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HOSPITAL
Tuberculosis Infection Prevention And
Control Policy
December 2014
This policy describes the infection control procedures that should be in place to prevent
the spread of tuberculosis (TB) to healthcare workers, patients and visitors within Good
Shepherd Hospital (GSH). It is the responsibility of all hospital staff to read this policy and
work towards improving TB infection control in their department.
Policy development supported by COMDIS-HSD. Funded with UK aid from the UK
government.
DOCUMENT INFORMATION
Good Shepherd Hospital: Tuberculosis Infection Prevention and Control
Title
Policy
For use by:
Authors
Other
Contributors
Approved by
Approved Date
Version
Accompanying
Guidelines
2 Contents
SECTION 1: Policy Background ...........................................................................................................7
1
Introduction ........................................................................................................................................................... 7
2
Background............................................................................................................................................................. 7
3
Latent TB Infection .............................................................................................................................................. 7
4
Active TB Disease ................................................................................................................................................. 8
4.1 Diagnosis ....................................................................................................................................... 8
4.2
5
Drug Resistant TB ................................................................................................................................................ 8
6
TB and HIV .............................................................................................................................................................. 9
SECTION 2: TB Infection Control....................................................................................................... 10
1
Introduction ......................................................................................................................................................... 10
2
Principles of TB Infection Prevention and Control .............................................................................. 10
2.1 Early detection and treatment of new cases ................................................................................. 10
2.2 The use of prophylactic antibiotics such as IPT .............................................................................. 10
2.3 The use of infection control measures ........................................................................................... 10
3
4.1
7
7.1
7.2
7.3
Outpatients Department............................................................................................................. 18
7.4
7.5
7.6
Transporting TB patients............................................................................................................. 19
8.1
MDR-TB .................................................................................................................................................................. 19
TB clinic ....................................................................................................................................... 20
8.2
8.3
9.1
9.2
9.3
9.4
10
Ethical and Legal Considerations ................................................................................................................ 22
10.1
Universal free TB services ....................................................................................................... 22
10.2
10.3
10.4
11
Monitoring and Policy Review ...................................................................................................................... 23
Appendices ...................................................................................................................................... 24
Appendix 1: TB screening tool ...................................................................................................................................... 24
Appendix 2: TB Infection Control Quarterly Reporting Tool ........................................................................... 25
Appendix 3: Measuring and Maximising Natural ventilation .......................................................................... 27
Appendix 4: Putting on and storing a N95 Respirator ........................................................................................ 29
Further Reading .................................................................................................................................................................. 30
Boxes
Box 1: Definitions of drug resistance
Box 2: Instructions for patients giving a sputum sample
Figures
Figure 1 Seating arrangements in naturally ventilated consultation room1
Acronyms
ART ................................................................................................................. Anti Retroviral Therapy
GSH ................................................................................................................ Good Shepherd Hospital
IPT ........................................................................................................ Isoniazid Preventive Therapy
LTBI ..................................................................................................... Latent Tuberculosis Infection
MTB ....................................................................................................................... Miliary Tuberculosis
NTCP.............................................................................................. National TB Control Programme
OPD ................................................................................................................. Out Patient Department
PPE ................................................................................................... Personal Protective Equipment
SMT .............................................................................................................Senior Management Team
TB .......................................................................................................................................... Tuberculosis
TB IPC ...............................................................Tuberculosis Infection Prevention and Control
URC .........................................................................................................University Research Council
UVGI........................................................................................... Ultra Violet Germicidal Irradiation
1 Introduction
GSH is committed to providing the best possible environment for promoting the health and
wellbeing of staff, patients and visitors to the hospital. This policy describes the infection
control measures that should be in place to prevent the spread of TB to healthcare workers,
patients and visitors.
All staff within the hospital, including those involved in outreach services, should be
familiar with these guidelines and be able to apply them to their day to day work.
2 Background
TB infection is caused by Mycobacterium tuberculosis (M. Tuberculosis) which most
frequently affects the lungs, although it can affect other organs. Pulmonary TB is
transmitted via droplet inhalation of M. Tuberculosis bacilli when the infected person
coughs, sneezes or spits. The droplets can remain suspended in the air for long periods,
facilitating transmission to susceptible individuals.
