1. CMO, Central TB Division
Summary of National Guidelines on Airborne Infection Control in Healthcare Settings
Dr. K. Sachdeva
CMO, Central TB Division

2. Overview Importance of airborne infection control
Summary of (draft) national guidelines
Managerial activities (National, State, Facility)
Administrative controls
Environmental/Engineering controls
Personal respiratory protection
Next steps

3. Airborne infection control: Why should you care?
Transmission – TB and other resp. pathogens
Protection – patients and staff
Preparedness – pandemic viral disease
Accreditation – NABL, MCI and others

4. Evidence shows airborne transmission happening in health care facilities
Objective:
Estimate incidence/prevalence of
TB in HCWs in Low/Middle income countries
Methods:
Search of medical literature electronic databases
Review and analysis of 42 articles, 51 studies
Findings:
LTBI prevalence: % (33 – 79%)
Annual risk of LTBI: – 14.3 %
Annual incidence TB disease: – 5,780/100,000
Attributable risk for TB disease: – 5,361/100,000
Joshi R et al. PLOS Medicine 2006; 3(12):

5. Work Location TB Incidence Rate Ratio Outpatient facilities 4.2-11.6
People in health care facilities are exposed to airborne transmission, as shown by example of high TB rates in HCW
Work Location TB Incidence Rate Ratio
Outpatient facilities
General medical wards
Inpatient facilities
Emergency rooms
Laboratories
*relative to general population where study conducted.
Joshi R et al. PLOS Medicine 2006; 3(12):

6. Airborne infection control measures implemented (1996)
Impact of Airborne Infection Control Measures on TB Transmission in Chiang Rai, Thailand,
Airborne infection control measures implemented (1996)
Administrative
Infection control plan and SOPs
HCW education and training (including laboratory staff)
HCW TST testing, with isoniazid preventive therapy
TB patient education
Environmental
Natural ventilation maximized in high-risk areas
Negative pressure ventilation in TB isolation rooms
Class II biosafety cabinet for laboratory
HCW respiratory protection (N-95 masks)
Known exposure to infectious TB patient
Laboratory staff processing TB cultures
Infection control and SOPS:
Isolation and transportation
Improved timeliness to diagnosis, and treatment of TB patients—time to admit, order labs, get results, start treatment
Compliance with therapy
Yanai H, Limpakarnnanarat K, Uthaivoravit W, et al. Int J Tuberc Lung Dis 2003;7:36-45.

7. Impact of Airborne Infection Control Measures on TB Transmission in Chiang Rai, Thailand (cont)
Implementation of IC package was followed by decreased health care worker TST conversion rates, even though more TB cases detected in Chiang Rai overall
HCW TST conversion rate (1995–7): /100 py
HCW TST conversion rate (1999): /100 py
Showed that implementation of IC package can reduce airborne transmission
Yanai H, Limpakarnnanarat K, Uthaivoravit W, et al. Int J Tuberc Lung Dis 2003;7:36-45.

8. What to do?

9. National Guidelines on Airborne Infection Control
Purpose: to provide up-to-date information about recommended methods of reducing the risk of airborne infections in health care facilities.
Target audience
Health officials (general, not just TB)
Health facility administrators and infection control focal points
Elements now included in NABH hospital accreditations

10. Contributors NAICC Chair Prof SK Jindal
Committee members – Dr D Behra, Dr R Sarin, Dr R Singla (LRS), Dr A Agarwal (PGI), Dr V Chandrashekar (DGHS), Dr Gupta (NCDC), Dr Thakur (NACO), Dr Solanki (BJMC), Dr Rajesekaran (Chennai), Dr Anand (NTI), Dr Mahilmaran (GHTM)
CTD - Dr LS Chauhan, Dr K Sachdeva, Dr D Gupta, Dr M Parmar, Dr S Chadha
WHO – Dr S Sahu, F Wares
CDC – Dr M Pearson & Dr P Jensen

11. Managerial activities  (National, State, Hospital administration and local health officials)
National level: Plan, establish policy, train, coordinate, evaluate
State/District level: Promote IC focal points at facilities, develop coordination mechanisms, Plan, train, monitor
Facilities: Develop local plan, implement, supervise

