DJ Christopher Prof amp Head

Department of pulmonary medicine

TB in healthcare workers

Magnitude of the problem

bull Dubbed the Captain of all the men of death

by John Bunyan at the end of the 17th century

bull TB kills 5000 people a day- 2 million a year

bull One third of the Worlds population is infected with TB

bull 40 of the TB cases in the world are in South-east Asia and here it is the leading single infectious cause of death

TB and health care scenario

bull Drug sensitive rarr Drug resistant rarrMDR TB

rarr XDR TB rarrTDR TB

bull TB as a health care issue important

bull HCW surveillance is not widely performed in TB endemic countries

Kwazulu Natal South Africa

bull 53 Patients with XDR TB

bull All tested were positive for HIV

bull 2 of the 53 were health workers in the

hospital

bull 4 other health workers suspected of

having TB but not seen at the hospital

bull Death of a health care worker with

nosocomial extensively drug-resistant

tuberculosis in India

James P Christopher DJ Balamugesh

T Gupta R Int J Tuberc Lung Dis 2009

Jun13(6)795-6

bull TB as a health care issue

Important rarr Serious rarrPotentially Fatal

Magnitude of the problem

bull Dubbed the Captain of all the men of death

by John Bunyan at the end of the 17th century

bull TB kills 5000 people a day- 2 million a year

bull One third of the Worlds population is infected with TB

bull 40 of the TB cases in the world are in South-east Asia and here it is the leading single infectious cause of death

TB and health care scenario

bull Drug sensitive rarr Drug resistant rarrMDR TB

rarr XDR TB rarrTDR TB

bull TB as a health care issue important

bull HCW surveillance is not widely performed in TB endemic countries

Kwazulu Natal South Africa

bull 53 Patients with XDR TB

bull All tested were positive for HIV

bull 2 of the 53 were health workers in the

hospital

bull 4 other health workers suspected of

having TB but not seen at the hospital

bull Death of a health care worker with

nosocomial extensively drug-resistant

tuberculosis in India

James P Christopher DJ Balamugesh

T Gupta R Int J Tuberc Lung Dis 2009

Jun13(6)795-6

bull TB as a health care issue

Important rarr Serious rarrPotentially Fatal

TB and health care scenario

bull Drug sensitive rarr Drug resistant rarrMDR TB

rarr XDR TB rarrTDR TB

bull TB as a health care issue important

bull HCW surveillance is not widely performed in TB endemic countries

Kwazulu Natal South Africa

bull 53 Patients with XDR TB

bull All tested were positive for HIV

bull 2 of the 53 were health workers in the

hospital

bull 4 other health workers suspected of

having TB but not seen at the hospital

bull Death of a health care worker with

nosocomial extensively drug-resistant

tuberculosis in India

James P Christopher DJ Balamugesh

T Gupta R Int J Tuberc Lung Dis 2009

Jun13(6)795-6

bull TB as a health care issue

Important rarr Serious rarrPotentially Fatal

Kwazulu Natal South Africa

bull 53 Patients with XDR TB

bull All tested were positive for HIV

bull 2 of the 53 were health workers in the

hospital

bull 4 other health workers suspected of

having TB but not seen at the hospital

bull Death of a health care worker with

nosocomial extensively drug-resistant

tuberculosis in India

James P Christopher DJ Balamugesh

T Gupta R Int J Tuberc Lung Dis 2009

Jun13(6)795-6

bull TB as a health care issue

Important rarr Serious rarrPotentially Fatal

bull Death of a health care worker with

nosocomial extensively drug-resistant

tuberculosis in India

James P Christopher DJ Balamugesh

T Gupta R Int J Tuberc Lung Dis 2009

Jun13(6)795-6

bull TB as a health care issue

Important rarr Serious rarrPotentially Fatal

Mechanism of Acquisition

Aerosolised

Mycobacterium

tuberculosis

Direction of Acquisition

bull Patient to health worker

bull Health worker to patient

bull Health worker to health worker

bull Patient to patient

bull Patient to visitor

bull Visitor to patient

bull Patient samples to health worker

bull Andhelliphelliphelliphelliphellip

Risk of Transmissionhellip1 bull Factors associated with patient

ndash Sputum AFB positivity

ndash Presence of cavitory pulmonary lesion

ndash Procedure causing aerosolization of TB bacilli

ndash Not following cough etiquette

Risk of Transmissionhellip2 bull Environmental factors

ndash Relatively inadequate space resulting in crowding

ndash Inadequate ventilation re-circulation of air containing infectious droplet nuclei