The risk of transmission is dependent on the closeness and duration of the contact with an
infected person, the number of bacilli in the sputum and the susceptibility of the contact to
acquiring the infection. The risk of infection is greatest in those with prolonged, close
household exposure to a person with infectious TB, although anyone who is in close
proximity with an infectious person, such as in a hospital environment, may be at risk. Only
a small number of mycobacterium needs to be inhaled to cause an infection.
The incubation period for TB disease is around 3 8 weeks and approximately 5 - 10% of
those infected develop clinical symptoms of TB disease. Of the rest some will clear the
infection and some will have a latent form of the disease which may reactivate in later life.
Those with pulmonary TB are those that transmit the disease and patients are infectious
for as long as bacilli are present in the sputum.
The presence of HIV infection increases the likelihood of becoming infected and
progression to active disease. Without treatment TB can be fatal, especially in persons with
HIV, however with good adherence to treatment most patients will be cured.
3 Latent TB Infection
Latent TB infection (LTBI) occurs when the individual has been infected with M.
Tuberculosis but does not have active disease. Latent infection has the potential to
reactivate, the risk of which increases with age, immunosuppression and chronic disease.
It is thought that around 5% (1 in 20) of those with latent infection will develop active TB
within 5 years of infection and around 10% (1 in 10) will develop it in their lifetime. This
7
risk increases in persons with dual HIV and TB infection in whom 1 in 10 will develop TB
disease in a year. Isoniazid preventive therapy (IPT) reduces the risk of developing active
TB disease.
4 Active TB Disease
Active TB disease occurs when the person is infected with M. Tuberculosis and shows signs
and symptoms of disease. TB disease can affect any organ or be disseminated through the
body.
Symptoms of pulmonary TB (TB disease in the lungs) include a persistent cough lasting
three weeks or more, fever, sweating at night, loss of appetite, weight loss, and fatigue.
People with TB in other organs or with disseminated TB may have similar symptoms,
depending on the site of the infection.
4.1
Diagnosis
In symptomatic cases and contacts pulmonary TB is diagnosed by considering symptom
history alongside a chest x-ray and the presence of acid fast M. tuberculosis bacilli on
sputum smear microscopy. GeneXpert is used to rapidly confirm the diagnosis and detect
resistance to Rifampicin. Following this, samples are sent to the national TB hospital for
culture and further drug sensitivity testing.
Smear positive cases (i.e. TB cases where TB is visible under a microscope) are more
infectious than smear negative cases.
4.2
Duration of Infectious Period
A person with TB of the lungs or larynx should be considered infectious until 2 consecutive
sputum samples are smear negative on microscopy. A TB suspect should be considered
infectious until TB is ruled out through sputum smear microscopy and chest x-ray.
People with drug sensitive TB are infectious for approximately 2 weeks after commencing
treatment. Those with significant lung disease, immunosuppression and drug resistant TB
will remain infectious for significantly longer (6 months for most patients with drug
resistant TB).
5 Drug Resistant TB
Drug resistant TB is associated with a history of failed or inappropriate treatment, either
due to poor treatment adherence, limited access to health services, or interruption of drug
supply. Drug resistant strains of TB can also be transmitted person to person in the same
way as drug susceptible TB. Definitions of drug resistance are shown in Box 1.
Without treatment the mortality rate of MDR-TB is high, particularly if there is co infection with HIV. Failure of MDR-TB treatment increases the risk of developing
extensively drug resistant TB (XDRTB) which presents an even higher risk of death.
Treatment for MDR - TB takes at least 20 months and starts with an intensive phase during
which the patient receives daily injections.
MDR-TB is not more infectious than drug sensitive TB, but the result of having the disease
can be worse. GSH as an MDR-TB treatment initiation site must make infection control
across the hospital the highest priority.
6 TB and HIV
People living with HIV are 30 times more likely to develop TB than those who are not, TB is
also a major cause of death in HIV patients, therefore early detection and treatment is
extremely important.
The Anti-Retroviral Therapy (ART) team and TB team should work together to detect and
treat patients with both TB and HIV infections. Newly diagnosed TB and HIV patients
should be initiated on TB treatment for 2 weeks before starting ARTs, or as soon as
possible after this.
GSH provides an integrated service and all patients attending the hospital should be
screened for TB and encouraged to know their HIV status.
