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GOOD SHEPHERD

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:

Good Shepherd Hospital: All departments

Authors

Helen McAuslane, Clare Humphreys, James Elton, David Mc Conalogue,


Bongekile Nxumalo(COMDIS-HSD), Dr Fred Busuulwa, Vusani Ndzimandze,
Soko Zakhele (Good Shepherd Hospital)

Other
Contributors

TB Team, Infection Control Committee, Lubombo Regional MDR TB


Decentralisation Committee

Approved by
Approved Date
Version

Good Shepherd Hospital, Senior Medical Officer


November 2014
1.0
1. Good Shepherd Hospital MDR TB Service Guidelines
2. Swaziland National Tuberculosis Infection Control Policy
3. WHO Policy on TB Infection Control in Health - Care Facilities,
Congregate Settings and Households

Accompanying
Guidelines

DOCUMENT REVIEW PLAN


Responsibility for
Infection Control Committee, supported by the TB Team
review
Next Review Date
November 2015

Foreword by Dr Kiron Koshy, Good Shepherd Hospital Senior Medical


Officer
GSH provides essential health services for the people living in the Lubombo region. A
key part of our work is caring for people with tuberculosis through screening,
diagnosis and treatment of the disease. It is through these services that we also have
an important role in halting TB transmission in this region.
The inpatient TB ward and development of an MDR - TB treatment service means that
we are now able to treat more people, more effectively. However, the continuing
development of TB services at GSH also means that we need a detailed and up-to-date
infection control policy that covers the entire hospital.
This document is the infection prevention and control policy and provides
detailed information on what hospital staff can do to protect themselves and
others from infection.
Protecting all staff and patients from TB infection is our priority and is everyones
business, from senior management to the most junior members of staff.
All staff should read these guidelines and put them into practice. Discuss the contents
of these guidelines with your colleagues and managers to see how you can make
changes where you work. Dont be afraid to challenge staff or patients who may be
putting others at risk.
These guidelines have been developed with the input of the National TB Control Team,
the hospital infection control team and staff working in the TB clinic. Please read them
in detail and use the information contained within to help GSH become a centre of
excellence for TB care.

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

Duration of Infectious Period........................................................................................................ 8

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

Rapid Detection and Treatment of TB ....................................................................................................... 11


3.1 Prompt identification of people with TB symptoms (triage).......................................................... 11
3.2 Sputum sample collection, storage and testing ............................................................................. 11
3.3 Contact tracing ............................................................................................................................... 12

4.1

Administrative and Work Practice Controls ........................................................................................... 13


Infection control team & committee .................................................................................... 13

4.2 TB Infection Control Plan ................................................................................................................ 13


4.3 Staff training ................................................................................................................................... 14
4.4 Separation of Infectious Patients ................................................................................................... 15
4.5 Information for patients and visitors ............................................................................................. 15
4.6 Cough hygiene education ............................................................................................................. 15
4.7 Minimise time spent in healthcare facilities .................................................................................. 16
5

Environmental Measures ................................................................................................................................ 16


5.1 Natural ventilation.......................................................................................................................... 16
5.2 Mechanical ventilation ................................................................................................................... 17

Personal Protective Equipment ................................................................................................................... 17


6.1 Patients ........................................................................................................................................... 17
6.2 Healthcare workers ........................................................................................................................ 17
4

7
7.1

TB Infection Control in Areas with Increased Risk .............................................................................. 17


Male and female TB wards ......................................................................................................... 18

7.2

Paediatric TB ward ...................................................................................................................... 18

7.3

Outpatients Department............................................................................................................. 18

7.4

X-ray department ........................................................................................................................ 19

7.5

GSH Outreach Teams .................................................................................................................. 19

7.6

Transporting TB patients............................................................................................................. 19

8.1

MDR-TB .................................................................................................................................................................. 19
TB clinic ....................................................................................................................................... 20

8.2

X-ray department ........................................................................................................................ 20

8.3

GSH outreach teams ................................................................................................................... 20

9.1

Staff TB Screening and Surveillance ........................................................................................................... 20


New staff ..................................................................................................................................... 21

9.2

Existing Staff .......................................................................................................................... 21

9.3

Staff TB screening events ...................................................................................................... 21

9.4

Surveillance of TB among staff ............................................................................................. 22

10
Ethical and Legal Considerations ................................................................................................................ 22
10.1
Universal free TB services ....................................................................................................... 22
10.2

Informed patients ................................................................................................................... 22

10.3

Healthcare worker protection ................................................................................................ 23

10.4

Involuntary isolation ............................................................................................................... 23

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

SECTION 1: Policy Background

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.

