1. Unit 4: InfectionUnit 4: Infection Control andControl and
Prevention of TuberculosisPrevention of Tuberculosis
Botswana National Tuberculosis Programme
Manual Training for Medical Officers
2. Slide 4-2Unit 4: Infection Control and Prevention of Tuberculosis
ObjectivesObjectives
At the end of this unit, participants will be able to:
• Identify the goals of infection prevention
• Identify 3 levels of prevention
• Identify infection control strategies to prevent
the transmission of TB in the healthcare setting
• Explain the importance of contact tracing
3. Slide 4-3Unit 4: Infection Control and Prevention of Tuberculosis
Levels of Prevention and Their GoalsLevels of Prevention and Their Goals
Prevention efforts focus on the following three
goals:
• Primary prevention – preventing TB infection
• Secondary prevention – preventing TB disease
• Tertiary prevention – preventing TB morbidity and
mortality
4. Slide 4-4Unit 4: Infection Control and Prevention of Tuberculosis
The TransmissionThe Transmission
of TB Knows No Boundariesof TB Knows No Boundaries
Patient to:
Worker
Visitor
Patient
Worker to:
Worker
Visitor
Patient
Visitor to:
Worker
Visitor
Patient
5. Slide 4-5Unit 4: Infection Control and Prevention of Tuberculosis
Hierarchy ofHierarchy of
Infection Prevention & ControlInfection Prevention & Control
• Administrative controls
• Reduce risk of exposure, infection and disease
thru policy and practice
• Environmental (engineering) controls
• Reduce concentration of infectious bacilli in air in
areas where air contamination is likely
• Personal respiratory protection
• Protect personnel who must work in environments
with contaminated air
6. Slide 4-6Unit 4: Infection Control and Prevention of Tuberculosis
ActivityActivity
• Discuss the following in small groups:
• What infection control methods are being done
currently in your facilities?
• What are some things you could change?
• Are there any potential barriers to implementing
those changes?
• Report back to the larger group and other
groups should give feedback/discuss solutions
to any possible barriers identified
7. Slide 4-7Unit 4: Infection Control and Prevention of Tuberculosis
Administrative ControlsAdministrative Controls
• Develop and implement written policies and
protocols to ensure:
• Rapid identification of TB cases (e.g., improving the turn-
around time for obtaining sputum results)
• Isolation of patients with PTB
• Rapid diagnostic evaluation
• Rapid initiation treatment
• Educate, train, and counsel HCWs about TB
• To the extent possible, avoid mixing TB patients and
HIV patients in the hospital or clinic setting
8. Slide 4-8Unit 4: Infection Control and Prevention of Tuberculosis
Environmental Controls:Environmental Controls:
Ventilation and Air FlowVentilation and Air Flow
• Ventilation is the movement of air
• Should be done in a controlled manner
• Types
• Natural
• Local
• General
• Simple measures can be effective
9. Slide 4-9Unit 4: Infection Control and Prevention of Tuberculosis
Evidence from PeruEvidence from Peru
• Open windows and doors produced 6x greater air
exchanges than mechanical ventilation and 20x
great air changes per hour than with windows closed
• Natural ventilation in “old-style” hospitals and clinics
resulted in much better ventilation and much lower
calculated TB risk, despite similar patient crowding
• More likely to have larger, higher ceilings; larger
windows; windows on opposite walls allowing
through-flow of air
Source: Escombe, et al. PLoS Medicine, 2007.
10. Slide 4-10Unit 4: Infection Control and Prevention of Tuberculosis
Estimated Risk ofEstimated Risk of
Airborne TB InfectionAirborne TB Infection
• Naturally ventilated, windows closed - 97%
• Mechanically ventilated with neg pressure
(ACH 12) - 39%
• Naturally ventilation, windows and doors
fully open:
• Modern (1970-1990) - 33%
• Old-fashioned (pre-1950) - 11%
Source: Escombe, et al. PLoS Medicine, 2007.
