Module 12: Infection Control in Health Care Settings

*Image courtesy of: World Lung Foundation

It may seem a strange principle to enunciate as the very first requirement of a hospital that it do the sick no harm
Florence Nightingale, Notes on Hospitals, 1863

Infection Control in the ERA of HIV

More PLWAs are attending health care and community facilities VCTs Primary care and ART clinics (IDCCs)
Patients and HCWs who are immunosuppressed may be vulnerable to TB as a result of exposure Some settings may have higher prevalence of TB/HIV, both known and undiagnosed jails/prisons mines

Why TB is a Problem in Healthcare Settings

Persons with undiagnosed, untreated and potentially contagious TB are seen in health care facilities 30-40% of PLWAs will develop TB in the absence of IPT or ART PLWAs can rapidly progress to active TB and may become reinfected HIV-infected HCWs are particularly vulnerable due to occupational exposure

What is Infection Control?

Patient to
Worker Visitor Patient

Worker to
Worker Visitor Patient

Visitor to
Worker Visitor Patient

Infectiousness
Patients should be considered infectious if they Are coughing Are undergoing cough-inducing or aerosol-generating procedures, or Have sputum smears positive for acid-fast bacilli and they

Are not receiving therapy

Have just started therapy, or Have poor clinical response to therapy

Infectiousness (cont.)
Patients no longer infectious if they meet all of these criteria: Have completed at least two weeks of directly-observed and ATT;

Have had a significant clinical response to therapy and

Have had 3 consecutive negative sputum-smear results;

Retreatment /MDR cases may take longer to convert

The only objective criteria is negative bacteriology

Fate of Droplets
Organisms Liberated Talking 0-200 Coughing 0-3500 Sneezing 4500-1,000,000

Droplets can remain suspended in the air for hours.

Hierarchy of Infection Control

Administrative controls to reduce risk of exposure, infection and disease thru policy and practice; Environmental (engineering) controls to reduce concentration of infectious bacilli in air in areas where air contamination is likely; and Personal respiratory protection to protect personnel who must work in environs with contaminated air.

Hierarchy of Infection Controls

Administrative Controls

Prevent droplet nuclei containing M. tuberculosis from being generated; Prevent TB exposure to HCWs, other patients and visitors; Implement rapid diagnostic evaluation and treatment for TB suspects

Specific Administrative Controls

Reduce risk of exposing uninfected persons to infectious disease:
Develop and implement written policies and protocols to ensure - Rapid identification of TB cases

- Isolation
- Diagnostic evaluation - Treatment Implement effective work practices among HCWs Educate, train, and counsel HCWs about TB

Test HCWs for TB infection and disease

Administrative Controls (cont.)

Perform risk assessment and classification of facility based on:

Profile of TB in community
Number of infectious TB patients admitted

Engineering Controls
To prevent spread and reduce concentration of infectious droplet nuclei In clinics Maximize airflow in outpatient clinics settings by opening doors and windows, using fans In hospitals Use ventilation systems in TB isolation rooms Use HEPA filtration and ultraviolet irradiation with other infection control measures

What is Ventilation?
The movement of air
Pushing or pulling of vapor or particles

Preferably in a controlled manner

Ventilation Control
Types of ventilation natural local general

Simple Measures Can Be Effective!

Personal Respiratory Protection

Respirators can protect health care workers; Respirators may be unavailable in low-resource settings;

Face/surgical masks act as a barrier to prevent infectious patients from expelling droplets
Face/surgical masks do not protect against

inhalation of microscopic TB particles

Masks and Respirators

Respirators rely on an airtight seal and have tiny pores which block droplet nuclei

respirators

Masks have large pores and do not have an airtight seal to around the edge, permitting inflow of droplet nuclei Face/surgical mask

Personal Respiratory Protection

Use of respirators should be encouraged in high risk settings: Rooms where cough-inducing procedures are done (i.e., bronchoscopy suites) TB isolation rooms

Referral centers or homes of infectious TB patients

CDC/NIOSH-certfied N95 (or greater) respirator should be used

N95 Respirator Dos and Donts

*Image courtesy of: CDC Image Library

Do
Be sure your respirator is properly fitted!

[Should fit snugly at nose and chin]

*Image courtesy of: CDC Image Library

Note poor fit at the bridge of nose

Note poor fit at the chinRespirator should cover chin and create a seal

Dont forget to WEAR it!

*Image courtesy of: CDC Image Library

Efficacy
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, and You have stored it and kept it in working order in accordance with the manufacturer's instructions
http://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respfact.html

Summary: Infection Control for TB

To reduce risk of TB to HIV positive patients and health workers, you can: Develop IC plan and identify responsible health workers Train staff on TB and TB infection control Screen HIV positive clients for TB symptoms and refer promptly Provide separate waiting areas and expedited care for TB suspects Use personal respiratory protection when indicated Use simple environmental control measures, like opening windows, turning on fans, etc.

Cough Etiquette

Common-sense Prevention

*Image courtesy of: World Lung Foundation

Infection Control (IC) for TB

To reduce risk of TB to HIV positive patients and health workers, you can: Screen HIV positive clients for TB symptoms and refer promptly Provide separate waiting areas and expedited care for TB suspects Provide surgical masks or tissues to TB suspects Use simple environmental control measures, like opening windows, turning on fans, etc. Screen health workers periodically for TB symptoms

5-Steps to Prevent TB Transmission

1 2 3 SCREEN EDUCATE SEPARATE
Early recognition of subjects with suspected or confirmed TB Instruct patients on cough hygiene when sneezing or coughing; provide tissues or mask Request patients to wait in a separate and well-ventilated area

PROVIDE HIV Triage symptomatic patients to front of line SERVICES for services sought, so they spend minimal
time around other patients

5 INVESTIGATE TB diagnostics (sputum smear) should be completed ASAP FOR TB

Infection Control (IC) for TB

Risks to Patients and Health Care Workers Alike! Patient to patient Patient to providers Nurses, doctors, pharmacists, FWEs Provider to patients Reduce TB transmission in health care settings

Devise an Infection Control Plan with your clinics

Teach your colleagues to protect themselves

References
Core Curriculum on Tuberculosis, What the Clinician Should Know. Fourth Edition, 2000. US Dept. of Health and Human Services, Centers for Disease Control and Prevention. hhttp://www.cdc.gov/nchstp/tb/pubs/corecurr/Chapter1/Chapter_1_Introduction.htm hhttp://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respfact.html

Guidelines for Prevention of TB in Healthcare Facilities in Resource-Limited Settings. World Health Organization, 99.269.

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