Infection Control in Health Settings: Strategies for Preventing Harm

1. Module 12:Infection Control in Health Care Settings *Image courtesy of: World Lung Foundation

2. Florence Nightingale, Notes on Hospitals, 1863 It may seem a strange principle to enunciate as the very first requirement of a hospital that it do the sick no harm

3. Infection Control in the ERA of HIV • More PLWAs are attending health care and community facilities • VCTs • Primary care and ART clinics (IDCCs) • Patients and HCWs who are immunosuppressed may be vulnerable to TB as a result of exposure • Some settings may have higher prevalence of TB/HIV, both known and undiagnosed • jails/prisons • mines

4. Why TB is a Problem in Healthcare Settings • Persons with undiagnosed, untreated and potentially contagious TB are seen in health care facilities • 30-40% of PLWAs will develop TB in the absence of IPT or ART • PLWAs can rapidly progress to active TB and may become reinfected • HIV-infected HCWs are particularly vulnerable due to occupational exposure

5. What is Infection Control? Patient to Worker Visitor Patient Worker to Worker Visitor Patient Visitor to Worker Visitor Patient

6. Infectiousness Patients should be considered infectious if they • Are coughing • Are undergoing cough-inducing or aerosol-generating procedures, or • Have sputum smears positive for acid-fast bacilli and they • Are not receiving therapy • Have just started therapy, or • Have poor clinical response to therapy

7. Infectiousness (cont.) Patients no longer infectious if they meet allof these criteria: • Have completed at least two weeks of directly-observed ATT; and • Have had a significant clinical response to therapy and • Have had 3 consecutive negative sputum-smear results; Retreatment /MDR cases may take longer to convert The only objective criteria is negative bacteriology

8. Fate of Droplets Organisms Liberated Talking 0-200 Coughing 0-3500 Sneezing 4500-1,000,000 Droplets can remain suspended in the air for hours.

9. Hierarchy of Infection Control • Administrative controlsto reduce risk of exposure, infection and disease thru policy and practice; • Environmental (engineering) controlsto reduce concentration of infectious bacilli in air in areas where air contamination is likely; and • Personal respiratory protectionto protect personnel who must work in environs with contaminated air.

10. Hierarchy of Infection Controls Administrative Worker Environmental Patient Respiratory Protection Facility

11. Administrative Controls • Prevent droplet nuclei containing M. tuberculosis from being generated; • Prevent TB exposure to HCWs, other patients and visitors; • Implement rapid diagnostic evaluation and treatment for TB suspects

12. Specific Administrative Controls Reduce risk of exposing uninfected persons to infectious disease: • Develop and implement written policies and protocols to ensure • Rapid identification of TB cases • Isolation • Diagnostic evaluation • Treatment • Implement effective work practices among HCWs • Educate, train, and counsel HCWs about TB • Test HCWs for TB infection and disease

13. Administrative Controls (cont.) Perform risk assessment and classification of facility based on: • Profile of TB in community • Number of infectious TB patients admitted

14. Engineering Controls • To prevent spread and reduce concentration of infectious droplet nuclei • In clinics • Maximize airflow in outpatient clinics settings by opening doors and windows, using fans • In hospitals • Use ventilation systems in TB isolation rooms • Use HEPA filtration and ultraviolet irradiation with other infection control measures

15. What is Ventilation? • The movement of air • “Pushing” or “pulling” of vapor or particles • Preferably in a controlled manner

16. Ventilation Control Types of ventilation • natural • local • general

17. Simple Measures Can Be Effective!

22. Personal Respiratory Protection • Respirators can protect health care workers; • Respirators may be unavailable in low-resource settings; • Face/surgical masks act as a barrier to prevent infectious patients from expelling droplets • Face/surgical masksdo not protect against inhalation of microscopic TB particles

23. Masks and Respirators Respirators rely on an airtight seal and have tiny pores which block droplet nuclei Masks have large pores and do not have an airtight seal to around the edge, permitting inflowof droplet nuclei respirators Face/surgical mask

24. Personal Respiratory Protection Use of respirators should be encouraged in high risk settings: • Rooms where cough-inducing procedures are done (i.e., bronchoscopy suites) • TB “isolation” rooms • Referral centers or homes of infectious TB patients • CDC/NIOSH-certfied N95 (or greater) respirator should be used

25. N95 Respirator Dos and Don’ts *Image courtesy of: CDC Image Library

26. Do Be sure your respirator is properly fitted! [Should fit snugly at nose and chin] *Image courtesy of: CDC Image Library

27. Note poor fit at the bridge of nose Note poor fit at the chin- Respirator should cover chin and create a seal

28. Don’t forget to WEAR it! *Image courtesy of: CDC Image Library

29. Efficacy Respiratory protection is effective only if: • The correct respirator is used, • It's available when you need it, • You know when and how to put it on and take it off, and • You have stored it and kept it in working order in accordance with the manufacturer's instructions • http://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respfact.html

30. Summary: Infection Control for TB To reduce risk of TB to HIV positive patients and health workers, you can: • Develop IC plan and identify responsible health workers • Train staff on TB and TB infection control • Screen HIV positive clients for TB symptoms and refer promptly • Provide separate waiting areas and expedited care for TB suspects • Use personal respiratory protection when indicated • Use simple environmental control measures, like opening windows, turning on fans, etc.

31. Cough Etiquette

32. Common-sense Prevention *Image courtesy of: World Lung Foundation

33. Infection Control (IC) for TB To reduce risk of TB to HIV positive patients and health workers, you can: • Screen HIV positive clients for TB symptoms and refer promptly • Provide separate waiting areas and expedited care for TB suspects • Provide surgical masks or tissues to TB suspects • Use simple environmental control measures, like opening windows, turning on fans, etc. • Screen health workers periodically for TB symptoms

34. 5-Steps to Prevent TB Transmission

35. Infection Control (IC) for TB • Risks to Patients and Health Care Workers Alike! • Patient to patient • Patient to providers • Nurses, doctors, pharmacists, FWEs • Provider to patients • Reduce TB transmission in health care settings • Devise an Infection Control Plan with your clinics • Teach your colleagues to protect themselves

36. References Core Curriculum on Tuberculosis, What the Clinician Should Know. Fourth Edition, 2000. US Dept. of Health and Human Services, Centers for Disease Control and Prevention. hhttp://www.cdc.gov/nchstp/tb/pubs/corecurr/Chapter1/Chapter_1_Introduction.htm hhttp://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respfact.html Guidelines for Prevention of TB in Healthcare Facilities in Resource-Limited Settings. World Health Organization, 99.269.

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