3 i

MESYUARAT PENCAPAIAN NEGERI JAN-SEPT
2014 & PERBINCANGAN HALATUJU
PROGRAM KAWALAN TB/KUSTA 2015
17-19 NOVEMBER, 2014
CROWN GARDEN HOTEL, KELANTAN
PENGENALAN 3I
DR. ASMAH RAZALI
PUBLIC HEALTH PHYSICIAN
DISEASE CONTROL DIVISION (TB/LEPROSY)
MOH PUTRAJAYA
November 17, 2014 MESY. TWG BIL 2/2014, CROWN GARDEN HOTEL, KELANTAN

INTRODUCTION
• The Three I’s,
 Isoniazid Preventive Therapy (IPT),
 Intensified Case Finding (ICF) for
active TB, and
 TB Infection Control (IC),
are key public health
strategies to decrease the
impact of TB on people
living with HIV.

INTENSIFIED CASE FINDING (ICF)
• Intensified Case Finding (ICF) is an activity, recommended
by the WHO, intended to detect possible TB cases as
early as possible among people living with HIV – usually by
using a simple questionnaire for the signs and symptoms of
TB.
• ICF: Intensified Case Finding for TB means regularly
screening all people with or at high risk of HIV or in
congregate setting for the symptoms and signs of TB,
followed promptly with diagnosis and treatment, and then
doing the same for household contacts.

ICF Goals
• Reduce morbidity and mortality
 More intensive case-finding leads to fewer TB deaths and less
severe post-TB complications
 Focus on those most at risk of severe morbidity
• Reduce TB transmission
 General community
 Institutional settings
 Marginalised populations
• Increase case-finding
 Target high risk groups
 Community-wide approach

ICF OPPORTUNITY
• Screening of high risk groups
Symptomatic out pt,
PLHIV,
Diabetes,
HCW
• Screening in institutions
Prisons
PUSPEN
Old folk homes
• Screening in community
High prevalence TB locality

What factors determine the yield and
cost-effectiveness of ACF?
Factor 1. TB prevalence among the target
Higher prevalence – higher yield
Factor 2. Diagnostic algorithms
More comprehensive screening- higher cost
&yield

3 Ì= Intensified case finding
MESY. TWG BIL 2/2014, November 17, 2014 CROWN GARDEN HOTEL, KELANTAN

ICF OBJECTIVES
1. To increase CASE DETECTION RATE among the high risk group of
TB
2. To identify suspected TB cases (symptomatic) among the high
risk group of TB
3. To collect and analyse sputum from symp. Individu
4. To provide health education
5. To treat symptomatic TB

ICF ACTIVITY I(3)T
IDENTIFY
TRAIN
TRACE
TREAT
• Identify the localities with high
burden of TB
• Conduct training to the staff &
community volunteers
• House to house visit- TB screening
& refer for positive symptoms
• Ensure treatment is given for
positive TB

ICF-PROCESS
1. Survey your data
2. Analyze -? High TB burden district- ? Localilities
3. Start planning your ICF project –
- Approval fr. TKPK KA, PKD, Local leaders
-Conduct meeting with local leaders
-Design your action plan- Gantt chart, budgetting, training,
ICF form
4. Conduct the training course
5. Start ICF- house to house visit, TB screening, refer positive
symptoms to nearby clinic.
6. Writing the report

INFECTION CONTROL

DEFINITION
•Infection control refers to policies and
procedures used to minimize the risk of
spreading infections, especially in
hospitals and human or animal health
care facilities

WHY DO WE NEED
INFECTION CONTROL?