ndash Long waiting times prolonging exposure

Risk of Transmissionhellip3 bull Increased susceptibility of the exposed person

ndash HIV-infected individuals may have increased susceptibility

TB among HCW

Compromised-----------------------------------------Competent

New York City

bull 2003 ndash Nurse from the Philippines

bull Working in Newborn Nursery and maternity

ward

bull Approximately 1500 infant contacts

bull Only one third able to be followed up 4 infected

bull On arrival in the country had positive Mantoux

test and no follow up treatment (Sterling and Hass Transmission of Mycobacterium tuberculosis from health

Workers New Eng J Med 13 July 2006 118-121)

Sevagram India

bull Cross sectional study ndash High prevalence of

latent TB in HCW

bull Risk factors age and years as a health care worker

bull 40 prevalence of LBTI ndash could be higher as a small number of attending physicians recruited

(Pai et al ndash JAMA 2005 293(22) 2746-2755)

Vellore ndash Gopinath et al

bull 125 HCW with TB diagnosed in 10 years

probably an underestimate

bull 71 pulmonary 54 extra-pulmonary

bull Mini epidemics may be occurring due to

staff to staff transmission

bull Largest number of cases among nurses

(256 nurses 192 nursing students)

CMC-Nursing students cohort Results

bull 219 (502) (CI 454-550) students had latent TB

Risk Factors - Course

TST +

Diploma 465

Degree 426

PcBSc 745

Post Diploma

SpecFell

842

MSc 727

502 (CI 454-550) students had latent

TB

What is the rate of new infections

every year

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Direction of Acquisition

bull Patient to health worker

bull Health worker to patient

bull Health worker to health worker

bull Patient to patient

bull Patient to visitor

bull Visitor to patient

bull Patient samples to health worker

bull Andhelliphelliphelliphelliphellip

Risk of Transmissionhellip1 bull Factors associated with patient

ndash Sputum AFB positivity

ndash Presence of cavitory pulmonary lesion

ndash Procedure causing aerosolization of TB bacilli

ndash Not following cough etiquette

Risk of Transmissionhellip2 bull Environmental factors

ndash Relatively inadequate space resulting in crowding

ndash Inadequate ventilation re-circulation of air containing infectious droplet nuclei

ndash Long waiting times prolonging exposure

Risk of Transmissionhellip3 bull Increased susceptibility of the exposed person

ndash HIV-infected individuals may have increased susceptibility

TB among HCW

Compromised-----------------------------------------Competent

New York City

bull 2003 ndash Nurse from the Philippines

bull Working in Newborn Nursery and maternity

ward

bull Approximately 1500 infant contacts

bull Only one third able to be followed up 4 infected

bull On arrival in the country had positive Mantoux

test and no follow up treatment (Sterling and Hass Transmission of Mycobacterium tuberculosis from health

Workers New Eng J Med 13 July 2006 118-121)

Sevagram India

bull Cross sectional study ndash High prevalence of

latent TB in HCW

bull Risk factors age and years as a health care worker

bull 40 prevalence of LBTI ndash could be higher as a small number of attending physicians recruited

(Pai et al ndash JAMA 2005 293(22) 2746-2755)

Vellore ndash Gopinath et al

bull 125 HCW with TB diagnosed in 10 years

probably an underestimate

bull 71 pulmonary 54 extra-pulmonary

bull Mini epidemics may be occurring due to

staff to staff transmission

bull Largest number of cases among nurses

(256 nurses 192 nursing students)

CMC-Nursing students cohort Results

bull 219 (502) (CI 454-550) students had latent TB

Risk Factors - Course

TST +

Diploma 465

Degree 426

PcBSc 745

Post Diploma

SpecFell

842

MSc 727

502 (CI 454-550) students had latent

TB

What is the rate of new infections

every year

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Risk of Transmissionhellip1 bull Factors associated with patient

ndash Sputum AFB positivity

ndash Presence of cavitory pulmonary lesion

ndash Procedure causing aerosolization of TB bacilli

ndash Not following cough etiquette

Risk of Transmissionhellip2 bull Environmental factors

ndash Relatively inadequate space resulting in crowding

ndash Inadequate ventilation re-circulation of air containing infectious droplet nuclei

ndash Long waiting times prolonging exposure

Risk of Transmissionhellip3 bull Increased susceptibility of the exposed person

ndash HIV-infected individuals may have increased susceptibility

TB among HCW

Compromised-----------------------------------------Competent

New York City

bull 2003 ndash Nurse from the Philippines

bull Working in Newborn Nursery and maternity

ward

bull Approximately 1500 infant contacts

bull Only one third able to be followed up 4 infected

bull On arrival in the country had positive Mantoux

test and no follow up treatment (Sterling and Hass Transmission of Mycobacterium tuberculosis from health

