Scaling Up TB Infection Control Infrastructure Considerations · A Moll, NR Gandhi, R Pawinski, U Lalloo, AW Sturm, K Zeller, J Andrews, G Friedland. Slide 13 ©CSIR 2006 MDR & XDR-TB

Scaling Up TB Infection Control

Infrastructure Considerations

Sidney A Parsons, Ph.D. Pr. Eng.

CSIR: Built Environment, Architectural Sciences.

Tuberculosis Infection Strategy Developing Workshop

22 – 23 Oct., 2007. WHO, Geneva, Switzerland

Stop TB ProgrammeStop TB Programme

Slide 2 © CSIR 2006 www.csir.co.za

Understand the Hazard to Manage the Risk

In attempting to arrive at the truth, I have

applied everywhere for information but scarcely

in an instance have I been able to obtain

hospital records fit for any purpose of comparison”

Florence Nightingale (1863)Florence Nightingale (1863)

Notes on Hospitals:

Infection

Ventilation

Space (spacing and volume)

Lighting

Observation

Nursing care

Hospital administration process

Steel beds (not wood), Glass mugs…

“Functionality and Infection Control”


Infection Control

Understanding the basics:

• Transmission dynamics:

• Food

• Fomites

• Water

• Air

• Air borne Infection:• Environment

• Host immunity and resistance

• Procedures and associated risks

• Disinfection, decontamination and sterilisation for Minimising Transmission


Wells’ Air Centrifuge, 1931

W. F. Wells*. “On Airborne Infection, Study II. Droplets and Droplet Nuclei” , Am J Hygiene, 1934:20. 611-18.

*Instructor, Sanitary Service, HSPH

In 1931 Wells developed his air centrifuge to sample bacteria from air


Droplets and Droplet Nuclei: The Origin

• Large respiratory particles

settle within about a meter of their source

• Fine particles nucleate into

droplet nuclei carried by air currents

Liberated by Coughing or Sneezes (respiratory tract activity):

Jennison [1942]

Richard L Riley M.D. and Francis O’Grady M.D., M.Sc. Et all


Notes from Toman’s TuberculosisQuestions and Answers (Second Edition 2004).

Rieder H, 2004: “Where is tuberculosis usually

spread and how can spread be reduced”

• The Number of cases capable of transmitting M.tuberculosis in a community (principally smear-positive cases)

• The duration of infectiousness of such cases

• The number and duration of encounters between a source of infection and susceptible individuals


Mathematical model of airborne infection

Wells-Riley Equation:

Probability of infectionProbability of infectionProbability of infectionProbability of infection = 1-e((((----Iqpt/Q)Iqpt/Q)Iqpt/Q)Iqpt/Q)

Where:• I = # infectors (i.e. # active pulmonary TB cases)• q = quanta infectious units produced• p = pulmonary ventilation rate/hr/per Susceptible• t = hours of exposure• Q = room volume


Hierarchy of Controls for the Prevention of M.Tuberculosis Transmission

Administrative

• Ensure OPD’s can

accommodate and support the

rapid triage process and

treatment of infectious cases

• Assess risk and develop

appropriate written protocols

based on the outcome of the

assessment and administer

“Risk assessment and Infection

control plans”.

• Implement and enforce effective

work practices including the

management of patient care

• HCW and facility staff training


Environmental Controls

• Dilution Ventilation with Pressure

differentials

� Forced

� Natural

• Filtration

� Practicality?

• Ultraviolet germicidal radiation

� Efficacy Supported under laboratory

conditions but no research to

support in a clinical setting

Environmental

Administrative


Infection Control Risk Assessment

� To evaluate the management of the TB infection controlprogram in a facility in order to reduce risk against infection (establish the constraints of the facility to implement such a programme).

� Review existing TB infection control protocols and patient flows through the facility being evaluated.

� Evaluate compliance with personal protection practices

� Evaluate facility engineering controls and maintenance practices, and to determine their effectiveness in reducing or preventing the likelihood of TB transmission.

Some of the objectives of an Infection control Risk Assessment

for TB would be to:


The Risk of Inadequate Maintenance

� Review the Original Design Specifications and Drawings

� Know What Safety Devices are Fitted

� Understand the Operation of the System (Control Algorithms and set

points etc.)

� Understand the Operational Limitations and Determine Improper

Settings

� Identify Poor Design and/or consequent Installation, Testing and

Balancing errors

� Determine cause and effect of Equipment Failures and identify remedial

measures as required.

