PREPARING APREPARING A TUBERCULOSIS TUBERCULOSIS

INFECTION CONTROL INFECTION CONTROL PLAN IN A PLAN IN A

FACILITYFACILITY

Dr. Filiz Duyar AğcaDr. Filiz Duyar Ağca5th TB Control Dispensary 5th TB Control Dispensary

AnkaraAnkara

NO CONFLICT OF INTERESTNO CONFLICT OF INTEREST

CONTENTSCONTENTS

► Factors affecting the risk of TB transmissionFactors affecting the risk of TB transmission

WHEN TRANSMISSION IS PREVENTED, RISK WHEN TRANSMISSION IS PREVENTED, RISK IS REDUCEDIS REDUCED

► Hierarchy of Infection Controls (IC)Hierarchy of Infection Controls (IC)

Managerial ActivitiesManagerial Activities

Administrative ControlsAdministrative Controls

Environmental (Engineering) ControlsEnvironmental (Engineering) Controls

Respiratory Protection Respiratory Protection

HIERARCHY of INFECTION HIERARCHY of INFECTION CONTROLCONTROL

Factors Affecting the Risk of Factors Affecting the Risk of TB Transmission-1TB Transmission-1

► 1- PATIENT FACTORS1- PATIENT FACTORS

Infectiousness, correct treatment and Infectiousness, correct treatment and adherenceadherence

► 2- RECIPIENT FACTORS2- RECIPIENT FACTORS

Closeness,duration and frequency of Closeness,duration and frequency of contact,age, immune statuscontact,age, immune status

► 3- BACTERIAL FACTORS3- BACTERIAL FACTORS

Intrinsic virulence of bacilli, prolonged Intrinsic virulence of bacilli, prolonged period of infectiousnessperiod of infectiousness

Factors Affecting the Risk of Factors Affecting the Risk of TB Transmission-2TB Transmission-2

► INSTITUTIONAL FACTORSINSTITUTIONAL FACTORS

Fixed characteristics (type, location, structure)Fixed characteristics (type, location, structure) Variable characteristics ( temperature, Variable characteristics ( temperature,

humidity)humidity) Type and number of people servingType and number of people serving Resources availableResources available Policies and practices governing patient Policies and practices governing patient

movement and housingmovement and housing Time lag between detection of disease, Time lag between detection of disease,

reporting and proper treatmentreporting and proper treatment

TB and HIVTB and HIV

WHO’S STRATEGY- 3 IWHO’S STRATEGY- 3 I

► Intensified Case FindingIntensified Case Finding► Isoniazid Preventive Therapy (IPT)Isoniazid Preventive Therapy (IPT)► Infection Control (IC)Infection Control (IC) Prevention of particle transmission,Prevention of particle transmission, control of particle spreadcontrol of particle spread

Screen, Educate, Separate, Provide HIV Screen, Educate, Separate, Provide HIV Service, Investigate for TBService, Investigate for TB

HIERARCHY of INFECTION HIERARCHY of INFECTION CONTROLS-1CONTROLS-1

►1) Administrative Controls1) Administrative Controls

Interventions with greatest impact and Interventions with greatest impact and least cost least cost

Policies which significantly Policies which significantly reducereduce the the risk of TB transmission by risk of TB transmission by preventingpreventing the generation of droplet nuclei or the generation of droplet nuclei or reducingreducing exposure to droplet nuclei exposure to droplet nuclei

HIERARCHY of INFECTION HIERARCHY of INFECTION CONTROLS-2CONTROLS-2

►2) Environmental (Engineering) 2) Environmental (Engineering) ControlsControls

Policies which Policies which decreasedecrease number of number of droplet nuclei by preventing droplet nuclei by preventing transmissiontransmission

►3) Respiratory Protection3) Respiratory Protection Policies which Policies which minimizeminimize the exposure the exposure

of droplet nuclei at TB facilities of droplet nuclei at TB facilities

MANAGEMENT OF ICMANAGEMENT OF IC► IC PLAN (budget, coordination team,IC PLAN (budget, coordination team, human resources, procedures)human resources, procedures) ACSM( advocasy,communication, social ACSM( advocasy,communication, social

mobilization)mobilization)

► RISK ASSESSMENT ( priorities at national/ RISK ASSESSMENT ( priorities at national/ facility level, triage for patients)facility level, triage for patients)

► EDUCATION AND TRAINING ( National TB EDUCATION AND TRAINING ( National TB Program, NTP related activities)Program, NTP related activities)

► SURVEILLANCE ( include datas of TB among SURVEILLANCE ( include datas of TB among health care workers)health care workers)

IC PLAN - 1IC PLAN - 1

►Develop Develop different IC plandifferent IC plan for every for every facility, also every area in a facilityfacility, also every area in a facility

►Develop comprehensive Develop comprehensive writtenwritten policies and protocolspolicies and protocols

