1. 12/12/1386 1 |1 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر

2. 12/12/1386 2 |2 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر General concepts on TB infection control

3. 12/12/1386 3 |3 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Transmission of TB Hierarchy of Infection Controls Administrative Infection Controls Environmental Controls Personal Respiratory protection HCW protection Presentation outline

4. 12/12/1386 4 |4 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر The purpose of infection control Program To reduce the risk of Mycobacterium tuberculosis transmission to health care workers, patients, and others in the health care facility

5. 12/12/1386 5 |5 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Mycobacterium tuberculosis Generated by coughing, sneezing, speaking Remains airborne and spreading air currents Aerobic, desiccation-resistant 1-100 organisms may infect Droplet nuclei, 1-5  Most exposed persons do not become infected

6. 12/12/1386 6 |6 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر “At risk” health care worker Nurses Physicians, specialists in internal medicine specialists in respiratory medicine (extra risk providing bronchoscopy, caring ventilated patients in ICU) Pathologists Laboratory staff

7. 12/12/1386 7 |7 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Respiratory Protection Administrative Controls Environmental Controls Fundamentals of Infection Control (1) Hierarchy of Infection Control

8. 12/12/1386 8 |8 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Prevention of droplet nuclei containing M. tuberculosis from being generated; Prevention of TB exposure to staff and patients; and Implementation of rapid and recommended diagnostic investigation and appropriate treatment for patients and staff suspected or known to have TB. Administrative control measures Administrative Controls

9. 12/12/1386 9 |9 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Assign responsibility for TB infection control (IC) Conduct TB risk assessment and develop written TB IC plan, including AII precautions Ensure timely lab processing and reporting Implement effective work practices for managing TB patients Administrative control measures Administrative Controls

10. 12/12/1386 10 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Test and evaluate HCWs at risk for TB or for exposure to M. tuberculosis Train HCWs about TB infection control Ensure proper cleaning of equipment Use appropriate signage advising cough etiquette and respiratory hygiene Administrative control measures Administrative Controls

11. 12/12/1386 11 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Administrative control measures Assignment of responsibilities Supervisory responsibility should be delegated to a specific person or infection control team with a leader Should include experts in: - infection control - hospital epidemiology - clinician - engineering IC team responsible for all aspects of the IC program

12. 12/12/1386 12 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Administrative control measures TB Risk Classifications (1) All settings should perform risk classification as part of risk assessment to determine need for and frequency of an HCW testing program, regardless of likelihood of encountering persons with TB disease.

13. 12/12/1386 13 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Administrative control measures TB Risk Classifications (2) Low risk – Persons with TB disease not expected to be encountered; exposure unlikely Medium risk – HCWs will or might be exposed to persons with TB disease Potential ongoing transmission – Temporary classification for any settings with evidence of person-to-person transmission of M. tuberculosis

14. 12/12/1386 14 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Administrative control measures TB Risk Classifications (3) Inpatient SettingsLowMedium Potential Ongoing Transmission <200 beds <3 TB patients/yr >3 TB patients/yr Evidence of ongoing transmission, regardless of setting ≥200 beds <6 TB patients/yr >6 TB patients/yr

15. 12/12/1386 15 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Outpatient SettingsLowMedium Potential Ongoing Transmission TB treatment facilities, medical offices, ambulatory care settings <3 TB patients/yr >3 TB patients/yr Evidence of ongoing transmission, regardless of setting Administrative control measures TB Risk Classifications (4)

16. 12/12/1386 16 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Administrative control measures Implement effective work practices for managing TB patients Infection control plan (including TB) specific to each area within facility, and HCW group based on level of risk Put all procedures in writing plan including: –Early detection isolation and treatment of infectious TB patients –Patient education –Decreasing of cough induction procedures Administrative support for procedures in the plan, including quality assurance; Educate staff about the plan - organization, rationale, and what is expected of them TB screening program for health care workers Education of patients and increasing community awareness; and Coordination and communication between the TB and HIV programs.