Box 1: Definitions of drug resistance

Mono - Resistant TB (DR-TB): Resistance to any first line anti-tuberculosis drug


Poly - Resistant TB (PR-TB): Resistance to more than one drug, other than rifampicin and
isoniazid
Multi - Drug Resistant TB (MDR-TB): Resistance to at least rifampicin and isoniazid
Extensively Drug Resistant TB (XDR-TB): Resistance to isoniazid and rifampicin, any
fluoroquinolone and one of the second-line injectable drugs.

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.

SECTION 2: TB Infection Control


1 Introduction
Strong infection control policies and procedures will help to protect staff, patients and
visitors at GSH from TB. This section describes the principles of TB infection control and
how to apply these throughout the hospital.

2 Principles of TB Infection Prevention and Control


There are 3 important elements to reducing the number of new TB infections. These are: 1)
early detection and treatment of new cases; 2) the use of prophylactic antibiotics such as
IPT; and 3) the use of infection control measures in healthcare and other high risk settings.
2.1 Early detection and treatment of new cases
The most important measure for preventing the transmission of TB is prompt detection
and treatment of cases. Left untreated, each person with active TB will infect about 10 to
15 people every year. Early identification, referral and treatment of people with symptoms
of TB is essential to halt the spread of disease, hence the importance of integrated TB
screening in all areas of GSH. Close contacts of patients with TB should be screened
promptly. People living with HIV & AIDS should be screened regularly and as a priority if
they are known to be a contact of someone with TB.
2.2 The use of prophylactic antibiotics such as IPT
IPT can prevent the progression from latent to active disease and is an important measure
to help stop the transmission of TB. Current Swaziland guidelines2 suggest that all HIV
patients over 12 months of age should be initiated on IPT if they screen negative for TB.
HIV positive infants aged less than 12 months should be initiated if they are a contact of a
TB case. Other high risk groups who should be offered IPT are children aged less than 5
years who are contacts of a TB case, individuals in institutional settings such as prisoners
or miners, and healthcare workers in contact with TB patients. Healthcare Workers who
are HIV+ and/or those assessed to be working in high risk areas such as medical wards or
TB clinic should be prioritised for IPT. IPT should be repeated every 2 years as indicated,
following a repeated negative TB screen. IPT is not recommended for contacts of MDR-TB
patients.
2.3 The use of infection control measures
Healthcare workers and others in the hospital environment are at a higher risk of TB
infection due to their close proximity to infectious TB patients. This risk is increased
further where there is also a high prevalence of HIV infection. Staff at particular risk
include those working in outpatient departments (OPD), TB wards or clinics, laboratory
2

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.

3 Rapid Detection and Treatment of TB


3.1 Prompt identification of people with TB symptoms (triage)
All patients must be screened at OPD and in the ART clinic at the start of every visit to
identify patients with TB symptoms. Children should be screened at Prevention of Mother
to Child Transmission Clinic.
Screening will be conducted using the appropriate Swaziland National Screening Tool
(Appendix 1). Screening results must be recorded in the national screening register and in
the patients notes.
Those with a positive screen should be prioritised to see the doctor and be referred to the
TB clinic to give a sputum sample immediately after this consultation.
3.2 Sputum sample collection, storage and testing
Sputum collection is best undertaken away from other patients and preferably outside.
There are 2 cough booths available for patients to use:

