TB INFECTION CONTROL IN HOSPITAL SATLD

1. TB INFECTION CONTROL IN HOSPITAL SATLD Vaira Leimane WHO Collaborative Centre for Research and Training on MDR-TB SATLD, Latvia, 2007

2. To introduce with TB infection control measures at the State Agency of TB and Lung Diseases (SATLD) central hospital in Latvia Objective

3. TB and MDR-TB, (XDR-TB), HIV trends in Latvia TB incidence among HCW in Latvia and in SATLD central hospital Infection control measures at the SATLD central hospital administrative engineering personal respiratory protection HCW protection Overview

4. TB incidence in Latvia 1971-2006

5. Number of patients with MDR-TB and XDR-TB in Latvia 2001 - 2006

6. TB among HCW in the SATLD central hospital 1998 - 2006

7. TB among HCW in the SATLD central hospital 1998 - 2004

9. Interventions

10. Administrative control measures SATLD  Assignment of responsibilities Administrative and supervisory responsibility delegated to a specific person team with a leader or infection controlSpecify responsibilities Supervisory responsibility delegate to a specific person or infection control team with a leader including experts in: - infection control, hospital epidemiology, clinics, engineering Should include experts in: - infection control - hospital epidemiology - clinician - engineering IC team responsible for all aspects of the IC programnodalas vecaka masa (slimnieku plusma, izvieto�ana nodala, epidemiologiska re�ima nodro�ina�ana, UV lampu, HEPA filtru kop�ana, personala un slimnieku izglito�ana); in�eniertehniskie darbinieki (in�eniertehnisko iekartu, ventilacijas sistemas pareiza darbiba; TB registrs (TB gadijumu uzskaite veselibas aprupes darbinieku vidu). Infekcijas izplati�anas ierobe�o�anas administrativo pasakumu ievie�ana, uzraudziba un kontrole (1) infekcijas ierobe�o�anas uzraudzibas administrators (infekcijas ierobe�o�anas pasakumu plana izstrada�ana, situacijas novertejums ar infekcijas riska pakapes noteik�anu da�adas iestades dalas, slimnieku plusma, TM transmisijas iespeja, infekcijas ierobe�o�anas pasakumu realizacija); infekcijas kontroles masa (infekcijas kontroles pasakumu ievero�ana, personala izglito�ana, UV lampu kop�ana, respiratoru parbaude, epidemiologiska re�ima ievero�ana); nodalas vaditajs, arsti (slimnieku izmekle�ana, izole�ana, zino�ana, arste�ana); Administrative and supervisory responsibility delegated to a specific person team with a leader or infection controlSpecify responsibilities Supervisory responsibility delegate to a specific person or infection control team with a leader including experts in: - infection control, hospital epidemiology, clinics, engineering Should include experts in: - infection control - hospital epidemiology - clinician - engineering IC team responsible for all aspects of the IC programnodalas vecaka masa (slimnieku plusma, izvieto�ana nodala, epidemiologiska re�ima nodro�ina�ana, UV lampu, HEPA filtru kop�ana, personala un slimnieku izglito�ana); in�eniertehniskie darbinieki (in�eniertehnisko iekartu, ventilacijas sistemas pareiza darbiba; TB registrs (TB gadijumu uzskaite veselibas aprupes darbinieku vidu). Infekcijas izplati�anas ierobe�o�anas administrativo pasakumu ievie�ana, uzraudziba un kontrole (1) infekcijas ierobe�o�anas uzraudzibas administrators (infekcijas ierobe�o�anas pasakumu plana izstrada�ana, situacijas novertejums ar infekcijas riska pakapes noteik�anu da�adas iestades dalas, slimnieku plusma, TM transmisijas iespeja, infekcijas ierobe�o�anas pasakumu realizacija); infekcijas kontroles masa (infekcijas kontroles pasakumu ievero�ana, personala izglito�ana, UV lampu kop�ana, respiratoru parbaude, epidemiologiska re�ima ievero�ana); nodalas vaditajs, arsti (slimnieku izmekle�ana, izole�ana, zino�ana, arste�ana);

11.