When Evaluating facility management and engineering controls, including

the maintenance practices, the risk assessment team should:


Extreme / Extensively Drug-Resistant TB (XDR TB)

First reported outbreak (2005/06), Tugela Ferry, South Africa

�53 of 221 MDR-TB patients identified as XDR-TB

�50% not tested previously for TB

�40 tested for HIV and all found positive

�52 died within 16 days of sputum collection

XDR first reported March 2006: Resistance to level 2 drugs suspected and identified in studies of samples from 49 countries internationally

A Moll, NR Gandhi, R Pawinski, U Lalloo, AW Sturm, K Zeller, J Andrews, G Friedland


MDR & XDR-TB

cases expected to

be treated by

country – 2007, 2008

The Global MDR-TB and XDR-TB Response Plan,

June 2007.

WHO, Stop TB Partnership



Infection Control measures must inform the need

However

The Design of the facility offers the solution by responding to

that need

Infection Control measures and the design

response.


Sustainable, Safe and Effective Functional and Healthcare

Facilities – Findings from 5 Case Studies in South Africa

Sidney Parsons, Renée du Toit, Nic Combrink, Angela Baker

The challenges of developing a TB Hospital:

� The original business case and needs interpretation

� The design briefing document submitted to the implementing agent

� How aware the hospital management were of the protocols and functional procedures called for in the TB Guidelines for healthcare provision.

� Design to ensure implementation of procedures, and;

� Appropriate Infection Controls (Administrative, Environmental and Personal), against Infection required (Reasons for and methodologies to be adopted by the design team)

.


� Healthcare planning Departments having little appreciation of epidemiological issues and procedures placing the responsibility on healthcare programs finding solutions for bed needs, and design teams needing to “fish” for the needs.

� Healthcare Planning Departments transgressing into the design domain ignoring the need for developing the essential “Briefing Document”:

� Focus on Impact and Building Durability issues far outweighing the need to address to functionality issues.

� Emphasis by building professionals on the Detailing, Documentation and Construction, rather than functionality and procedural issues.

� Following the lead from the Planners with respect to unequal emphasis on Building durability and Impact.

� Costing and development of business proposals most often based on historical, uniformed data.

Sustainable, Safe and Effective Functional and Healthcare

Facilities – Findings from 5 Case Studies in South Africa

(cont.) Sidney Parsons, Renée du Toit, Nic Combrink, Angela Baker


The Modern Challenge:• Scant appreciation of the need of a detailed brief for the planners, with very little input by healthcare staff on needs, with planners confusing the difference between a business plan and briefing document.

• Environments predisposed to infection which are not conducive to healthcare provision, least of all healing should be identified, in order to ensure against the inappropriate accommodation and mixing of;� Patients with infectious diseases

� Immune-compromised patients (and staff)

� Paediatric patients

• Limited understanding of the dynamics of infection control needs (e.g.. airborne infectious diseases) by building professionals and maintenance staff

Parsons; WHO Workshop: Making Healthcare Facilities Safe, IFHE 2006

The need for an appropriate briefing document


Current Facility Shortcomings (out-patient areas):

• Unsuspected cases visiting OPD’s that have not been designed

for triaging of suspected pulmonary cases

• OPD’s not designed for the number of visitors

• Patient flow paths in Hospitals (and clinics) due to department

relationships (i.e. Laboratory, sputum collection and waiting

areas)

• In most cases no outside waiting areas.


Observed practices due to design constraintsNo physical separation among

pts until sputum smear results available

No physical separation among

pts until sputum smear results available

Clinics & wards crowded with

TB “suspects” and susceptibles (PT’s & HCW’s)

Clinics & wards crowded with

TB “suspects” and susceptibles (PT’s & HCW’s)

Rare isolation beds;

no negative pressure rooms.

Rare isolation beds;

no negative pressure rooms.


Patient Pathways

• Proposal to separate

patients suspected

to have TB from other

OPD patients, particularly

from HIV positive patients

• Separate facilities

for MDR and XDR TB

Treatment?

Problem: many HIV

patients with Pulmonary

TB are sputum negative

Triage incl. cough

SN/clerk/Sister?

Sp-

Sp+nebulisation

CD4

counts

Clinic

referral Pt

via OPD

reception

Repeat

visit

First

Visit

Veranda outside clinic

Number given by security

OPD reception admitting clerk:

(computer) data & pt record

Paed 0-4 yrs

Assessment

consult

Immunisation

TB section

Nurses

Education

History

TB drugs

DOT

TB doctor

X Ray?

TB social

worker?