11. Slide 4-11Unit 4: Infection Control and Prevention of Tuberculosis
Direction of Natural Ventilation andDirection of Natural Ventilation and
Correct Working Locations (1)Correct Working Locations (1)
Source: CDC, 2007
12. Slide 4-12Unit 4: Infection Control and Prevention of Tuberculosis
Direction of Natural Ventilation andDirection of Natural Ventilation and
Correct Working Locations (2)Correct Working Locations (2)
Source: CDC, 2007
13. Slide 4-13Unit 4: Infection Control and Prevention of Tuberculosis
Direction of Natural Ventilation andDirection of Natural Ventilation and
Correct Working Locations (3)Correct Working Locations (3)
Source: CDC, 2007
14. Slide 4-14Unit 4: Infection Control and Prevention of Tuberculosis
Direction of Natural Ventilation andDirection of Natural Ventilation and
Correct Working Locations (4)Correct Working Locations (4)
Source: CDC, 2007
15. Slide 4-15Unit 4: Infection Control and Prevention of Tuberculosis
Environmental Controls (2)Environmental Controls (2)
Ultraviolet Light HEPA (high efficiency
particulate air) filters
Source: iStockphoto, 2008.
Source: MedlinePlus, 2008.
16. Slide 4-16Unit 4: Infection Control and Prevention of Tuberculosis
Personal Respiratory ProtectionPersonal Respiratory Protection
• Respirators:
• Can protect HCWs
• Should be encouraged in high-risk settings
• May be unavailable in low-resource settings
• Face/surgical masks:
• Act as a barrier to prevent infectious patients from
expelling droplets
• Do not protect against inhalation of microscopic
TB particles
17. Slide 4-17Unit 4: Infection Control and Prevention of Tuberculosis
N95 Respirator Dos and Don’tsN95 Respirator Dos and Don’ts
Source: CDC, 2007
18. Slide 4-18Unit 4: Infection Control and Prevention of Tuberculosis
DoDo
Be sure your
respirator is
properly fitted!
It should fit snugly
at nose and chin
Source: CDC, 2007
19. Slide 4-19Unit 4: Infection Control and Prevention of Tuberculosis
Note poor fit at the
bridge of nose
Note poor fit at the
chin
Respirator should
cover chin and
create a seal
Source: CDC, 2007
20. Slide 4-20Unit 4: Infection Control and Prevention of Tuberculosis
Don’t Forget to WEAR It!Don’t Forget to WEAR It!
Source: CDC, 2007
21. Slide 4-21Unit 4: Infection Control and Prevention of Tuberculosis
TB Prevention & ControlTB Prevention & Control
in the Community: MO Rolein the Community: MO Role
• Begin TB treatment as soon as possible
• Screen other people in the household
• Ensure that TB patients complete treatment
• Minimise crowding in congregate settings
22. Slide 4-22Unit 4: Infection Control and Prevention of Tuberculosis
TB Prevention & Control in theTB Prevention & Control in the
Community: Community RoleCommunity: Community Role
Teach members of the community to:
• Recognize the early symptoms of TB
• Minimise crowded living conditions
• Allow natural light into buildings and rooms as
ultra-violet rays quickly kill TB bacilli
• Open windows to air out rooms to dilute the
load of infectious TB bacilli
23. Slide 4-23Unit 4: Infection Control and Prevention of Tuberculosis
TB Prevention & Control in theTB Prevention & Control in the
Community: Patient RoleCommunity: Patient Role
• Patient should maintain a well-balanced diet
to keep the immune system strong
• Patient should TB patient to stop smoking
and minimize intake of alcohol
• Patient should hold a cloth or handkerchief
over mouth when coughing
• Patient should not spit on the floor but in a
container (preferably disposable) and dispose
of properly
24. Slide 4-24Unit 4: Infection Control and Prevention of Tuberculosis
TB Prevention & Control AmongTB Prevention & Control Among