Ministry of Health, Kingdom of Swaziland. National Guidelines for implementing tuberculosis intensified case
finding, isoniazid preventive therapy and infection control in health care and congregate settings. January 2012.
Swaziland National Tuberculosis Control Programme/ Swaziland National Aids Programme.
10
staff handling sputum samples, and community outreach teams who visit patients at home.
Patients and visitors, including children, are at risk in busy waiting areas and inpatient
wards.
To ensure good ventilation the door to cough booths must be kept open during the day and
only shut and locked at night when they are not in use.
For bed bound patients in the TB ward sputum samples should be taken under bed clothes
to avoid coughing in the open space of the ward.
Sputum collection should be organised by the TB unit for outpatients and by the ward for
inpatients.
Collection of early morning specimens is preferred because of the overnight accumulation
of secretions, although specimens can be collected at any time for patients who have a
productive cough.
Instructions for patients about how to give a sputum sample are given in Box 2
11
Prevent TB exposure to staff and patients through reducing contact with infectious
patients
Reduce the spread of infection by ensuring rapid diagnosis and treatment.
4.1
Infection control team & committee
The infection control team, under the leadership of the Clinical Matron, is responsible for
leading infection control in the hospital, including TB infection control. The team are
supported by an infection control committee who are responsible for the development and
implementation of infection control plans and policies and monitoring and evaluating of
their impact.
The infection control team consists of a nurse and a nursing assistant, and is led by the
senior Clinical Matron. The team is supported by a doctor.
The infection control committee should consist of representatives from each area of the
hospital, including the TB clinic. The committee meets on the first Wednesday of each
month to discuss infection control issues, implement infection control measures, support
best practice and monitor infection control rates.
The TB clinic nurse on the infection control team should monitor the infection control
measures described in this policy using the Infection Control Quarterly Reporting Tool in
Appendix 2 and report back to the committee every quarter. All staff should identify any
problems with TB infection control and promptly report this to a senior manager.
4.2 TB Infection Control Plan
There should be a TB Infection Prevention and Control (TB IPC) plan for the hospital that
describes how this TB infection control policy will be put into practice. Each area within the
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hospital should also have their own plan with named leads for TB infection control
activities.
The TB plan should also have clear guidelines for monitoring and reporting on this. The
development of plans should be overseen by the infection prevention and control
committee, led by the infection prevention and control lead. Staff should be informed of the
plan through training and a copy should be available to everyone employed at GSH. The
plan in each area should be kept in the staff office.
The National TB Control Programme (NTCP) infection control regional co-ordinator can
support the development of infection control plans.
4.3 Staff training
All staff should be trained regularly on infection prevention and control. This should
include specific education about TB infection control, this policy and the TB IPC plan.
Educational materials on TB prevention and cough hygiene should be available at the staff
Wellness Clinic.
New staff should receive educational material and training on TB infection control during
their orientation to the hospital. In-service training should be held annually to coincide
with staff screening (see section below on in-service training). In addition, staff at the
Wellness Clinic should screen staff and talk about TB risk reduction strategies every time
they visit the clinic.
The NTCP regional infection control officer can support staff training and should be
contacted when planning any training. Please contact the TB clinic for more details.
In-service training
Staff training should include the following:
Basic information about TB disease and how it is transmitted
Risk of TB transmission to health care workers, staff and visitors
Cough hygiene
Symptoms and signs of TB
HIV and TB coinfection
Details of the TB IPC plan and the responsibility that each staff member has to
implement and maintain infection prevention and control practices
Specific infection prevention and control measures and work practices that reduce TB
transmission
14
the hospital. Patients should be encouraged to wash their hands after giving a sputum
sample.
Healthcare workers should always use proper cough etiquette and encourage its use by
families and visitors.
4.7 Minimise time spent in healthcare facilities
Sputum collection and the receipt of laboratory results should be as fast as possible. Initial
reports for MTB and rifampicin resistance using Gene Xpert should be available within 24
hours.
TB patients should, wherever possible, be treated in the community. If admission is
required, doctors should encourage discharge at the earliest possible date to reduce risk of
transmission to other patients, visitors and staff.
5 Environmental Measures
Environmental control measures aim to reduce the number of infectious particles in the
environment by diluting contaminated air, removing particles and controlling airflow in
patient areas. This is done through increasing natural ventilation or installing mechanical
ventilation.