Need for infection control

Overburdened health services

Notification Rate per 100,000 (NR) and Cases of TB
Among HCW, 2002-2013
Cases NR
33
300
250
200
150
100
50
November 17, 2014
77 88 93 103 92
119 124
182 192
221
111.9
81.0
248
120.0
100.0
80.0
60.0
40.0
20.0
0.0
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
TB Cases among HCW
Kadar Notifikasi (NR) Anggota KKM (100,000 Anggota KKM)
Kadar Notifikasi(NR) Penduduk ( 100,000 Penduduk)
MESY. TWG BIL 2/2014, CROWN GARDEN HOTEL, KELANTAN

MDRTB MALAYSIA (2004-2013)
Cases %
200
180
160
140
120
100
80
60
40
20
November 17, 2014
0.3 0.3
0.7
0.6
0.9
0.8
0.9
1.3
0.8
0.7
13 17 42 41 56 55 64 141 74 124
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Notified MDR Cases Propotion MDR (%)

Risk factors for TB infection
• Concentration of infectious droplet nuclei in the
air produced by index case when coughing.
•Duration of exposure - How long did the
exposure last?
• Proximity to source -How close was the person
to the TB patient? Household, workplace,
congregate setting..

Standard Precautions
• Use with every patient, at every health care visit
• Main elements include:
• Hand hygiene
• Respiratory hygiene, cough etiquette
• Use of personal protective equipment to avoid direct contact with
patient’s blood, body fluids, secretions, and non intact skin
• Prevention of needle stick/sharp injury
• Cleaning and disinfection of the environment and equipment

STANDARD PRECAUTIONS
Healthcare workers must treat all blood &
body fluids as infectious.

Airborne vs. droplet transmission
Airborne
• Small droplet nuclei <5 microns diameter
• Stay suspended in air
•When inhaled, can reach the alveoli and cause
infection
Droplet
• Large droplets > 5 microns in diameter.
•Do not remain suspended in the air, so no special
air handling or ventilation is required
• If inhaled, do not reach alveoli

Number and size of organisms
Number of organisms released
Talking 0-200
Coughing 0-3,500
Sneezing 4,500- 1,000,000
Size of the droplets (function of air velocity)
Sneeze ~3-10 m/s
75% are ~10 μm in diameter
< 25% are droplet nuclei (1-5 μm in diameter).
Wells 1955, Duguid 1945, Wells/Riley 1961, et al. November 17, 2014 MESY. TWG BIL 2/2014, CROWN GARDEN HOTEL, KELANTAN

Who can infect whom?
Patient to Worker to Visitor to
Patient
Worker
Visitor

AIRBORNE PRECAUTIONS
• Airborne precautions are required to protect against
airborne transmission of infectious agents.
• Diseases requiring airborne precautions include, but are not
limited to: Measles, Severe Acute Respiratory Syndrome
(SARS), Varicella (chickenpox), and Mycobacterium
tuberculosis.
• Airborne precautions apply to patients known or suspected
to be infected with microorganisms transmitted by airborne
droplet nuclei.
• Preventing airborne transmission requires personal
respiratory protection and special ventilation and air
handling.

AIRBORNE PRECAUTIONS
• Place patients in airborne precaution room
which has:
• 12 or more air changes per hour
• Control of airflow direction
• Limit the movement of the patient
• Ensure patients wear a surgical mask if outside
their room
•Use a particulate respirator whenever entering
and providing care

Factors affecting the risk of transmission
•Patient
•Recipient
•Bacterial
•Institutional

What are managerial activities?
Activities used by programme managers to support and
facilitate the
• implementation
• operation
• maintenance
• evaluation
of TB infection control at the national, sub-national and facility
levels

MANAGERIAL ACTIVITIES
1. Identify and strengthen a coordinating body, and develop
an IC plan
2. Ensure health facility design, construction, renovation
and use are appropriate
3. Conduct surveillance of TB disease among health care
workers, and assessment of health and settings at all
levels
4. Address advocacy, communication and social mobilization
(ACSM)
5. Conduct monitoring and evaluation of the set of IC
measures
6. Enables and conduct research

Administrative controls
1. Promptly identify people
with TB symptoms (Triage)
2. Separate infectious cases
3. Ensure patients cover their
cough
4. Minimize time in health
care facilities
5. Health worker protection

Administrative controls are
first priority because they:
•Block the first step in the pathway of TB
transmission
•Stop TB at the source: prevent release of
droplet nuclei in the first place
•Have been shown to be effective
•Are less expensive
•Can be readily implemented by managers
and health care workers

ISTC of Administrative controls
Identify people with TB symptoms (triage)
Separate infectious cases
Time is minimized in health care facilities (also
ensure effective Treatment)
Cough etiquette
(ISTC is also International Standards for TB Care)

B. Clinics: Identify people
with TB symptoms
Ask screening questions at intake:
• Do you have a cough? If yes, for how long?
• Are you being evaluated or treated for TB?

