WHO policy on TB infection control in health care facilities, congregate settings and households. Rose Pray Stop TB, WHO Why should we develop a policy on TB infection control? To guide countries on what to do and why To provide an evidence base for the recommendations. 1
Evidence base Systematic review on: TB transmission in health facilities and congregate settings Selected administrative and environmental controls and PPE. Managerial activities need to be evaluated. Results Higher incidence of TB in staff in HCFs and congregate settings. Combination of controls does work Administrative controls given priority. Recommendation: Separate infectious cases Population: Patients accessing health-care facilities and congregate settings Intervention: Separation of infectious cases Factor Decision Explanation Quality of evidence Low The quality of the evidence available is low only one study shows a direct impact of physical separation as an individual intervention on reduction of TB transmission Benefits or desired effects Strong (benefits outweigh disadvantages) Early diagnosis and initiation of proper treatment Reduction of transmission among individuals attending health-care facilities Reduction of transmission among health workers and close contacts Disadvantages or undesired effects Values and preferences Costs Feasibility Overall ranking Research gap Strong Strong (may range form minimal to significant capital investment in infrastructure) Conditional to country setting People living with HIV (TB suspects) might be separated together with smear-positive TB patients Health workers will appreciate measures that reduce their exposure Communities will like measures that make health-care facilities safer But Increases workload for health workers May stigmatize people with chronic cough Reduced by: averted diagnostic costs of suspected new cases acquired nosocomially patient being able to continue working less transmission of TB TB cases are averted break in chain of transmission Increased by: staff training infrastructure (separated waiting area, isolation rooms ) additional AFB and CXR for positive TB triage Generally feasible in HIC Lack of human resources in MIC/LIC Lack of infrastructures in MIC/LIC Slow process to diagnose TB (slow turnaround time due to inadequate laboratory capacity) STRONG RECOMMENDATION Need to develop and assess the effect of TB of different models of physical separation based o smear, HIV status and suspected or confirmed TB sensibility pattern 2
Pooled estimates (reference general population) population Outcome Settings Studies Risk Ratio Health care workers TB infection Low income 9 5.77* TB infection High income 40 10.06 TB Low income 37 5.71 TB High income 15 1.99 Congregate TB infection High income 5 2.74* TB High income 18 21.41* Household TB infection & TB Low income 7 1.73* TB infection & TB High income 15 3.19 LMICs: Low- & Medium- Income countries (World Bank ranking) HICs: High- Income countries (World Bank ranking) *with outliers 2009 WHO TB infection control policy Promotes a combination of controls Addresses health facilities, congregate settings, and households Adds a managerial component at the national level Promotes the role of the civil society in designing, implementing and evaluating TB IC Promotes minimizing time spent in a health facility Emphasizes community involvement in raising awareness, promoting behavior change, reducing stigma Promotes integrating TB infection control with other infection control activities 3
Managerial activities at national and sub-national level Provides the managerial framework for the implementation of TB IC in health care facilities, congregate settings and households Facilitates funding proposal development Enhances visibility Managerial activities Identify or strengthen a coordinating body Develop a comprehensive and budgeted plan Ensure health facility design, construction or renovation Conduct surveillance for TB disease among HCWs Address advocacy, communication and social mobilization Conduct monitoring and evaluation Enable operational research 4
Health care facilities Health facility level managerial activities Administrative controls Environmental controls Personal protective equipment What are administrative controls? Measures to significantly reduce the risk of TB transmission by preventing the generation of droplet nuclei or reducing exposure to droplet nuclei Administrative controls will specify the appropriate work practices for a particular setting 5
Administrative controls Strategies to promptly identify potentially infectious cases (triage), separate them, control the spread of pathogens (cough etiquette) and minimize time in health care settings 1) Triage 2) Separation 3) Cough etiquette 4) Minimize time in health care settings Separation Separate infectious patients from noninfectious patients Identify patients with potential TB with the use of a screening questionnaire Move them to the front of the line for treatment Place them in separate waiting area away from susceptible patients Give them specific times for follow-up appointments 6
Cough etiquette Promote cough etiquette among symptomatic patients Patient education Posters Cough officer Use of tissues, surgical mask, hands, elbow to cover mouth when coughing or sneezing Time in health settings Minimize time in HCF Prioritize care Ensure rapid laboratory time around time Emphasize ambulatory treatment, where possible Minimize time in hospital ward Utilize community treatment models Attention to TB IC in the home and community 7
Protection of HCWS Encourage TB diagnostic investigation when signs and symptoms suggestive of TB occur or when exposed to smearpositive and culture-positive TB patients Encourage HIV testing If HIV-positive, make available a package of care, including IPT, ART, if needed, job relocation, and screen for TB Environmental controls & personal protective equipment Environmental controls 10. Use ventilation systems. 11. Use ultraviolet germicidal irradiation (UVGI) fixtures, at least when adequate ventilation cannot be achieved. Personal protective equipment 12. Use particulate respirators. 8
Ventilation systems In existing health-care facilities that have natural ventilation, when possible, effective ventilation should be achieved by proper operation and maintenance on a regular schedule. Simple natural ventilation may be optimised by maximising the size of the opening of windows and locating them on opposing walls. Well-designed, maintained mechanical ventilation systems can help to obtain adequate dilution when natural ventilation alone cannot provide sufficient ventilation rates Personal protective equipment Use of particulate respirators is recommended for health workers when caring for patients or suspects with infectious TB In particular, health workers should use respirators: during high-risk aerosol-generating procedures associated with high risk of TB transmission (e.g. bronchoscopy, intubation, sputum induction procedures, aspiration of respiratory secretions, and autopsy or lung surgery with high-speed devices) when providing care to infectious MDR-TB and XDR- TB patients or people suspected of having infectious MDR-TB and XDR-TB. 9
Prioritization of TB IC measures Evidence based Choice of controls or a combination of controls should be based on a comprehensive TB IC assessment Epidemiological, climatic, socioeconomic conditions, and cost considerations. Specific recommendations for high HIV prevalent settings and for MDR-TB and XDR-TB. Congregate settings Prisons, jails, military barracks, homeless shelters, refugee camps, dormitories and nursing homes. Each facility differs in type of population and duration of stay of the dwellers. 10
Congregate settings Avoid overcrowding Focus on DOT in prisons. Be part of the national planning and assessment of facilities. Recommendations are less specific than those for HCF. Recommendations on medical services as per HCF. Long-term stay (prisons) and short term stay (jails) Household Importance of early case detection and TB contact investigation Emphasis on behaviour-change campaigns for patients and families of smear/culture positive patients Focus on cough etiquette and respiratory hygiene and to spend as much time as possible outside Use of respirators by HWs in specific situations Renovation of houses for MDR and XDR TB 11
Conclusions Implementation of TB IC involves multiple stakeholders. TB IC truly cuts across the disciplines TB programme unable to implement all aspects. HIV prompted TB programmes to collaborate with HIV counterpart. TB IC should prompt TB programmes to collaborate with other airborne disease control programmes efforts and contribute to health systems strengthening. 12