ANC/

O&G/

FPAdult Waiting &

assessment room: vitals,

urine testing, blood sugar

VCT

for

hospital

Paed 5-12

years

consulting

SOPD /

other

Wait/cons

ult

MOPD

Wait

Sputum wait & collection

& TB sputum lab

Pharmacy

General

antibiotics

X-ray

MOPD consulting

MOPD / shared

Procedure /

dressing / blood

General wards

Sputum neg.

TB suspect

patients

Paed OPD

TB wards

TB

confirmed

Home / referral

clinics

R du Toit, Health Facility Planning


Current Facility Shortcomings (in-patient accommodation):

• All types of existing rooms have been pressed into service as

MDR and XDR wards, including offices, staff housing units, etc.

• Wards were originally designed for low-cost habitation by non-

infectious TB patients

• 6 patients and more per room (20 in some facilities)

• Low floor to ceiling height (2,4m) and Inadequate thermal

performance of the building design - windows closed when cold

• Design for long stay patients in certain healthcare settings need

attention ( Landscaped areas for outdoor activity, occupational

therapy etc.)


Low floor to ceiling heights with

inadequate ventilation and

thermal performance.

A.R. EscombeA.R. Escombe


Current Ventilation Shortcomings (Observed):

• Rooms ventilated using passages and other patient rooms –possible cross infection opportunity

• Natural ventilation is dependent on user-controlled opening windows

• Inconsistent wind conditions vary natural ventilation rates

• Inappropriate mechanical ventilation measures.


Administrative measures by informed design:

• Active triaging of PHC patients in all identification areas - Clinics, OPD’s etc.

• Early separation into appropriately designed rooms for further diagnosis and management

• Improved management of patients by infectious status and TB strain

• Improved management of patient movement within controlled zones

• Improved service levels in laboratory testing, diagnosis and notification

• Isolation rooms of ‘as-yet-undiagnosed’ patients in all TB Admission wards in all facilities

• Drastic reduction in number of patients per room recommended.

• Improved management of patient flow in all health facilities (patient pathways)


Detailed attention to air rate and flow management:

• Air dilution and pressure gradient design, irrespective of wind conditions, to ensure clean air workspaces

• Effective dilution ventilation by natural or mechanical means (or by mixed mode systems)

• Pressure gradients relative to room functions and layouts

• On-site validation of ventilation design prior to occupation – standard methodology in development

• Regular re-assessment as part of facility risk management SOP


Infection Control measures must inform the need

However

Design of the facility offers the solution by responding to thatneed

But

The solution must be validated to ensure quality of outcome

Health Facilities: The design response


The Risk of Inadequate Maintenance

“AppropriateDesign

Parameters”

“Service level Agreement

Procurement Policies”

“FM Standards

ofProcedures forenvironmentalServices”

“Operatingand Maintenance

Manuals”

“Maintenance”

“Integrated design approach” for engineering controls and for least risk maintenance of

all systems to ensure effective infection control strategies.


The Risk of Inadequate Maintenance:Environment & Health

Whilst being the prime means of intervention, certain systems myalso be the primary Pathogenic transmission mechanism if not maintained:

� Air Systems

� Water Systems

� Environmental (Cleaning) Services

� Services Handling Laundry and Bedding

� Regulated Medical Waste

Guidelines for Environmental Infection Control in

Health Care Facilities

Centers for Disease Control and Prevention

Healthcare Infection Control Practices Advisory Committee (HICPAC)


Issues still to be addressed

Resulting from the policy, further attention must be paid at facilities treating infectious patients over an extended period (2-6 months) to providing access to broader basic social services e.g.:

• Postal services

• Banking facilities

• Visitors

• Education

• Home Affairs processes – ID documents etc.

• Support for Children far from home

• Community Services support for breadwinners under treatment

A balance needs to be struck between the constitutional rights of patients, of staff and the broader community and the affordability of public health measures in order to protect and uphold those rights.


Advocacy and resource mobilization

• On a national level, guidance needs to be provided to healthcarefacility planners and designers

• Engineering and Architectural societies worldwide, need to be informed of the need to include IC in their design guides (e.g. ASA, ASHRAE, CIBSE. RHEVA, IFHE, UIA etc).

• Life cycle costing needs to be undertaken

• IC for airborne diseases needs to be included in the patient safety arena.

“Inform and Educate”


The World Needs Safe and Effective Functional Planning to Ensure Sustainable

Healthcare Provision

Thank YouThank You

Documents

Scaling Up TB Infection Control Infrastructure Considerations · A Moll, NR Gandhi, R Pawinski, U Lalloo, AW Sturm, K Zeller, J Andrews, G Friedland. Slide 13 ©CSIR 2006 MDR & XDR-TB