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Tb ipc respiratory protection
- 3. 3 WHO recommendations ā¢ When used with administrative and environmental controls, particulate respirators may provide health care workers (HCW) additional protection from TB ā¢ Respirators ā Must meet or exceed standards ā Be properly used ā Be part of a training programme
- 4. 4 WHO recommends particulate respirators for HCWs: ā¢ Caring for patients with confirmed or suspected infectious TB (in particular MDR- TB) ā¢ Performing aerosol-generating procedures on infectious TB patients ā Bronchoscopy, intubation, sputum induction ā Use of high speed devices for lung surgery or autopsy
- 5. 5 Personnel Protective Equipment: Masks ā¢ Surgical masks reduce the spread of microorganisms from the wearer (protection from exhaled droplets). ā¢ They do not provide protection to the wearer from inhaling small infectious aerosols.
- 6. 6 Surgical masks (yes for patients)
- 7. 7 Surgical masks (not for staff)
- 8. 8 Personnel Protective Equipment: Respirators N95/ FFP2 FFP3 N95 respirators effectively filter out > 95% (98% for FFP3) of the particles ā„ 03 Ī¼m)
- 9. 9 Other types of respirators ā¢ Negative pressure respirators ā¢ Air-purifying respirators (APR) ā¢ High Efficiency Particulate Air (HEPA) filter
- 10. 10 Negative pressure respirator A respirator in which the air pressure inside the facepiece is negative during inhalation with respect to the ambient air pressure outside the respirator
- 11. 11 Air-purifying respirator (APR) A respirator with an air-purifying filter, cartridge, or canister that removes specific air contaminants by passing ambient air through the air-purifying elements
- 12. 12 Respirator programme elements ā¢ Person assigned responsibility ā¢ Procedures on use of respirators ā¢ Training ā HCW training on risk of TB transmission ā HCW medical evaluation ā¢ Field testing ā¢ Selection of respirator ā¢ Fit testing ā¢ Maintenance and care ā¢ Disposal ā¢ Respirator programme evaluation
- 13. 13 Why is fit testing necessary? ā¢ Ensure a proper seal between respirator and wearer ā¢ Determine appropriate make/model ā¢ Determine appropriate size
- 14. RespiratorRespirator FittingFitting Practical demonstration of respirator fitting ā¢Get a respirator ā¢Check expiry date ā¢Check for any physical damage ā¢Read the manufacturerās/user instructions ā¢Fit the face mask ā¢Demonstrate storage of a respirator. 14
- 15. 15 When should fit testing be done? Employees should pass a fit test: ā¢ Prior to initial use ā¢ Whenever a different respirator facepiece (size, type, model or make) is used ā¢ Whenever changes in the workerās physical condition or job description that could affect respirator fit are noticed or reported
- 16. 16 Sources of facepiece leakage ā¢ Around facepiece/skin interface ā¢ Through air-purifying element ā¢ Through exhalation valve
- 28. 28 Fit test
- 29. 29 Qualitative fit tests: ā¢ Rely on the individualās response to the test agent to assess the adequacy of respirator fit ā¢ Are scored as pass/fail
- 30. 30 Test solutions for qualitative fit testing Four methods recognized and accepted ā¢ Isoamyl acetate ā¢ Irritant aerosol ā¢ Saccharin ā¢ BitrexTM (Denatonium benzoate)
- 31. 31 Is this respirator put on properly?
- 32. 32 Factors contributing to poor fit ā¢ Weight loss or gain ā¢ Facial scarring ā¢ Changes in dental configuration (dentures) ā¢ Facial hair ā¢ Cosmetic surgery ā¢ Excessive makeup ā¢ Mood of workers (smiling/ frowning) ā¢ Body movements
- 33. 33 Care for respirators ā¢ How do we take care of our respirators? āDecontamination? āCleaning? āStorage?
- 34. 34 How to take care of respirators? ā¢ To take care of our respirators ā Decontamination NO! ā Cleaning NO! ā Storage Clean & Dry place! ā¢ Take care when re-using respirator ā closely monitor service life ā¢ Dispose respirator if you question its performance ā¢ Do not share the respirator ā¢ Follow the manufacturers instruction
- 35. Reasons for disposal ā¢ If wet ā¢ If damaged ā¢ If dirty 35
- 36. 36 Golden rules
- 37. Methods of disposal ā¢ Burn and bury ā¢ Incineration ā¢ Autoclaving
- 38. Respirator programme evaluation ā¢ Use Appendix 1
- 40. 40 Exercise on Respiratory protection
- 41. Exercise for participants ā¢ Discuss and comment on the pictures given ā¢ Discuss for 20 minutes then report the groupsā comments to the plenary 41
- 42. 42 Bronchoscopy room in Eastern Europe
- 43. 43 DOT room in Eastern Europe
- 45. 45 TB/HIV clinic
- 46. 46 Summary ā¢ Surgical masks prevent infectious particles from being expelled by the wearer ā¢ Respirators protect the health care worker from inhaling infectious particles ā¢ When used with administrative and environmental controls, N95, FFP2 or FFP3 respirators provide additional protection when HCWs care for infectious TB patients ā¢ Whenever respirators are used, a respirator programme is necessary
Editor's Notes
- Title
- The slide is designed to explain to whom the different IC interventions should be applied. In this Unit we are focusing on respiratory protection of HCW and patients.
- [Review slide] WHO also recommends when to use respirators, as weāll see on the next slide. Citation WHO. WHO policy on TB infection control in health-care facilities, congregate settings, and households. 2009. WHO/HTM/TB/2009.419 http://www.who.int/tb/publications/2009/en/index.html
- [Review slide] Citation WHO. WHO policy on TB infection control in health-care facilities, congregate settings, and households. 2009. WHO/HTM/TB/2009.419 http://www.who.int/tb/publications/2009/en/index.html
- What is the person in the picture wearing? Is the device presented in the picture effective to protect the individual from inhaling droplet nuclei? What is the difference between mask and respirator? Respirators have tiny pores blocking droplet nuclei and rely on air tight seal around the entire edge. Face mask have large pores and lack air tight seal around edges. Who should were masks? Who should wear respirators? An initial discussion at this stage will allow facilitators to understand what is the knowledge on this topic within the class. The answer to the question mentioned above will be given in the next couple of slides: the masks are designed not to let the droplets to go out, while the respirators are designed not to let nuclei to come in.
- The slide shows patients wearing surgical masks in a MDR-TB department in (facility name, Kenya). The facilitator may want to ask the class to comment on the IPC measures in this ward. What about natural ventilation? Are the windows open? What is the health care worker wearing? Are all the patients wearing the mask? Are all the masks correctly worn? Why do you think the patients (all accept one) are wearing surgical masks? Courtesy of Facility Name??????
- HCWs wearing surgical masks are shown in the pictures. The picture in the left side of the slide shows a physician wearing a mask, in a DOT room. The picture in the right side shows a surgical intervention in a hospital. The concept is that surgical masks do not protect HCWs from TB. The facilitator may want to raise a discussion on this aspect. Courtesy of Paul Jensen (upper left) and GB Migliori (lower right)
- The slide shows N95 (left) and FFP3 (right) respirators. N95 respirators effectively filter out > 95% of the particles 0.3 Ī¼m in aerodynamic diameter. FFP2 respirators effectively filter out > 94% (>98% for FFP3) of the particles 0.4 Ī¼m in aerodynamic diameter. The remaining percentage will be taken care by other elements of infection control. (FFP ā Filtering Face - Piece)
- The slide is self-explanatory. The above respirators are not necessarily needed to prevent transmission of TB.
- The definition of negative pressure respirator is also given. The picture shows an HCW wearing a negative pressure respirator in Eastern Europe. If there is an exaust valve you can keep it longer since it is more comfortable. This is because the valve opens when you exale. If there is an exhaust valve, the wearer may feel ācoolerā than when wearing a respirator without an exhaust valve. In addition, respirators with exhaust valves should not be used when a sterile field is needed (e.g., surgery). Courtesy of Paul Jensen.
- The respirator on the left does not have an exhaust valve; the other two do have exhaust valves. The pictures represent air-purifying respirators of different kind. The definition of APR is given in the slide. The picture on the left side shows a disposable APR. The picture in the middle of the slide shows an HCW wearing an elastomeric half-facepiece APR device. The picture on the right side shows how the elastomeric full-facepiece APR looks like. Courtsey of Paul Jensen.
- The main elements of the respirator programme are summarized in the slide. One person should be given the authority and responsibility to manage the programme. Written procedures should describe when and how respirators are to be used. Health screening is done to be sure that health care workers are physically capable of performing job duties when wearing a respirator. Training should include information on the risk of TB transmission and how to prevent it, and the appropriate use of respirators. Respirators should be selected that meet standards for protection (N95, FFP2 or FFP3). Several sizes are necessary to fit a range of faces. Weāll talk about fit-testing next and maintenance later in this unit. Finally, the respirator programme should be evaluated periodically.
- We conduct fit testing in order to be sure that each personās respirator fits adequately. This means checking that there is a proper seal, as face seal leakage compromises the respiratorās ability to protect the wearer. We do not want people to have a false sense of security when wearing the respirator. The fit test is required to select the appropriate model and size.
- [Review slide] [Ask participants]: What is done in the participantsā own hospitals/settings?