Workers New Eng J Med 13 July 2006 118-121)

Sevagram India

bull Cross sectional study ndash High prevalence of

latent TB in HCW

bull Risk factors age and years as a health care worker

bull 40 prevalence of LBTI ndash could be higher as a small number of attending physicians recruited

(Pai et al ndash JAMA 2005 293(22) 2746-2755)

Vellore ndash Gopinath et al

bull 125 HCW with TB diagnosed in 10 years

probably an underestimate

bull 71 pulmonary 54 extra-pulmonary

bull Mini epidemics may be occurring due to

staff to staff transmission

bull Largest number of cases among nurses

(256 nurses 192 nursing students)

CMC-Nursing students cohort Results

bull 219 (502) (CI 454-550) students had latent TB

Risk Factors - Course

TST +

Diploma 465

Degree 426

PcBSc 745

Post Diploma

SpecFell

842

MSc 727

502 (CI 454-550) students had latent

TB

What is the rate of new infections

every year

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Risk of Transmissionhellip2 bull Environmental factors

ndash Relatively inadequate space resulting in crowding

ndash Inadequate ventilation re-circulation of air containing infectious droplet nuclei

ndash Long waiting times prolonging exposure

Risk of Transmissionhellip3 bull Increased susceptibility of the exposed person

ndash HIV-infected individuals may have increased susceptibility

TB among HCW

Compromised-----------------------------------------Competent

New York City

bull 2003 ndash Nurse from the Philippines

bull Working in Newborn Nursery and maternity

ward

bull Approximately 1500 infant contacts

bull Only one third able to be followed up 4 infected

bull On arrival in the country had positive Mantoux

test and no follow up treatment (Sterling and Hass Transmission of Mycobacterium tuberculosis from health

Workers New Eng J Med 13 July 2006 118-121)

Sevagram India

bull Cross sectional study ndash High prevalence of

latent TB in HCW

bull Risk factors age and years as a health care worker

bull 40 prevalence of LBTI ndash could be higher as a small number of attending physicians recruited

(Pai et al ndash JAMA 2005 293(22) 2746-2755)

Vellore ndash Gopinath et al

bull 125 HCW with TB diagnosed in 10 years

probably an underestimate

bull 71 pulmonary 54 extra-pulmonary

bull Mini epidemics may be occurring due to

staff to staff transmission

bull Largest number of cases among nurses

(256 nurses 192 nursing students)

CMC-Nursing students cohort Results

bull 219 (502) (CI 454-550) students had latent TB

Risk Factors - Course

TST +

Diploma 465

Degree 426

PcBSc 745

Post Diploma

SpecFell

842

MSc 727

502 (CI 454-550) students had latent

TB

What is the rate of new infections

every year

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Risk of Transmissionhellip3 bull Increased susceptibility of the exposed person

ndash HIV-infected individuals may have increased susceptibility

TB among HCW

Compromised-----------------------------------------Competent

New York City

bull 2003 ndash Nurse from the Philippines

bull Working in Newborn Nursery and maternity

ward

bull Approximately 1500 infant contacts

bull Only one third able to be followed up 4 infected

bull On arrival in the country had positive Mantoux

test and no follow up treatment (Sterling and Hass Transmission of Mycobacterium tuberculosis from health

Workers New Eng J Med 13 July 2006 118-121)

Sevagram India

bull Cross sectional study ndash High prevalence of

latent TB in HCW

bull Risk factors age and years as a health care worker

bull 40 prevalence of LBTI ndash could be higher as a small number of attending physicians recruited

(Pai et al ndash JAMA 2005 293(22) 2746-2755)

Vellore ndash Gopinath et al

bull 125 HCW with TB diagnosed in 10 years

probably an underestimate

bull 71 pulmonary 54 extra-pulmonary

bull Mini epidemics may be occurring due to

staff to staff transmission

bull Largest number of cases among nurses

(256 nurses 192 nursing students)

