TB Infection Control within the palliative care context

1. Kath Defilippi TB Infection Control within thepalliative care context Patient Care Portfolio Manager Hospice Palliative Care Association of South Africa (HPCA)

2. TB infection control will be discussed in relation to the disease transmission cycle • Additional interventions implemented by HPCA will be shared • Although drug resistant TB will be specifically mentioned, the focus is on general infection control iro TB in the palliative care context and includes both adults and children During this presentation:

3. Disease Transmission Cycle Disease-producing agent Place where the agent lives Person who can become infected Where the agent leaves the host Where the agent enters the next host Adapted from JHPIEGO, 2003 How the agent moves from place-to-place or person-to-person

4. Has been active in humans for hundreds of years Acid fast slightly curved rod shaped bacillus 0.2-0.5 microns in diameter; 2-4 microns in length Thick lipid cell wall Multiplies slowly (every 18-24 hours) Aerobic – pulmonary TB most common variety One cough can release 3,000 droplet nuclei – one sneeze can release tens of thousands Initial infection – can remain dormant for decades as latent TB Infection (LTBI) CDC Training, Pretoria University, August, 2010 The agent – mycobacterium tuberculosis

5. fibrosis COURSE OF INFECTION Granuloma Control of replication inadequate control of replication Latent TB Immunosuppression No disease (control of replication) Bacterial replication REACTIVATION ACTIVE TB G Kaplan, CDC Training, University of Pretoria, Aug, 2010

6. Overcrowding Malnutrition Age very young – immature immune system very old – deteriorating immune system HIV infection – immune suppression - A healthy person with a strong immune system has a 10% chance per lifetime of developing TB disease - An HIV+ person has a 10% chance per year of developing TB Conditions that promote progression of LTBI toactive TB disease

7. “Everywhere in the world, whenever a new case of infectious tuberculosis emerges, the diagnosis and commencement of treatment are usually only made after that case has already infected one or more other persons”. JD Klausner, CDC Training , Pretoria University, August , 2010 • Given the HIV/TB co-infection rate, statistics collected from HPCA member organizations suggest that there are a large number of undiagnosed TB patients already on palliative care programmes in South Africa. • In Sept 2010 out of a total of 31,685 HIV+ patients there were only 4,831 diagnosed with TB (15.2%)

8. Screening and referral for further investigation of TB: • all new patients admitted to the pall care programme • all existing patients who develop any of the signs and symptoms on TB screening tool • all staff and volunteers on appointment and thereafter at least annually • all staff and volunteers developing any of the signs and symptoms listed on TB screening tool NB for palliative care programmes to liaise with DOH partners 1. Decreasing the reservoir

9. 9 Contacts who are at risk of contracting TB in the home care setting where 99% of palliative care patients are to be found * Especially children under 5 years

10. According to studies done by Hardman and Ong the most important indicators are: Significant recent weight loss Persistent low grade fever Night sweats Cough Only 60% of patients had a cough in Ong study CK Ong et al Tuberculosis -HIV Coinfection: The relationship between manifestation of tuberculosis and the degree of immune-suppression le JSME: 2(2): 17-21 Indicators of probable TB disease in severely immune-suppressed patients

11. All newly admitted patients to IPU and HBC programmes Visitors and family members All new staff /annual screening HPCA TB Screening Tool

12. Information regarding TB disease included in the health education given to all HIV+ patients and their families A person-centred approach to the provision of treatment adherence support and the management of side effects of TB drugs Promoting the relevant rights and responsibilities from the Patients Charter for Tuberculosis Care (p15 HPCA Guidelines) Advocating for all HIV+ patients with TB to commence with ART asap, including those on TB treatment 1.1 Decreasing the reservoir iro of patients/families

13. Challenging environment in which infection control is implemented in HBC setting Photo South Coast Hospice Kwa-ZuluNatal Open air support group Photo St Bernard’s Hospice E Cape Photo Msunduzi Hospice KZN

14. Staff wellness programme to promote and maintain optimal immune status • Mandatory training on TB including infection control, for all categories of staff and volunteers • Creating an organisational environment conducive to disclosure of HIV and TB status • INH preventive therapy for HIV+ staff without signs of active TB 1.2 Decreasing the reservoir iro staff and volunteers