Environmental controls are the second line of defence for preventing the spread of TB in
health care settings. Environmental controls will not completely remove the risk of TB
transmission and they need to be used alongside administrative controls and Personal
Protective Equipment
It is the responsibility of the infection control lead nurse to regularly check environmental
controls in the hospital following the guidance in appendix 3.
5.1 Natural ventilation
Each area in the hospital should make the most of natural ventilation so that airflow is
increased. This includes but is not limited to keeping doors and windows open.
Tall or bushy trees near windows should be trimmed regularly to improve airflow
around buildings
Installation of wind turbines to roofs of hospital wards, clinics, OPD and the laboratory
can help to increase airflow.
The chairs for patients in consultation rooms should be position to ensure a good
airflow between the health care worker and the patient, as recommended by the WHO
(see fig 1).
Outpatients waiting to be seen should wait in well ventilated waiting.
16
USAID & CDC Implementing the WHO Policy on TB Infection Control in Health-Care Facilities,
Congregate Settings and Households
17
7.1
Male and female TB wards
The male ward has 7 beds and 1 private/isolation room. The female ward has 9 beds and 1
private/isolation room.
General information
Patients should be given a surgical mask which should be worn during any contact with
a healthcare professional such as ward rounds, drug dispensing, bed bathing and
dressing changes. Change surgical masks every day.
Make sure beds in the TB wards are 1.5m apart.
Keep windows open at all times.
Patients who need to produce sputum should use the cough booth outside the TB ward.
If they are not ambulatory they should cough under their blankets/sheets.
Visitors to TB wards
7.2
Paediatric TB ward
Children 13 and under with confirmed pulmonary TB should be admitted to the paediatric
TB ward. Although children pose less of an infectious risk than adults, the same control
measures for the TB ward apply.
7.3
Outpatients Department
Staff working in the OPD are likely to be exposed to undiagnosed TB patients. Therefore it
is extremely important that all patients attending OPD are screened immediately by the
cough officer using the national screening tool.
All patients seen in OPD who screen positive for TB symptoms should be:
provided with a surgical mask;
prioritised for assessment by an OPD doctor; and
referred to the TB clinic for further investigations.
18
Patients with TB symptoms should spend the minimum time possible in the OPD waiting
area.
7.4
X-ray department
The x-ray department should prioritise TB patients/suspects to reduce the risk of
transmission to other patients in the waiting area:
All TB patients/ suspects sent for an x-ray should have the words 'TB', MDR - TB' or 'TB
suspect' clearly marked on their x-ray form.
All TB patients attending x-ray should be encouraged to wear a surgical mask.
The x-ray department should take all infection control precautions as outlined above,
including the use of N95 masks.
7.5
GSH Outreach Teams
All hospital teams visiting patients at home (e.g. Home Based Care, Mental Health and
Epilepsy) should be aware that they may come into contact with known TB cases as well as
undiagnosed TB patients. Outreach teams should take the following precautions:
When visiting TB patients staff should wear N95 respirator masks and conduct the
consultation outside if possible.
If collecting sputum samples, this should be done in a well ventilated area; preferably
outside and away from other members of the household.
Patients should be encouraged to practice cough hygiene as described in section 4.6.
Staff should be alert to TB symptoms in both patients and their contacts and encourage
anyone with symptoms to seek healthcare at GSH.
7.6
Transporting TB patients
TB patients may need hospital transport if they require urgent medical treatment or for
referral to the National MDR-TB Hospital. If hospital transport is used to make sure that:
all people handling the patient should have an N95 respirator;
if the drivers compartment is sealed he/she does not need to wear the respirator;
where possible people accompanying the patient should sit in the front with the driver,
but if they sit in the back with the patient they should wear the N95 respirator; and
the windows in the part of the ambulance where the patient is travelling should be open
to allow airflow
8 MDR-TB
GSH will be a treatment initiation site for MDR-TB patients not requiring hospital
admission and will run an MDR clinic every Thursday. Although MDR-TB is not more
infectious than drug sensitive TB the consequences of infection can be more serious.
Therefore it is particularly important that contact with MDR patients is minimised. The
19
above all staff should also attend regular screening at the Staff Wellness Clinic. The purpose
of staff screening is to rapidly detect and treat any staff that may have TB.
