Experiences from Peru; ¿What have we learned?

Dr. Martin Yagui Moscoso

1. PERU

Area: 1,285,215 Km

Total population: 28 millions

Average life expectancy:69years

Population living in poverty: 54%

TB incidence: 108 x 100,000

MDR TB among new patients: 3%

National HIV prevalence: 0.6%

TB among HIV patients: 30%

HIV among TB patients: 3%

1. Health Services

7,501TOTAL

5,237

Post

Centers

1,778

Health

Centers

486Hospitals

Number

Health

Services

2. Tasa de Morbilidad e Incidencia de TuberculosisPerú 1990 - 2005

3. TB transmission in Health services in Peru

• 2000: A Study in Callao-Peru using tuberculin skin Test (TST) between residents measured incidence of TST conversion

• Of 98 residents that had been evaluated, 59% had a positive TST before the study

• Of 36 residents that were initially negative TST, 6 converted to positive TST (Annual rate of TST conversion: 17%)

Bonifacio N.; Saito M., Gillman R et al. High Risk for Tuberculosis in Hospital Physicians, Peru. Letter in EmergInfect. Dis. 8:747-748. 2002

TB outbreak in Health services in Peru

• Outbreak in Almenara Hospital in 1997. 44 health workers with TB suspects.

• TB incidence 1994: 167 x 100,000

• TB incidence 1997:– Laboratory: 6977 x 100,000

– Medicine: 932 x 100,000Alonso Echanobe J et al. Transmision of M Tuberculosis in Heahthcare workers University

Hospital in Lima Peru Clin Infec Dis 2001;33:589-596

TB outbreak in Health services in Peru

• 36 health workers had TB confirmed

• Multivariate analysis: independent risk factor for TB infection in laboratory health workers was the use of common areas

Alonso Echanobe J et al. Transmision of M Tuberculosis in Heahthcare workers University Hospital in Lima PeruClin Infec Dis 2001;33:589-596

Susceptibility and resistance of M. tuberculosis in Health workers. Peru -

2004

10065TOTAL

13.89Non viable or contaminated

23.115Poli or monoresistance

10.87MDR

52.334Pan-susceptible

%#Results

4. Chronology of IC in Peru

1990-1997 1998 2002 2004 2005 2006 2007

TB IC plans

In 10 Health

Centers and

hospitals

Global Fund

finance TB IC

Plans in

18 hospitals

Beginning of

Activities of

General IC

The first

guideline

of TB IC

in Peru

The first course

for engineers/

Updated TB

Guidelines

Beginning

of the TB

IC trainings

Organization

and

improvement

of NTP/

Biosafety

5. Peruvian Guidelines of IC

• 1998: the first Infection Control Guidelines (in general):

– Surveillance of Nosocomial infections (NI)

– Control and prevention of NI

– Sterilization

– Hospital Solids residues

5. Peruvian Guidelines of TB-IC

• 2002: specific guidelines for TB-IC– Isolation Guideline (2002)

– TB Infection Control for Health establishments: Training module (2004)

– Manual de doctrina de TB (2006)

www.epiredperu.net/SPE/spe.htm

6. Training in Infection Control

1997-2007: • 70 hospitals were training

in surveillance of Nosocomial infections, control and prevention, isolation and sterilization.

• More than 2000 health workers were training in general and specifics aspects of Infection control.

6. Training in Infection Control

• 2002: Training in TB-IC for health workers of Lima and Callao in courses to:– Doctors and nurses of TB programs

– Laboratorists

– Hospital directors

– Doctors and nurses of emergency, ICU and medicine departments

– Engineers and architects

6. Training in Infection Control

• The content of those courses include: general concepts about TB transmission, administrative controls, environmental controls (natural and mechanical ventilation, UV Light, HEPA filters) and respiratory protection (fit test)

• Time: 3 or 4 days.

7. Implementation of TB-IC Plans

• TB-IC Plans were subsequent to the training courses.

• We help to participants to develop a TB-IC Plan in the last day of the course and then select the best TB-IC Plan

7. Implementation of TB-IC Plans

• Criteria for selection are:– 3 controls (administrative, environmental, rp)

– political commitment of authorities of the hospital

– Health services that have high rates of TB and MDR

• Amount of money for each TB-IC Plan:– Health centers: $5000

– Hospitals: $15,000 – 20,000

8. Example of TB-IC Plans in LimaBefore - After

9. Biosafety in Mycobacterium laboratory

• 1996: NHI of Peru has developed the norms of biosafety for TB laboratories

• 2006: these norms were updated

9. Biosafety in Mycobacterium laboratory

• With the support of the State Laboratory of Massachusetts courses have been developed to form certifiers of biosafetycabinets

• TB Laboratory network in Peru:– 60 laboratories process

cultures– 6 laboratories process DST

9. Biosafety in Mycobacterium laboratories

• Since 2004 were remodeled and/or built intermediate laboratories for processing Rapid DST (Griess), conventional DST and cultures in Lima with the followings criteria:– More than 12 air exchange/hour

– Negative pressure

– Functional distribution of the areas

10. Future activities in TB-IC

• The Global Fund TB Project has planned Infection Control activities for 18 hospitals at national level, this includes:

– Trainings for health workers in 18 hospitals

– Financing the implementation of 18 Infection Control Plans.

11. Infection Control in Latin America

• Since 2002, PAHO promoted some activities on General Infection Control this included the following:– Elaboration of protocols (cost, supervision)

– Technical assistance

– Visits of supervision to hospitals

11. Isolation Rooms in Latin America hospitals

• 2006: evaluated 31 hospitals in 5 countries of Latin America.

• We used a Rapid Guideline of PAHO for IC

• Only 7 hospitals had respiratory isolation room (23%)

11. TB Infection Control in Latin America

• Courses in Bolivia, Paraguay and Ecuador during 2006-2007

• Approximately 40 participants for each course

• These courses included doctors, nurses and laboratorist of referalhospitals of each country

11. TB Infection Control in Latin America

• Included trainers from Peru and CDC

• Practice include:

• Administrative controls: identify risk areas for TB transmission

• Environmental controls: evaluation of natural and mechanical ventilation, measure of air flow and # of air exchange, etc

• Respiratory protection: Fit test

12. Lessons learned: Guidelines

The existence of local and national guidelines on general aspects of Infection Control facilitates the introduction of TB-IC measures

12. Lessons learned: Guidelines

It's important to be careful in adopting recommendations of other countries with different prevalence of TB, more resources, etc.

12. Lessons learned: Elaboration and implementation of TB-IC Plans

In many hospitals aspects of environmental controls and respiratory protection are prioritized neglecting the implementation of administrative controls.

12. Lessons learned: Training

Frequent rotation of health workers forces to National TB program to have constant trainings in infection control

12. Lessons learned: Training

It is important to include to engineers and architects who work in health services in these trainings.

12. Lessons learned: donors

• National TB programs must be able to supervise construction or remodeling TB areas (inpatient, laboratories, etc) not to increase the risk of transmission

Donors not necessarily know about IC

Acknowledgements

• Peruvian National Tuberculosis Program• Peruvian National Institute of Health • CDC• PAHO/WHO• Socios en Salud• Harvard Medical School• Brigham and Women’s Hospital• Massachusetts State Laboratory Institute

THANKS

Martin Yagui Moscoso, MD

myaguim2002@yahoo.com

www.epiredperu/SPE/spe.htm