To reduce the risk of tuberculosis (TB) transmission in healthcare settings, facilities should implement infection control measures. Administrative controls include developing written TB policies, isolating suspected TB patients, and educating healthcare workers. Engineering controls like ventilation systems and HEPA filters work to reduce infectious droplets. Personal protective equipment like respirators protects workers during high-risk procedures. Facilities should screen patients and workers for TB symptoms and use simple measures until diagnostic results, such as providing masks to suspected TB patients and opening windows. Prompt evaluation and treatment are also important to control the spread of TB.

1. Module 12: Infection Control in
Health Care Settings
*Image courtesy of: World Lung Foundation

2. 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

3. 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

4. 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

5. What is Infection Control?
Patient to
Worker
Visitor
Patient
Worker to
Worker
Visitor
Patient
Visitor to
Worker
Visitor
Patient

6. 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

7. 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

8. Fate of Droplets
Organisms Liberated
Talking 0-200
Coughing 0-3500
Sneezing 4500-1,000,000
Droplets can remain
suspended in the air for
hours.

9. 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.

10. Hierarchy of Infection Controls
Patient
R
espiratory
Protection
Environm
ental
Adm
inistrative
W
orker
Facility

11. 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

12. 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
•

13. Administrative Controls (cont.)
Perform risk assessment and
classification of facility based
on:
• Profile of TB in community
• Number of infectious TB
patients admitted

14. 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

15. • The movement of air
• “Pushing” or “pulling” of vapor or
particles
• Preferably in a controlled manner
What is Ventilation?

16. Types of ventilation
–natural
–local
–general
Ventilation Control

17. Simple Measures Can Be Effective!

22. 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

23. 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

24. 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

25. N95 Respirator Dos and Don’ts
*Image courtesy of: CDC Image Library

26. Do
Be sure your respirator
is properly fitted!
[Should fit snugly at
nose and chin]
*Image courtesy of: CDC Image Library

27. Note poor fit at the bridge
of nose
Note poor fit at the chin-
Respirator should cover
chin and create a seal

28. Don’t forget to WEAR it!
*Image courtesy of: CDC Image Library

29. 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

30. 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.

31. Cough Etiquette

32. Common-sense Prevention
*Image courtesy of: World Lung Foundation

33. 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

34. 5-Steps to Prevent TB Transmission
1 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

35. 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

36. References
Core 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.htm
hhttp://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.

37. VIDEO:
Why Don’t We DO IT
in Our Sleeves?