1. Policy update on TB infection control Fabio Scano STB, WHO TBIC TBIC

2. Outline 1.Where we stand 1.Literature review 2.Formulation of the recommendations 3.Finalization of the document 2.Next steps 1.Policy dissemination 2.Scale up

3. Timeline and progress Oct 07-April 08May 2008Sept 2008Nov 2008Dec 08-Jan 09 1. Questions formulation 2. Systematic review 3. Drafting of the recommendations 4. Sharing with the panel 5. Finalization

4. Questions for systematic reviews 1.Where does TB transmission happen? 2. What is the efficacy of TB IC interventions –Cough etiquette –Triage & co-horting –Hospital stay –Ventilation –UVGI –Respirators

5. Quality of Evidence – GRADE approach Grading approach to assess the quality of evidence. To inform the strength of the public health intervention Low quality evidence does not mean weak recommendation Public health recommendation to also consider programmatic issues. BMJ 2004;328; 1490–98

6. Where does TB transmission happen

7. Pooled estimates (reference general population) populationOutcomeSettingsStudies Risk Ratio Health care workers TB infectionLow income95.77* TB infectionHigh income4010.06 TBLow income375.71 TBHigh income151.99 CongregateTB infectionHigh income52.74* TBHigh income18 21.41 21.41* HouseholdTB infection & TBLow income71.73* TB infection & TBHigh income153.19 *with outliers LMICs: Low- & Medium- Income countries (World Bank ranking) HICs: High- Income countries (World Bank ranking)

8. Conclusions Clear higher risk for health care workers Need for a careful and further analysis for household and congregate settings RR is higher in all the observed settings. Impact at population level?

10. Efficacy of cohorting

11. Study Selection 50 articles on triage from which only 12 articles contained data Triage and cohorting: 2095 articles from two databases

12. Results for triage and co-horting (12 studies) Two studies from LMIC show significant reduction One study from LMIC shows little impact. In 11 studies, indicators of nosocomial transmission decline following implementation of IC measures Two studies show that implementation of administrative interventions alone reduced TB transmission. One study shows great benefit of isolation. Implementation of administrative interventions alone reduced nosocomial transmission of MDR in HIV ward.

13. Conclusions The quality of evidence available is low Always part of a package of interventions. Evidence suggests that reduction in the risk of TB infection is possible with simple administrative control Strong theoretical benefit to implement these interventions TBICTBIC

14. Recommendation Implementation of strategies to separate patients (cohorting) after triage are recommended in health care and congregate settings. The specific criteria for cohorting patients may vary depending on the local settings and patient population. HIV infected patients should be physically separated from those with suspected or confirmed infectious TB. Drug resistant TB suspects/patients should be separated from other patients including other TB patients. Strong recommendations, low quality evidence (see annex 6b,and chapter VI: table 6b) Remarks These recommendations place high value on avoiding exposure of non-infected patients (in particular if immunocompromised) to infectious ones irrespective of the drug susceptibility testing pattern.

15. Recommendation: physical separation of suspected and known infectious cases Population: patients accessing Health Care and Congregate Settings FactorDecisionExplanation Quality of evidence Low The quality of the evidence available is low. Only one study shows a direct impact of physical separation as an individual intervention on reduction of TB transmission. Benefits or desired effects Strong Early diagnosis and initiation of proper treatment Reduction of transmission among individuals attending HCFs Reduction of transmission among HCWs and families Disadvantages or undesired effects PLWH (TB suspects) might be separated together with smear positive TB patients. Values and preferences Strong HCWs will like measures that reduce their exposure Communities will like measures that will make HCFs a safer place But.. Increase workload for HCWs and Stigmatization Costs Moderate (will increase cost but not much) Reduced by: Diagnostics costs of suspected new cases Averted cases Break chain of transmission Increased by: Staff training Infrastructures (separated waiting area, isolation rooms…). This may require major capital investment. Additional AFB and CXR for positive TB triage Feasibility Conditional to country Setting Generally feasible in HIC Lack of human resources in MIC/LIC Lack of infrastructures in MIC/LIC Slow diagnostic process to exclude TB infection (turnaround time…lab facilities) Overall ranking of recommendation STRONG RECOMMENDATION Research gap To develop and assess the impact on reduction of TB of different models of physical separation based on smear; HIV status and suspected or confirmed TB sensibility pattern

