TUBERCULOSIS INFECTION CONTROL IN LOW INCOME COUNTRIES: A LITERATURE REVIEW

Anders Chen, MDInternal Medicine R34/5/2011

OUTLINE

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

TB IC: BACKGROUND

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

1Pearson, Ann Int Med 1992, 2Beck-Sague JAMA 1992, 3Menzies NEJM 1995

Guidelines

Implementation

TB IC BACKGROUND: LOW INCOME COUNTRIES

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

4Menzies, Int J Tuberc Lung Dis 2007

Guidelines

Implementation?

WHO POLICY RECOMMENDATIONS

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

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

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

Personal Protective Equipment N95 or equivalent respirators for staff

CHALLENGES TO IMPLEMENTATION

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

5WHO 2009 annexes

LITERATURE REVIEW

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

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

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

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

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

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: DISCUSSION

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

NEXT STEPS

Practical tools to aid in implementation of TB IC guidelines.

Guidelines

Implementation?

WORLD TB DAY 3/24/11

ACKNOWLEDGEMENTS

I-TECH (International Training and Education Center for Health

Chris Behrens, Scott Barnhart, Tom Heller