Identify people with TB symptoms
If the patient reports cough > 2 weeks and/or being evaluated
or treated for TB, then:
• Suspect the person may have infectious TB
• Instruct patients to cover cough
• Triage (next slide)

Separate potentially infectious patients
• In a well-ventilated area away from others
•Requires rational design and use of buildings,
attention to patient flow
• Provide care for infectious TB patients in clinics
separated space from clinics for people living
with HIV/AIDS
How do (or can) you accomplish separation in your
countries’ facilities?

Minimize Time to expose others
If suspect TB:
• Quickly provide the services originally requested (fast track
instead of queue)
• Initiate a TB diagnostic evaluation, or facilitate referral for
diagnostic services
• Separate from other patients

November 17, 2014
Promote Cough etiquette
Among patients, visitors, and health workers
• Use tissue or cloth to cover nose and mouth when
coughing or sneezing
• Use surgical mask if patient unable to cover own cough,
or patient is moving through facility
• If no physical barrier available, cover mouth and nose
with bend of the elbow
• Posters in all patient care and staff areas
• Staff vigilance to identify coughing patients in waiting
areas (if missed by screening)

PROTECTION OF HEALTH CARE
WORKERS
•Appropriate information and
education
•Encourage HIV testing
•Encourage screening
•Training

Environmental controls—
facility level
Reduce the concentration of infectious particles in the air via:
• Ventilation
• Natural, mechanical, or mixed mode
• Can direct the flow of infectious air away from health care workers
and other patients
• Ultraviolet germicidal irradiation (UVGI)

A. What is ventilation?
• Movement of air
• “Pushing” and/ or “pulling” of particles and vapours
• Preferably in a controlled manner

THE BETTER VENTILATED
THE AREA, THE LOWER
RISK OF TRANSMISSION OF
TB AND OTHER AIRBORNE
INFECTIONS

Window openings

Sputum collection
Don’t!
Do!
Sputum
collection
outside: a simple
solution!

Air Changes Per Hour (ACH)
• Calculating ACH is the most simple way to
assess ventilations
•ACH = Volume of air moved in one hour
•One ACH means that the volume of air in the
room is replaced in one hour
•WHO recommends at least 12 ACH to prevent
airborne infection
• The higher the ACH, the better the dilution and
the lower the risk of airborne infection
•But too much airflow can be uncomfortable

ACH = air flow rate
divided by room
volume

What do you need to measure ACH?
1.A tape measure
2.Vaneometer
3.Smoke tube
4. Calculator
5. Note pad

Measure dimensions of the opening
to calculate area
Area of window opening = length x width
Example 1:
Area = 0.5 m x 0.5 m = 0.25 m2

Use the vaneometer to measure
velocity, direction
Speed = metres per second = m/s

Calculate room volume
Room volume = width x depth x height
Example 1:
3 m wide x 5 m deep x 3 m high = 45 m3

Example : ACH calculation
•Window area = length x width = 0.25 m2
•Air velocity through window= 1 m/s
•Air flow rate
= window area x air velocity = 900 m3/h
•Room volume
= width x depth x height = 45 m3
•ACH
= Air flow rate divided by room volume
= 900 m3/hour = 20 ACH
45 m3

Ventilation is more effective if:
1. Directional airflow
2. There is good air-mixing (no
stagnant or short circuiting)

Directional airflow
•Air flows from “clean” to
“contaminated”
•Locate the health care workers (or other
patients) near the clean air source
•Locate the person who may be infectious
near a place where the air is exhausted
away

