Guidelines on the Prevention and Control of Tuberculosis in Ireland

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<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSCStaff supervising DOT should be appropriately trained. The regimen should be determined by the treatingphysician in conjunction with the patient. In some cases, an intermittent regimen may be appropriate. Inothers, a daily regimen is more appropriate. See HSE South (Cork and Kerry) DOT referral form in appendix 9.In addition, procedures for monitoring compliance such as pill counts need to be established early in thetreatment of the disease. Blister packs labelled with each day’s TB medication will also facilitate compliance.Pharmacists should be involved in monitoring compliance. In order to monitor and improve compliance,the patient should receive their anti-TB medications from the same pharmacy on a monthly basis. Electronicrecords of each dispensing should be maintained and ongoing liaison between the pharmacist andprescriber is recommended. Medication must be easily accessible for the patient and ideally should beavailable at the diagnosing clinic/hospital.A directly observed therapy short-course strategy (DOTS strategy), the internationally recommendedapproach by WHO to TB control has been successfully implemented in many countries but requires carefulinstitution and monitoring. This comprises five components as follows: (i) political commitment withincreased and sustained financing; (ii) case detection through quality-assured bacteriology; (iii) standardisedtreatment with supervision and patient support; (iv) an effective drug supply and management system;and (v) a monitoring and evaluation system and impact measurement. 5 The committee recommendsendorsement of the WHO DOTS strategy at the highest level.Use of DOT in MDR-TB and XDR-TBIn all cases of MDR-TB and XDR-TB the use of DOT is recommended. A daily regimen is more appropriate.Use of DOT in childrenThree times weekly therapy is not generally recommended for children but twice or thrice weeklyadministration of rifampicin and isoniazid by DOT can be considered after completion of the initial twomonth period of treatment in selected circumstances.5.7 LegislationCompliance with medication is core to TB control. In practice, a subset of patients are noted who are noncompliantwith treatment and are resistant to any intervention in the community. Under Section 38 of theHealth Act, 1947 the MOH may order the detention and isolation of an infectious person until that personis no longer a probable source of infection. 225 Section 35 of the Health Act, 1953 amends the 1947 Act,directing that the order must be signed by the MOH and another registered medical practitioner. 226This legislation dates back to the 1940s and 1950s (1947 and 1953). It gives the power to detain noncompliantpatients but does not give the power to ensure that patients comply with treatment. Personalcommunication with HSE areas has highlighted a number of enforcement-related issues in recent timesprimarily with regard to treatment refusal, place of detention and personal rights. This legislation is currentlybeing reviewed by a HSE committee.-73-
<strong>Guidelines</strong> on the Prevention and Control of Tuberculosis in Ireland 2010HSE/HPSC6. Infection Prevention and ControlThe extent and duration of measures required to prevent and control TB infection, depends upon theestimated degree of infectiousness of the patient, the response to treatment, the nature of the activitiesundertaken, and who will be exposed to the patient in the course of those activities.Risk factors for acquiring TB infectionThe risk of acquiring TB is determined by a number of factors such as the degree of infectiousness of thesource patient or the presence of predisposing medical conditions in contacts e.g. HIV infection, diabetes,alcoholism, drug addiction, immunosuppression and renal failure. The following features in the source casehave been shown to increase the risk of infection:• Close contact with the source case (section 8.5)• Duration of contact (the longer the contact the greater the risk)• Sputum smear positive• Presence of a productive cough• Delay in diagnosis• Open TB lesions requiring irrigation• Institutional contact with the source case (prisons, nursing homes, shelters, etc).6.1 Classification of Risk of Procedures in HealthcareHCWs are at risk of infection depending on their contact with patients and the clinical proceduresundertaken during care. These procedures have been categorised into high, medium and low risk activities.High risk- Cough inducing procedures (including sputum induction and bronchoscopy)- Autopsy- Pathology examination- Bronchoscopy- Designated TB laboratory procedures especially handling cultures of TBMedium RiskStaff whose work entails regular contact with the patient (e.g. nursing, physiotherapy, nursingattendants, cleaning staff, catering staff)Low riskStaff with minimal patient contact (e.g. administration, maintenance).6.2 Definition of an Infectious TB CasePatients aged 10 years and over with suspected or confirmed pulmonary or laryngeal TB should beconsidered infectious if any of the following are present and if they are not receiving therapy, have juststarted therapy or have a poor response to therapy 77;227-229• Are coughing• Are undergoing sputum inducing procedures• Have cavitations on chest X-ray• Are sputum AFB smear positive• Have suspected laryngeal involvement (i.e. hoarseness)-74-
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Guidelines on the Prevention and Control of Tuberculosis in Ireland

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