CMC-Nursing students cohort Results

bull 219 (502) (CI 454-550) students had latent TB

Risk Factors - Course

TST +

Diploma 465

Degree 426

PcBSc 745

Post Diploma

SpecFell

842

MSc 727

502 (CI 454-550) students had latent

TB

What is the rate of new infections

every year

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

TB among HCW

Compromised-----------------------------------------Competent

New York City

bull 2003 ndash Nurse from the Philippines

bull Working in Newborn Nursery and maternity

ward

bull Approximately 1500 infant contacts

bull Only one third able to be followed up 4 infected

bull On arrival in the country had positive Mantoux

test and no follow up treatment (Sterling and Hass Transmission of Mycobacterium tuberculosis from health

Workers New Eng J Med 13 July 2006 118-121)

Sevagram India

bull Cross sectional study ndash High prevalence of

latent TB in HCW

bull Risk factors age and years as a health care worker

bull 40 prevalence of LBTI ndash could be higher as a small number of attending physicians recruited

(Pai et al ndash JAMA 2005 293(22) 2746-2755)

Vellore ndash Gopinath et al

bull 125 HCW with TB diagnosed in 10 years

probably an underestimate

bull 71 pulmonary 54 extra-pulmonary

bull Mini epidemics may be occurring due to

staff to staff transmission

bull Largest number of cases among nurses

(256 nurses 192 nursing students)

CMC-Nursing students cohort Results

bull 219 (502) (CI 454-550) students had latent TB

Risk Factors - Course

TST +

Diploma 465

Degree 426

PcBSc 745

Post Diploma

SpecFell

842

MSc 727

502 (CI 454-550) students had latent

TB

What is the rate of new infections

every year

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Compromised-----------------------------------------Competent

New York City

bull 2003 ndash Nurse from the Philippines

bull Working in Newborn Nursery and maternity

ward

bull Approximately 1500 infant contacts

bull Only one third able to be followed up 4 infected

bull On arrival in the country had positive Mantoux

test and no follow up treatment (Sterling and Hass Transmission of Mycobacterium tuberculosis from health

Workers New Eng J Med 13 July 2006 118-121)

Sevagram India

bull Cross sectional study ndash High prevalence of

latent TB in HCW

bull Risk factors age and years as a health care worker

bull 40 prevalence of LBTI ndash could be higher as a small number of attending physicians recruited

(Pai et al ndash JAMA 2005 293(22) 2746-2755)

Vellore ndash Gopinath et al

bull 125 HCW with TB diagnosed in 10 years

probably an underestimate

bull 71 pulmonary 54 extra-pulmonary

bull Mini epidemics may be occurring due to

staff to staff transmission

bull Largest number of cases among nurses

(256 nurses 192 nursing students)

CMC-Nursing students cohort Results

bull 219 (502) (CI 454-550) students had latent TB

Risk Factors - Course

TST +

Diploma 465

Degree 426

PcBSc 745

Post Diploma

SpecFell

842

MSc 727

502 (CI 454-550) students had latent

TB

What is the rate of new infections

every year

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

New York City

bull 2003 ndash Nurse from the Philippines

bull Working in Newborn Nursery and maternity

ward

bull Approximately 1500 infant contacts

bull Only one third able to be followed up 4 infected

bull On arrival in the country had positive Mantoux

test and no follow up treatment (Sterling and Hass Transmission of Mycobacterium tuberculosis from health

Workers New Eng J Med 13 July 2006 118-121)

Sevagram India

bull Cross sectional study ndash High prevalence of

latent TB in HCW

bull Risk factors age and years as a health care worker

bull 40 prevalence of LBTI ndash could be higher as a small number of attending physicians recruited

(Pai et al ndash JAMA 2005 293(22) 2746-2755)

Vellore ndash Gopinath et al

bull 125 HCW with TB diagnosed in 10 years

probably an underestimate

bull 71 pulmonary 54 extra-pulmonary

bull Mini epidemics may be occurring due to

staff to staff transmission

bull Largest number of cases among nurses

(256 nurses 192 nursing students)

CMC-Nursing students cohort Results

bull 219 (502) (CI 454-550) students had latent TB

Risk Factors - Course

TST +

Diploma 465

Degree 426

PcBSc 745

Post Diploma

SpecFell

842

MSc 727

502 (CI 454-550) students had latent

TB

What is the rate of new infections

every year

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Sevagram India

bull Cross sectional study ndash High prevalence of

latent TB in HCW

bull Risk factors age and years as a health care worker

bull 40 prevalence of LBTI ndash could be higher as a small number of attending physicians recruited

