 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
Natural ventilation refers to open windows and doors to capture wind
Local ventilation refers to strategically placed fans
General ventilation refers to a centralised air conditioning system that does not allow air from rooms of patients with infectious TB to be re-circulated
Some simple measures to increase ventilation and air flow include different types of fans (standing, window, ceiling, etc.)

9. 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
Source: Escombe AR, Oeser CC, Gilman RH, et al. Natural Ventilation for the Prevention of Airborne Contagion. PLoS Medicine. 2007; 4(2):e68
Source: Escombe, et al. PLoS Medicine, 2007.

10. 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 ( ) %
Old-fashioned (pre-1950) - 11%
These are the percent of susceptible individuals who were infected after 24 hours of exposure in each of the settings listed
Source: Escombe AR, Oeser CC, Gilman RH, et al. Natural Ventilation for the Prevention of Airborne Contagion. PLoS Medicine. 2007; 4(2):e68
Source: Escombe, et al. PLoS Medicine, 2007.

11. Direction of Natural Ventilation and Correct Working Locations (1)
Explain that this and the following 3 slides are examples of methods that could be used to take advantage of natural ventilation as an infection control measure. Emphasise that the point of these graphics are not necessarily to show exact placement, rather to demonstrate examples and how wind can be used in a variety of ways
Emphasize also that it is the patient TB-infected patient is the one that would be transmitting TB to the HCW
When increasing ventilation and air flow, care should be taken as to the appropriate positioning of the windows, doors, the patient and the HCW to control infection
Source: CDC, 2007

12. Direction of Natural Ventilation and Correct Working Locations (2)
Source: CDC, 2007

13. Direction of Natural Ventilation and Correct Working Locations (3)
Source: CDC, 2007

14. Direction of Natural Ventilation and Correct Working Locations (4)
Remember, the patient is the one that is infected and might pass on TB to the HCW.
Source: CDC, 2007

15. Environmental Controls (2)
Ultraviolet Light
HEPA (high efficiency particulate air) filters
Both indirect ultraviolet irradiation of air and HEPA filters have been used in some high-risk settings to reduce the concentration of infectious TB particles in the ambient air
Image source (sun): iStockphoto. [database on the Internet]. iStock International, Inc [cited 2008 Feb 4]. Image # Available from: istockphoto.com
Image source (HEPA): MedlinePlus [database on the Internet]. Bethesda (MD): National Library of Medicine and National Institutes of Health; 2008 Jan 2 [cited 2008 Jan 23]. Medical Encyclopedia: HEPA Air Filter; Available from:
Source: iStockphoto, 2008.
Source: MedlinePlus, 2008.

16. 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
High-risk setting in which respirators should be encouraged include:
Rooms where cough-inducing procedures are done (i.e., bronchoscopy suites)
When collecting sputum specimens from patients
TB “isolation” rooms
Referral centers or homes of infectious TB patients
CDC/NIOSH-certfied N95 (or greater) respirator should be used
Respiratory protection is effective only if:
The correct respirator is used
It's available when you need it
You know when and how to put it on and take it off
You have stored it and kept it in working order in accordance with the manufacturer's instructions
How it works: The patient coughs out droplets, therefore the surgical mask is protective as it will collect the droplets and not allow them to spread. The droplet evaporates, leaving the organism in microbe form in the air. The HCW must wear the N95 mask as he/she is breathing in microbes, which are much smaller than the droplet the patient has coughed out
Some clinics may not have access to CDC/NIOSH-certified N95 (or greater) respirators. The MoH and government are making every effort to make these masks widely available. HCWs may be able to access respirators from CMS through special order. One person can use the same respirator for one month
It’s also important to note that these respirators are for healthcare providers and the surgical masks may be given to patients to wear

17. N95 Respirator Dos and Don’ts
The mask used in this picture is one of many N95 respirator masks. This and the following slides are used to show correct usage and placement of the mask on the face
Show the green mask made by 3M to participants, as this is the mask used in Botswana
Either demonstrate correct usage with mask in hand, or use the images in next few slides
Source: CDC, 2007

18. Do Be sure your respirator is properly fitted!
It should fit snugly at nose and chin
Source: CDC, 2007

19. Note poor fit at the bridge of nose
Note poor fit at the chin
Respirator should cover chin and create a seal
Source: CDC, 2007

20. Don’t Forget to WEAR It! Source: CDC, 2007
Remember, respirators and masks don’t do you any good if kept in your pocket or purse!
Source: CDC, 2007

21. 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
Most TB patients will no longer be able to spread the bacteria after two weeks of treatment. Therefore, it is very important that a person starts on treatment as soon as possible to avoid spreading the bacteria to others

22. 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

23. 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
It is our job as HCW to teach the patients these things!
It is very important that the TB patient maintain a healthy lifestyle to keep their immune system strong. This includes maintaining a good diet and not drinking or smoking
Smoking damages the lungs and will continue to weaken the lungs while they are trying to heal. Drinking alcohol can also be dangerous for a patient on TB treatment
Both alcohol and the TB medication are processed by the liver. If the liver has too much work to do, it can become damaged and no longer function properly

24. 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
The issue of keeping HIV infected health care workers away from TB patients is complex
It may be difficult for an HIV+ health care worker to avoid TB exposure, since there are so many patients with TB in Botswana
It is still useful to understand that there is an increased risk for HIV+ health care workers who are exposed to TB

25. 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
Ask participants if they have an HIV/AIDS workplace policy

26. 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
A rapid assessment of TB in Botswana in 2002 showed the prevalence of TB among prisoners was 3,797 cases per 100,000, equivalent to 5x higher than the general population. On the basis of this survey several recommendations were made:
Screening for TB at prison entry or transfer and periodically thereafter (e.g, annually) using a symptom-based questionnaire
Contact investigations of newly identified smear-positive cases
Assessment of administrative and environmental measures to reduce ongoing transmission within the prison
Implementation of isoniazid preventive therapy among HIV-infected prisoners and guards according to existing MOH guidelines
Source: Centers for Disease Control and Prevention. Rapid Assessment of Tuberculosis in a Large Prison System --- Botswana, MMWR Weekly [serial on the Internet] March 28 [reviewed 2003 March 27; cited 2008 Jan 23]; 52(12): Available from:
Some police officers won’t give ARVs and TB meds to inmates in the police holding cells. Inmates could be there 6 months – 1 year before going to trial
Make sure prisons in your district/region have a referral policy for inmates with tuberculosis who will be released
Explain that police officers need to be trained as DOT supporters

27. 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

28. Contact Tracing
What is it? How does it work? Why is it important? What are some strategies?
The next few slides will deal with contact tracing. These questions will be answered in the next few slides and will be discussed in small groups at the end of the section.

29. 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
Open the Botswana National Tuberculosis Programme Manual to Annex 11, Form 7

30. 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
As capacity in Botswana grows, the effort devoted to screening and follow-up of TB contacts will increase

31. 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
Refer to The Tuberculosis Contact Examination Form (MH 2035) in the Botswana National Tuberculosis Programme Manual, Annex 11, form 7

32. 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
Document INH prophylaxis in child’s clinic card– there is no register for children who are given preventive IN after exposure
The IPT register should NOT be used

33. 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
Case finding in households is important for control of TB in the community

34. 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?
Large group discussion:
Allow ~3-5 minutes for discussion of each question above, allowing participants to engage in reciprocal discussion about their experiences with contact tracing
If few people have experience with it, encourage them to brainstorm keys to success and potential barriers in their own work settings, based on what they have just learned

35. 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