PREVENTION

Principles of TB control
 Prevention by BCG vaccine
 Case finding
 Proper treatment to cut off chain of
transmission
 Treatment of latent infection
 Health education and public relation
 Prevention of tuberculosis
 Economic development: better nutrition & housing
 Universal health coverage & social protection
 TB care widely accessible to all and of high-
standards
 Focused, high-intensity interventions, including BCG
in children
 Screening of high-risk groups and mass TLTBI
 Infection control practices
BCG vaccination
 Vaccine BCG

 BACILLUS CALMETTE GUERIN

 Lived attenuated vaccine
 Efficacy to prevent pulmonary TB 0-
80% (overall protection 50%)
 Disseminated TB 78%
 TB meningitis 64%
 Vaccine BCG
 Vaccine finally first used in July 1921, providing
mainly children with protection
 Derivative of virulent Mycobacterium bovis
 1/10000 of 1 mg of M. bovis killed a 400g guinea pig
 With a protective waxy coating and resistant to
many physical and chemical agents, the slow-
growing deadly strain was tamed by Calmette
and Guérin in Lille, France
 Used transplantation every 3 weeks in potato-beef
bile medium
 Vaccine BCG
 BCG vaccine consists of live bovine tubercle
bacilli whose virulence has been attenuated by
multiple passages through glycerinated potato
 The bacilli of the vaccine are therefore alive, but
have lost some of their virulence
 When these bacilli are injected into the body the
development of protective immunity is
stimulated, and the person’s means of defence
is increased without causing disease
 Vaccine BCG
 Will be applied to
every newborn,
normally on the
second, third or
fourth day
 How do you vaccinate?
 the skin must be disinfected on the front of the
left upper arm in deltoid region
 the dose is drawn into the syringe - 0.05ml for
newborns and children aged up to one year
 the injection must be given intradermally
 if the injection is done subcutaneously local
complications can developed
 injection of the dose should raise a wheal, and
the skin takes on an “orange peel” aspect
 after injection, the arm should be wiped and left
open to the air for several minutes
How do you vaccinate?
 How does the normal reaction
of vaccination develops?
 The weal from the vaccination disappears within half an
hour
 After 3 or 4 weeks, a small red induration appears which
swells to 6–8mm in diameter and can persist for one or
two months
 it may ulcerate and ooze serous fluid
 This stops after 2 to 8 weeks, a scab forms and later a
scar develops which is round, lightly depressed, and
approximately half a centimeter in diameter (5 -10 mm)
 The child’s parents and the health personnel should be
informed that this process of scar formation is normal, and
that the vaccination site should not be cleaned with any
product
 Contraindications
to BCG Vaccination
 Inherited disorders of immunity (e.g.
congenital alymphocytic
agammaglobulinaemia, thymic hypoplasia
etc.)
 Children during lymphocyte-depressing viral
infections (e.g. measles or rubella). They can,
however, be vaccinated after the acute
infection is over
 Immunosuppressed children, except
asymptomatic HIV+ children
 Dermatitis in the deltoid region
BCG complications
 Possible factors affecting
the rate of adverse reactions
 theBCG dose
 vaccine strain
 method of vaccine administration
 Errors made by a new member
of the health staff
 who has not been adequately trained
 who makes injections that are too deep
 who gives newborns 0.1ml instead of
0.05ml
 or who prepares the vaccine incorrectly
before injection (insufficient volume of
solvent, solution insufficiently mixed)
 Mild adverse events
 Swelling of the ipsilateral regional lymph nodes (usually
axillary but may also be cervical and/or supra-clavicular)
may also occur
 However, the lymph nodes remain small (< 1.5cm) and
do not adhere to overlying skin
 Mild local reactions occur despite correct intradermal
administration and the extent of the reaction will depend
on a number of factors including:
 the strain used in the vaccine
 number of viable bacilli in the batch, and
 variation in injection technique.
 No treatment is required for mild injection site reactions
with or without mild regional lymphadenopathy.
 Severe adverse events
 Local adverse events
 Injection site reactions. Reactions which have been reported
include local sub-cutaneous abscess and keloids (thickened scar
tissue)
 Skin lesions distinct from the vaccination site. Tuberculosis
infection can cause a number of cutaneous lesions (such as TB
chancre, lupus vulgaris, scrofuloderma, papulonecrotic tuberculids
etc).
 Lymphadenitis. When severe, this includes nodes which become
adherent to overlying skin with or without suppuration.
 Systemic adverse events
 Osteitis and Osteomyelitis
 Disseminated BCG disease or systemic BCG-itis
 Immune reconstitution inflammatory syndrome (IRIS)
 Other rare events. A number of events have been reported as case
reports or series. These include sarcoidosis, ocular lesions
(conjunctivitis, choroiditis, optic neuritis), and erythema nodosum.
Tuberculous meningitis (due to the BCG) has been described but is
exceptionally rare
 BCG: complications
 Local ulcers and
regional
lymphadenitis in
normal hosts
 Osteomyelitis
 Disseminated BCG
infection
 Keloid scar formation
 Death: 0.02 per million
 Subcutaneous abscesses

