Module 12: Infection Control inHealth Care Settings

*Image courtesy of: World Lung Foundation

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

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

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

What is Infection Control?

Patient toWorkerVisitorPatient

Worker toWorkerVisitorPatient

Visitor toWorkerVisitorPatient

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

Infectiousness (cont.)

Patients no longer infectious if they meet all of 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

Fate of Droplets

Organisms LiberatedTalking 0-200Coughing 0-3500Sneezing 4500-1,000,000

Droplets can remain suspended in the air for

hours.

Hierarchy of Infection Control

•Administrative controls to reduce risk of exposure, infection and disease thru policy and practice;

•Environmental (engineering) controls to reduce concentration of infectious bacilli in air in areas where air contamination is likely; and

•Personal respiratory protection to protect personnel who must work in environs with contaminated air.

Hierarchy of Infection Controls

Patient

Respiratory Protection

EnvironmentalAdministrative W

orker

Facilit

y

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

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

Administrative Controls (cont.)

Perform risk assessment and classification of facility based on:

• Profile of TB in community

• Number of infectious TB patients admitted

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

• The movement of air

• “Pushing” or “pulling” of vapor or particles

• Preferably in a controlled manner

What is Ventilation?

Types of ventilation– natural– local – general

Ventilation Control

Simple Measures Can Be Effective!

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 masks do not protect against inhalation of microscopic TB particles

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 inflow of droplet nuclei

respirators

Face/surgical mask

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

N95 Respirator Dos and Don’ts

*Image courtesy of: CDC Image Library

DoBe sure your respirator

is properly fitted!

[Should fit snugly at nose and chin]

*Image courtesy of: CDC Image Library

Note poor fit at the bridge of nose

Note poor fit at the chin-

Respirator should cover chin and create a seal

Don’t forget to WEAR it!

*Image courtesy of: CDC Image Library

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

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.

Cough Etiquette

Common-sense Prevention

*Image courtesy of: World Lung Foundation

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

5-Steps to Prevent TB Transmission1 SCREEN Early recognition of subjects with

suspected or confirmed TB

2 EDUCATE Instruct patients on cough hygiene when sneezing or coughing; provide tissues or mask

3 SEPARATE Request patients to wait in a separate and well-ventilated area

4 PROVIDE HIV SERVICES

Triage symptomatic patients to front of line for services sought, so they spend minimal time around other patients

5 INVESTIGATE FOR TB

TB diagnostics (sputum smear) should be completed ASAP

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

ReferencesCore 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.htmhhttp://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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