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TB Infection Control – Hospitals, health care facility, settings

TB infection control is a combination of measures aimed at minimizing the risk of TB transmission within populations, that is groups of people.

Doctors and other health care workers who provide care for patients with TB, must follow TB infection control procedures to ensure that TB infection is not passed from one person to another.

Hospitals in India

The following has been said about hospitals in India.

The hospital is the last place where you would expect to get sick. It is where you go to get help. But a lot of people do contract TB while they are in hospital. They come in for something else and leave the hospital having TB as well.1“Frightening injection sends never-ending pain throughout your body”, www.health24.com

In Mumbai it has been found that around 10% of municipal health posts in the city need major structural changes to prevent transmission of TB among patients and hospital staff. A study of around 140 clinics to find out whether they followed the central government guidelines, recommended the addition of new floors and windows to improve ventilation at these centres. At the remaining 90% of facilities simple yet practically feasible changes were recommended.

Suggestions included the rearrangement of tables so that the air flow is in the direction of doctor to patient. Sliding windows were removed, and an opening was created in the ceiling. Exhaust fans and pedestal fans were installed to improve air ventilation. The study showed how simple practical solutions can help cut down the risk of transmission

An example of effective changes being made is at a dispensary in Santacruz (East). The dispensary treats seven multi drug resistant TB patients and 21 drug sensitive TB patients. The 70 other daily visitors, who come to the dispensary’s outpatient department were at risk of getting infected with TB.2“Revamp Mumbai’s civic clinics to prevent spread of airborne diseases says study, Hindustan Times, 14 February 2018 www.hindustantimes.com/mumbai-news/civic-clinics-in-mumbai-need-revamp-to-prevent-spread-of-airborne-diseases-study/

We rearranged the tables and opened the windows. We also have separate entrances for TB patients, to reduce the rate of transmission. Daksha Shah, civic TB officer

Hospitals in the UK

It is not just in resource poor countries that TB transmission occurs in hospitals. In 2012 it was reported that a patient in the UK had become infected with TB and had died, as a result of receiving kidney dialysis when sitting next to another patient with infectious TB.3Exclusive: patient deaths spark tuberculosis investigation, Health Service Journal, 12 October 2012 www.hsj.co.uk

Health care facility & settings

Every country should have infection control guidance which clearly needs to take into account local settings and resources, as well as the numbers of people being provided with care.

The term health care facility is usually used to refer to a physical building or set of buildings, such as a hospital. A health care setting, to which TB infection control must also apply, is any establishment, whether private or public, that is engaged in direct patient care on site. A health care setting is any place where health care workers might share air space with people with TB disease or in which health care workers might be in contact with clinical specimens.

Various setting types might be present in a single facility. Health care settings include inpatient settings, outpatient settings, and non traditional facility based settings. People working in health care settings have a higher incidence of TB than the general population.

Facility level infection control

There are various levels of TB infection control depending on whether a facility or setting is being considered.

Facility level measures for TB infection control should include

  • Identifying and strengthening local coordinating bodies for TB infection control, and developing a facility plan (including human resources, and policies and procedures to ensure proper implementation of the controls listed below) for implementation;
  • rethinking the use of available spaces and considering the renovation of existing facilities or construction of new ones to optimize implementation of controls;
  • conducting an on site surveillance of TB disease among health workers and assessing the facility;
  • addressing advocacy, communication and social mobilization for health workers, patients and visitors;
  • monitoring and evaluating the set of TB infection control measures.

TB infection control in health care settings

The basis of TB infection control in health care settings is early and rapid diagnosis, and the proper management of TB patients.

Infection control guidance must not only be written but also implemented. The implementation of administrative and environmental controls, and the use of personal protective equipment, has been shown to reduce the transmission of TB in health care settings.

So the organization of TB infection control at the level of health care setting can be considered as being in three parts, administrative controls, environmental controls, and respiratory protection controls. The most important part of TB infection control is the use of administrative measures to reduce the risk of exposure to people who might have TB disease.

Administrative measures should include

  • Promptly identifying people with TB symptoms (triage), separate infectious patients, control the spread of pathogens (cough etiquette and respiratory hygiene) and minimize time spent in health care facilities;
  • provide a package of prevention and care interventions for health workers, including HIV prevention, antiretroviral therapy, and isonniazid prevention therapy (IPT) for HIV positive health workers;
  • there should also be a reduction of diagnostic delays, the use of rapid diagnostic tests, the reduction of turnaround time for sputum testing and culture, and the prompt initiation of treatment.

There are also environmental controls which are an important part of TB infection control. Environmental controls are controls which prevent and reduce the concentration of infectious droplets.

Environmental controls are of two types

  • Primary environmental controls consist of controlling the source of infection by using local exhaust ventilation. Examples of this are hoods, tents or booths. It also involves diluting and removing contaminated air by using general ventilation.
  • Secondary environmental controls consist of controlling the airflow to prevent contaminated air in areas adjacent to the airborne source. Environmental controls also include the use of ultraviolet germicidal irradiation (UVGI) fixtures, when inadequate ventilation cannot be achieved.
Putting on a protective mask

Putting on a protective mask

Although environmental controls can include major work such as the rebuilding of certain areas, and ventilation improvements such as ducting, they can also include simpler measures such as those given in the example from India above.

There is finally the use of respiratory protective equipment. This consists of the use of protective equipment in situations that pose a high risk of exposure to TB disease. Use of respiratory protection equipment can further reduce the risk for exposure of health care workers to infectious droplets that have been expelled into the air from a patient with infectious TB disease.

The following measures can be taken to reduce the risk for exposure

  • Implementing a respiratory protection program;
  • training health care workers on respiratory protection;
  • and educating patients on respiratory hygiene and the importance of cough etiquette procedures.

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You can read more about:

Latent TB

TB Prevention

Major sources for TB infection control

WHO Policy on TB Infection Control in Health Care Facilities, Congregate Settings and Households, 2009, http://www.who.int/tb/publications/2009/infection_control/en/

CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Settings, 2005 https://www.cdc.gov/tb/publications/guidelines/infectioncontrol.htm

References

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1. “Frightening injection sends never-ending pain throughout your body”, www.health24.com
2. “Revamp Mumbai’s civic clinics to prevent spread of airborne diseases says study, Hindustan Times, 14 February 2018 www.hindustantimes.com/mumbai-news/civic-clinics-in-mumbai-need-revamp-to-prevent-spread-of-airborne-diseases-study/
3. Exclusive: patient deaths spark tuberculosis investigation, Health Service Journal, 12 October 2012 www.hsj.co.uk