16. Efficacy of respirators

17. Study Selection respirators 4593 articles from six databases 103 articles on respirators, from which only 13 articles contained relevant data after full-text review

18. Results for Respirators (13 papers) 3 epidemiologic studies ( benefit of using respirators) Modeling studies (lower infection risk with better respirator and use of masks/respirators can prevent XDR-TB cases) Better respirators cost more, HEPA respirators are not cost- effective, and costs have decreased with time Low compliance by HCWs User seal check should not be used as surrogate fit test

19. Recommendation: Use of respirators Population: health care settings Intervention: Respirators FactorDecisionExplanation Quality of evidence Low Theoretical basis low evidence No clear guidance on the duration of use Benefits or desired effects Benefits not always outweigh disadvantages Provide additional protection to the HCWs Disadvantages or undesired effects Not clear additional protection if environment is well ventilated Requires training Requires adherence Affect HCW's performance on practices. Allergies to material Values and preferences moderate HCWs will like measures that reduce their exposure But.. Reduces comfort of HCWs Generate stigma Costs moderate Increased by: Purchase Training programme Feasibility Conditional to country setting Lack of expertise Lack of training Requires commitment to wear them from health care workers Overall ranking of recommendation STRONG RECOMMENDATION (MDR and high risk procedures) CONDITIONAL RECOMMANDATION (susceptible TB) Research gap 1. To determine the effectiveness of the intervention on the reduction of TB transmission 2: To determine the programmatic role of fit testing versus fit checking

20. Recommendation 1. In addition to implementation of administrative and environmental interventions, respirators should be used by HCWs when providing care for patients/suspects with susceptible TB, whenever possible. Conditional recommendation (see annex 11, and chapter VI: table 11) 2. Respirators should be used by HCWs during aereosol-generating procedures associated to higher risk of TB transmission (e.g bronchoscopy, intubation, aspiration of respiratory secretions and autopsy or lung surgery with high speed device) and when providing care to MDR-XDR TB patients. Strong recommendation (see annex 11, and chapter VI: table 11) The use of respirators should be part of a comprehensive training programme. Ideally, the training programme should also include fit testing.

21. Congregate settings Include prisons, army barracks and homeless shelters. TB incidence exceeds the incidence among the general population (complex transmission dynamics) Recommendations cannot be too specific because they cover such a wide range of settings.

22. Congregate settings Recommendations: Programmatic and administrative interventions –as per health care facilities –high focus on case detection, cohorting and no overcrowding Environmental and personal protective –Follow country legislation for public buildings Remarks Any HCF within a congregate setting should be considered as an health care setting.

23. Infection control in the community Background 1. Major risks for contacts lies in the exposure to the infectious case before the diagnosis 2. Early case detection remains a pillar intervention 3. IC literacy messages should be part of any community

24. Infection control in the community Guidance: Shared space should be well ventilated (natural ventilation). If possible patients should spend as much time as possible outside. Patients should be educated and always respects cough etiquette Ideally, patients should sleep in a separate room if smear positive. Patients should avoid public transportation and congregate settings if smear positive. DO we need specific recommendations for MDR patients?

25. Prioritization Essential package for airborne infections: 1.cough etiquette 2.patient placement 3.well ventilated rooms Package of interventions based on the burden of TB, HIV and MDR-XDR TB.

26. Targets By 2009: 1) 50% of the countries, according to the prioritization, should have developed a plan; set up surveillance activities; and assessed all the HCF and congregate settings for TB IC By 2010: 1) all countries, according to the prioritization should have developed a plan; set up surveillance activities; and assessed all the HCF and congregate settings for TB IC 5) 50% of countries should be reporting on the implementation of the package of TB/IC interventions.

27. Next steps… to ensure safer health facilities, congregate settings and household Dissemination of the policy (including the evidence) Development of an advocacy strategy for generating demand and fund raising Working through regional and country offices (WHO and partners) for changes in policy and regulations Budget the package for quantifying the costs of scaling up TB IC At country level assess responsibilities for the implementation of the package (TB, HIV, Occupational Health, Justice department, health system and civil society) TBICTBIC