 Subcutaneous or subepidermal collections of

pus may form around the vaccinal ulcer and
empty intermittently through a tiny central
opening
 This complication is rare and is usually due to
too deep an injection or the percutaneous
vaccine being wrongly given intradermally
 Scar formation may be delayed but invariably
takes place within six months
 Extensive ulceration

 An ulcer over 10mm formed at the

vaccinal site, may be considered unduly
extensive
 Healing is often also delayed
 This complication is usually due to the
inoculation of an excessive amount of
vaccine
Local ulcers
Local ulcers
Local ulcers
 Lymphadenitis
 Lymphadenitis is the most frequent, and the only
common complication of BCG vaccination. It
may occur with either the intradermal or
percutaneous technique
 The lymph node involved is usually the one
draining the site of penetration of the vaccine
 Occasionally more than one lymph node in the
same region is involved
 With vaccination given in the lower deltoid
region, lymphadenitis occurs in the axillary
group, but if vaccination is inadvertently given
higher up — near the shoulder — the
supraclavicular group will be involved
 Lymphadenitis

 Clinically evident lymphadenitis usually

develops two to four months after
vaccination, when the local lesion may
have completely cleared up
 Some cases may occur much later,
sometimes up to a year after vaccination
 This complication occurs more frequently
in vaccinated infants than in school
children
Regional lymphadenitis
 Lymphadenitis
 The recommendations for management of BCG
adenitis are variable (i.e., the recommended
management ranges from no treatment to
treatments such as surgical drainage,
administration of anti-TB drugs, or a combination
of drugs and surgery)
 For adherent or fistulated lymph nodes, the
World Health Organization (WHO) suggests
drainage and direct instillation of an anti-TB drug
into the lesion
 Nonadherent lesions will heal spontaneously
without treatment
 Osteomyelitis
 This is a rare and severe complication of BCG
vaccination which has primarily been reported in
Scandinavia and Eastern Europe and typically
associated with changes in BCG vaccine strain
 BCG osteitis affecting the epiphyses of the long
bones, particularly the epiphyses of the leg, can
occur from 4 months to 2 years after vaccination
 The skeletal lesions can be treated effectively
with anti-TB medications, although surgery also
has been necessary in some cases
Osteomyelitis
 Disseminated BCG disease
or systemic BCG-itis
 This recognized but rare consequence of BCG vaccination
traditionally has been seen in individuals with severe cellular
immune deficiencies
 The risk (fatal and non-fatal) is thought to be between 1.56 and 4.29
cases per million doses (Lotte et al., 1988)
 This is based on pre-HIV data
 However, the exact incidence is debated because few centers are
able to differentiate Mycobacterium bovis BCG from other forms of
Mycobacterium in patients presenting with disseminated disease
 In a recent retrospective case series review of Mycobacteriunm
tuberculosis complex 5% of cases were found to have the M. bovis
BCG strain (Hesseling et al., 2006)
 Additional data from studies in South Africa confirm the significantly
high risk of disseminated BCG (dBCG) disease in HIV-positive
infants, with rates approaching 1% (Hesseling et al., 2009).
Immune reconstitution inflammatory
syndrome (IRIS)
 This has recently been identified as a BCG vaccine-
related adverse event in immunocompromised
individuals due to HIV started on antiretroviral therapy
(ART) (DeSimone et al., 2000)
 It usually presents within 3 months of immune restoration
and manifests as local abscesses or regional
lymphadenitis usually without dissemination
 No fatal cases have yet been documented
 The etiology is unknown but postulated to be a
deregulated inflammatory reaction directed against
opportunistic pathogens including mycobacterial
organisms following immune reconstitution
 Conclusions
1. The protective efficacy is uncertain and unpredictable (varied
from 0 to 80%)
2. Protective effect against meningeal TB of 64% and against
disseminated TB of 78%
3. Skin test reactivity resulting from vaccination does not
correlate with protection against tuberculosis
4. BCG should not be given to infants with active HIV disease; it
is contraindicated in older asymptomatic children who are
found to be HIV positive
5. It may protect the immunized individuals; it will not affect the
spread of the disease and thus can do little ultimately to
control TB
Guidance on BCG Immunisation