12. Administrative controls at SATLD Includes -assignment of responsibilities -risk assessment -written infection control plan Isolation procedures Patient flow within facility Reducing cough inducing procedures -staff and client education -screening program for HCW -implementation, supervision of IC Assignment of responsibilities Supervisory responsibility should be delegated to a specific person or infection control team with a leader Should include experts in: - infection control - hospital epidemiology - clinician/ nurse - engineering IC team responsible for all aspects of the IC program Prevention of hospital infection SATLD 1. ADMINISTRATIVE CONTROL MEASURES Risk assessment of TB transmission Plan specific to each area within facility, and HCW group based on level of risk Put all procedures in writing plan including Early detection isolation and treatment of infectious TB patients Patient education Decreasing of cough induction procedures Educate staff about the plan - organization, rationale, and what is expected of them TB screening program for health care workers Prevention of hospital infection SATLD 1. ADMINISTRATIVE CONTROL MEASURES Risk assessment of TB transmission Plan specific to each area within facility, and HCW group based on level of risk Put all procedures in writing plan including Early detection isolation and treatment of infectious TB patients Patient education Decreasing of cough induction procedures Educate staff about the plan - organization, rationale, and what is expected of them TB screening program for health care workers

13. Administrative control measures, SATLD 3. Risk assessment within SATLD Infekcijas kontroles pasakumi: pacientu izmeklejumu telpas, kliniskaja laboratorija, krepu indukcijas telpas, bakteriologiskaja laboratorija, endoskopijas kabineta, operaciju bloka, funkcionalas diagnostikas nodala, anesteziologijas un reanimacijas nodala, Rtg, TB nodalas Infekcijas kontroles pasakumi: pacientu izmeklejumu telpas, kliniskaja laboratorija, krepu indukcijas telpas, bakteriologiskaja laboratorija, endoskopijas kabineta, operaciju bloka, funkcionalas diagnostikas nodala, anesteziologijas un reanimacijas nodala, Rtg, TB nodalas

14. 2001 developed and implemented IC program Contents- Specify responsibilities Supervisory responsibility delegate to a specific person or infection control team with a leader including experts in: infection control, hospital epidemiology, clinics, engineering Written policies for patients hospitalization/ flow/ transfer/ discharge monitoring of infectiousness special precautions for high risk procedures and locations monitoring of engineering controls personal respiratory protection program staff and client education Screening and management of health care workers Ongoing monitoring/ annual evaluation of the program

15. Administrative control measures Isolation in ward (general requirements) Nonspecific pulmonary diseases TB suspects, primary TB patient MDR-TB suspects (TB relapses, failures, contact persons of MDR-TB patients, treatment interruptions) MDR-TB patients (infectious XDR-TB patients are sent to other hospital)

16. Administrative control measures Isolation in TB ward Isolation departments - infectious TB cases (smear positive) placed in the separate part of the ward (locked doors; see next slide)) Rules and regulations of isolation Patients have to stay in the isolation rooms (nutrition, examination, treatment etc.) Infectious patients must wear surgical masks during leaving isolator Make only high priority examinations Relatives visits restricted

17. Administrative control measures Isolation department Isolation department: AFB+ new TB case or strongly suspected for TB Patient with TB again become smear positive Determine infectiousness and drug resistance as soon as possible Isolation department: AFB+ new TB case or strongly suspected for TB Patient with TB again become smear positive Determine infectiousness and drug resistance as soon as possible