12. Facility-Level Management Activities
Designate focal points for the facility-level activities
Conduct a facility-risk assessment
Develop a facility plan for airborne infection control
Rethink the use of available spaces and consider renovation and/or construction, e.g. waiting areas
Support trainings
Ensure proper implementation of the administrative controls – especially relocation of waiting areas, implementation of systems for queing, screening, fast tracking
Keep adequate budget for maintenance of any controls
Supervise and monitor infection control activities

13. Education & training of staff is the key to infection control
Principles & practices of infection control – standard precautions
Issues about airborne infection risk and prevention
Realities about personal respiratory protection
Responsibilities of personnel and institution should be clear

14. Specific controls recommended in National Guidelines
Administrative controls
Reduce potential opportunities for exposure
Environmental controls
Reduce concentration of infectious particles that may be present
Personal respiratory protection
Further reduce risk to staff (not other patients) in very high-risk settings where exposure not avoidable

15. What is meant by administrative controls?
All policies developed by infection control team to decrease risk
Procedures for implementing, enforcing, monitoring, evaluating, and revising infection control plan

16. Recommended outpatient administrative controls
Patient screening
Cough hygiene IEC for patients
Segregation of respiratory symptomatics (where possible)
Fast-tracking of respiratory symptomatics
Jumping the queue
Alternate evaluation pathway

17. Triage
Identify people with respiratory symptoms

18. Respiratory Infection Control in Health Care Facilities18 18

20. Separate
Where possible, separate persons with respiratory symptoms in a separate well-ventilated waiting area
The specific criteria for separating patients will depend on the local settings and patient population
Guiding priorities
Minimize opportunities for transmission
Protect immuno-compromised patients
Keep drug-resistant TB from spreading

21. Examples of waiting areas

22. Fast-track respiratory symptomatics to minimize time in health care facilities
Example: Screening and marking OP tickets for fast-tracking PTB suspects through diagnosis

23. Inpatient administrative controls
Minimize hospitalization as per current practice under DOTS
Educate patients and attendants on cough hygiene
Routine segregation of patients to separate wards (or separate areas in same ward) so to reduce risk of transmission, particularly to immune-compromised
Where possible, isolate infectious patients
Maintain spacing, ward decompression

24. Segregation 1. Keep HIV+ persons safe from
Persons with MDR TB
Known S+ patients
2. Keep the most infectious patients (any S+ newly-starting treatment) away from others

25. Segregation does not happen without both policy and enforcement
Designating appropriate areas
Routine (voluntary) HIV testing at admission
Automatic procedures to move patients when indicated

26. Safe sputum collection
Keep aerosol generating procedures away from other patients
Sputum collection
Sputum induction

27. Environmental controls
Indoor patient segregation and bed spacing
Ensure effective ventilation at all times and seasons
Special attention for high-risk areas

28. Segregation and Spacing
Keep infectious patients away from vulnerable patients using whatever approach is feasible:
Airborne precaution areas
Individual rooms
Designated wards or ward areas

29. Ventilation
Health-care facilities should seek to achieve minimum standards for air exchange.
High-risk settings should be prioritized for immediate assessment and implementation of improved ventilation.

30. Minimum air-changes per hour (ACH) required for various health care settings
Type of Health care setting
Minimum ACH
Registration/Waiting
> 6 ACH
Outpatient departments
Inpatient departments
High-risk settings
ART centres
TB /  Chest departments (outpatient and inpatient)
Bronchoscopy procedure rooms
MDR-TB wards and clinics
Airborne isolation rooms
> 12 ACH

31. Natural Ventilation
In most settings, natural ventilation is the preferred method for ensuring adequate air exchange.
Ensure effective ventilation at all times and in all climatic conditions through proper operation and maintenance, and by regular checks to ensure fixed, unrestricted openings.
Example: Use of louvered shutters instead of glass windows to ensure ventilation day and night

32. Assessing if natural ventilation is adequate
Where ACH is not able to be measured, as is usually the case in rooms with natural ventilation, the following standards for ventilation should be followed to ensure that air exchange is safely >6 ACH under all climactic conditions.
Natural ventilation should be "controlled", with fixed, unrestricted openings that are insensitive to climactic conditions
Openings should constitute >20% of floor area
Openings should be on 2 sides, preferably opposite sides. For example, a 100 ft 2 room should have >10 ft 2 fixed, unrestricted openings on two sites, for a total of 20 ft2

33. If natural ventilation not adequate…
Guidelines caution against use of technologically driven interventions (mechanical ventilation, UVGI) without sustained commitment and clear commitment for maintenance and budget
Blocked air intake duct for ventilation of waiting area

34. Mechanical ventilation
Mechanical ventilation – with or without climate control – may be appropriate where natural ventilation cannot be implemented effectively or is inadequate given local conditions (e.g. building structure, climate, regulations, culture, cost and outdoor air quality)
If mechanical ventilation is used, the system should be well designed, maintained and operated, to achieve adequate airflow rates and fresh air exchange.

