TB Transmission Risk Reduction

Transcription

1 TB Transmission Risk Reduction Dr. Grigory Volchenkov Chief Doctor Vladimir Oblast TB Dispensary Center of Excellence for TB Infection Control, Vladimir, Russia

2 Vladimir Region, Russia Population ~ 1.5 mln WHO DOTS pilot project since 1999 TB Infection control program since 2002 Both civil and penitentiary TB control sectors involved

3 Occupational TB notification rate among HCW in TB Facilities in Russia Region/facility Authors, publication date Timing TB notification rate Yaroslavl, TB services B.Kibrik, Yu.Makovey, O.Smaglo, Samara, TB services and in-patient hospital Dimitrova B, Hutchings A, Atun R, Drobniewski F. et al., (in-patient facility) Tomsk, Regional TB Hospital G.Yanova, A.Strelis,N.Chukova, Vladimir Regional TB Dispensary (in- and out patient departments staff) G.Volchenkov,

4 MDR TB Transmission in Tomsk I. Gelmanova, E. Nardell et al., Bull WHO, 2007; 85: Retrospective study of the role of non-adherence and default and the acquisition of multidrug resistance Substance abuse was a strong predictor of non-adherence (OR 7.3 ( ) o But non-adherence NOT associated with MDR-TB MDR-TB occurred among adherent patients who had been hospitalized in the course of therapy compared to those treated as out-patients o o OR 6.34 ( ) began treatment in hospital OR 6.26 ( ) hospitalized later during treatment Courtesy of Ed Nardell

5 Important! TB alveolar macrophages infection TB is airborne infection, transmitted predominantly through stable aerosol of droplet nuclei, viable M.tuberculosis To reduce nosocomial TB transmission risk we need to control air movemen Effective therapy rapidly and dramatically reduces contagiousness (in hours days)

6 Alveolar Macrophage

7 TB Infection Control Hierarchy Administrative controls to reduce risk of exposure, infection, and disease through policy and practice Engineering controls to reduce concentration of infectious bacilli in air in areas where contamination of air is likely Personal respiratory protection to protect personnel who must work in environments with infectious aerosols PRP ENVIRONMENTAL CONTROLS ADMINISTRATIVE CONTROLS

8 Education Key Administrative Interventions Facility TB transmission risk assessment and zoning Development and implementation of rapid molecular diagnostics based case finding and treatment algorithms Optimal patient, staff and visitors flow separation Early EFFECTIVE TB treatment to eliminate transmission risk TB control services restructuring to reduce transmission risk for patients and staff Radical hospitalization approach change Education

9 Rapid treatment impact on infectiousness Courtesy E.Nardell, HSPH, PIH

10 Hospitalization policy Sharp reduction of indications for in-hospital TB care Length of In-patient stay should be substantially reduced Diagnostic hospitalization should be avoided Involvement of primary health care workers and community based TB care approaches Special approach to TB/HIV patients!

11 Administrative Control Trends TB patient contagiousness dramatically drops shortly after starting Effective treatment Rapid methods to identify M. tuberculosis and resistance to Rif, Fq, Injectables are urgently needed Early beginning of first and second line drugs chemotherapy according to evidence based treatment protocols based on reliable DST Isolation and separation approaches are being revised: More TB care without hospitalization!

12 Specific TB IC Issues for Former Soviet Union Countries Cold climate Long term hospitalization with poor isolation tradition; neglect of administrative infection control principles is quite common Weak PHC involvement in TB outpatient services Lack of airborne TB transmission oriented precautions in current national regulations Investments for TB control often lack prioritization

13 Specific TB IC Issues for Former Soviet Union region (cont-d) Not rational use of UVGI (open lamp fixtures) Effective respiratory protection is not common, often staff use surgical masks Massive investments into Hi Tech waste disposal and sewage disinfection equipment Lack of expertise and experience in ventilation and bisafety equipment design, construction, commissioning and maintenance

14 Management of patients with M/XDR TB in Europe From a TBNET consensus statement, to be published in ERJ in early 2014 Hospitalization should include airborne isolation precautions and be limited primarily to contagious AFB sputum smear-positive TB patients. Infectiousness is substantially reduced once a patient is on an adequate regimen and it is probably not necessary to keep a patient in hospital until culture becomes negative In some settings, patients with M/XDR-TB are discharged from the hospital after 2 weeks of an adequate treatment, although many centers require a negative result from 3 sputum cultures collected over a 14 day period in patients with M/XDR-TB before they are considered for discharge. At this time, the optimal time for safe discharge of patients with M/XDR-TB is not known.

15 Problems to be solved Risk of MDR TB transmission in household cold climate settings for patients on SLD treatment criteria for hospitalization / discharge Enforcement of out-patient primary health care and community supported treatment (paradigm shift for most Former Soviet Union states) Sustainability of IC interventions