18. Administrative control measures SATLD  ISOLATION PROCEDURES Patient education, signed informed consent Examinations 3 consecutive sputum samples Chest X-ray examination Sputum examination with BACTEC, MIGIT for smear positive TB patients, MDR TB suspects Ideal: separate rooms Isolation together, according patient infectiousness, and risk for MDR-TB Patient education, signed informed consent TB symptoms, treatment, Etiology of TB, pathogenesis, symptoms, treatment and prognosis Importance of isolation, Importance of using surgical masks, Hygiene, cough hygiene, correct using of sputum containers Role of isolation, Use of surgical mask, Sanitary norms, Isolation department: AFB+ new TB case or strongly suspected for TB Patient with TB again become smear positive Determine infectiousness and drug resistance as soon as possible Ideal: separate rooms Isolation together, according patient infectiousness, in different rooms decrease transmission from patient to patient easier to use personal protective measures Monitor infectiousness (frequency) Interrupt isolation Received treatment 2-3 weeks Three negative smears, collected in consecutive days Clinical improvement izolacijas noteikumi slimniekiem maksimali jaatrodas palatas (edina�ana, izmeklejumi, arste�ana); atstajot izolatoru jalieto kirurgiskas maskas; nesutit uz izmeklejumiem, kurus var atlikt lidz abacile�anai; slimnieki bez personala atlaujas izolatoru nedrikst atstat, apmekletaji izolatora netiek ielaisti; slimnieki tiek iepazistinati ar izolacijas noteikumiem un parakstas par to ievero�anu. krepu savak�ana bacilariem slimniekiem izolatora speciali �im nolukam paredzeta telpa; nebacilariem slimniekiem aerosolu kabineta 1 � nebacilari slimnieki (nespecifiskas plau�u saslim�anas, stabili abacileti TB slimnieki); 2 � iespejami bacilari (aizdomas uz TB, jaunatklati TB slimnieki, kuri vel nav sanemu�i arste�anu) Major contents of written IC plan will:Specify who has responsibility and authority Specify the procedures for the risk assessment Include written policies for the: Triage and evaluation of suspected cases Transfer into and out of designated high-risk areas for TB and MDR TB patients or suspects Monitoring infectiousness (frequency) Note to speaker: Why are suspects important in the IC plan? They may be transmitters of TB and we want to prevent transmission to others. If they don�t have TB, we don�t want them to become infected while their diagnosis is being performed. izolaciju partrauc: iztriepe pozitiviem TB slimniekiem, kuri sanemu�i vismaz 2nedelas prettuberkulozes kimioterapiju, ir kliniska uzlabo�anas un sanemtas 3 negativas krepu iztriepes; MR TB slimniekiem izolaciju partrauc pec vismaz 8nedelu ilgas adekvatas terapijas, kliniskas uzlabo�anas un 2negativam krepu iztriepem 2mene�us pec kartas. Patient education, signed informed consent TB symptoms, treatment, Etiology of TB, pathogenesis, symptoms, treatment and prognosis Importance of isolation, Importance of using surgical masks, Hygiene, cough hygiene, correct using of sputum containers Role of isolation, Use of surgical mask, Sanitary norms, Isolation department: AFB+ new TB case or strongly suspected for TB Patient with TB again become smear positive Determine infectiousness and drug resistance as soon as possible Ideal: separate rooms Isolation together, according patient infectiousness, in different rooms decrease transmission from patient to patient easier to use personal protective measures Monitor infectiousness (frequency) Interrupt isolation Received treatment 2-3 weeks Three negative smears, collected in consecutive days Clinical improvement izolacijas noteikumi slimniekiem maksimali jaatrodas palatas (edina�ana, izmeklejumi, arste�ana); atstajot izolatoru jalieto kirurgiskas maskas; nesutit uz izmeklejumiem, kurus var atlikt lidz abacile�anai; slimnieki bez personala atlaujas izolatoru nedrikst atstat, apmekletaji izolatora netiek ielaisti; slimnieki tiek iepazistinati ar izolacijas noteikumiem un parakstas par to ievero�anu. krepu savak�ana bacilariem slimniekiem izolatora speciali �im nolukam paredzeta telpa; nebacilariem slimniekiem aerosolu kabineta 1 � nebacilari slimnieki (nespecifiskas plau�u saslim�anas, stabili abacileti TB slimnieki); 2 � iespejami bacilari (aizdomas uz TB, jaunatklati TB slimnieki, kuri vel nav sanemu�i arste�anu) Major contents of written IC plan will:Specify who has responsibility and authority Specify the procedures for the risk assessment Include written policies for the: Triage and evaluation of suspected cases Transfer into and out of designated high-risk areas for TB and MDR TB patients or suspects Monitoring infectiousness (frequency) Note to speaker: Why are suspects important in the IC plan? They may be transmitters of TB and we want to prevent transmission to others. If they don�t have TB, we don�t want them to become infected while their diagnosis is being performed. izolaciju partrauc: iztriepe pozitiviem TB slimniekiem, kuri sanemu�i vismaz 2nedelas prettuberkulozes kimioterapiju, ir kliniska uzlabo�anas un sanemtas 3 negativas krepu iztriepes; MR TB slimniekiem izolaciju partrauc pec vismaz 8nedelu ilgas adekvatas terapijas, kliniskas uzlabo�anas un 2negativam krepu iztriepem 2mene�us pec kartas.

