Infection Prevention and Control Guidelines for TB, MDR-TB and XDR-TB
*The following information draws on National Infection Prevention and Control Guidelines Published by National Department of Health, Republic of South Africa in 2015.
1 Why Infection Prevention and Control Guidelines?
An increased risk of TB has been documented amongst all categories of health care personnel including facility staff, community health workers and volunteers) compared to the general population. The prevalence of HIV amongst health care personnel correlates with that in the general population. Health care personnel are at risk due both to frequent exposure to patients with infectious TB. The rising incidence of Multidrug-Resistance Tuberculosis (MDR-TB) and Extensively Drug-Resistance Tuberculosis (XDR-TB) with high mortality have led to a stronger focus on TB infection control.
It is the responsibility of management and staff to minimize the risk of TB transmission in health settings. Infection control measures should be established to reduce the risk of TB transmission to both the general population and to health care personnel. Since the majority of patients are seen at primary health care level, it is important to ensure that infection prevention and control measures are implemented not only in the hospitals but clinics, community health centers and community or household level.
People with active tuberculosis generate droplets of different sizes. The larger droplets which contain higher numbers of bacilli do not remain airborne for long periods. If they are inhaled, they do not reach the alveoli because they are trapped by the mucous in the upper airway and from there transported by mucociliary action to the oro-pharynx and swallowed or expectorated. The smaller droplets which are 1 to 5 µm in diameter containing fewer (±1 – 5 bacilli), are highly infectious. They remain airborne for long periods of time in any indoor space. When inhaled they can easily reach the alveolar spaces within the lungs, where the organisms replicate. It is estimated that one cough can produce 3,000 droplet nuclei and a sneeze up to a million droplets; about 10 – 200 droplet nuclei are sufficient to cause infection. The most infectious people are those who have smear positive pulmonary TB (coughing up the bacilli), particularly with lung cavities. People with smear negative pulmonary TB cases are much less infectious and those with extra-pulmonary TB are almost never infectious, unless they have pulmonary tuberculosis as well.
3 How people are Exposed to TB Bacilli?
- When someone with pulmonary TB coughs, invisible droplets containing TB bacilli are dispersed into the air;
- The remain suspended in the air and fall at a rateof 12mm/hr; and
- These droplets can then be inhaled by others.
Transmission generally occurs indoors, in dark, damp spaces where the bacilli can survive for several hours. Direct sunlight has a bactericidal effect on the tubercle bacilli. Close contact with a person who has infectious PTB for a prolonged time increases the risk of transmission.
4 What are theFactors that Determine the Likelihood of Transmission of M. Tuberculosis?
- The number of organisms expelled into the air; and
- The concentration of organisms in the air, determined by the volume of the space and its ventilation; and
- The length of time an exposed person breathes the contaminated air
Once infected, the progression to active disease is dependent on the immune status of the individual.
5 What are the Key Factors for Progression to Active Disease?
- Age: children <5 years of age and the elderly are less infectious as they have paucibacillary disease
- HIV: people who are HIV positive and have a high CD4 count would be as infectious as HIV negative patients. Those with low CD4 count are considered less infectious as they would have paucibacillary disease.
- diabetes mellitus,
- corticosteroids and other immuno-suppressive drugs and
6 What are the Dey Patient Factors that Determine the Risk of Transmission?
- Sputum smear positive
- Chest x-rays shows cavities in the lungs
- Active affective TB Not on treatment
- Just started TB treatment (on treatment less than a week)
- Poor clinical response to TB treatment
7 What are the Key Environmental Factors that Determine the Risk of Transmission?
- Ventilation: Inadequate ventilation results in failure of air dilution or removal of infectious droplet nuclei thereby increasing the risk of transmission.
- Duration of exposure: Spending eight continuous hours with an infectious person poses a higher risk than two hours or occasional contact.
- Concentration of the droplet nuclei: The risk of transmission is higher if the concentration of the droplet nuclei in the air is high.
- Space: The risk is higher in a small enclosed space.
- Air circulation: Recirculation of air poses a risk when it contains infectious droplets.
8 How to Reduce the Risk of Transmitting TB Infection in Health Care Facilities?8.1 What are Key Management Control Measures?
- National and Provincial level managerial control activities include:
- The development of minimum standards for health facility design which take airborne infection control into consideration.
- Ensuring compliance to these standards for any new construction and renovations
- Developing occupational health policies for staff working in the health facilities
- Ensuring that regular TB medical surveillance for all health workers is conducted.
