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Unit 4: Infection Control and Prevention of Tuberculosis

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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: 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

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