 WHC 2005 (062): Changes to BCG

Immunisation Programme, 8th July, 2005
 WHC 2005 (077): Guidance on changes to the
BCG vaccination programme, 6th September,
2005
 Information sheet observed rate of vaccine
reactions bacille Calmette-Guerin (BCG)
vaccine. WHO, April 2012
 Definitions of contact
 Index case (index patient) - the initially identified case of new
or recurrent TB in a person of any age in a specific household or
other comparable setting in which others may have been
exposed. An index case is the case around which a contact
investigation is centered.
 Contact - any person who has been exposed to an index case:
 Household contact - a person who shared the same enclosed
living space for one or more nights or for frequent or extended
periods during the day with the index case during the 3 months
before commencement of the current treatment episode
 Close contact - a person who is not in the household but
shared an enclosed space, such as a social gathering,
workplace or facility, for extended periods during the day with
the index case during the 3 months before commencement of
the current treatment episode
 Contact investigation
 - a systematic process intended to identify
previously undiagnosed cases of TB among the
contacts of an index case
 In some settings, the goal also includes testing
for LTBI to identify possible candidates for
preventive treatment
 Contact investigation consists of two
components:
 identification and prioritization, and
 clinical evaluation
 Contact identification
and prioritization
 A systematic process to identify contacts with or
at increased risk for development of TB
 The definition of contact identification and
prioritization includes an interview with the index
case to obtain the names and ages of contacts
and an assessment of contacts’ risk for having
(generally based on the presence of symptoms
compatible with TB) or developing TB, to
determine those for whom clinical evaluation is
indicated
 Interview with the index case
 Additional information to be obtained from index patients
should include a description of their residence and, when
relevant, of other sites in which transmission might have
occurred
 Information that is essential for determining the potential
risk posed by the index case includes:
 the results of sputum smears or other microbiological
evaluations
 radiographic features of the disease (if available)
 the severity, type and duration of symptoms (especially
cough)
 the presence of risk factors for drug resistance
 known or presumed HIV infection; and
 the setting in which exposure occurred
 Priority should be given to
 people of all ages with symptoms suggestive of TB
 children < 5 years of age (the rationale for
assigning high priority to contacts of index cases <
5 years of age is to find the source of the infection,
not to find secondary cases from the child)
 people with known or suspected
immunocompromising conditions (especially
PLHIV) and
 contacts of index cases with MDR-TB or XDR-TB
(proven or suspected)
 Contact clinical evaluation
 - a systematic process for the diagnosis or exclusion of active TB
among contacts
 Clinical evaluation is undertaken if the results of contact
identification and prioritization indicate a risk for having or
developing TB
 The definition of contact clinical evaluation includes, at a minimum,
a more extensive assessment of symptoms compatible with TB
 Additional components may include:
 a more detailed medical history
 a physical examination
 microbiological assessment of specimens from sites of suspected
involvement
 radiographic examinations
 invasive diagnostic tests
 Timing of interviews and
identification of contacts
 If contact investigation is to be initiated, the index case should be
interviewed as soon as possible after diagnosis (generally within 1
week) to elicit the names of household and close contacts
 The focus should be on household members, but people in the
workplace and other settings in which there is exposure should not
be ignored
 Moreover, contacts in residential care facilities, long-term care
facilities, gaols and prisons and acute medical care facilities,
especially when exposure is by coughing, should be evaluated
 Ideally, the interview should be conducted by a person who speaks
the same language as the index patient and is familiar with his or
her social and cultural context
 Investigations should be conducted for patients who have died, if
information can be gathered from family members
 A sense of urgency should be conveyed in contact investigations,
including prompt interviewing of the index case
 Occasionally, a second interview is useful to elicit additional
contacts
Infection Control
… A need for infection control
 What is Infection Control?