35. Directional control of air-flow
Directional control of air flow (i.e, negative pressure) is recommended in specific high-risk settings where infectious patients with drug-resistant TB or other acute respiratory diseases of potential concern are likely to be managed – i.e. airborne isolation rooms, MDR-TB wards and clinics, and bronchoscopy suites

36. Arrangement of patients and staff
Optimal arrangement of patients and staff should be implemented in all outpatient departments, DOT centers, microscopy centers, and radiology

37. What’s wrong with this picture?
Chest clinic, Oct 2009

38. What’s wrong with this picture?
Very poor ventilation, blocked windows, re-circulating A/C
Ineffective filtration devices gives false security
Exhaust fan would draw air from waiting to doctor’s chamber
Crowded waiting area (wait outside!)

39. UVGI
In high-risk settings where it is not possible to achieve adequate air exchange using natural ventilation, a complementary option is to use upper room or shielded ultraviolet germicidal irradiation (UVGI) devices.
Installation should seek to irradiate the maximal air volume with the highest intensity UV, while keeping staff and patient exposure to less than 6.0 mg/cm2 over an 8-hour period.
Emphasis on proper installation and maintenance.

40. Personal Respiratory Protection
Only N95 particulate respirator for HCW, properly fitting and used, provides some additional protection to the user against airborne infection
Masks (including 3-layer surgical masks) are effective primary for source control of patient, to catch what is going out, not what is coming in
Masks for HCW may be useful for large respiratory droplets and protection of mucous membranes (i.e. catch the spray from a sneeze before it hits your face) and remain a part of droplet precautions

41. Place of respirators in infection control activities
Proper implementation of administrative and environmental controls is first and second line of defense;
Respirators only add a layer of insurance where the risk to HCW is especially high.
Guidelines address situations where respirators appropriate, training, selection and fit, and re-use

42. When should respirators be used?
Settings in India where particulate respirators are recommended for protection against airborne infection
1) Laboratories: When manipulating cultures (solid or liquid media), despite use of biosafety hood or negative pressure facility
2) Bronchoscopy: for all staff in bronchoscopy suite
3) MDR Wards (opt): Respirators should be made available for optional use by staff, with all staff receiving training and sensitization on their use.
4) As recommended by MoH to contain spread of disease of public health importance and unknown transmission (e.g. Influenza H1N1)

43. Households
Behaviour change campaigns for family members of smear positive TB patients
Maximize home ventilation
Practice cough etiquette
When smear positive, where possible sleep in separate room & spend as little time as possible in congregate settings
Sensible, practical, yet hygienic sputum disposal

44. Next Steps Dissemination of national guidelines
Large facilities should begin managerial activities
Pilot testing of feasibility of interventions
40 facilities, various types (MC, DH, CHC/RH, B-PHC), West Bengal, Gujarat, and Andhra Pradesh
Development of IC capacity
Managers, programme officers, facility administrators,
Architects and engineers
Engage with MCI / NCI / IPHS to integrate recommendations into curriculum/standards
Frontline healthcare workers on Standard Precautions, including airborne/TB

45. Thanks NAICC Chair Prof SK Jindal
Committee members – Dr D Behra, Dr R Sarin, Dr R Singla (LRS), Dr A Agarwal (PGI), Dr V Chandrashekar (DGHS), Dr Gupta (NCDC), Dr Thakur (NACO), Dr Solanki (BJMC), Dr Rajesekaran (Chennai), Dr Anand (NTI), Dr Mahilmaran (GHTM)
CTD - Dr LS Chauhan, Dr K Sachdeva, Dr D Gupta, Dr M Parmar, Dr S Chadha
WHO – Dr S Sahu, F Wares
CDC – Dr M Pearson & Dr P Jensen