Module 12: Infection Control in
Health Care Settings
*Image courtesy of: World Lung Foundation
It may seem a strange principle
to enunciate as the very first requirement
of a hospital
that it do the sick no harm
Florence Nightingale, Notes on Hospitals, 1863
Infection Control in the ERA of HIV
More PLWAs are attending health care and community facilities
VCTs
Primary care and ART clinics (IDCCs)
Patients and HCWs who are immunosuppressed may be
vulnerable to TB as a result of exposure
Some settings may have higher prevalence of TB/HIV, both
known and undiagnosed
jails/prisons
mines
Why TB is a Problem
in Healthcare Settings
Persons with undiagnosed, untreated and
potentially contagious TB are seen in health care
facilities
30-40% of PLWAs will develop TB in the absence of
IPT or ART
PLWAs can rapidly progress to active TB and may
become reinfected
HIV-infected HCWs are particularly vulnerable due
to occupational exposure
What is Infection Control?
Patient to Worker to
Worker Worker
Visitor Visitor
Patient Patient
Visitor to
Worker
Visitor
Patient
Infectiousness
Patients should be considered infectious if they
Are coughing
Are undergoing cough-inducing or aerosol-generating
procedures, or
Have sputum smears positive for acid-fast bacilli and they
Are not receiving therapy
Have just started therapy, or
Have poor clinical response to therapy
Infectiousness (cont.)
Patients no longer infectious if they meet all of these criteria:
Have completed at least two weeks of directly-observed ATT;
and
Have had a significant clinical response to therapy and
Have had 3 consecutive negative sputum-smear results;
Retreatment /MDR cases may take longer to convert
The only objective criteria is negative bacteriology
Fate of Droplets
Organisms Liberated
Talking 0-200
Coughing 0-3500
Sneezing 4500-1,000,000
Droplets can remain
suspended in the air for
hours.
Hierarchy of Infection Control
Administrative controls to reduce risk of
exposure, infection and disease thru policy and
practice;
Environmental (engineering) controls to reduce
concentration of infectious bacilli in air in areas
where air contamination is likely; and
Personal respiratory protection to protect
personnel who must work in environs with
contaminated air.
Hierarchy of Infection Controls
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Administrative Controls
Prevent droplet nuclei containing M. tuberculosis from
being generated;
Prevent TB exposure to HCWs, other patients and
visitors;
Implement rapid diagnostic evaluation and treatment
for TB suspects
Specific Administrative Controls
Reduce risk of exposing uninfected persons to infectious disease:
Develop and implement written policies and protocols to ensure
- Rapid identification of TB cases
- Isolation
- Diagnostic evaluation
- Treatment
Implement effective work practices among HCWs
Educate, train, and counsel HCWs about TB
Administrative Controls (cont.)
Perform risk assessment and
classification of facility based
on:
Profile of TB in community
Number of infectious TB
patients admitted
Engineering Controls
To prevent spread and reduce concentration of
infectious droplet nuclei
In clinics
Maximize airflow in outpatient clinics settings by
opening doors and windows, using fans
In hospitals
Use ventilation systems in TB isolation rooms
Use HEPA filtration and ultraviolet irradiation with
other infection control measures
What is Ventilation?
The movement of air
Pushing or pulling of vapor or
particles
Preferably in a controlled manner
Ventilation Control
Types of ventilation
natural
local
general
Simple Measures Can Be Effective!
Personal Respiratory Protection
Respirators can protect health care workers;
Respirators may be unavailable in low-resource
settings;
Face/surgical masks act as a barrier to prevent
infectious patients from expelling droplets
Face/surgical masks do not protect against
inhalation of microscopic TB particles
Masks and Respirators
Respirators rely on an
airtight seal and have tiny
pores which block droplet respirators
nuclei
Masks have large pores and
do not have an airtight seal
to around the edge,
permitting inflow of droplet
nuclei
Face/surgical mask
Personal Respiratory Protection
Use of respirators should be encouraged in high risk
settings:
Rooms where cough-inducing procedures are
done (i.e., bronchoscopy suites)
TB isolation rooms
Referral centers or homes of infectious TB
patients
CDC/NIOSH-certfied N95 (or greater) respirator
should be used
N95 Respirator Dos and Donts
*Image courtesy of: CDC Image Library
Do
Be sure your respirator
is properly fitted!
[Should fit snugly at
nose and chin]
*Image courtesy of: CDC Image Library
Note poor fit at the bridge
of nose
Note poor fit at the chin-
Respirator should cover
chin and create a seal
Dont forget to WEAR it!
*Image courtesy of: CDC Image Library
Efficacy
Respiratory protection is effective only if:
The correct respirator is used,
It's available when you need it,
You know when and how to put it on and take it off,
and
You have stored it and kept it in working order in
accordance with the manufacturer's instructions
http://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respfact.html
Summary: Infection Control for TB
To reduce risk of TB to HIV positive patients and health workers,
you can:
Develop IC plan and identify responsible health workers
Train staff on TB and TB infection control
Screen HIV positive clients for TB symptoms and refer
promptly
Provide separate waiting areas and expedited care for TB
suspects
Use personal respiratory protection when indicated
Use simple environmental control measures, like opening
windows, turning on fans, etc.
Cough Etiquette
Common-sense Prevention
*Image courtesy of: World Lung Foundation
Infection Control (IC) for TB
To reduce risk of TB to HIV positive patients and health
workers, you can:
Screen HIV positive clients for TB symptoms and refer
promptly
Provide separate waiting areas and expedited care for
TB suspects
Provide surgical masks or tissues to TB suspects
Use simple environmental control measures, like
opening windows, turning on fans, etc.
Screen health workers periodically for TB symptoms
5-Steps to Prevent TB Transmission
1 SCREEN Early recognition of subjects with
suspected or confirmed TB
2 EDUCATE Instruct patients on cough hygiene when
sneezing or coughing; provide tissues or
mask
3 SEPARATE Request patients to wait in a separate and
well-ventilated area
4 PROVIDE HIV Triage symptomatic patients to front of line
SERVICES for services sought, so they spend minimal
time around other patients
5 INVESTIGATE TB diagnostics (sputum smear) should be
FOR TB completed ASAP
Infection Control (IC) for TB
Risks to Patients and Health Care Workers Alike!
Patient to patient
Patient to providers
Nurses, doctors, pharmacists, FWEs
Provider to patients
Reduce TB transmission in health care settings
Devise an Infection Control Plan with your clinics
Teach your colleagues to protect themselves
References
Core Curriculum on Tuberculosis, What the Clinician Should Know. Fourth Edition,
2000. US Dept. of Health and Human Services, Centers for Disease Control and
Prevention.
hhttp://www.cdc.gov/nchstp/tb/pubs/corecurr/Chapter1/Chapter_1_Introduction.htm
hhttp://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respfact.html
Guidelines for Prevention of TB in Healthcare Facilities in Resource-Limited Settings.
World Health Organization, 99.269.
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