15. Training community caregivers on infection control Photo St Bernard’s Hospice, East London

16. 2.0 Infection control linked to place of exit of MTB COUGH HYGIENE! COUGH HYGIENE! COUGH HYGIENE! Picture – G Kaplan, CDC Training, Pretoria University, August, 2010

17. Policies in place regarding criteria for admission of TB patients to palliative care programmes (HPCA Draft Guidelines p 12-14) • Generally patients with TB in the lungs or larynx should be considered infectious until they have: • Completed 2 wks of TB treatment and show improvement in clinical symptoms • In the case of MDRTB: • Had two consecutive negative sputum smears on two different days. At least one specimen should be an early morning specimen • Safe sputum collection(HPCA Draft Guidelines p 23) 2.1 Infection control linked to place of exit

18. Good ventilation can help reduce the risk of infection by diluting and/or removing infectious particles in the air A well-ventilated space has air constantly entering and leaving, allowing an effective mixture of air This effective mixture increases the dilution of infectious particles 3.1 Prevention of transmission

19. Keep doors and windows open especially in areas where people congregate inside a building • Where electricity is available, use fans to blow air out of the room • Hold support groups in the open air whenever the weather permits • Encourage patients and family members to sit outside in the sun 3.2 Promote good natural ventilation to prevent airborne transmission of MTB

20. All children who have been exposed to an adult with infectious TB must be referred for investigation - they should then either receive first or second line treatment or be given INH preventive therapy (IPT) Young children with TB are usually not a risk to other children or adults 5.1 Susceptible children

21. Personal Controls 4.0 Infection Control linked to place of entry - airborne mycobacterium tuberculosis • Surgical masks • No protection against infectious droplets • May limit distribution of large particles • Consider for coughing patients • Respirators for caregivers • Filter >95% of infectious droplets (N95) • Fit-testing required • Valuable during aerosol-producing procedures • May be re-used if handled properly

22. Hand washing and the wearing of gloves whenever there is contact with bodily secretions Covering any breaks in the skin Effective disposal of all potentially contaminated waste Safe disposal of sharps 4.1 Implement universal precautions linked to the prevention of HIV infection

23. In the case of MDR TB • Assess home prior to admission of patient, prepare and capacitate family to implement the necessary infection control measures • Ensure that there are separate sleeping arrangements • No children under 5 years in the household • If possible no elderly relatives in the household • Monitor response to second line treatment and liaise with MDR unit re management of side effects 5.0 Protection of susceptible family members

24. Provide effective facial masks and monitor their use As far as is possible do not allow immune compromised staff and volunteers to have direct contact very ill AIDS patients who could have undiagnosed TB or with MDR TB patients Promote disclosure of HIV and TB status INH preventive therapy Care for the caregiver programmes 5.1 Protection of susceptible health care workers in palliative care teams

25. 5.2 Personal Protective Equipment In order for facial masks to be effective: -Must be large enough to fully cover the nose, lower face, jaw, and facial hair -Must be made of fluid-resistant materials All staff/volunteers caring for patients must be given gloves and have access to aprons

26. 5.3 Infection Control Plan • Designated responsibility reflected on job description/s • Includes assessment of TB infection control risks • Written policies and procedures • In-service training for all categories of staff /volunteers • Forms part of Risk Management Programme which is evaluated annually

27. 5.6 Staff Training • Each staff person should understand the importance of infection control & their role in implementing infection control • Job descriptions should include specific infection control duties • Infection control should be included as part of staff orientation and in-service training, and include those not directly involved in patient care

28. 2nd edition of the Hospice Palliative Care Standards include criteria on: • Screening for TB as part of initial and ongoing assessments • TB infection control and training • Inclusion of TB in risk management and quality improvement programmes Surveys are conducted to assess compliance with the standards on a regular basis Infection control guidelines distributed to all members • Implementation of infection control monitored via audit tool Development of Guidelines for providing palliative care to patients with TB Development of a specific 5-day training course for TB in the palliative care setting Additional interventions adopted by HPCA

30. Topics included in TB master training course

31. HPCA TB Task Team and the reference group of TB experts - in particular Prof David Cameron Open Society Institute Worldwide Palliative Care Alliance Sincere thanks to: