module 12: infection control in health care settings * image courtesy of: world lung foundation
TRANSCRIPT
Florence Nightingale, Notes on Hospitals, 1863
It may seem a strange principle
to enunciate as the very first requirement
of a hospital
that it do the sick no harm
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 toWorker
Visitor
Patient
Worker toWorker
Visitor
Patient
Visitor toWorker
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 ATT; and
• 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 LiberatedTalking 0-200Coughing 0-3500Sneezing 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
Patien
t
Respiratory Protection
Environmental
Administrative W
orke
r
Facilit
y
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
• The movement of air
• “Pushing” or “pulling” of vapor or particles
• Preferably in a controlled manner
What is Ventilation?
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
Masks have large pores and do not have an airtight seal to around the edge, permitting inflow of droplet nuclei
respirators
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
DoBe 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 chin-
Respirator should cover chin and create a seal
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.
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 Transmission1 SCREEN Early recognition of subjects with
suspected or confirmed TB
2 EDUCATE Instruct patients on cough hygiene when sneezing or coughing; provide tissues or mask
3 SEPARATE Request patients to wait in a separate and well-ventilated area
4 PROVIDE HIV SERVICES
Triage symptomatic patients to front of line for services sought, so they spend minimal time around other patients
5 INVESTIGATE FOR TB
TB diagnostics (sputum smear) should be completed ASAP
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.