PREPARING A TUBERCULOSIS INFECTION CONTROL PLAN IN A FACILITY

1. PREPARING A TUBERCULOSIS INFECTION CONTROL PLAN IN A FACILITY Dr. Filiz Duyar Ağca 5th TB Control Dispensary Ankara

2. NO CONFLICT OF INTEREST

3. CONTENTS • Factors affecting the risk of TB transmission WHEN TRANSMISSION IS PREVENTED, RISK IS REDUCED • Hierarchy of Infection Controls (IC) Managerial Activities Administrative Controls Environmental (Engineering) Controls Respiratory Protection

4. HIERARCHY of INFECTION CONTROL

5. Factors Affecting the Risk of TB Transmission-1 • 1- PATIENT FACTORS Infectiousness, correct treatment and adherence • 2- RECIPIENT FACTORS Closeness,duration and frequency of contact,age, immune status • 3- BACTERIAL FACTORS Intrinsic virulence of bacilli, prolonged period of infectiousness

6. Factors Affecting the Risk of TB Transmission-2 • INSTITUTIONAL FACTORS • Fixed characteristics (type, location, structure) • Variable characteristics ( temperature, humidity) • Type and number of people serving • Resources available • Policies and practices governing patient movement and housing • Time lag between detection of disease, reporting and proper treatment

7. TB and HIV WHO’S STRATEGY- 3 I • Intensified Case Finding • Isoniazid Preventive Therapy (IPT) • Infection Control (IC) Prevention of particle transmission, control of particle spread Screen, Educate, Separate, Provide HIV Service, Investigate for TB

8. HIERARCHY of INFECTION CONTROLS-1 • 1) Administrative Controls Interventions with greatest impact and least cost Policies which significantly reduce the risk of TB transmission by preventing the generation of droplet nuclei or reducing exposure to droplet nuclei

9. HIERARCHY of INFECTION CONTROLS-2 • 2) Environmental (Engineering) Controls Policies which decrease number of droplet nuclei by preventing transmission • 3) Respiratory Protection Policies which minimize the exposure of droplet nuclei at TB facilities

10. MANAGEMENT OF IC • IC PLAN (budget, coordination team, human resources, procedures) ACSM( advocasy,communication, social mobilization) • RISK ASSESSMENT ( priorities at national/ facility level, triage for patients) • EDUCATION AND TRAINING ( National TB Program, NTP related activities) • SURVEILLANCE ( include datas of TB among health care workers)

12. IC PLAN - 1 • Develop different IC plan for every facility, also every area in a facility • Develop comprehensive written policies and protocols • Evaluate the parameters during practice • Evaluate IC plan results periodically, revise as needed

13. IC PLAN - 2 • Assign responsibility and authority of health care workers (HCWs) • Educate and train HCWs • Implemented IC plan includes Definitions, priorities, budget, maintenance and repair (for example, separating 10% of annual budget for maintenance and equipment repair is suggested)

14. (Plan your work, work your plan) Develop Education Implement Education Education Education Evaluate Revise

15. Risk Assessment-1 • Different risk assessment for facilities within same region,areas within same facility (low, medium, potential ongoing transmission) • Risk assessment according to TB and HIV/ AIDS prevalance • Risk assessment for high risk groups and occupational risk groups • Different risks between geographical regions

16. Risk Assessment-2 Sign risk assessment conducting group Sign who responsible from what Program risk classification of facility Evaluate TB IC plan Periodic evaluation preferred and revised according to results

17. DR TB UNITS

19. Education and Training • Information about TB and drugresistant TB, also prevention • Initial and annual training • Different programs for each group ofHCWs • Program for patients • Informing community

20. Surveillance • Periodic collection of TB datas • Include TB datas among HCWs • Procedures for initial, periodic screening and follow up for HCWs (chest x-ray, TST)

22. ADMINISTRATIVE CONTROLS(High priority) • Triage, determining the pathway of patient • Prompt diagnosis and treatment • Cough etiquette for potential TB patients • Separation by time and location • Prevention and care for HCWs

23. Cough Etiquette

24. ENVIRONMENTAL CONTROLS 1 ISSUES TO DISCUSS • Design • Operational • Maintainable • Sustainable • See: Design to Heal (designtoheal.org)

25. ENVIRONMENTAL CONTROLS 2 • TECHNICAL STAFF AND EQUIPMENT • VENTILATION (Natural and/ or Mechanical) • FILTERS (Pleated, HEPA filters) • UVGI (Ultraviolet Germicidal Irradiation)

26. VENTILATION Concepts • Air Change per Hour (ACH) • Positive Pressure (for HCWs) • Negative Pressure (for patients) • Air Flow Rate • Laminar Flow (laboratory, surgical suits) References CDC, WHO, AIA, ASHRAE, OSHA

27. Natural Ventilation • Basic and the cheapest • Control airflow direction in a facility (with smokepipe or velocitymeter) • Create patient and specimen flow • Control temperature and humidity (glass film) • Control air flow rate with grill placed doors, upper windows and sliding doors etc.

28. VelocitymeterAir Flow Rate= Cubicmeters/ Hour

29. Smoke pipe

32. Mechanical Ventilation • Fans (window extractor, floor type) • Wind driven turbins • Areas of negative and positive pressure • Local systems (biosafety cabinets, isolation rooms and air cleaners) • Central systems (for DR TB units)

34. TB Laboratory • Settings should be done according to types of tests / procedures • Procedures should be performed in separate places before and after TB culture • Work flow from clean towards dirty should be followed • Separated office area and working areas • Controlled work flow; it must be in the same way with air flow

35. Smear Microscopy Laboratory Work Flow Microscopy Registr. Report. Staining unit Specimen acceptance

36. Biosafety cabinet (BSC)

37. BSL-2 Potential aerosolized procedures should be done in a BSC. Doors kept closed; warning signs must be hanged on . Autoclav used for infectious wastes There must be a lavatory for hand washing Potential contaminated wastes separated according to their speciality. 37 ( CUH2A, Princeton, NJ, USA)

38. Filters • It is necessary to supply and removal of air through a space for negative pressure • Filters placed at exhaust holes for cleaning air ( placed both sides if air recirculates) • Used at local and central ventilation systems • Technical specifications and assistance • HEPA (High Efficiency Particulate Air) filters provide 99.97% filtration

39. Air cleaner

40. UVGI - 1 • Ultraviolet Germicidal Irradiation • Additional system to ventilation • Fixed 2,10- 2.15 cm above the floor • Fixed opposite to air flow • Shielded or upper room UV fixtures preferred • For optimum UVGI efficacy,should be cleaned and measured periodically

41. UVmeters

42. Natural ventilation and UV light

44. UVGI - 2 • Factors increasing UVGI efficacy 1: Concentration of irrediation 2: Period of exposure time 3: Distance between lamp and particles • Factors decreasing UVGI efficacy Humidity: >70% NOT suggested • Occupational Exposure Limit • Dose= Time x Irrediance (max 6000 µJ/cm²)

45. Respiratory Protection • Respirators For the HCWs and close contacts N 95 (USA) ; FFP 3 (Europe) • Surgical Masks For patients • Negative Pressure Respirators For bronchoscopy and DR TB units • Fit Testing

46. Respirators

47. Negative Pressure Respirator

48. Fit Testing

49. THANKSfilizduyaragca@gmail.com • References 1- WHO Policy on TB Infection in Health Care Facilities, Congregate Settings and Households; 2009 2- CDC Guidelines, MMWR 2005 3- WHO European Training on TB Infection Control, course notes, 2008 4-www.TuberculosisTextbook.com ,2007