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TUBERCULOSIS INFECTION CONTROL IN LOW INCOME COUNTRIES: A LITERATURE REVIEW
Anders Chen, MDInternal Medicine R34/5/2011
OUTLINE
TB infection control (TB IC): Background WHO Policy recommendations Literature review Practical next steps
TB IC: BACKGROUND
Increased nosocomial TB in high income countries in 1980s and 1990s1,2,3.
Increased focus on TB IC in health care settings, with creation of guidelines and manuals to aid in their implementation
1Pearson, Ann Int Med 1992, 2Beck-Sague JAMA 1992, 3Menzies NEJM 1995
TB IC BACKGROUND: LOW INCOME COUNTRIES
Resurgence of TB in low income countries fueled by HIV pandemic
Higher rates of HIV and TB Already small health care workforce Less resources for infection control Nosocomial transmission risk for patients HCW rates of TB well above average
population rates4
4Menzies, Int J Tuberc Lung Dis 2007
WHO POLICY RECOMMENDATIONS
At the facility level: Managerial controls:
Coordinating body for TB IC Facility risk assessment Surveillance of TB disease in HCW Rethinking use of space Advocacy Monitoring and evaluation of TB IC efforts
WHO POLICY RECOMMENDATIONS
Administrative controls: Prompt identification of
suspected/confirmed TB patients Separation of such patients away from
others, especially immunocompromised patients, into well ventilated areas
Cough etiquette, respiratory hygiene Rapid diagnosis Protection of HCW
WHO POLICY RECOMMENDATIONS
Environmental Controls: Ventilation: optimizing natural ventilation
where appropriate Large open windows Directional flow Adequate ACH
Mechanical or mixed mode ventilation where natural ventilation not appropriate
UVGI as a supplemental control Lab safety
CHALLENGES TO IMPLEMENTATION
Lack of tools to aid in implementation in low income countries
Data supporting TB IC measures in high income countries has been with packages of multiple interventions simultaneously, including expensive measures
Few data looking at effectiveness of any individual interventions5
5WHO 2009 annexes
LITERATURE REVIEW
In low and middle income countries, are there examples of successful implementation of low cost TB IC interventions?
Are there data showing reduced nosocomial TB spread with limited, low cost interventions?
LITERATURE REVIEW
Limited resources, limited implementation, limited reports.
Literature review including conference abstracts and grey literature yielded 23 articles describing TB IC in low and middle income countries.
16 descriptions of successful implementation 2 report efforts to monitor and evaluate TB IC efforts
9 report data on nosocomial transmission before and after TB IC efforts 5 published in peer reviewed journals with statistical
analysis, of which 4 yielded positive results.
LITERATURE REVIEW
da Costa, J Hosp Infect 2009, Brazil Low cost administrative measures
including HCW training, cough etiquette, separating coughing patients, rapid sputum processing, clustering of TB services to reduce exposure. Also respirators for staff
Reduced LTBI incidence in HCW Upper middle income country, relatively
low cost interventions
LITERATURE REVIEW
Roth et al. Int J Tuberc Lung Dis 2005 2 Brazilian hospitals with higher levels of
TB IC, 2 with lower levels. TB IC measures include rapid
diagnosis/testing, isolation rooms. Biosafety cabinets in labs.
Lower LTBI incidence in HCW in 2 hospitals with higher levels of TB IC measures
Upper-middle income country, some higher cost measures
LITERATURE REVIEW
Yanai, Int J Tuberc Lung Dis. 2003 Thailand, referral hospital Many lower cost interventions incl. administrative
controls of triage, cough etiquette, rapid sputum processing, natural ventilation
Some higher cost measures: biosafety cabinets, 1 isolation room
Lower LTBI incidence in HCW after measures implemented
Lower middle income country, mix of low and higher cost measures
LITERATURE REVIEW
Catterick, South African AIDS Conference 2009 Church of Scotland Hospital, Tugela Ferry, site of well
publicized highly fatal XDR outbreak Administrative controls: TB IC officer. Cough officers
to screen patients. Separated DOTS and HIV and moved both to periphery of hospital campus. Screened HCW for TB
Environmental: Unannounced audits on open window policy
PPE: Unannounced audits on staff respirator use Report successful low cost measures, no data Poor area in an upper middle income country, with
inexpensive measures implemented
LITERATURE REVIEW: DISCUSSION
Existing data do suggest that low cost measures can be implemented and can reduce nosocomial TB spread
More data would be useful, as would monitoring and evaluation of efforts