17. 12/12/1386 17 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Administrative control measures Ensure early identification, diagnostic evaluation, isolation and treatment (2) Focus on high risk groups: –contacts, –HIV+, –positive medical history, –People with social and epidemiologic factors) Use appropriate diagnostic methods for TB/MDR-TB Following Isolation protocols and procedures Being sure about adequate effective treatment

18. 12/12/1386 18 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Administrative control measures Isolation procedures Designate high-risk areas (isolation rooms) for TB and MDR-TB patients or suspects Establish rules and regulations for isolation (eg. Starting & interruption of isolation, target group, …) Patient education, signed informed consent*

19. 12/12/1386 19 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Second defense in TB IC program, after administrative controls, Control of infection source Dilute and remove contaminated air Control airflow Environmental Controls

20. 12/12/1386 20 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر UV lamps HEPA filters Ventilation systems Natural airflow Environmental Controls Technologies for removing or inactivating M. tuberculosis consist of Local exhaust ventilation, General ventilation Air-cleaning methods, e.g., high-efficiency particulate air (HEPA) filtration, ultraviolet germicidal irradiation (UVGI)

21. 12/12/1386 21 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Local Exhaust Ventilation Source-control method for capturing airborne contaminants –Enclosing device: fully or partially enclosed source; include tents, booths, and biologic safety cabinets (BSCs) –External device: source near but outside enclosure Should remove at least 99% of particles before next patient or HCW enters Use –for cough-inducing and aerosol-producing procedures

22. 12/12/1386 22 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر General Ventilation Systems that dilute and remove contaminated air and control airflow patterns in a room Single-pass system preferred for AII rooms Maintain AII rooms under negative pressure –Existing settings: ≥6 air changes/hr (ACH) –New or renovated settings: ≥12 ACH Recirculation (HEPA filtration, UV irradiation) Engineers Engineers must look after function of ventilation system, to determine airflow and air exchange per hour

23. 12/12/1386 23 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Ventilation Airflow In places with highest risk of infection TB isolation rooms; Bronchoscopy rooms Aerosol rooms Sputum induction rooms TB patient admission rooms Bacteriological laboratory wrong Wright

24. 12/12/1386 24 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Air flow measurements

25. 12/12/1386 25 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Natural ventilation

26. 12/12/1386 26 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Air-Cleaning Methods HEPA filters Use as supplement to ventilation Used to filter infectious droplet nuclei from the air Must be used –When discharging air from local exhaust ventilation booths directly into surrounding room –When discharging air from an AII room into the general ventilation system Can be used to clean air that is exhausted to outside

27. 12/12/1386 27 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر HEPA Filter Use of filters Replacement of filter depends on: - volume and type of exposition - environmental condition - Airflow rate - type of filter - place of ventilation system

28. 12/12/1386 28 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Air-Cleaning Methods UVGI Kills or inactivates M. tuberculosis Use as supplement to ventilation Not substitute for negative pressure rooms Not substitute for HEPA filtration when air recirculated from AII room into other areas Emphasis on safety and maintenance Occupational exposure limits: –Overexposure can cause damage to skin, eyes –UVGI systems must be properly installed and maintained

29. UVGI - cleaning

30. 12/12/1386 30 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر UVGI - measurements

31. 12/12/1386 31 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Respiratory Protection General Third level in the IC hierarchy Should be used by persons –Entering rooms of suspected/confirmed TB patients –Around cough / aerosol-producing procedures –In settings where administrative and environmental controls will not prevent the inhalation of infectious droplet nuclei Decision on use of respiratory protection (RP) in labs should be made on case-by-case basis

32. 12/12/1386 32 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Respiratory Protection (RP) Controls Implement RP program Train HCWs on RP Train patients on respiratory hygiene

33. 12/12/1386 33 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Nine NIOSH filter types 3 levels of filter efficiency: –95% (called “95”) –99% (called “99”) –99.97% (called “100”) 3 categories of resistance to filter efficiency degradation: –N (NOT resistant to oil) –R (Resistant to oil) –P (Oil proof)

34. 12/12/1386 34 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Respirators vs. Masks Personal protective equipment

35. 12/12/1386 35 | اداره كنترل سل و جذام نشست سالانه برنامه كنترل سل مازندران - بابلسر Periodic screening of health workers to detect disease at an early stage Each year for employees Medical questionnaire Chest x-ray, PPD test Sputum exam if cough > 2-3 weeks Special consideration for employees with increased individual risk