1. Anders Chen, MD Internal Medicine R3 4/5/2011

2.  TB infection control (TB IC): Background  WHO Policy recommendations  Literature review  Practical next steps

3.  Increased nosocomial TB in high income countries in 1980s and 1990s 1,2,3.  Increased focus on TB IC in health care settings, with creation of guidelines and manuals to aid in their implementation 1 Pearson, Ann Int Med 1992, 2 Beck-Sague JAMA 1992, 3 Menzies NEJM 1995

4. Guidelines Implementation

5.  Resurgence of TB in low income countries fueled by HIV pandemic  Higher rates of HIV and TB  Already small health care workforce  Less resources for infection control  Nosocomial transmission risk for patients  HCW rates of TB well above average population rates 4 4 Menzies, Int J Tuberc Lung Dis 2007

6. Guidelines Implementation?

7.  At the facility level:  Managerial controls:  Coordinating body for TB IC  Facility risk assessment  Surveillance of TB disease in HCW  Rethinking use of space  Advocacy  Monitoring and evaluation of TB IC efforts

8.  Administrative controls:  Prompt identification of suspected/confirmed TB patients  Separation of such patients away from others, especially immunocompromised patients, into well ventilated areas  Cough etiquette, respiratory hygiene  Rapid diagnosis  Protection of HCW

9.  Environmental Controls:  Ventilation: optimizing natural ventilation where appropriate  Large open windows  Directional flow  Adequate ACH  Mechanical or mixed mode ventilation where natural ventilation not appropriate  UVGI as a supplemental control  Lab safety

10.  Personal Protective Equipment  N95 or equivalent respirators for staff

11.  Lack of tools to aid in implementation in low income countries  Data supporting TB IC measures in high income countries has been with packages of multiple interventions simultaneously, including expensive measures  Few data looking at effectiveness of any individual interventions 5 5 WHO 2009 annexes

12.  In low and middle income countries, are there examples of successful implementation of low cost TB IC interventions?  Are there data showing reduced nosocomial TB spread with limited, low cost interventions?

13.  Limited resources, limited implementation, limited reports.  Literature review including conference abstracts and grey literature yielded 23 articles describing TB IC in low and middle income countries.  16 descriptions of successful implementation  2 report efforts to monitor and evaluate TB IC efforts  9 report data on nosocomial transmission before and after TB IC efforts  5 published in peer reviewed journals with statistical analysis, of which 4 yielded positive results.

14.  da Costa, J Hosp Infect 2009, Brazil  Low cost administrative measures including HCW training, cough etiquette, separating coughing patients, rapid sputum processing, clustering of TB services to reduce exposure. Also respirators for staff  Reduced LTBI incidence in HCW  Upper middle income country, relatively low cost interventions

15.  Roth et al. Int J Tuberc Lung Dis 2005  2 Brazilian hospitals with higher levels of TB IC, 2 with lower levels.  TB IC measures include rapid diagnosis/testing, isolation rooms. Biosafety cabinets in labs.  Lower LTBI incidence in HCW in 2 hospitals with higher levels of TB IC measures  Upper-middle income country, some higher cost measures

16.  Yanai, Int J Tuberc Lung Dis. 2003  Thailand, referral hospital  Many lower cost interventions incl. administrative controls of triage, cough etiquette, rapid sputum processing, natural ventilation  Some higher cost measures: biosafety cabinets, 1 isolation room  Lower LTBI incidence in HCW after measures implemented  Lower middle income country, mix of low and higher cost measures

17.  Catterick, South African AIDS Conference 2009  Church of Scotland Hospital, Tugela Ferry, site of well publicized highly fatal XDR outbreak  Administrative controls: TB IC officer. Cough officers to screen patients. Separated DOTS and HIV and moved both to periphery of hospital campus. Screened HCW for TB  Environmental: Unannounced audits on open window policy  PPE: Unannounced audits on staff respirator use  Report successful low cost measures, no data  Poor area in an upper middle income country, with inexpensive measures implemented

18.  Existing data do suggest that low cost measures can be implemented and can reduce nosocomial TB spread  More data would be useful, as would monitoring and evaluation of efforts

19.  Practical tools to aid in implementation of TB IC guidelines.

20. Guidelines Implementation?

22.  I-TECH (International Training and Education Center for Health  Chris Behrens, Scott Barnhart, Tom Heller