Policy update on TB infection control

Fabio Scano

STB, WHO

TBIC

OutlineOutline

1. Where we stand1. Literature review

2. Formulation of the recommendations

3. Finalization of the document

2. Next steps1. Policy dissemination

2. Scale up

Timeline and progress

Oct 07-April 08 May 2008 Sept 2008 Nov 2008 Dec 08-Jan 09

1. Questions formulation

2. Systematic review

3. Drafting of the recommendations

4. Sharing with the panel

5. Finalization

Questions for systematic reviewsQuestions for systematic reviews

1. Where does TB transmission happen?

2. What is the efficacy of TB IC interventions– Cough etiquette– Triage & co-horting– Hospital stay– Ventilation– UVGI– Respirators

Quality of Evidence – GRADE approachQuality of Evidence – GRADE approach

• Grading approach to assess the quality of evidence.

• To inform the strength of the public health intervention

• Low quality evidence does not mean weak recommendation

• Public health recommendation to also consider programmatic issues.

BMJ 2004;328; 1490–98

Where does TB transmission happenWhere does TB transmission happen

Pooled estimates (reference general population)Pooled estimates (reference general population)

populationpopulation OutcomeOutcome SettingsSettings StudiesStudies Risk RatioRisk Ratio

Health care workers

TB infection Low income 9 5.77*5.77*

TB infection High income 40 10.0610.06

TB Low income 37 5.715.71

TB High income 15 1.991.99

Congregate TB infection High income 5 2.74*2.74*

TB High income 18 21.4121.41*

Household TB infection & TB Low income 7 1.73*1.73*

TB infection & TB High income 15 3.193.19

*with outliersLMICs: Low- & Medium- Income countries (World Bank ranking)HICs: High- Income countries (World Bank ranking)

ConclusionsConclusions

• Clear higher risk for health care workers

• Need for a careful and further analysis for household and congregate settings

• RR is higher in all the observed settings. Impact at population level?

Package for infection prevention and control of TB in health care settings Programmatic interventions 1 To identify and strengthen coordinating systems for planning and implementation at all levels 2 To conduct surveillance and assessment at all levels of the health system 3 To address ACSM, HR requirements and capacity building and engage the civil society 4 To conduct monitoring, evaluation 5 To enable and conduct research

Administrative strategies 6 To develop strategies to: a) promptly sort TB suspects (triage) and b) cohort them c) implement cough etiquette practices d) reduce hospital stay Engineering and environmental control strategies 7 Natural Ventilation 8 Mechanical Ventilation 9 UVGI lights 10 Health facility revitalization Personal protective interventions 11 Respirators 12 Package of prevention and care for HCWs including IPT for HIV-infected health care workers

Efficacy of cohortingEfficacy of cohorting

Study Selection

50 articles on triage from which only 12 articles contained data

Triage and cohorting: 2095 articles from two databases

Results for triage and co-horting (12 studies)

• Two studies from LMIC show significant reduction

• One study from LMIC shows little impact.

• In 11 studies, indicators of nosocomial transmission decline following implementation of IC measures

• Two studies show that implementation of administrative interventions alone reduced TB transmission.

• One study shows great benefit of isolation.

• Implementation of administrative interventions alone reduced nosocomial transmission of MDR in HIV ward.

Conclusions

• The quality of evidence available is low

• Always part of a package of interventions.

• Evidence suggests that reduction in the risk of TB infection is possible with simple administrative control

• Strong theoretical benefit to implement these interventions

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Recommendation

Implementation of strategies to separate patients (cohorting) after triage are recommended in health care and congregate settings.

The specific criteria for cohorting patients may vary depending on the local settings and patient population.

HIV infected patients should be physically separated from those with suspected or confirmed infectious TB.

Drug resistant TB suspects/patients should be separated from other patients including other TB patients.

Strong recommendations, low quality evidence (see annex 6b,and chapter VI: table 6b)

Remarks

These recommendations place high value on avoiding exposure of non-infected patients (in particular if immunocompromised) to infectious ones irrespective of the drug susceptibility testing pattern.

Recommendation: physical separation of suspected and known infectious cases

Population: patients accessing Health Care and Congregate Settings

Factor Decision Explanation

Quality of evidence LowThe quality of the evidence available is low. Only one study shows a direct impact of physical

separation as an individual intervention on reduction of TB transmission.

Benefits or desired effects

Strong

Early diagnosis and initiation of proper treatment Reduction of transmission among individuals attending HCFs Reduction of transmission among HCWs and families

Disadvantages or undesired effects

PLWH (TB suspects) might be separated together with smear positive TB patients.