9.1
New staff
All new staff members should be screened for TB on the pre-employment check.
Screening should include TB symptom screening, chest x-ray, HIV testing and
counselling, and base line blood test including LFTs and RFTs.
Staff who are HIV positive or otherwise immuno-compromised should avoid working
directly with TB patients and TB suspects. GSH should support this by avoiding the
allocation of staff known to be immunocompromised to the TB Ward, TB Clinic or
Outpatients Department.
All new staff that screen negative for TB should be encouraged to take a 6 month course
of IPT. This will be coordinated by the Wellness Clinic. Healthcare Workers who are
HIV+ and/or those working in high risk areas such as the medical wards and the TB
clinic, should be prioritised for IPT.
9.2
9.3
Existing Staff
Any staff members who have TB symptoms should present to the Wellness Clinic.
If staff identify colleagues with TB symptoms they should encourage that staff member
to present to the Wellness Clinic. If they do not present at the Wellness Clinic, the
matrons office should be informed.
All healthcare workers should promptly be evaluated for TB disease if they have a
cough, bloody sputum, night sweats or weight loss.
Health care workers and other staff should be informed about the specific risks for TB
infection in people living with HIV.
All staff attending the Wellness Clinic for any reason should be screened for TB as part
of their initial assessment.
Staff TB screening events
TB Screening events will be run by the Wellness Clinic every September and February.
All staff are encouraged to attend staff TB screening events at least once per year.
It is the responsibility of senior managers, matrons and senior sisters to encourage staff
to attend.
Each department will be invited to attend an information session and be given a specific
day to attend the clinic.
Staff working in the following areas should attend TB screening every 6 months:
1. Staff working in the TB clinic
2. Staff working on the TB ward
21
3. Staff working in the OPD where they are likely to come into contact with
undiagnosed TB patients
4. Any other staff working in close contact with TB patients including those in the xray department , TB laboratory and Home Based Care team
The results of screening events should be reported to the Infection Prevention and
Control Team and the Senior Management Team (SMT) and should include the
following information:
o
o
o
o
o
o
9.4
Surveillance of TB among staff
It is the responsibility of the Wellness Clinic to work with the Infection Control Team to
monitor the number of cases of TB infection in staff to ensure that infection prevention
and control measures are working.
The number of staff screened and the results of this should be reported to the Infection
Control Team on a monthly basis and reported to SMT at regular intervals.
The annual report should also provide information on treatment outcomes for all staff
commenced on TB treatment.
22
23
Appendices
Appendix 1: TB screening tool
Screening Tool for TB
The Swaziland Tuberculosis Screening Tool has 5 questions. Each patient on presentation
at outpatients department, ART or at the Wellness Clinic should be asked:
1. Cough, any duration
2. Fever, 2 weeks or more
3. Night sweats, 2 weeks or more
4. Weight loss, 4 weeks or more
5. Chest pain, any duration
If a patient has any of these symptoms, the patient should be considered a TB suspect and
referred to the TB clinic for further investigation.
24
Total number
Percentage
Number screened/total
outpatients appointments x 100
n/a
n/a
Total
Number
Percentage
Visitors to the TB ward who are not already on TB treatment should be screened at regular intervals.
25
Comments:
Comments:
Environmental checks
Are all windows and doors open?
Comments:
Comments:
General comments (please highlight any areas for improvement or training needs)
26
WHO. Guidelines for Infection of TB including MDR TB and XDR TB. Malawi July 2008.
27
28
29
Further Reading
1. WHO. Implementing the Stop TB Strategy: a handbook for national tuberculosis control
programmes (2008).
http://www.who.int/tb/publications/2008/who_htm_tb_2008_401_eng.pdf?ua=1
2. The Tuberculosis Coalition for Technical Assistance. Implementing the WHO Policy on
TB Infection Control in Health - Care Facilities, Congregate Settings and Households
(2010).
http://www.stoptb.org/wg/tb_hiv/assets/documents/TBICImplementationFramewor
k1288971813.pdf
3. CDC Tuberculosis Infection Control and Prevention. Infection Control in Health Care
Settings (online) http://www.cdc.gov/TB/topic/infectioncontrol/default.htm
30