- Building capacity for staff to conduct facility risk assessments and developing IPC plans
- Ensuring that risk assessments are conducted in all health facilities annually
- The development and distribution information, education and communication (IEC) materials on infection control health care workers and communities
- Conducting social mobilization and awareness campaigns on TB infection control
- Engaging civil society in TB prevention and control activities
- Monitoring and evaluation of the implementation of the TB infection control measures.
- Support operational research activities in TB IPC.
- District level managerial activities
- The establishment of an Infection Prevention and Control committee and appoint infection prevention and control officer, where this exists ensuring that TB infection prevention and control is included in their responsibilities.
- Appointment of an IPC Officer to coordinate the implementation of infection prevention and control programme within the district
- Conduct health facility TB risk assessments annually
- Review facility TB IPC plans annually
- Provide occupational health services for all staff working in the health facilities
- Monitoring the number of health staff diagnosed with TB monthly
- Train and educate health workers on infection prevention and control measures.
- Ensure availability of appropriate commodities for TB IPC
- Monitoring of the implementation of TB Infection Prevention and Control interventions.
- Facilitate operational research activities in TB IPC.
8.2 What are the Key Administrative Control Measures?
- Infection control plan
Each facility must have a written TB Infection prevention and Control plan that outlines a protocol for the prompt recognition, separation, provision of services, investigation for TB and referral of patients presenting with TB symptoms or confirmed TB disease. The plan will include, but not be limited to, the following measures:
- Early recognition of people with TB symptoms through symptomatic screening of all patients entering facility or soon after arrival. A staff member should be assigned to screen patients using the TB screening tools(adult and children). The form must be completed and included in the patients file. Presumptive TB cases should be investigated
- People with chronic cough must wait in a designated, well-ventilated waiting area, for example in outdoor waiting areas, or a well-ventilated section of the waiting
- They must be educated on cough hygiene and provided with a face mask or tissue to cover their mouth and nose when Tissues and face masks should be provided in the waiting areas and discarded in the bins after use. Hand washing should be encouraged after contact with respiratory secretions.
- Fast tracking confirmed TB cases coming for follow up appointments or to take/ collect their treatment to ensure that they spend as little time as possible in the
- Educating health care personnel, patients and communities to seek health care early when symptoms of TB are present and to protect themselves and others e.g. through appropriate cough hygiene and good ventilation in the household.
- Improved TB and HIV integration in the health facility, with symptomatic TB screening of HIV positive patients at routine clinical visits and appropriate tests for those who are symptomatic,
- Training of facility staff on IPC plan
Infection prevention and control is effective only if all staff working in a facility understands the importance of the infection prevention and control policies and the irrole in implementing them. Training should include the following:
- Basic concepts of M. tuberculosis transmission and pathogenesis;
- Risk of TB transmission to health care workers and staff;
- Symptoms and signs of TB;
- Impact of HIV infection on increasing risk of developing TB disease and the importance of TB as a major cause of disease and death in PLWHA;
- Importance of the infection prevention and control plan and the responsibility that each staff member has to implement and maintain;
- Specific infection prevention and control measures and work practices that reduce the likelihood of transmitting TB;
- Measures staff can take to protect themselves from TB; and
- TB disease surveillance among HCW
- Community education and awareness. Educate communities and patients on the following:
- To recognize symptoms of TB and promptly seek health care;
- To undergo HIV Counselling and Testing;
- Cough hygiene; and
- Prevent ion of transmission in the community
- Surveillance of TB disease among health workers
Surveillance of TB among Health Care Workers serves as an indication of performance of IPC Plan. All facility staff must be included in the TB medical surveillance programme in line with Occupational Health and Safety Act (Act No. 85 of 1993). This medical surveillance programme consist of the following main components:
- Pre-employment medical: Baseline screening and testing for M. tuberculosis infection for all newly employed HCWs as part of the pre-employment. This serves as a baseline for comparison in the event that a person contract TB disease. It provides an opportunity to identify high risk individuals (HIV, diabetes etc) for appropriate placement and enables early detection and initiation of treatment.
- Periodic medical: Sceening and testing for TB every six months. This should also be conducted as part of outbreak investigations.
- Exit medical: Screening and testing for TB disease to exclude undiagnosed TB disease at the time of leaving the facility and ensure early treatment.
- Training of staff on TB medical surveillance programme, and
- Education of staff on the importance of using the service.
All staff with confirmed infectious TB disease pose a risk of transmitting TB infection and should be initiated on treatment promptly.
- Administrative Control Strategies to prevent TB transmission in Health Care settings
In general, administrative control measures have the greatest impact on preventing TB transmission and they are the first priority in any setting regardless of available resources. These measures aim to reduce the droplet nuclei in health facilities by eliminating the generation of droplet nuclei and risk of exposure. The administrative control activities include;
- Early recognition of people with TB symptoms through screening of all patients entering the health facility
- Separation of people who are coughing from the other patients, this will require identification of a well- ventilated area that can be used as a sub-waiting area.