Booth 1: outside the TB clinic for outpatient use


Booth 2: outside the TB ward for inpatients and those in a wheelchair

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

Box 2: Instructions for patients giving a sputum sample


1. Gargle with water to rinse out your mouth, ensure you have not smoked,
eaten or taken a drink before providing the sample.
2. Breathe deeply several times and cough from deep down in the lungs.
Sputum is the mucous or phlegm coughed up from the lungs, it is not
saliva or mucous from the back of the throat. A large spoonful is a good
amount.
3. Open the collection pot and hold it close to your mouth. Spit the sputum
into the pot without getting any on the outside and screw the lid on
tightly.
4. Wash your hands.
Sample storage
Sputum sample should be stored in a cool box and transported to the refrigerator in the TB
laboratory within 2 hours of collection. At weekends or holidays samples should be
delivered to the laboratory and placed in the specimen fridge by the member of TB clinic
staff on duty. The TB clinic should have a key to the TB laboratory so that they can do this.
Testing and results
Sputum samples are tested using sputum smear microscopy and Xpert MTB/RIF
(GeneXpert). The results should be available within 24 hours. If the result shows
Rifampicin resistance the TB clinic should be contacted immediately and the patient should
follow the MDRTB patient pathway. Further details can be found in the MDRTB Service
Guidelines.
3.3 Contact tracing
Contact tracing is extremely important in reducing onward transmission and identifying TB
suspects. Systematic contact tracing should be conducted for all pulmonary (or laryngeal)
TB patients. This is organised by the TB clinic. Please see TB contact tracing guidelines and
Swaziland National Guidelines for implementing TB intensified case finding, IPT and
infection control in health care and congregate settings for more information. Staff in
healthcare and other congregate settings (e.g. prisons) should be offered regular screening
for TB symptoms.
There are 3 levels of TB infection control in healthcare settings. These are: 1)
administrative and work practice controls, 2) environmental measures, and 3) the use of
personal protective equipment. Each of these is described below.
1. Administrative and work practice measures aim to reduce staff and patient
exposure through comprehensive policies, training and infection control plans.
12

2. Environmental measures aim to reduce the concentration of infectious particles


3. Personal protective equipment protects staff that work in high risk areas, including
the use of N95 masks.
This policy describes the administrative, environmental and personal protective measures
that should be implemented to protect staff, patients and visitors from TB.

4 Administrative and Work Practice Controls


Administrative and work practice control measures have the greatest impact on preventing
TB transmission and serve as the first line of defence within health care settings. The aim of
these measures is to:

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
13

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

Staff should be screened for TB as part of their in-service training

4.4 Separation of Infectious Patients


Outpatients suspected of having TB disease should be provided a surgical mask (if
coughing) and taken to the front of the queue for urgent review by the doctor.
After review by the doctor, the TB patient should be taken to the TB department for TB
suspect follow up as this is a well ventilated area and will minimise the potential spread
of infection.
Care should be taken when infectious cases such as TB suspects and patients are
scheduled for procedures like chest radiography. Measures e.g. triaging, should be
adhered to as much as possible to minimise risk of mycobacterium exposure to high
risk groups including immuno-suppressed persons (this applies to laboratory services
also).
Any inpatients suspected to have pulmonary TB should have their sputum tested
immediately. They should be placed near the window for good ventilation and should
spend the daylight hours outside the ward where possible. They must be educated on
cough hygiene and given a surgical mask if necessary. If confirmed they should be
moved to the TB ward.
4.5 Information for patients and visitors
Educational materials on TB prevention and cough hygiene should be available for patients
and visitors at each outpatient clinic and for visitors on the ward.
Educational posters should be visible at strategic points at Wellness Clinic, outpatient
department, beside the TB ward and in TB OPD.
The infection control lead and lead person in the TB clinic are responsible for ensuring that
posters and leaflets are restocked regularly from the NTCP and University Research
Council (URC).
4.6 Cough hygiene education
All coughing patients should be educated about cough hygiene. Cough hygiene includes the
following when sneezing, coughing or during any other forced expiration:
Turning the head to the side
Covering the nose and mouth with a tissue or surgical mask
Disposing of tissues appropriately
Regular handwashing, particularly after disposing of tissues or providing a sputum
sample
Patients should be supplied with tissues and a waste receptacle. If patients cannot or will
not use appropriate cough etiquette they should wear a surgical mask when moving about
15

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

Figure 2: Seating arrangements in naturally ventilated consultation room 3

5.2 Mechanical ventilation


Mechanical ventilation is used to remove air from buildings, particularly where natural
ventilation is difficult.
Examples include extractor fans and the use of air filters and Ultra Violet Germicidal
Irradiation (UVGI) lights.

