Tuberculosis infection control in low income countries: a literature review

1. Anders Chen, MD Internal Medicine R3 4/5/2011 Tuberculosis infection control in low income countries: a literature review

2. TB infection control (TB IC): Background WHO Policy recommendations Literature review Practical next steps Outline

3. Increased nosocomial TB in high income countries in 1980s and 1990s1,2,3. Increased focus on TB IC in health care settings, with creation of guidelines and manuals to aid in their implementation TB IC: background 1Pearson, Ann Int Med 1992, 2Beck-Sague JAMA 1992, 3Menzies NEJM 1995

4. Guidelines Implementation

5. Resurgence of TB in low income countries fueled by HIV pandemic Higher rates of HIV and TB Already small health care workforce Less resources for infection control Nosocomial transmission risk for patients HCW rates of TB well above average population rates4 TB IC Background: low income countries 4Menzies, Int J Tuberc Lung Dis 2007

6. Guidelines Implementation?

7. At the facility level: • Managerial controls: • Coordinating body for TB IC • Facility risk assessment • Surveillance of TB disease in HCW • Rethinking use of space • Advocacy • Monitoring and evaluation of TB IC efforts WHO policy recommendations

8. Administrative controls: • Prompt identification of suspected/confirmed TB patients • Separation of such patients away from others, especially immunocompromised patients, into well ventilated areas • Cough etiquette, respiratory hygiene • Rapid diagnosis • Protection of HCW WHO policy recommendations

9. Environmental Controls: • Ventilation: optimizing natural ventilation where appropriate • Large open windows • Directional flow • Adequate ACH • Mechanical or mixed mode ventilation where natural ventilation not appropriate • UVGI as a supplemental control • Lab safety WHO policy recommendations

10. Personal Protective Equipment • N95 or equivalent respirators for staff WHO policy recommendations

11. Lack of tools to aid in implementation in low income countries Data supporting TB IC measures in high income countries has been with packages of multiple interventions simultaneously, including expensive measures Few data looking at effectiveness of any individual interventions5 Challenges to implementation 5WHO 2009 annexes

12. In low and middle income countries, are there examples of successful implementation of low cost TB IC interventions? Are there data showing reduced nosocomial TB spread with limited, low cost interventions? Literature review

13. Limited resources, limited implementation, limited reports. • Literature review including conference abstracts and grey literature yielded 23 articles describing TB IC in low and middle income countries. • 16 descriptions of successful implementation • 2 report efforts to monitor and evaluate TB IC efforts • 9 report data on nosocomial transmission before and after TB IC efforts • 5 published in peer reviewed journals with statistical analysis, of which 4 yielded positive results. Literature review

14. da Costa, J Hosp Infect 2009, Brazil • Low cost administrative measures including HCW training, cough etiquette, separating coughing patients, rapid sputum processing, clustering of TB services to reduce exposure. Also respirators for staff • Reduced LTBI incidence in HCW • Upper middle income country, relatively low cost interventions Literature review

15. Roth et al. Int J Tuberc Lung Dis 2005 • 2 Brazilian hospitals with higher levels of TB IC, 2 with lower levels. • TB IC measures include rapid diagnosis/testing, isolation rooms. Biosafety cabinets in labs. • Lower LTBI incidence in HCW in 2 hospitals with higher levels of TB IC measures • Upper-middle income country, some higher cost measures Literature review

16. Yanai, Int J Tuberc Lung Dis. 2003 • Thailand, referral hospital • Many lower cost interventions incl. administrative controls of triage, cough etiquette, rapid sputum processing, natural ventilation • Some higher cost measures: biosafety cabinets, 1 isolation room • Lower LTBI incidence in HCW after measures implemented • Lower middle income country, mix of low and higher cost measures Literature review

17. Catterick, South African AIDS Conference 2009 • Church of Scotland Hospital, Tugela Ferry, site of well publicized highly fatal XDR outbreak • Administrative controls: TB IC officer. Cough officers to screen patients. Separated DOTS and HIV and moved both to periphery of hospital campus. Screened HCW for TB • Environmental: Unannounced audits on open window policy • PPE: Unannounced audits on staff respirator use • Report successful low cost measures, no data • Poor area in an upper middle income country, with inexpensive measures implemented Literature review

18. Existing data do suggest that low cost measures can be implemented and can reduce nosocomial TB spread More data would be useful, as would monitoring and evaluation of efforts Literature review: discussion

19. Practical tools to aid in implementation of TB IC guidelines. Next steps

20. Guidelines Implementation?

21. WORLD TB Day 3/24/11

22. I-TECH (International Training and Education Center for Health Chris Behrens, Scott Barnhart, Tom Heller Acknowledgements