1. Module 12: Infection Control in Health Care Settings
*Image courtesy of: World Lung Foundation

2. 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

3. 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

4. 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.

5. 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!

6. 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

7. 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

8. 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.

9. 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.

10. Hierarchy of Infection Controls
Administrative
Worker
Environmental
Patient
Respiratory Protection
Facility

11. 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

12. 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

13. Administrative Controls (cont.)
Perform risk assessment and classification of facility based on:
Profile of TB in community
Number of infectious TB patients admitted

14. 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

15. What is Ventilation? The movement of air
“Pushing” or “pulling” of vapor or particles
Preferably in a controlled manner

16. Ventilation Control
Types of ventilation
natural
local
general

17. Simple Measures Can Be Effective!

22. 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

23. 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

24. 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

25. N95 Respirator Dos and Don’ts
*Image courtesy of: CDC Image Library

26. Do Be sure your respirator is properly fitted!
[Should fit snugly at nose and chin]
*Image courtesy of: CDC Image Library

27. Note poor fit at the bridge of nose
Note poor fit at the chin-
Respirator should cover chin and create a seal

28. *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

29. 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

30. 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.

31. Cough Etiquette

32. Common-sense Prevention
*Image courtesy of: World Lung Foundation

33. 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

34. 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

35. 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

36. 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,

37. VIDEO:
Why Don’t We DO IT
in Our Sleeves?