Worker to
Patient 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
Patients no longer considered infectious if they
meet all of these criteria:
Are on adequate therapy
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
 Infection Control Measures

 Management / Administrative
Controls
 Engineering Controls
 Personal Respiratory
Protection
 Methods of Infection Control

 Patient Management & Administrative controls to

reduce risk of exposure, infection, and disease
through policy and practice
(applicable to HCWs, Patients, visitors & health
facility)
 Environmental controls to reduce concentration of
infectious bacteria in on surfaces, in the air, in
specimens, and in equipment
(applicable to HCWs, Patients, visitors & health
facility)
 Respiratory protection to protect personnel who must
work in environments with droplets (large and small)
(applicable to HCWs, Patients & visitors)
 Administrative Controls
 Infection control plan
 Administrative support for procedures in
the plan, including quality assurance
 Training of staff
 Education of patients and increasing
community awareness
 Coordination and communication with the
TB program
 Administrative Controls

 Afterdiagnostic evaluation, patients

for whom TB has been confirmed or
is suspected should start appropriate
therapy at once
 Administrative Controls
 Patients should be educated about the
transmission of TB, the reasons for TB isolation,
and the importance of staying in their rooms
 Every effort should be made to help the patient
follow the isolation policy - including the use of
incentives, such as providing telephones or
televisions or allowing special dietary requests
 As few persons as possible should enter the TB
isolation room, and anyone entering the room
should wear respiratory protection
 Administrative Controls

 In addition, all health care workers should

be educated about the basic concepts of
TB transmission and pathogenesis,
infection control practices, the signs and
symptoms of TB, and the importance of
participating in the employee skin testing
program
 Environmental Controls
 Control source of infection

 Dilute and remove contaminated air

 Control airflow
 Keep infectious air moving outside
 Keep HCWs ‘upwind’, infectious patients
‘downwind’
 Engineering Controls
 For preventing spread and reducing
concentration of infectious droplet nuclei
through:
 use of ventilation systems in TB isolation
rooms
 use of HEPA filtration
 ultraviolet irradiation with other infection
control measures
 Engineering Controls
 In isolation rooms, ventilation systems are
necessary to maintain negative pressure and to
exhaust the air properly
 Isolation rooms should be monitored daily when in
use to ensure the negative pressure maintained
 Isolation room doors should be kept closed,
except when patients or personnel must enter or
exit the room, in order to maintain negative
pressure
 Ventilation systems can also be designed to
minimize the spread of TB in other areas of the
health care facility
 What is ventilation?

 Movement of air

 “Pushing” and/or “pulling” of particles and

vapors

 Preferably in a controlled manner

56
 Ventilation control
 Types of ventilation

 Natural

 Local

 General

57
Local exhaust ventilation

 Source capture
Uganda
 Exterior hoods

 Enclosing hoods
 Natural vs Mechanical Ventilation
 Good natural ventilation is better than bad
mechanical ventilation

 Major limitation of natural ventilation is that it depends

upon outdoor weather conditions

 Can control odor and improve comfort of occupants , but

not if very cold or very hot

 Usually we do not have a choice and must work with

where we are!
 HEPA filtration
Must be used
 When discharging air from local exhaust
ventilation booths or enclosures directly
into the surrounding room, and

 When discharging air from an AII room

into the general ventilation system

60
 HEPA filtration
 HEPA filters can be used in ventilation
systems to remove droplet nuclei from the
air
 These filters can be installed in ventilation
ducts to filter air for recirculation into the
same room or recirculation to other areas
of a facility
 All HEPA filters must be carefully installed
and maintained to ensure adequate
function
Room Air Cleaners

62
TB Outpatient unit – Helio Fraga Institute, MoH, Rio de Janeiro
63
 Ultraviolet Germicidal Irradition
(UVGI)
 Used as supplement or back-up to dilution
ventilation