Values and preferences Strong

HCWs will like measures that reduce their exposureCommunities will like measures that will make HCFs a safer placeBut.. Increase workload for HCWs and Stigmatization

Costs Moderate(will increase cost

but not much)

Reduced by:Diagnostics costs of suspected new cases Averted casesBreak chain of transmissionIncreased by:Staff trainingInfrastructures (separated waiting area, isolation rooms…). This may require major capital

investment.Additional AFB and CXR for positive TB triage

Feasibility Conditional to

countrySetting

Generally feasible in HICLack of human resources in MIC/LICLack of infrastructures in MIC/LICSlow diagnostic process to exclude TB infection (turnaround time…lab facilities)

Overall ranking ofrecommendation

STRONG RECOMMENDATION

Research gap To develop and assess the impact on reduction of TB of different models of physical separation based on smear; HIV status and suspected or confirmed TB sensibility pattern

Efficacy of respiratorsEfficacy of respirators

Study Selectionrespirators

4593 articles from six databases

103 articles on respirators, from which only 13 articles contained relevantdata after full-text review

Results for Respirators (13 papers)

• 3 epidemiologic studies ( benefit of using respirators)

• Modeling studies (lower infection risk with better respirator and use of masks/respirators can prevent XDR-TB cases)

• Better respirators cost more, HEPA respirators are not cost-effective, and costs have decreased with time

• Low compliance by HCWs

• User seal check should not be used as surrogate fit test

Recommendation: Use of respirators

Population: health care settings

Intervention: Respirators

Factor Decision Explanation

Quality of evidenceLow

Theoretical basislow evidence No clear guidance on the duration of use

Benefits or desired effects

Benefits not alwaysoutweigh

disadvantages

Provide additional protection to the HCWs

Disadvantagesor undesired effects

Not clear additional protection if environment is well ventilatedRequires trainingRequires adherenceAffect HCW's performance on practices.Allergies to material

Values and preferences

moderate

HCWs will like measures that reduce their exposureBut..Reduces comfort of HCWsGenerate stigma

Costsmoderate

Increased by:PurchaseTraining programme

Feasibility Conditional to country

setting

Lack of expertiseLack of trainingRequires commitment to wear them from health care workers

Overall ranking of recommendation STRONG RECOMMENDATION (MDR and high risk procedures)CONDITIONAL RECOMMANDATION (susceptible TB)

Research gap 1. To determine the effectiveness of the intervention on the reduction of TB transmission2: To determine the programmatic role of fit testing versus fit checking

Recommendation

1. In addition to implementation of administrative and environmental interventions, respirators should be used by HCWs when providing care for patients/suspects with susceptible TB, whenever possible.

Conditional recommendation (see annex 11, and chapter VI: table 11)

2. Respirators should be used by HCWs during aereosol-generating procedures associated to higher risk of TB transmission (e.g bronchoscopy, intubation, aspiration of respiratory secretions and autopsy or lung surgery with high speed device) and when providing care to MDR-XDR TB patients.

Strong recommendation (see annex 11, and chapter VI: table 11)

The use of respirators should be part of a comprehensive training programme. Ideally, the training programme should also include fit testing.

Congregate settingsCongregate settings

Include prisons, army barracks and homeless shelters.

TB incidence exceeds the incidence among the general population (complex transmission dynamics)

Recommendations cannot be too specific because they cover such a wide range of settings.

Congregate settingsCongregate settings

Recommendations:• Programmatic and administrative interventions

– as per health care facilities– high focus on case detection, cohorting and no overcrowding

• Environmental and personal protective– Follow country legislation for public buildings

RemarksAny HCF within a congregate setting should be considered as an

health care setting.

Infection control in the communityInfection control in the community

Background

1. Major risks for contacts lies in the exposure to the infectious case before the diagnosis

2. Early case detection remains a pillar intervention

3. IC literacy messages should be part of any community

Infection control in the communityInfection control in the community

Guidance:

• Shared space should be well ventilated (natural ventilation). If possible patients should spend as much time as possible outside.

• Patients should be educated and always respects cough etiquette

• Ideally, patients should sleep in a separate room if smear positive.

• Patients should avoid public transportation and congregate settings if smear positive.

DO we need specific recommendations for MDR patients?

PrioritizationPrioritization

Essential package for airborne infections:

1. cough etiquette

2. patient placement

3. well ventilated rooms

Package of interventions based on the burden of TB, HIV and MDR-XDR TB.

TargetsTargets

By 2009:1) 50% of the countries, according to the prioritization, should have developed a plan; set up surveillance activities; and assessed all the HCF and congregate settings for TB IC

By 2010:1) all countries, according to the prioritization should have developed a plan; set up surveillance activities; and assessed all the HCF and congregate settings for TB IC5) 50% of countries should be reporting on the implementation of the package of TB/IC interventions.

Next steps…to ensure safer health facilities, congregate settings and household

• Dissemination of the policy (including the evidence)

• Development of an advocacy strategy for generating demand and fund raising

• Working through regional and country offices (WHO and partners) for changes in policy and regulations

• Budget the package for quantifying the costs of scaling up TB IC

• At country level assess responsibilities for the implementation of the package (TB, HIV, Occupational Health, Justice department, health system and civil society)

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