- Prompt investigation for TB in symptomatic patients
- Sputum test results must be followed up and patient started on treatment immediately if diagnosed with TB.
- Educating all patients on respiratory hygiene
- Isolation of confirmed TB patients
8.3 What are the Environmental Control Measures?
- Ventilation (natural and mechanical)
- High Efficiency particulate air filtration (HEPA)
- Ultraviolet germicidal irradiation (UVGI)
8.4 How to Ensure Proper Ventilation?
- Natural ventilation is created by the use of external natural forces such as wind. It is however difficult to control the direction of the airflow as this depends on the wind speed or direction. It relies on open windows and doors to allow the air to move in and out of the room. Designing waiting areas and examination rooms in such a way they maximize natural ventilation can help reduce the spread of TB. Open air shelters with a roof to protect patients from sun and rain can be used as waiting areas.
- Directional airflow: Fans can be used to enhance flow of air in and out of the room when installed in the windows or wall opening where there are inadequate windows. They can also be used to exhaust air outside, away from people. For example, in a room which has a door/ window on one side and nothing on the opposite side, when the door/ window is kept open, the overall effect of installing fans on the opposite side is to draw in fresh air through the front of the building and exhaust air out.
It is therefore important to be mindful of the direction of airflow in a room to ensure that the sitting arrangement is such that air will blow from behind the health care worker over the patient and out of the room.
- Mechanical ventilation: This is created using an air supply or an exhaust fan to force air exchange and to drive airflow. Such ventilation works by generating negative or positive pressure in the room to drive air changes. To be effective, all doors and windows must be kept closed, with controlled air leakage into or out of the room.
8.5 What is High Efficiency Particulate Air (HEPA) filtration?
HEPA filtration may have a place as an additional measure to adequate ventilation in booths or enclosed areas designed for sputum collection/ induction. Portable units are available but have not been evaluated adequately to determine their role in tuberculosis infection control.
However, recirculating air from areas intended to isolate a patient with tuberculosis is not recommended and these units are also expensive and need regular engineering attention.
8.6 What is Ultraviolet germicidal irradiation (UVGI)?
UVGI is dependent on room air mixing to be effective because contaminated air must be circulated to the irradiated upper part of the room where the organisms can be rapidly inactivated. Several studies have shown that well-designed UVGI upper room devices can disinfect mycobacteria in conditions that have an equivalent of 10–20 air changes per hour. It is ineffective in humid and dusty environments. UVGI devices have to be installed properly for maximum effect; testing and maintenance must be conducted regularly.
Upper UVGI devices are hazardous if not properly designed or installed. The NIOSH guidelines recommended the occupational exposure limit of 6mJ/cm2 over an 8 hour period for a short wave ultraviolet irradiation (254 nm). It has been reported that exposure above this limit may result in erythema/ photo dermatitis and photo- keratitis and/or conjunctivitis.
9 What is the Role of Infection Prevention and Control Committee (IPC Committee)?
The roles and responsibilities of this committee in relation to TB IPC are to:
- Ensure development of the Infection Prevention and Control plans
- Provide technical support on TB prevention and control to district and facilities
- Review TB surveillance data trends (including MDR and XDR-TB)
- Advise on potential outbreaks and management thereof.
10 What is the Role of infection Prevention and Control Teams (IPC Teams)?
11 What is Personal Respiratory Protection?
- Respirator masks: Respirator masks are designed to filter out the droplet nuclei thus protecting health care workers and visitors from inhaling the droplet nuclei. They are most appropriately used for short-term protection against high-risk exposures e.g. during sputum inducing procedures and bronchoscopy. The recommended respirator is the type that covers the mouth and nose and is fitted with a special particulate filter to filter out very small particles. NIOSH certified N95 or greater or E.U. specified filtering face piece FFP2 or greater are recommended for use in health care settings.
These face masks have a capacity to filter small particles thus protecting against inhaling infectious droplet nuclei. The N95 respirator has a filter efficiency level of 95% or more against particulate aerosols oil free when tested against 0.3 μm particles. The “N” indicates that the mask is not resistant to oil; the “95” refers to a 95% filter efficiency. The FFP2 respirator has a filter efficiency level of 94% or more against 0.4 μm particles and is tested against both oil and oil free aerosols.
Fit testing must be performed on all health care workers to determine which type or size of respirator fits properly. It makes use of a noxious substance that is sprayed in a hood covering the head
- If the individual can smell the substance, it means the respirator does not fit well
- If the individual cannot smell the substance, it means the respirator fits well.
