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Module 12: Infection Control in Health Care Settings
*Image courtesy of: World Lung Foundation
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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 Florence Nightingale, Notes on Hospitals, 1863
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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
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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 Up to 10% of HIV-infected persons attending VCT and/or PMTCT services may have active TB, and 50% of these may be infectious. The only way to de-stigmatize TB is to normalize TB.
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What is Infection Control?
Patient to Worker Visitor Patient Worker to Worker Visitor Patient Visitor to Worker Visitor Patient Keep in Mind that transmission is not one-way and does not discriminate! Patients can Transmit to workers, visitors and other patients and vice versa. Any infectious person puts everyone in her immediate surroundsing s at risk!
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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
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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
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Droplets can remain suspended in the air for hours.
Fate of Droplets Organisms Liberated Talking 0-200 Coughing Sneezing ,000,000 Droplets can remain suspended in the air for hours.
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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.
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Hierarchy of Infection Controls
Administrative Worker Environmental Patient Respiratory Protection Facility
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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
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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
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Administrative Controls (cont.)
Perform risk assessment and classification of facility based on: Profile of TB in community Number of infectious TB patients admitted
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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
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What is Ventilation? The movement of air
“Pushing” or “pulling” of vapor or particles Preferably in a controlled manner
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Ventilation Control Types of ventilation natural local general
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Simple Measures Can Be Effective!
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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
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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
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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
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N95 Respirator Dos and Don’ts
*Image courtesy of: CDC Image Library
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Do Be sure your respirator is properly fitted!
[Should fit snugly at nose and chin] *Image courtesy of: CDC Image Library
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Note poor fit at the bridge of nose
Note poor fit at the chin- Respirator should cover chin and create a seal
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*Image courtesy of: CDC Image Library
Don’t forget to WEAR it! Respirators are like condoms, they don’t do you any good if kept in your pocket or purse!! *Image courtesy of: CDC Image Library
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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
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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.
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Cough Etiquette
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Common-sense Prevention
*Image courtesy of: World Lung Foundation
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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
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5-Steps to Prevent TB Transmission
1 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
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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
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References Core Curriculum on Tuberculosis, What the Clinician Should Know. Fourth Edition, US Dept. of Health and Human Services, Centers for Disease Control and Prevention. hhttp:// hhttp:// Guidelines for Prevention of TB in Healthcare Facilities in Resource-Limited Settings. World Health Organization,
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