HIV+ Patients and HCWsHIV+ Patients and HCWs
• Immunosuppressed persons are much more
susceptible to TB and therefore should not be
housed with inpatients who have undiagnosed
cough or untreated TB
• Encourage patients and HCWs to know their
HIV status so they can reduce their exposure
to TB infection
25. Slide 4-25Unit 4: Infection Control and Prevention of Tuberculosis
Infection Prevention &Infection Prevention &
Control in the WorkplaceControl in the Workplace
• Provide a well-ventilated, sun-lit environment
• Educate all staff on TB transmission &
prevention
• Implement HIV/AIDS workplace policy
• Link with health facilities for treatment &
support
26. Slide 4-26Unit 4: Infection Control and Prevention of Tuberculosis
TB Prevention in Special SettingsTB Prevention in Special Settings
Prisons and Police Holding Cells
• Screen all prisoners
• Treat & isolate
• Implement strict DOT during entire
treatment
• Refer all released prisoners under
treatment to nearest healthcare facility
27. Slide 4-27Unit 4: Infection Control and Prevention of Tuberculosis
TB Prevention in Special SettingsTB Prevention in Special Settings
Barracks
• Educate all personnel
• Screen all recruits
• Start treatment & organise workplace
DOT
• Identify & screen all close contacts
• Advise TB patients to have an HIV test
29. Slide 4-29Unit 4: Infection Control and Prevention of Tuberculosis
Contact Tracing (1)Contact Tracing (1)
The identification and diagnosis of persons
who may have come into contact with an
infected person
An important element to infection prevention
and control
30. Slide 4-30Unit 4: Infection Control and Prevention of Tuberculosis
Contact Tracing (2)Contact Tracing (2)
• Identify and evaluate contacts of persons with smear
positive pulmonary TB within 3 days of new case
discovery
• All close contacts should be evaluated
• Particular attention give to children under 5
• If index case is a child, source of disease will be a person
with PTB
• If source unknown, ask household contacts for symptoms
and investigate any contact with symptoms of PTB
31. Slide 4-31Unit 4: Infection Control and Prevention of Tuberculosis
Contact Tracing (3)Contact Tracing (3)
• Generally done by FWE or nurse
• Not necessary for smear-negative PTB or
EPTB, unless index case is a child
• Contact examination form completed for each
confirmed case’s contacts
• Suspects should be entered into the “Suspect
and Sputum Dispatch Register” and evaluate
appropriately
32. Slide 4-32Unit 4: Infection Control and Prevention of Tuberculosis
Contact Tracing: ChildrenContact Tracing: Children
• Nurses can give INH to child contacts <5 who
have been screened and are asymptomatic
• Treatment lasts 6 months, but a monthly
supply is handed out
• Pyridoxine is not routinely indicated for
children
33. Slide 4-33Unit 4: Infection Control and Prevention of Tuberculosis
TB Screening Among ContactsTB Screening Among Contacts
• Basic screening for TB done in home by FWE
or nurse
• Refer the following individuals to clinic for
further evaluation and follow-up (evaluation for
active TB and evaluation for INH prophylaxis
or IPT):
• Children in household < 5 years old
• Persons in household who are HIV+
• Persons in household who are ill
34. Slide 4-34Unit 4: Infection Control and Prevention of Tuberculosis
Large Group DiscussionLarge Group Discussion
• Who here works in a facility that does contact
tracing?
• Why is it important?
• What are some strategies you use at your
facility to make contact tracing successful?
• What are some challenges/barriers you have
encountered in the process?
35. Slide 4-35Unit 4: Infection Control and Prevention of Tuberculosis
Key PointsKey Points
• Prevention efforts should focus on primary,
secondary, and tertiary prevention
• Attention to the potential spread of infection
and disease among special populations,
including among those who are HIV+ is crucial
• Contact tracing is an important component of
TB control in the community
Editor's Notes
All three of these goals are important in the prevention of TB. Use the following examples to explain the levels of prevention
Primary prevention:
Using infection control measures in healthcare settings can prevent TB among patients and staff – i.e., wearing masks, appropriate ventilation
Offering INH-preventive therapy to infants living with adults with infectious TB
Secondary prevention
INH is used to prevent the progression to TB disease
Persons who benefit the most from secondary prevention are those most likely to develop severe forms of active TB (such as contacts less than 5 years old and immunosuppresed persons)
Early diagnosis and treatment
Tertiary prevention
BCG vaccination does not prevent infection with TB but it does prevent severe forms of childhood TB and thus can be considered tertiary prevention
The more commonly used interpretation of tertiary prevention is the early diagnosis of TB before complications have developed and that will be discussed in subsequent units
Emphasise that transmission is not one-way and does not discriminate!
Patients can transmit to workers, visitors and other patients and vice versa. Any infectious person puts everyone in his/her immediate surroundings at risk!
Infection prevention and control is the PREVENTION of transmission from individual to individual (as above) through administrative, environmental, and personal protection equipment
Infection control is divided into three different control measures
First two levels are the most important
Use of personal respiratory protection cannot compensate fully for missing administrative and environmental controls
Have the participants break into small groups and discuss the questions, 3 minutes for each question. They should then report back as a large group quickly
After the small groups have discussed as a large group, present slides 7-27 to summarize what participants have just discussed and add some additional information
Administrative controls refer to policies and procedures that reduce the risk of exposing uninfected persons to infectious TB
Ask participants what administrative measures they can think of to accomplish this goal
Ask participants to discuss specific advice for HIV+ healthcare workers
Natural ventilation refers to open windows and doors to capture wind
Local ventilation refers to strategically placed fans
General ventilation refers to a centralised air conditioning system that does not allow air from rooms of patients with infectious TB to be re-circulated
Some simple measures to increase ventilation and air flow include different types of fans (standing, window, ceiling, etc.)
Source: Escombe AR, Oeser CC, Gilman RH, et al. Natural Ventilation for the Prevention of Airborne Contagion. PLoS Medicine. 2007; 4(2):e68
These are the percent of susceptible individuals who were infected after 24 hours of exposure in each of the settings listed
Source: Escombe AR, Oeser CC, Gilman RH, et al. Natural Ventilation for the Prevention of Airborne Contagion. PLoS Medicine. 2007; 4(2):e68
Explain that this and the following 3 slides are examples of methods that could be used to take advantage of natural ventilation as an infection control measure. Emphasise that the point of these graphics are not necessarily to show exact placement, rather to demonstrate examples and how wind can be used in a variety of ways
Emphasize also that it is the patient TB-infected patient is the one that would be transmitting TB to the HCW
When increasing ventilation and air flow, care should be taken as to the appropriate positioning of the windows, doors, the patient and the HCW to control infection
Remember, the patient is the one that is infected and might pass on TB to the HCW.
Both indirect ultraviolet irradiation of air and HEPA filters have been used in some high-risk settings to reduce the concentration of infectious TB particles in the ambient air
Image source (sun): iStockphoto. [database on the Internet]. iStock International, Inc. 2008 [cited 2008 Feb 4]. Image # 3025335. Available from: istockphoto.com
Image source (HEPA): MedlinePlus [database on the Internet]. Bethesda (MD): National Library of Medicine and National Institutes of Health; 2008 Jan 2 [cited 2008 Jan 23]. Medical Encyclopedia: HEPA Air Filter; Available from: http://www.nlm.nih.gov/medlineplus/ency/imagepages/19338.htm
High-risk setting in which respirators should be encouraged include:
Rooms where cough-inducing procedures are done (i.e., bronchoscopy suites)
When collecting sputum specimens from patients
TB “isolation” rooms
Referral centers or homes of infectious TB patients
CDC/NIOSH-certfied N95 (or greater) respirator should be used
Respiratory protection is effective only if:
The correct respirator is used
It&apos;s available when you need it
You know when and how to put it on and take it off
You have stored it and kept it in working order in accordance with the manufacturer&apos;s instructions
How it works: The patient coughs out droplets, therefore the surgical mask is protective as it will collect the droplets and not allow them to spread. The droplet evaporates, leaving the organism in microbe form in the air. The HCW must wear the N95 mask as he/she is breathing in microbes, which are much smaller than the droplet the patient has coughed out
Some clinics may not have access to CDC/NIOSH-certified N95 (or greater) respirators. The MoH and government are making every effort to make these masks widely available. HCWs may be able to access respirators from CMS through special order. One person can use the same respirator for one month
It’s also important to note that these respirators are for healthcare providers and the surgical masks may be given to patients to wear
The mask used in this picture is one of many N95 respirator masks. This and the following slides are used to show correct usage and placement of the mask on the face
Show the green mask made by 3M to participants, as this is the mask used in Botswana
Either demonstrate correct usage with mask in hand, or use the images in next few slides
Remember, respirators and masks don’t do you any good if kept in your pocket or purse!
Most TB patients will no longer be able to spread the bacteria after two weeks of treatment. Therefore, it is very important that a person starts on treatment as soon as possible to avoid spreading the bacteria to others
It is our job as HCW to teach the patients these things!
It is very important that the TB patient maintain a healthy lifestyle to keep their immune system strong. This includes maintaining a good diet and not drinking or smoking
Smoking damages the lungs and will continue to weaken the lungs while they are trying to heal. Drinking alcohol can also be dangerous for a patient on TB treatment
Both alcohol and the TB medication are processed by the liver. If the liver has too much work to do, it can become damaged and no longer function properly
The issue of keeping HIV infected health care workers away from TB patients is complex
It may be difficult for an HIV+ health care worker to avoid TB exposure, since there are so many patients with TB in Botswana
It is still useful to understand that there is an increased risk for HIV+ health care workers who are exposed to TB
Ask participants if they have an HIV/AIDS workplace policy
A rapid assessment of TB in Botswana in 2002 showed the prevalence of TB among prisoners was 3,797 cases per 100,000, equivalent to 5x higher than the general population. On the basis of this survey several recommendations were made:
Screening for TB at prison entry or transfer and periodically thereafter (e.g, annually) using a symptom-based questionnaire
Contact investigations of newly identified smear-positive cases
Assessment of administrative and environmental measures to reduce ongoing transmission within the prison
Implementation of isoniazid preventive therapy among HIV-infected prisoners and guards according to existing MOH guidelines
Source: Centers for Disease Control and Prevention. Rapid Assessment of Tuberculosis in a Large Prison System --- Botswana, 2002. MMWR Weekly [serial on the Internet]. 2003 March 28 [reviewed 2003 March 27; cited 2008 Jan 23]; 52(12):250-252. Available from: http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5212a3.htm
Some police officers won’t give ARVs and TB meds to inmates in the police holding cells. Inmates could be there 6 months – 1 year before going to trial
Make sure prisons in your district/region have a referral policy for inmates with tuberculosis who will be released
Explain that police officers need to be trained as DOT supporters
The next few slides will deal with contact tracing. These questions will be answered in the next few slides and will be discussed in small groups at the end of the section.
Open the Botswana National Tuberculosis Programme Manual to Annex 11, Form 7
As capacity in Botswana grows, the effort devoted to screening and follow-up of TB contacts will increase
Refer to The Tuberculosis Contact Examination Form (MH 2035) in the Botswana National Tuberculosis Programme Manual, Annex 11, form 7
Document INH prophylaxis in child’s clinic card– there is no register for children who are given preventive IN after exposure
The IPT register should NOT be used
Case finding in households is important for control of TB in the community
Large group discussion:
Allow ~3-5 minutes for discussion of each question above, allowing participants to engage in reciprocal discussion about their experiences with contact tracing
If few people have experience with it, encourage them to brainstorm keys to success and potential barriers in their own work settings, based on what they have just learned