Once the correct type and size has been determined for an individual, fit testing does not need to be repeated.
11.1 How to put on and test seal an N95 respirator mask?
- Wash your hands using soap and water or clean with hand sanitizer
- Inspect the mask to ensure that it is not damaged.
- Cup the respirator in your hand with the nosepiece at your fingertips, allowing the headbands to hang freely below your hand
- Position the nosepiece under your chin with the nosepiece up
- Pull the top strap over your head resting it high at the back of your head. Pull the bottom strap over your head and position it around your neck below your ears
- Place fingertips of both hands at the top of the metal nose piece. Mould the nose piece (using two fingers of each hand) to the shape of your nose.
- Cover the front of the respirator with both hands, being careful not to disturb its position.
- Exhale sharply and adjust if leaking
- Inhale deeply and adjust if leaking
Source of graphics: WHO Epidemic and pandemic Alert and Response, 2008
Seal checking is performed to check if the respirator is sealing the face off properly and that air is not leaking between the face and the respirator. This should be done every time the respirator is worn.
- Positive seal-check: Exhale sharply. A positive pressure inside the respirator means that there is no leakage. If there is leakage, adjust the position and/or the tension straps. Retest the seal. Repeat the steps until the respirator is secured properly.
- Negative seal-check: Inhale deeply. If there is no leakage, negative pressure will make the respirator cling to your face. Leakage will result in loss of negative pressure due to air entering through gaps in the seal. Adjust the position and/or the tension straps and check for damage. Retest the seal. Repeat the test until the respirator is secured properly.
11.2 How to remove an N95 Mask?
- Wash hands using soap and water
- Avoid touching the front part of the mask with wet and greasy hands
- Support the front part of the mask and remove by lifting the top and then the bottom elastic over the head.
Respirators are disposable but can be re-used repeatedly over the course of an 8 hour shift for up to 5 days, if they are properly stored in a clean dry place, used by one person, not soiled or wet, do not contain holes, tears or damaged in any other way. If the respirator has been breached it must be disposed of and a new respirator should be used.
Things to avoid
- Do not write on the mask.
- Do not store in a plastic bag
- Do not leave mask hanging around your neck.
- Do not fold and do not share
12 How to Ensure Infection Prevention and Control in Congregate Setting?
- TB wards
One of the most effective means to reduce the risk of transmission of M. tuberculosis in hospital settings is to manage TB patients in the outpatient setting whenever possible. Many patients can be managed entirely as outpatients, thereby avoiding hospitalization and the risk of exposing other patients and staff. If hospitalized, patients should be re-evaluated frequently for possible discharge with continuation of treatment as outpatients. Ideally, infectious TB patients should be isolated from other patients to prevent others from being exposed to the infectious droplet nuclei that they generate. If sputum smear is performed at the time of admission, those who have positive sputum smear results, and thus most infectious, should be isolated or separated from other TB patients already on treatment.
The hospital administration should ensure that:
- There is a limited number of areas (preferably none) in the facility where exposure to potentially infectious TB patients may occur.
- Separate wards for confirmed infectious TB patients are established. These wards should be located away from wards with non-TB patients, especially wards with paediatric or immuno-compromised patients.
- In the outpatient setting, early identification, diagnosis, and treatment of TB cases is the highest priority.
- X-ray departments schedule inpatient chest x-ray appointments for patients with confirmed or unconfirmed PTB during non-peak times.
- Surgical masks are provided to coughing patients to wear when leaving isolation wards for any reason and in crowded waiting areas.
Isolation may be in patient’s homes, hospitals, or at designated TB or MDR-TB hospitals. Isolation is voluntary however; it may be legally enforced where a patient poses a risk to the public. Patients should remain in isolation until they are not infectious. People with infectious tuberculosis who are ill must be admitted in separate wards from other patients and their movement restricted to prevent the spread of infection. Ideally patients with suspected or confirmed infectious PTB should be admitted in a single ward that has;
- Monitored negative air pressure
- 6 –12 air changes per hour
- Appropriate discharge of room air to the outside
- Monitored high efficiency filtration of room air before the air is circulated to other areas of the hospital.
- Simple extraction fan providing at least 6 air changes per hour or
- Open windows and adequate ventilation.
When single wards are not available the patient should be placed in a ward with patients who are infected with the same micro-organisms. Patients at the same stage of treatment may be admitted in the same wards – cohorting. The same environmental measures as mentioned above apply in such a ward.