6 Personal Protective Equipment


6.1 Patients
A surgical mask should be worn by the TB patient if moving about the hospital and the
patient does not exhibit the use of proper coughing etiquette. Surgical masks prevent the
wearer from spreading microorganisms by capturing large wet particles from the nose and
mouth. They do not provide protection to the wearer from inhaling TB-containing droplets
in the air and therefore are not recommended for staff or visitor use for TB infection
control. N95 respirators should not be given to TB patients.
6.2 Healthcare workers
Healthcare Workers and other staff should use an N95 respirator mask to protect
themselves when close to a TB suspect or TB patient. This includes staff in the TB ward, TB
clinic, OPD or other parts of the hospital, when transporting infectious cases or when
carrying out sputum inducing procedures such as gastric lavage or chest physiotherapy.
Instructions of how to store, put on, and take off the respirator are presented in Appendix
4.

7 TB Infection Control in Areas with Increased Risk


3

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

Visitors should report to the nursing station before the visit.


All visitors should be screened for TB by staff on the TB ward using the form provided.
Visitors to the TB wards should be strongly encouraged to meet the patient outside
with the patient using proper cough etiquette or wearing a surgical mask.
In rare circumstances, visitors may need to go onto the ward; this should be for a
minimum time unless they have a N95 mask. If visitors are using a N95 mask they
should be instructed on how to put on, remove and store the respirator (Appendix 4).
Children under 5 and people living with HIV should be prohibited from visiting the TB
ward.

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

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Lubombo Region Drug Resistant Tuberculosis Decentralisation Service guideline provides


more details of the decentralised service in Lubombo.
All patients with Rifampicin resistance on Xpert MTB/ Rif should be contacted immediately
and asked to attend the TB clinic accompanied by a family treatment supporter. To prevent
delays in treatment initiation this appointment may not necessarily occur on a designated
MDR-TB clinic day. If the treatment initiation is not on a designated MDR-TB day, follow
these procedures:
8.1
TB clinic
When the patient arrives they should be identified as an MDR-TB patient and be
prioritised by clinic staff before any other patients that are waiting, so that they spend
minimum time in the clinic.
If MDR-TB patients have to wait to be seen they should be provided with a waiting area
separate from other patients in the clinic and preferably outside.
As with drug susceptible TB patients MDR patients should be encouraged to wear a
surgical mask.
Staff should wear N95 masks.
8.2
X-ray department
Infection prevention and control should be as outlined as for all TB, however in addition to
this, diagnosed MDR-TB patients should be escorted to x-ray by a member of the TB clinic
team to ensure they are seen immediately. MDR-TB patients should not spend any time in
the general waiting area with other patients.
8.3
GSH outreach teams
Teams that may be likely to visit MDR-TB patients at home include the TB Clinic Home
Assessment Team, Home Based Care and Mental Health teams. It is very important that
these teams are aware of where MDR patients are so that they can take suitable
precautions. It is therefore the responsibility of the TB Team to ensure patient referrals are
given to each of the GSH outreach teams.
All staff visiting patients at home should follow infection prevention and control
procedures as outlined above, including the use of PPE and minimising the time spent
inside the patient's home or in unventilated rooms with the patient.

9 Staff TB Screening and Surveillance


Healthcare workers have a high risk of developing TB and of transmitting the infection to
vulnerable patients. In addition to adhering to the infection control measures described
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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
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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

Number and percentage of staff screened from each department


Number/percentage that screened positive
Number diagnosed with MDR-TB
Number commenced on treatment
Number commenced on IPT
Work history for previous year of those who have started treatment. This should be
a description of which areas of the hospital they have been working in and for how
long. Gathering this information may help to identify areas where infection control
could be strengthened.

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.

10 Ethical and Legal Considerations


10.1 Universal free TB services
GSH has a responsibility to provide free and universal TB diagnostic and treatment
services. This obligation is grounded in their duty to fulfil the human right to health. Not
only does TB treatment significantly improve the health condition of individuals, it also
benefits the broader community by stopping the spread of a highly infectious disease.
10.2 Informed patients
Patients need to be fully informed and counselled about testing and treatment and should
receive comprehensive information about the risks, benefits and alternatives available to
them. As with any medical treatment, the voluntary and informed decision of the patient is
necessary to start TB treatment.