(Pai et al ndash JAMA 2005 293(22) 2746-2755)

Vellore ndash Gopinath et al

bull 125 HCW with TB diagnosed in 10 years

probably an underestimate

bull 71 pulmonary 54 extra-pulmonary

bull Mini epidemics may be occurring due to

staff to staff transmission

bull Largest number of cases among nurses

(256 nurses 192 nursing students)

CMC-Nursing students cohort Results

bull 219 (502) (CI 454-550) students had latent TB

Risk Factors - Course

TST +

Diploma 465

Degree 426

PcBSc 745

Post Diploma

SpecFell

842

MSc 727

502 (CI 454-550) students had latent

TB

What is the rate of new infections

every year

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Vellore ndash Gopinath et al

bull 125 HCW with TB diagnosed in 10 years

probably an underestimate

bull 71 pulmonary 54 extra-pulmonary

bull Mini epidemics may be occurring due to

staff to staff transmission

bull Largest number of cases among nurses

(256 nurses 192 nursing students)

CMC-Nursing students cohort Results

bull 219 (502) (CI 454-550) students had latent TB

Risk Factors - Course

TST +

Diploma 465

Degree 426

PcBSc 745

Post Diploma

SpecFell

842

MSc 727

502 (CI 454-550) students had latent

TB

What is the rate of new infections

every year

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

CMC-Nursing students cohort Results

bull 219 (502) (CI 454-550) students had latent TB

Risk Factors - Course

TST +

Diploma 465

Degree 426

PcBSc 745

Post Diploma

SpecFell

842

MSc 727

502 (CI 454-550) students had latent

TB

What is the rate of new infections

every year

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Risk Factors - Course

TST +

Diploma 465

Degree 426

PcBSc 745

Post Diploma

SpecFell

842

MSc 727

502 (CI 454-550) students had latent

TB

What is the rate of new infections

every year

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

What is the rate of new infections

every year

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Annual risk of TB infection(ARTI)

bull 78 of the subjects previously negative became positive in I yr

bull The National annual rate of TB infection is 15

bull Thus we have a five fold increase in health care trainees

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Facility-level measures Managerial activities

bull Identify and strengthen local coordinating bodies for TB infection control and develop a facility plan

ndash human resources

ndash policies and procedures

ndash to ensure proper implementation of the controls

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Facility-level measures Managerial activities

bull Rethink the use of available spaces and consider renovation of existing facilities or construction of new ones to optimize implementation of controls

bull Conduct on-site surveillance of TB disease among health workers and assess the facility

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Facility-level measures Managerial activities

bull Address advocacy communication and social mobilization (ACSM) for health workers patients and visitors

bull Monitor and evaluate the set of TB infection control measures

bull Participate in research efforts

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Administrative controls

bull Promptly identify people with TB symptoms (triage)

bull It is also crucial to separate infectious patients

ndash smear and culture status

ndash MDR and XDR-TB

ndash HIV or immunosuppression

bull Implement

ndash Cough etiquette and respiratory hygiene

ndash Minimize time spent in health-care facilities

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Administrative controls

bull Provide a package of prevention and care interventions for health workers

bull Isoniazid preventive therapy (IPT) for high risk group

bull Prompt diagnosis amp therapy

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Environmental controls amp Personal protective equipment

bull Use ventilation systems

bull Use ultraviolet germicidal irradiation (UVGI) fixtures at least when adequate ventilation cannot be achieved

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Environmental controls amp Personal protective equipment

bull Use particulate respirators

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Conclusions

bull Mean prevalence of latent TB is in excess of 50

bull This increases to gt90 in those with longer periods of exposure

bull The annual risk of infection was 8 - 5 folds higher than the National average

bull 3 students developed active TB ndash None of them received prophylactic Rx

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Our recommendation bull Screening healthcare trainees and workers is

an important occupational health need

bull TST is a safe amp cost effective tool for screening

bull We recommend annual screening

bull All new converters(LTBI) should be given prophylaxis with shorter possibly Rifampicin based regimen

bull All symptomatics should be promptly tested

bull Infection control measures should be put in place in healthcare settings on war footing

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Acknowledgements

bull CMC college of Nursing ndashstudents amp faculty

bull Canadian Institutes of Health Research

bull Indian amp Canadian co-investigators

Thanks for your patient listening

Thanks for your patient listening