TB infection control in the era of MDR and XDR TB

1. TB infection control in the era of MDR and XDR TB Haileyesus Getahun Stop TB Department WHO/HQ

2. Collaborative TB/HIV activities A. Establish the mechanism for collaboration A.1. TB/HIV coordinating bodies A.2. HIV surveillance among TB patient A.3. TB/HIV planning A.4. TB/HIV monitoring and evaluation B. To decrease the burden of TB in PLWHA B.1. Intensified TB case finding B.2. Isoniazid preventive therapy B.3. TB infection control in health care and other settings C. To decrease the burden of HIV in TB patients C.1. HIV testing and counselling C.2. HIV preventive methods C.3. Cotrimoxazole preventive therapy C.4. HIV/AIDS care and support C.5. Antiretroviral therapy to TB patients. TB infection control is an important TB/HIV activity

3. The Tugela Ferry case TB transmission & PLHIV Increased susceptibility to TB infection Smear negative and paucibacillary in HIV+ Frequent clinical visit and hospitalisation Delay in diagnosis is common TB is the commonest presenting illness in PLHIV receiving ART Why TB infection is important for HIV care? • 1539 samples tested – 475 (%) culture positive TB; 44 HIV+ • 221 MDR; 53 XDR • 52 XDR cases died • Median survival was 16 days

4. The Tugela Ferry case continued • 51% of patients have no prior TB treatment • Genotyping reveals similar strains in 85% • 67% of patients hospitalized in prior 2 years • Community contact tracing (>1,600) of XDR patients revealed no additional cases • Health workers also died of XDR (n=6) • Confirmed in 2 and suspected in 4 Evidence of nosocomial and community XDR transmission 555 XDR cases in SA by March 2007 (267 in Tugela Ferry)

5. Infection control measures are needed, but.. Meanwhile, in South Africa, 100 patients fled a hospital after paramedics wearing head-to-toe protection brought in eight people with the same contagious infection.

6. Good work practice and administrative measures Greatest impact and topmost priority action Environmental measures Ventilation (natural and mechanical) Filtration UV radiation Protection of HCW and staff Increasing awareness Increasing access to HIV testing Personal respiratory protection Not priority action in HIV settings Face masks help to prevent the spread of TB from the patient (cough hygiene) Respirators to protect health workers and patients but expensive What needs to be done?

7. Good work practice and administrative measures include • Written infection control plan for each facility • Administrative support for procedures in the plan, including quality assurance • Training of staff • Education of patients and increasing community awareness • Coordination and communication with the TB program.

8. Five steps to in HIV care settings for preventing TB transmission • Step I: Screen • early recognition of cases or suspects • Step II: Educate • cough hygiene • Step III: Separate • cases or suspects in OPDs and wards • Step IV: Provide HIV/AIDS services • prompt services to reduce exposure • Step V: Investigate for TB or refer • TB diagnosis on site or prompt referral

9. Conclusion • TB infection control should be integrated and prioritised into HIV services. • Attention should also be paid to other congregate settings • Military barracks • Rehabilitation centres (ID use) • Prisons • Refugees • Schools • Long haul flights