Natural ventilation
Open
Window
Open
Window
Door
C D E F
Beds
B
Beds
A
Health care worker (HCW) is near the clean
air source

Natural ventilation
• Created by the use of external
airflows generated by natural forces
such as:
• Wind
• Differences in temperature (stack)
• Naturally ventilated rooms can
achieve very high ventilation rates
(ACH) under ideal conditions

Stack ventilation
• Stack ventilation is another
type of natural ventilation
• It is driven by differences in
temperature.
• When the room air is
warmed, it is lighter and
rises.
• This building is designed to
let the warmed air escape
near the top, which is then
replaced by fresh air entering
through the lower opening.

Turbine driven ventilation
(whirly bird)
• A whirly bird (turbine) can draw
even more air once it starts
spinning.
• These take advantage of the
stack effect.
• Photo courtesy of Hans Mulder

Maximize Natural Ventilation
• Openings on opposite walls (cross
ventilation)
• Openings are unrestricted (stay open)
• 10% of floor space should be openable
window area on each wall
• Upper levels of the building (higher from the
ground floor)
• Building and openings are oriented to use the
prevailing wind, without obstruction by other
nearby buildings

Mechanical and
mixed mode ventilation

Mechanical ventilation
• Is created by using a fan to force air exchange
and to drive air flow
• Works by generating negative pressure in the
room to drive airflow inward
To be effective, it is essential that:
• All doors and windows kept closed
• A minimum of 12 ACH is maintained
• The ventilation system is well-designed,
maintained and operated

Principles of ventilation
Which is an easier way to extinguish the
flame?
• Inhale (pull, exhaust)
• Exhale (push, supply)

Two ways to dilute and remove
contaminated air
First
choice:
Single
pass
Re-circulation +
HEPA filtration
Rooms in a health facility

Designs to provide air mixing
Airflow patterns are
affected by:
•Air temperature
• Location of furniture
• Space configuration
•Movement of health
care workers (hcw)
hcw
supply
exhaust
hcw
exhaust

Short circuiting
•Clean air is
removed before it
is mixed with room
air
•Contaminated air
in the room is not
effectively diluted
or removed
supply
exhaust

Negative pressure keeps droplet
nuclei in the room
• Air flows from a higher pressure area to a
lower one
• A room under negative pressure has a lower
pressure than adjacent areas, so air is drawn
into the room; negative pressure directs the
airflow
• Negative pressure is achieved by exhausting
more air from a room than is supplied

What is negative pressure?
225 m3/h
200 m3/h
25 m3/h
200 m3/h
225 m3/h
135 m3/h
135 m3/h
Patient room
(Negative)
Nurse room
(Positive)

Negative pressure room
•Air flows into room, from higher to lower
pressure
•10% flow differential is minimum required
•Keep doors and windows closed
•Monitor to ensure negative pressure is
maintained

Mixed mode ventilation
• Combines the use of mechanical and natural
ventilation
• Is done through the installation of an exhaust fan
to increase the rate of air changes in the room
• Can be useful in places where
• natural ventilation is not suitable (e.g. very cold
weather)
• fully mechanically ventilated rooms are not
available

Fans
•Fans can be used to mix the air
in a naturally ventilated area.
• A ceiling fan - circulates air but
doesn’t move it in a particular
direction. This type of fan mixes
the air, and is more effective
with an open window to dilute
and remove droplet nuclei
• The other fans can direct the
air, and be positioned to
enhance air movement into and
out of a room to remove droplet
nuclei.

Window exhaust fan
• Fan used for exhaust ventilation.
Photo courtesy of Paul Jensen November 17, 2014 MESY. TWG BIL 2/2014, CROWN GARDEN HOTEL, KELANTAN

Airflow with window exhaust fan
Corridor
Patient room
Window
fan
•Exhausted air is expelled through the fan.
• The exhaust fan has generated negative pressure in the patient room.
• This difference in pressure allows the air to enter the room from the
corridor.
• The directional airflow prevents droplet nuclei from escaping into the
corridor.