►EvaluateEvaluate the parameters during the parameters during practicepractice

►Evaluate IC plan results Evaluate IC plan results periodicallyperiodically, , reviserevise as needed as needed

IC PLAN - 2IC PLAN - 2

►Assign Assign responsibilityresponsibility and authority of and authority of health care workers (HCWs)health care workers (HCWs)

►Educate and trainEducate and train HCWs HCWs► Implemented IC plan includesImplemented IC plan includes

Definitions, priorities, budget, Definitions, priorities, budget, maintenance and repair (for example, maintenance and repair (for example, separating 10% of annual budget for separating 10% of annual budget for maintenance and equipment repair is maintenance and equipment repair is suggested)suggested)

((Plan your work, work your Plan your work, work your plan)plan)

DevelopDevelop EducationEducation

ImplementImplementEducation EducationEducation Education EducationEducation Evaluate ReviseEvaluate Revise

Risk Assessment-1Risk Assessment-1

►Different risk assessment for facilities Different risk assessment for facilities within same region,areas within same within same region,areas within same facility (low, medium, potential ongoing facility (low, medium, potential ongoing transmission)transmission)

►Risk assessment according to TB and Risk assessment according to TB and HIV/ AIDS prevalanceHIV/ AIDS prevalance

►Risk assessment for high risk groups Risk assessment for high risk groups and occupational risk groupsand occupational risk groups

►Different risks between geographical Different risks between geographical regions regions

Risk Assessment-2Risk Assessment-2

► Sign risk assessment conducting Sign risk assessment conducting groupgroup

► Sign who responsible from what Sign who responsible from what ► Program risk classification of facilityProgram risk classification of facility► Evaluate TB IC planEvaluate TB IC plan► Periodic evaluation preferred and Periodic evaluation preferred and

revised according to resultsrevised according to results

DR TB UNITSDR TB UNITS

Education and TrainingEducation and Training

► Information about Information about TB and drugTB and drug resistant TBresistant TB, also prevention, also prevention

► InitialInitial and and annualannual training training►Different programs Different programs for each group offor each group of

HCWsHCWs►Program for Program for patientspatients► Informing Informing communitycommunity

SurveillanceSurveillance

►Periodic collection of TB datasPeriodic collection of TB datas

►Include TB datas among HCWsInclude TB datas among HCWs►Procedures for initial, periodic Procedures for initial, periodic

screening and follow up for HCWs screening and follow up for HCWs (chest x-ray, TST)(chest x-ray, TST)

ADMINISTRATIVE CONTROLSADMINISTRATIVE CONTROLS(High priority)(High priority)

►TriageTriage, determining the pathway of , determining the pathway of patientpatient

►Prompt diagnosis and treatmentPrompt diagnosis and treatment►Cough etiquetteCough etiquette for potential TB for potential TB

patientspatients►Separation by time and locationSeparation by time and location►Prevention and care for HCWsPrevention and care for HCWs

Cough EtiquetteCough Etiquette

ENVIRONMENTAL CONTROLS ENVIRONMENTAL CONTROLS 11

ISSUES TO DISCUSSISSUES TO DISCUSS

►DesignDesign►OperationalOperational►MaintainableMaintainable►SustainableSustainable►See: Design to Heal (designtoheal.org)See: Design to Heal (designtoheal.org)

ENVIRONMENTAL CONTROLS ENVIRONMENTAL CONTROLS 22

►TECHNICAL STAFF AND EQUIPMENTTECHNICAL STAFF AND EQUIPMENT►VENTILATIONVENTILATION

(Natural and/ or Mechanical)(Natural and/ or Mechanical)►FILTERSFILTERS

(Pleated, HEPA filters)(Pleated, HEPA filters)►UVGI UVGI

(Ultraviolet Germicidal Irradiation(Ultraviolet Germicidal Irradiation))

VENTILATIONVENTILATION

ConceptsConcepts► Air Change per Hour (ACH)Air Change per Hour (ACH)► Positive Pressure (for HCWs)Positive Pressure (for HCWs)► Negative Pressure (for patients)Negative Pressure (for patients)► Air Flow RateAir Flow Rate► Laminar Flow (laboratory, surgical suits)Laminar Flow (laboratory, surgical suits)

ReferencesReferences

CDC, WHO, AIA, ASHRAE, OSHACDC, WHO, AIA, ASHRAE, OSHA

Natural VentilationNatural Ventilation

► Basic and the cheapestBasic and the cheapest

► Control Control airflow directionairflow direction in a facility in a facility (with smokepipe or velocitymeter) (with smokepipe or velocitymeter) ► Create Create patient and specimen flowpatient and specimen flow

► Control Control temperature and humiditytemperature and humidity (glass film)(glass film)► Control Control air flow rateair flow rate with grill placed with grill placed

doors, upper windows and sliding doors etc.doors, upper windows and sliding doors etc.