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10.3 Healthcare worker protection


Health care workers have obligations to provide care, but also a right to adequate
protection. The hospital has a duty to protect its staff from infection and must provide a
safe working environment and adequate personal protective equipment. Also, health-care
workers who are at heightened risk of contracting TB themselves, such as those who are
HIV positive, should be accommodated by the hospital to work away from highly infectious
areas.
10.4 Involuntary isolation
Involuntary isolation is rarely justified and should be a very last resort. TB treatment
should be provided on a voluntary basis. If a patient refuses treatment, this is likely to be
due to insufficient counselling or lack of treatment support. In very rare cases, where all
efforts to engage a patient to adhere treatment fail, the rights of other members of the
community might justify efforts to isolate the contagious patient involuntarily. It is
essential that the manner in which a patient is involuntarily isolated complies with ethical
and human rights principles and in accordance with the law. In these cases, the regional
social worker, police and community leaders should be engaged to facilitate isolation in a
sensitive manner.

11 Monitoring and Policy Review


The responsibility for monitoring TB infection control is with the infection prevention and
control team with the support of the TB Team. The infection prevention and control team
will report to the infection prevention and control committee quarterly on the
administrative, environmental and PPE controls described here.
In addition, the Infection Control Team should include TB infection as a separate section in
their annual report to the SMT. Indicators for TB infection control are included in Appendix
2.
This policy should be reviewed by the Infection Control Committee in November 2015.

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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.

Screening Tool for Children


The following are questions which have been derived from the Tuberculosis Screening
Questionnaire for Children. For the full screening tool, please refer to the National
Screening Tool for Children.
1. I s there a history of TB contact? (Y/N)
2. Has the child had a cough for two weeks or more? (Y/N)
3. Has the child had night sweats for 2 or more weeks? (Y/N)
4. Has the child lost noticeable weight in the last 4 weeks? (Y/N)
5. Has the child had a fever for 2 or more weeks? (Y/N
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.

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Appendix 2: TB Infection Control Quarterly Reporting Tool


This reporting tool should be completed by the lead person for TB infection control in each
area and collated by the infection control lead nurse. Please complete all fields that are
relevant, marking those that are not with N/A. The results should be reported at infection
prevention and control meetings once every quarter and a copy should be given to the SMT.
DATE:
DEPARTMENT
NAME OF PERSON CONDUCTING ASSESSMENT
TB Screening Checks
Indicator

Total number

Percentage

Number of patients screened for TB

Number screened/total
outpatients appointments x 100

Number of TB contacts screened

n/a

Number of visitors to the TB ward


who were screened4
Number of staff screened for TB

n/a

Number of staff who screened


positive for TB

Number screening positive/


number screened x 100

Number screened/total number


of staff x100

Number of cases of TB diagnosed in


staff
PPE Checks
Indicator

Total
Number

Percentage

Staff who have been fit tested for an N95


mask
Staff who have an N95 mask

Number fit tested/Staff


who have a mask x100

Visitors to the TB ward who are not already on TB treatment should be screened at regular intervals.

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Are N95 masks are being stored correctly (in


a cool dry place and not in a plastic bag)?

Yes / No / Not Applicable.

Are surgical masks for patients and suspects


are available and in use

Yes / No / Not Applicable.

Comments:

Comments:

Environmental checks
Are all windows and doors open?

Yes / No / Not Applicable.


Comments:

Is furniture in consultation rooms set up


correctly? (see diagram in infection control
policy)

Yes / No / Not Applicable.

Are fans in place and working?

Yes / No / Not Applicable.