19. Administrative control measures SATLD ADHERANCE TO ISOLATION PROCEDURES Books; Newspapers, magazines Hygiene kits delivery; radio, televizors; phone;

20. Sputum smear positive TB patients � after 3 negative sputum smear microscopy, who have received treatment more than 2 weeks clinical improvement; MDR-TB patients � after 2 negative sputum smear analysis 2 consecutive month, who received treatment more than 8 weeks clinical improvement

21. Administrative control measures Reducing of cough induction procedures Bronhoscopy (with substantial reason) Inhalations (only sputum induction aerosols) Examination of respiratory functions (surgery) Special room for bacillary patients (for MDR �TB patients separately) Flow of patients: First - non-bacillary patients, or patients who completes treatment Second � possibly bacillary, i.e. TB suspects or smear positives In prisons convenient � outdoors in specially designated area Sputum induction for non infectious cases Special room for bacillary patients (for MDR �TB patients separately) Flow of patients: First - non-bacillary patients, or patients who completes treatment Second � possibly bacillary, i.e. TB suspects or smear positives In prisons convenient � outdoors in specially designated area Sputum induction for non infectious cases

22. Administrative control measures SATLD  PATIENTS FLOW From admission department to isolation room From isolation room to examination rooms, Flow of patients in X-ray ward Special time of examination for patients from different groups Patients with non specific pulmonary diseases and TB patients TM negative Bacillary TB patients Bacillary MDR � TB patients

23. Administrative control measures SATLD 2002 implemented engineering controls Aim- decrease concentration of infectious droplets nuclei in the air UV lamps HEPA Filters Ventilation system Natural airflow

24. Engineering control measures Ventilation General ventilation system (old) Ventilation through open windows Controlled airflow Local ventilation system with negative pressure in bacteriological laboratory

25. Engineering control measures HEPA filters In laminar boxes Ventilators (fans) with HEPA filters 15 big HEPA filters (surgery; consultation ward; ward of functional diagnostics; intensive care) 6 small HEPA filters (sputum induction room)

26. Engineering control measures UV lamps Closed type of UV lamps 72 W � 154 UV lamps 36 W � 69 UV lamps UV lamps are working 24 hours Cleaning with 960 of alcohol 1 time per 3 months Measuring of UV irradiance after cleaning

27. 2003 implemented personal respiratory program (FIT test) Employees should pass an qualitative fit test test: prior to initial use whenever a different respirator face piece (size, style, model or make) is used, and at least annually thereafter Additional fit test whenever changes in physical condition or job description that could affect respirator fit are noticed or reported

28. Respiratory protection Respirators Respirator FFP3 (CEN standards) Qualitative fit test with Bitrex prior to initial use when change respirator (size, style, model) one time per year Surgical masks for patients

29. Fit test done at SATLD Physical factors contributing to poor fitting respirators Weight loss/gain Facial scarring Changes in dental configuration (dentures) Facial hair Cosmetic surgery Excessive makeup Mood of worker (smiling/frowning) Body movements

30. Administrative control measures Staff Education on IC since 2001 2001 comprehensive training on IC by CDC Aim to get comprehensive knowledge on IC control issues about measures, job descriptions, responsibilities Target audience Representatives from MoH, MoJ, Public Health Agency, administration and all level medical staff of SATLD Curricula- transmission, administrative/ engineering and personal respiratory protection controls

31. Administrative control measures Staff Education Introduce with responsibilities, inform of the risk of TB transmission Inform about risk for immunosuppressive persons Training course about TB epidemiology, diagnosis and treatment Introduce with TB infectious control program

32. Administrative control measures Staff Education on IC since 2001 Training and education for HCW to ensure good work practices IC plan - organization, rationale, and what is expected of them Personal respiratory protection program Target audience: all level administrative and medical staff Contents: Inform about risk of transmission, immunosuppressive persons about TB epidemiology, diagnosis and treatment personal protection cough hygiene administrative/engineering controls disinfection aids/ usage hand hygiene

33. Administrative control measures TB screening program for HCW (1) Prophylactic examination Chest X-ray examination once a year Sputum examination and chest X-ray for HCW with TB symptoms or if they have any complains

34. Administrative control measures TB screening program for HCW(2) Regulations of Ministry of Health of Latvia HCW for working in harmful conditions receive Additional vacation (3 � 10 days) Additional payment (10 % - 15% from salary every month) Insurance HCW are insured for accidents in work place and for risk to get TB/MDR-TB (1000 $ / 2000$ respectively)

35. Prevention of hospital infection LIFECYCLE OF IC PLAN Develop Evaluate Revise Implement

36. Administrative control measures, SATLD CONCLUSIONS Administrative IC are the most important component of IC plan in setting with limited resources and high incidence of TB and MDR-TB Administrative IC Program can ensure Early detection Early isolation Early treatment TB infection control can effectively prevent nosocomial transmission of TB and MDR-TB to HCW

37. "You (we) might not be able to change the life of a whole population, but you (we) can make an impact on individual people's lives.� Emily Chan Hong Kong, China

38. Thank you!