VelocitymeterVelocitymeterAir Flow Rate= Cubicmeters/ HourAir Flow Rate= Cubicmeters/ Hour

Smoke pipeSmoke pipe

Mechanical VentilationMechanical Ventilation

►Fans (window extractor, floor type)Fans (window extractor, floor type)►Wind driven turbinsWind driven turbins►Areas of negative and positive Areas of negative and positive

pressurepressure►Local systems (biosafety cabinets, Local systems (biosafety cabinets,

isolation rooms and air cleaners)isolation rooms and air cleaners)►Central systems (for DR TB units)Central systems (for DR TB units)

TB LaboratoryTB Laboratory

► Settings should be done according to types Settings should be done according to types of tests / proceduresof tests / procedures

► Procedures should be performed in separate Procedures should be performed in separate places before and after TB cultureplaces before and after TB culture

► Work flow from clean towards dirty should Work flow from clean towards dirty should be followedbe followed

► Separated oSeparated office area and working areasffice area and working areas► Controlled work flow; it must be in the same Controlled work flow; it must be in the same

way with air flowway with air flow

Smear Microscopy Smear Microscopy LaboratLaboratory ory Work FlowWork Flow

Staining

unit

Specimen acceptance

MicroscopyRegistr. Report.

Biosafety cabinet (BSC)Biosafety cabinet (BSC)

37( CUH2A, Princeton, NJ, USA)

Potential contaminated wastes separated according to their speciality.

Potential aerosolized procedures should be done in a BSC.

Doors kept closed; warning signs must be hanged on .

There must be a lavatory for hand washing

BSL-2

Autoclav used for infectious wastes

FiltersFilters

► It is necessary to supply and removal of air It is necessary to supply and removal of air through a space for negative pressurethrough a space for negative pressure

► Filters placed at exhaust holes for cleaning Filters placed at exhaust holes for cleaning air ( placed both sides if air recirculates)air ( placed both sides if air recirculates)

► Used at local and central ventilation systemsUsed at local and central ventilation systems► Technical specifications and assistanceTechnical specifications and assistance

► HEPA (High Efficiency Particulate Air) filtersHEPA (High Efficiency Particulate Air) filters

provide 99.97% filtrationprovide 99.97% filtration

Air cleanerAir cleaner

UVGI - 1UVGI - 1

►Ultraviolet Germicidal IrradiationUltraviolet Germicidal Irradiation►Additional system to ventilationAdditional system to ventilation►Fixed 2,10- 2.15 cm above the floorFixed 2,10- 2.15 cm above the floor►Fixed opposite to air flowFixed opposite to air flow►Shielded or upper room UV fixtures Shielded or upper room UV fixtures

preferred preferred ►For optimum UVGI efficacy,should be For optimum UVGI efficacy,should be

cleaned and measured periodically cleaned and measured periodically

UVmetersUVmeters

Natural ventilation and UV lightNatural ventilation and UV light

UVGI - 2UVGI - 2► FactorsFactors increasing increasing UVGI efficacy UVGI efficacy 1: Concentration of irrediation1: Concentration of irrediation 2: Period of exposure time2: Period of exposure time 3: Distance between lamp and particles3: Distance between lamp and particles

► FactorsFactors decreasing decreasing UVGI efficacy UVGI efficacy Humidity: >70% NOT suggestedHumidity: >70% NOT suggested

► Occupational Exposure LimitOccupational Exposure Limit► Dose= Time x IrredianceDose= Time x Irrediance (max 6000 (max 6000 µµJ/cmJ/cm²²))

Respiratory ProtectionRespiratory Protection

►RespiratorsRespirators For the HCWs and close contactsFor the HCWs and close contacts N 95 (USA) ; FFP 3 (Europe)N 95 (USA) ; FFP 3 (Europe)►Surgical MasksSurgical Masks For patientsFor patients►Negative Pressure RespiratorsNegative Pressure Respirators For bronchoscopy and DR TB unitsFor bronchoscopy and DR TB units►Fit TestingFit Testing

RespiratorsRespirators

Negative Pressure RespiratorNegative Pressure Respirator

Fit TestingFit Testing

THANKSTHANKSfilizduyaragca@gmail.comfilizduyaragca@gmail.com

► ReferencesReferences

1- WHO Policy on TB Infection in Health Care 1- WHO Policy on TB Infection in Health Care Facilities, Congregate Settings and Facilities, Congregate Settings and Households; 2009Households; 2009

2- CDC Guidelines, MMWR 20052- CDC Guidelines, MMWR 2005

3- WHO European Training on TB Infection 3- WHO European Training on TB Infection Control, course notes, 2008Control, course notes, 2008

4-4-www.TuberculosisTextbook.com ,2007www.TuberculosisTextbook.com ,2007