- Patient transportation
The ventilation system in the ambulance should be circulate air within the vehicle but facilitate dilution by bringing in air from outside. If the vehicle has a rear exhaust fan, the fan must be on during transport. Air should flow from the front of vehicle, over the patient, and out through the rear exhaust fan.
After transporting the patient the vehicle must be ventilated by opening all doors and windows switching on the fans to flush out the air inside the vehicle.
If patient transport vehicles are used to transport a patient with infectious TB disease;
- If possible separate the infectious patients from other patients.
- The patient must wear a surgical mask
- Ensure that all windows are open.
- Educate patients in transit, driver and the accompanying staff on the use of masks and respirators.
- Correctional facilities
Compared with the general population, TB prevalence is higher among inmates and it is associated with a higher prevalence of HIV infection, overcrowding, suboptimal ventilation, longer duration of potential exposure and limited access to health care services. TB is a public health concern in correctional facilities; employees and inmates are at high risk of infection. All correctional facilities must therefore have a written TB infection prevention and control plan based on the TB risk assessment report.
13 What is the Role of Advocacy, Communication and Social Mobilisation (ACSM) in Infection Prevention and Control?
- Imparting knowledge about the benefits as well as consequences of not implementing TB IPC measures in a given setting
- Mobilizing communities to demand infection control measures for prevention of the spread of TB infection.
- Mobilisation of resources to fund infection control activities.
- IEC material: Develop TB IPC posters and pamphlets with clear and consistent messages.
- Awareness and education campaigns: Identify key populations to target for TB awareness and infection prevention campaigns. These include schools, correctional services, mines and informal settlements and key populations to conduct
- Media coverage
- Make use of TV slots, radio and newspapers to communicate concise and consistent messages on TB infection prevention and control.
- Engagement of all relevant stakeholders (e.g. Metrorail, Busses, taxis) to advocate Infection Prevention and Control
- Branding of taxis on infection prevention messages
- Bill boards in strategic points on Infection Prevention messages – short, consistent messages.
14 How to Conduct TB Risk Assessment?
- Planning based on the HACCP process and determine what sections of the risk assessment tool will be used.
- Assemble a multi-disciplinary risk assessment team
- Establish procedures for documentation of all activities and the results of the assessment.
- Establish procedures for validation and verification of the interventions currently being implemented and that they are periodically reassessed.
- Conduct a hazard analysis by investigating all patient pathways to identify critical control points
- Determine the appropriate IC intervention implemented for each critical control point by using the risk assessment questionnaire
- Evaluate the management of the infection control plan in the facility in order to reduce risk against infection
- Evaluate compliance with the use of personal protection
- Evaluate facility environmental controls and maintenance practices, and determine their effectiveness
- Establish what monitoring plan for the applied IC intervention has been implemented at each of the critical control points
- Identify and recommend corrective action.
15 What are the Infection Prevention and Control Measures for Household?
- educating patients regarding the importance of reporting symptoms or signs of TB disease early and the importance of reporting any adverse effects to treatment
- counselling of patients on treatment adherence
- administering DOT and providing support to the patient
- precautions to be taken when collecting sputum
- educate the patient and family members on cough hygiene and importance of ventilation
- the importance of using N95 masks when entering a home/ room of a person with confirmed or suspected infectious TB
- the importance of undergoing routine medical screening for TB disease and screening for risk factors
- Administrative controls
- Ensure treatment compliance at home: Care and support must be provided to the patient by community health workers.
- Screen all close contacts for TB symptoms: people who are symptomatic must be investigated for TB, children less than 5 years and all people living with HIV in the household must be offered IPT.
- Education: Educate patients, family members, care providers, and close contacts on the importance of isolation and infection control measures to be implemented at home.
- Hospital isolation: Patients with confirmed infectious TB disease and family support or homeless must be admitted and isolated in the hospital. This will ensure that risk of infecting others is minimized and treatment compliance.
- Environmental controls
Windows and doors must be kept open (weather permitting) to increase the ventilation and dilution of infectious droplet nuclei in the house. If a sputum sample needs to be collected at home, this must be done in a well- ventilated preferably outside.
- Personal protective equipment
- Patient: Mask: Patients do not need to wear masks at home once they are on adequate treatment (after two weeks of appropriate treatment). Give patients surgical masks and advise them to wear them at home if necessary, during transportation and medical consultations until they are no longer infectious.
- Healthcare Worker: Respirator: Healthcare workers should wear respirators when entering the home of a patient with infectious TB disease or when transporting a patient with infectious TB. The respirators should be NIOSH-approved (N-95 or higher) or E.U. specified filtering face piece FFP2. Healthcare workers should be provided with respirators after appropriate education and testing.
TB Infection Control measures in the home environment