Guidelines for TB Infection Control in High-HIV Burden ... - GHDonline

Guidelines for TB Infection Control
in High-HIV HIV Burden Settings
Paul A. Jensen, PhD, PE
Centers for Disease Control and Prevention
Coordinating Center for Infectious Diseases
National Center for HIV, STD, and TB Prevention
Division of Tuberculosis Elimination
Atlanta, Georgia USA

http://www.who.int/gtb/publications/
healthcare/PDF/WHO99-269.pdf

Tuberculosis Infection Control
in the Era of
Expanding HIV Care and Treatment
Addendum to WHO Guidelines for the Prevention of
Tuberculosis in Health Care Facilities in Resource-
Limited Settings, 1999
CDC:
WHO:
IUATLD:
Naomi Bock, Paul Jensen, Wanda Walton,
Michael Iademarco, , Bess Miller
Alasdair Reid, Pierre-Yves
Norval,
Paul Nunn
Riitta Dlodlo

http://www.cdc.gov/mmwr/PDF/rr/rr5417.pdf
http://www.cdc.gov/mmwr/PDF/rr/rr5509.pdf

Why were Guidelines Developed?
• People living with HIV/AIDS receive
diagnosis, care, treatment, and/or support;
and
• High prevalence of HIV infection, both
known and undiagnosed, in settings such
as prisons, jails, other detention centers,
and drug rehabilitation centers.

Number and size of organisms liberated
“Wells 1934, Duguid 1945, Wells/Riley 1953, et al.”
Number of Organisms Liberated:
Talking 0 – 200
Coughing 0 – 3 500
Sneezing 4500 – 1 000 000
Bacteria bearing droplets < Ø100
µm
Jennison [1942]
Size of Droplets (Fcn(
of air velocity):
Sneeze
~ 300 m/s
Ø100µm ~ 100 m/s
75 % ~ Ø10
µm

Fate of Droplets
• Large droplets fall to ground relatively fast.
• ThefateoftheSmaller
droplets will depend on
the relative humidity of the air in the space.
• With evaporation of droplet, “crystallisation“
crystallisation” ” will
occur, resulting in Droplet Nucleation, ,withthe
nucleus containing the infectious organism(s).
• A1.0µm Droplet Nucleus will settle at a rate of
0.0035 cm/s or 3 m in 24 hours!

What is Infection Control?
Prevention of Transmission
Patient to:
Worker
Patient
Visitor
Worker to:
Worker
Patient
Visitor
Visitor to:
Worker
Patient
Visitor

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

Hierarchy of Infection Controls
Hierarchy of Infection Controls
Worker
Administrative
Patient
Facility
Environmental
Respiratory
protection

How can we decrease the risk?

Hierarchy of Infection Controls
• Administrative controls to reduce risk of
exposure, infection, and disease through policy
and practice;
• Environmental (engineering) controls to
reduce concentration of infectious bacilli in air in
areas where contamination of air is likely; and
• Respiratory protection to protect personnel who
must work in environments with contaminated air

Administrative Controls
• Prevention of droplet nuclei containing M.
tuberculosis from being generated;
• Prevention of TB exposure to staff and patients;
and
• Implementation of rapid and recommended
diagnostic investigation and appropriate
treatment for patients and staff suspected or
known to have TB.

Administrative Control Program
• Infection control plan (including TB);
• Administrative support for procedures in the plan,
including quality assurance;
• Training of staff;
• Education of patients and increasing community
awareness; and
• Coordination and communication between the
TB and HIV programs.

Five Proposed Steps for Patient Management to
Prevent Transmission of TB in HIV Care Settings

What is Ventilation?
• Movement of air
• “Pushing” and/or “pulling” of particles and
vapors
• Preferably in a controlled manner

Ventilation Control
• Types of ventilation
– Natural
– Local
– General

Natural Ventilation

Natural Ventilation

Natural Ventilation

Natural Ventilation

Natural Ventilation

Filters Filters
Filters Filters
Filters Filters

Room Air Cleaners

Evaluation of Room Air Cleaners
1,000
Colony Forming Units (CFUs)
100
10
Off
On
Position 1
Position 2
Position 3
Position 4
Position 5
Position 6
Position 7
Position 8
Position 9
Linear
1
0 2 4 6 8 10
Elapsed Time (hours)

Ultraviolet Germicidal Irradiation

Respiratory Protection
• Respirators can protect health workers;
• Frequently, they are unavailable in resource-
limited settings;
• Respirator use should encouraged in high risk
areas of hospitals and referral centers (e.g.,
bronchoscopy and MDR-TB);
• A CDC/NIOSH-certified
N95 (orgreater)orCEN-
certified FFP2 (or greater) respirator should be
used; and
• Use of a face mask does not protect health care
workers, other staff, patients, or visitors against
inhalation of TB.

Respirator vs. Face Mask
• Respirator has only
tiny pores which block
droplet nuclei and
relies on an air tight
seal around the entire
edge
• Face mask has large
pores and lacks air
tight seal around
edges

Ray’s Take-Home Message
We can immediately start
implementing Infection Control
measures by “Thinking TB”