Window exhaust fan
• A window exhaust fan with a window open directly below it.
• The picture is taken outside the room. We are standing outdoors looking into the
room.
• The fan is exhausting contaminated air to the outside, right above an open window.
• Air is flowing into the room through the window.
Photo courtesy of Paul Jensen.

Where goes that air?
Short-circuiting
• Locating the exhaust next to the supply of incoming air results in
short circuiting of the air outside the building.

Respiratory protection

A. Risk of TB transmission
Work location TB incidence rate ratio
(relative to population
TB incidence rate)
Outpatient facilities 4.2 – 11.6
General medical wards 3.9 – 36.6
Inpatient facilities 14.6 – 99.0
Emergency rooms 26.6 – 31.9
Laboratories 42.5 to 135.3
Joshi R, Reingold AL, Menzies D, Pai M [2006]. Tuberculosis among health-care workers in low- and middle-income countries: a
systematic review. PLoS Med 3(12): e494.
Menzies D, Joshi R, Pai M [2007]. Risk of tuberculosis infection and disease associated with work in health care settings. Int J
NovTeumbbeercr 1L7u, n20g1 D4is 11(6): 593-605. MESY. TWG BIL 2/2014, CROWN GARDEN HOTEL, KELANTAN

WHO RECOMMENDATIONS
• When used with administrative and
environmental controls, particulate
respirators may provide health care
workers (HCW) additional protection
from TB
• Respirators
• Must meet or exceed standards
• Be properly used
• Be part of a training programme

Surgical masks
• Reduce the spread of
microorganisms from the
wearer to others, by
capturing large wet particles
• Do not protect the wearer
from inhaling small infectious
aerosols.

Particulate respirators
• Protect the wearer
from inhaling
droplet nuclei
• Filter out infectious
aerosols
• Fit closely to the
face to prevent
leakage around the
edges

Surgical masks
(yes for patients)

Surgical masks
do not protect staff
from TB

USER SEAL CHECK
Cover respirator with both hands
1. Exhale sharply
• Should feel positive
pressure inside respirator
• If leakage, adjust, re test
2. Inhale deeply
• Negative pressure should
make respirator cling to face
• If leakage, adjust, re test

WHY IS FIT TESTING NECESSARY?
•Ensure a proper seal between
respirator and wearer
•Determine appropriate
make/model
•Determine appropriate size

WHEN SHOULD FIT TESTING BE DONE?
Employees should pass a fit test:
• Prior to initial use
• Whenever a different respirator facepiece (size,
type, model or make) is used
• Periodically thereafter
• Whenever changes in the worker’s physical
condition or job description that could affect
respirator fit are noticed or reported

SOURCES OF FACEPIECE LEAKAGE
• Around facepiece/skin interface
• Through air-purifying element
• Through exhalation valve

HOME INFECTION CONTROL
• Ensure adequate ventilation / open windows.
• Isolating patients- own bedroom if possible
• Promoting cough hygeine
• Ensuring that patients use surgical mask during waking hours
while at home or when meeting with others;
• Refraining from close contact with children;
• Maximising time in open-air environment (e.g., receiving visitors
outside);
• Minimising contact with known HIV positive patients; and
• Ensuring that household members are screened for TB and DR-TB

INFECTION CONTROL HCW
• Wearing an N95 respirator (health workers and DOTS
supporters);
• Keeping HOME visits or clinical evaluations brief, and whenever
possible, conduct these outside or in a well-ventilated room with
as much distance as possible from the patient;
• Educating the patient on cough hygiene
• Providing the patient with a surgical mask when close contact is
required

IPT

TB/HIV
• HIV is the strongest risk factor for developing
tuberculosis (TB) disease in those with latent or new
Mycobacterium tuberculosis infection.
• The risk of developing TB is between 20 and 37 times
greater in people living with HIV than among those who do
not have HIV infection.
• TB is responsible for more than a quarter of deaths in
people living with HIV.
• A high rate of previously undiagnosed TB is common
among people living with HIV.