- [Review slide] Arrows show leakage points if the fit is not correct. from: Control de infecciones de tuberculosis en establecimientos de salud- MĆ³dulo de capacitaciĆ³n. Ministerio de Salud, Peru, courtesy of Paul Jensen
- Is everything OK with the respirator shown in the picture? In the upper part of the slide, 2 arrows are showing where problems with fit of the respirator can be observed: the lower elastic band is not there and the filter is not centered. In the lower part of the slides arrows are showing other points where correct fit is not observed. The facilitator may want to raise a discussion on this, asking the class to comment. Courtesy of Paul Jensen (upper pictures) and from: Control de infecciones de tuberculosis en establecimientos de salud- MĆ³dulo de capacitaciĆ³n. Ministerio de Salud, Peru, courtesy of Paul Jensen (lower pictures).
- [Review slide] Photo from: Control de infecciones de tuberculosis en establecimientos de salud- MĆ³dulo de capacitaciĆ³n. Ministerio de Salud, Peru, courtesy of Paul Jensen
- ā¢ Four methods are presently accepted to perform qualitative fit tests. ā¢ Among them, saccharin and BitrexTM tests are the easiest to perform
- [Ask participants]: Is this respiratory put on properly? Problems include: The filter is not centered. In the side view, you can see some of the wearerās right nostril. The lower elastic band is missing. In many respirators, the elastic is of poor quality, and it stretches or can break after pulling it a couple of times only. Photo courtesy of Paul Jensen
- Which are the factors responsible for poor fitting respirators? [Review slide] There is no one size that fits all. You will always have people who will require a different model.
- Some practical suggestions related to fit-test and care of respirators. You cannot decontaminate or clean the respirator but you can store it. How to do it: Dispose the respirator: it is a qualitative assessment. If you feel uncomfortable, dispose respirator Any comments? The facilitator should stimulate discussion to see if the class agrees on the proposal to decontaminate and clean the respirator.
- The facilitator needs to raise a discussion on what should be done and what should not be done to take care of the respirator. Never try to clean or decontaminate it! The respirator should be kept in a clean & dry place. Respirator may be used until damaged or until 2 weeks, breathing becomes difficult, or contaminated with blood or body fluids Filtering facepieces must be inspected prior to each use
- The slide shows the warning sign to be kept in mind before entering a patientās room. The picture is an example from a Kenyan hospital. The facilitator may want to emphasize that this is a reminder . . . Warns people and tells them what to do . . . Respiratory precautions for aerosols.
- It is time for discussion.
- Title For this classroom and group exercise, the facilitator will stimulate the class to discuss the issue of respiratory protection. He will divide the participants into groups of three-four. The purpose of the exercise is to apply in practice the concepts discussed in Unit 6. on ensuring respiratory protection. Each group will be asked a) to look at the slides in document 6.2; b) to comment the slides within the group; c) to report the groupās comment in plenary discussion. The facilitator will assign 5 minutes per slide. After 5 minutes a member of the first group will report the groupās findings on the first slide. The other groups will intervene and comment if necessary Once the first discussion will be completed, the facilitator will allow 5 minutes to discuss the second slide. The process requires that a different member of the group reports on the group findings. The process will continue till the facilitator will close it or the slides will be all discussed.
- The picture shows a busy bronchoscopy room in central Europe. Too many staff are there, several without any mask. The physician has a mask on and one nurse (at the riht side of the table) has the mask at the neck level. These masks are not providing any protection from droplet nuclei. The surgical masks are giving a false sense of protection. The window is closed and apparently there are no other IC control measures in place. The risk of transmitting TB infection in this room is significant. Courtesy of GB Migliori
- No individual respiratory protection measures in place for the nurse providing DOT. There is insufficient information from the picture on the real risk of TB transmission. We do not know if infectious patients are accessing the room, if undetected TB cases (e.g. suspects) are accessing the room or are already in the room (e.g. waiting in the opposite site of it), or if TB patients newly diagnosed (e.g. attending the room for the first days of the intensive phase of treatment being still potentially infectious) are attending the room. We do not know how ventilation is organized: natural ventilation? Other IC measure in place? The facilitator may want to raise a discussion on the issue, stimulating participants to list which details needs to be checked in performing risk assessment in this setting. Courtesy of GB Migliori
- The tent above is an isolation tent placed in front of the Kenyatta National hospital for DOT.
- TB clinic in Uganda. The nurse is taking care of the TB register. Is the room well ventilated (2 windows open)?. Nobody else in in the room. No individual protection measure taken by the nurse. The information provided by the picture is not sufficient. We need to know if patients had already started the morning access to the clinic, which kind of patients they are, where are they waiting, which IC measures are in place, etc . Is there cross-ventilation due to other windows or doors? If no other opening is avaialble, we can say the room is marginally ventilated. In fact there is cross-ventilation, as on the left side (not visible) there is a large door always open, and above the windows and the door there are additional ventilation spaces protected by a net (it is common in East African buildings) The facilitator may want to raise a discussion on the different elements seen in the slide. Courtesy of GB Migliori
- [Review slide]