Comments:

Comments:

General comments (please highlight any areas for improvement or training needs)

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Appendix 3: Measuring and Maximising Natural ventilation5


A. Checking natural ventilation
People can usually feel the existence or lack of air movement in a space. A ventilated space
has a slight draft. In the absence of ventilation, air will feel stuffy and stale and odours will
linger. Use the following checklist to assess natural ventilation in your waiting areas and
examination rooms. Check air mixing and determine directional air movement in all parts
of rooms or areas. One way to visualise air movement is to use incense sticks as described
in these 4 steps.
1. Hold two incense sticks together and light them.
2. As soon as the incense starts to burn, blow out the flame. Now the incense should
produce a continuous stream of smoke.
3. Observe the direction of the smoke.
4. Observe how quickly the smoke dissipates. This is a subjective test that may require
some practice it does not give a definite result but is useful for comparing one room
or area to another.
Alternatively refer to USAID & CDC Implementing the WHO Policy on TB Infection Control
in Health-Care Facilities, Congregate Settings and Households for more quantifiable
methods.
B. Controlled natural ventilation
Natural ventilation refers to fresh dilution of air that enters and leaves a room or other area
through openings such as windows or doors. Natural ventilation is controlled when
openings are deliberately secured open to maintain air flow. Unrestricted openings (that
cannot be closed) on opposite sides of a room provide the most effective natural
ventilation.
C. Propeller fans
Propeller fans may be an inexpensive way to increase the effectiveness of natural
ventilation, by increasing the mixing of airborne TB as well as assisting in the direction of
air movement by pushing or pulling of the air.
Types of propeller fans
Ceiling fans
Small fans that sit on a desk or other surface

WHO. Guidelines for Infection of TB including MDR TB and XDR TB. Malawi July 2008.

27

Fans that stand on the floor


Fans mounted in a window opening
Air mixing and removal
A propeller fan helps mix air in a room. Mixing of air will reduce pockets of high
concentrations, such as in the corners of a room or in the vicinity of patients where natural
ventilation alone is not enough. The total number of infectious particles in the room will
not change with mixing; however, the concentration of particles near the source will be
reduced, and the concentration in other parts of the room may increase. If this dilution
effect is combined with a way to replace room air with fresh air, such as by opening
windows and doors, the result will be fewer infectious particles in the room. A room with
an open window, open door, and a fan will have less risk than an enclosed room with no
fan, an enclosed room with a fan, or a room with an open window but no fan. In addition,
mixing may increase the effectiveness of other environmental controls.
Directional airflow
If placed in or near a wall opening, propeller fans can also be used to enhance air
movement into and out of a room. Consider fans installed in the windows or through wall
openings on the back wall of a building. The fans exhaust air outside, away from people or
areas where air may come back into the building. If doors and windows in the front of the
building are kept open, the overall effect should be to draw in fresh air through the front of
the building and exhaust air through the rear. Health care staff should be mindful of the
direction of airflow to ensure the patient is closest to the exhaust fans and the staff is
closest to the clean air source. With this arrangement, the risk that TB will be spread is
greater near the back of the building; however, once the contaminated air is exhausted,
dilution into the environment will be fast.
D. Exhaust fans
There are a wide variety of exhaust fan systems. A system can be as simple as a propeller
fan installed in the wall, or it could include a ceiling grille, a fan, and a duct leading to
discharge on an outside wall or on the roof. Over time, dust and lint accumulate on exhaust
fan blades. The fans, motors, blades, and ducts become dirty and less air is exhausted. For
this reason, these systems should be cleaned regularly.

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Appendix 4: Putting on and storing a N95 Respirator


A. Putting on a N95 Respirator

Wash hands with soap and dry hands.


Place the date and your name on the respirator as the respirator should not be worn by
others and used only for a month.
Hold the respirator in front of your face and place the lower elastic band around the
lower part of your head or upper neck.
Place the upper elastic band so that the respirator fits snugly. The elastic band should
be fairly horizontal for a tight fit.
Bend the flexible nose piece. N95 Respirators need to fit snugly to be effective and
should not be worn with beards or unshaven faces.
If glasses are worn fit the upper edge of the respirator under the glasses to prevent
fogging of glasses and a snugger fit.
Gently shape the respirator to your face but do not crush it.
Wash hands with soap.

B. Removing and storing a N95 Respirator

Wash hands with soap and dry hands.


Remove the respirator by the elastic bands and minimise contact with the face
respirator itself. Do not crush the face respirator.
Store in a cool dry location and not in a plastic bag (collects humidity). For example
hanging on a wall to avoid contamination . Discard the respirator as infectious waste
after wearing for a month.
Wash hands with soap.

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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

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