ESTIMATED TB INCIDENCE, 2012
November 17, 2014
•WHO estimated that there
were 8.6 million new TB
cases in 2012 and 1.1
million (13%) were HIV-positive.
• 75% of these HIV-positive
TB cases were in the
African Region.
• There were 1.3 million
people died from TB in
2012 with 320,000 deaths
from HIV-associated TB.


ESTIMATED HIV PREVALENCE IN NEW TB CASES, 2012
November 17, 2014
• Globally, 0.4 million TB patients
living with HIV were enrolled on CPT
in 2012.
• The coverage of CPT among TB
patients with a documented HIV-positive
test result was 80% in 2012,
similar to the level of 2010 and 2011.
• In 2012, 4.1 million people enrolled
in HIV care were reported to have
been screened for TB, up from 3.5
million in 2011.
• Of the reported 1.6 million people
newly enrolled increased, since
about 50% of those newly enrolled in
HIV care and screened for TB are
likely to be eligible for IPT.


HIV SITUATION IN MALAYSIA
Cumulatifve HIV = 98,279
Cumulative deaths = 15,688
PLHIV = 82,591
‘By end of 2013, Malaysia reported a cumulative figure of
101,672 HIV cases with 85,332 people living with HIV.

40000
35000
30000
25000
20000
15000
10000
5000
0
ESTIMATED ARV COVERAGE , MALAYSIA
Expected coverage
NO OF HAART
2003 2004 2005 2005 2007 2008 2009 2010 2011 2012 2013 2014 2015

TBHIV (%) IN TB CASES, MALAYSIA
(2000- June,2014)
No.of cases
%TBHIV
11,945
16
12
8
5.8
692
4
0
25,000
20,000
15,000
10,000
5,000
0
No.TB Cases No.of new TB Cases with HIV Positive %TBHIV in TB cases

TB-HIV cases were first detected in 1990 and contribute
to about 10% of the total TB cases reported in Malaysia.
• In 2013, there were 24,071 cases of TB registered in
Malaysia. About 20, 635 (86%) cases were tested for HIV
at the same time of TB diagnosis.
• Off 20,635 TB patients tested for HIV, about 1,510 (7.3%)
cases were recorded to be HIV positive.
• Off 1,510 patients with TB-HIV co-infection, 1,299 (86%)
cases were pra- diagnoses and 211 (14%) post diagnoses
of TB-HIV co-infection.
November 17, 2014
TB HIV COINFECTION

TB-HIV DEATH, MALAYSIA

Impact of HIV on TB
• HIV increases risk of developing
active tuberculosis
• 5 -10% chance per year of re-activation
• 9 times greater risk compared to HIV
negative people
• 50% chance per lifetime of re-activation
IPT
Isoniazid prophylaxis treatment
reduces risk of developing TB by 33%
regardless of Mantoux status
(relative effect 0.67; CI 0.51–0.87)
(Cochrane review Level 1)

2 Ì = Isoniazid Prophylaxis Theraphy

Isoniazide 5mg/kg od
(Max 300mg)
+
Pyridoxine 50mg od
for 6 months

IPT
• A meta-analysis showed that there was no difference in
development of active TB between six month and 12 month IPT
(RR=0.58, 95% CI 0.30 to 1.12). (WHO, 2010)
• Thus, our local circular recommends that IPT to be given for six
months. (Circular, 2011)

TBHIV MALAYSIA
• TB-HIV collaborative activities started in Malaysia since year 1990.
• Approaches to engage TB and HIV programme in management of TB-HIV
co-infection need to be improved.
• All cases diagnosed with TB should be screened for HIV and vice
versa.
• There was decrease in ART coverage among HIV positive TB
patients; 434 (32%) in 2012 compared to 407 (27%) in 2013.
• CPT coverage among TB-HIV patients was still low (<5%).
• There was encouraging increased in IPT coverage among HIV
positive TB patients ; 459 in 2011, 1120 in 2012 and 1220 in 2013.

THANK YOU ….
•
•
• 3 Ì

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