 Does NOT provide negative pressure

 Requires maintenance, esp. cleaning bulbs

 Not effective at high humidity (>70%)

 Occupational exposure limits: eye & skin

64
 Ultraviolet Germicidal Irradition
(UVGI)
 UVGI, or ultraviolet lighting, may kill M.
tuberculosis contained in droplet nuclei
 Because exposure to ultraviolet light can
be harmful to the skin and eyes, the lamps
must be installed in the upper part of
rooms or corridors or placed in exhaust
vents
 The effectiveness of UVGI in preventing
the transmission of TB is not known
 Ultraviolet Germicidal Irradition
(UVGI)
Ultraviolet irradiation kills
M. tuberculosis in 5 min

 UV lamps open
 UV lamps closed
Open UV lamps
Open UV lamps
Closed UV lamp screened
Closed UV lamps
71
Xu P et al. Atmospheric Environment 2003; 37:405
- Escombe AR et al. Plos Med 2009 (March) ; 6
 Environmental Controls:
Which one and When?
 Dilution ventilation, UVGI, and HEPA filter units are all
effective under IDEAL laboratory conditions
 Best data in field support dilution ventilation
 Advantage of ventilation is usually ‘always on’,
minimizing human errors.
 Disadvantages of UVGI and HEPAs
 Maintenance (increased human errors)
 Large variability of effectiveness
 May cause false sense of reassurance
 Summary – TBIC Engineering Controls

 First priority is ADMINISTRATIVE controls,

but EC are complementary
 Dilution ventilation is most important for all
 Can add to comfort
 But limited by technology, comfort, expense
 Negative pressure or directional airflow can
keep infected air away (even if diluted) from
HCWs
 UVGI and filtration devices are adjuncts for
high risk areas
 Back-up when not possible to ventilate well
 Personal Respiratory Protection
 Respirators can protect health care workers

• 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 Respirators
droplet 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
Personal Respiratory
Protection
N95 Respirator Dos and Don’ts

*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
Don’t 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
Thank you
 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 Triage symptomatic patients to front of
HIV line for services sought, so they spend
minimal time around other patients
SERVICES
5 INVESTIGAT TB diagnostics (sputum smear) should
E FOR TB be completed ASAP
NATIONAL TUBERCULOSIS
PROGRAMME PRINCIPLES
 What are the specific objectives
of tuberculosis control?
 To cure 85% of smear-positive cases
diagnosed
 To diagnose at least 70% of cases in the
community
How to structure the services

 The peripheral level:

the basic management unit (district)
 The intermediate level
 The central level
 The peripheral level:
the basic management unit (district)
 The basic management unit (district) is the
geographical, demographic, administrative
and technical entity that enables the health
authorities to organize and sustain primary
health care and anti-tuberculosis activities.
 The peripheral level:
the basic management unit (district)
 At the district level the principal antituberculosis
activities performed on a permanent basis are
targeted at identifying tuberculosis patients,
particularly the sources of infection, and
providing treatment
 The application of BCG vaccination is organized
by the teams responsible for the Expanded
Programme on Immunization
 The intermediate level
 The intermediate level is a geographical
entity that covers 8 to 10 basic units
 The clinician responsible for tuberculosis
control at the intermediate level is the
point of reference for the basic
management units
 The regional hospital can generally
perform X-rays, microscopy and
sometimes culture
 The clinician responsible for the NTP
at intermediate level
 Coordination and supervision of the tuberculosis control
activities of the basic management units, liaison with the
central level, evaluation at intermediate level, training or
retraining of health staff in coordination with the central
level
 Development of an intermediate level laboratory which
must be able to provide training and quality control for
the microscopists within the region as soon as possible,
in coordination with the reference laboratory
 Coordination with the other national programmes,
particularly those dealing with leprosy, acute respiratory
infection and AIDS
 The central level
 At the central level, a number of structures
are involved in the programme:
 The central unit, which is attached to the
Ministry of Health, is directed by the
manager of the programme and plans the
activities and budget of the programme at
the national level
 The central level
 It is responsible for ensuring the delivery of
supplies of medications and laboratory reagents
to the basic management units, receiving and
collating their quarterly reports, coordinating the
tuberculosis control activities, training and
supervision, and evaluating the programme’s
activities at national level
 It provides the basic management units with
technical support, and carries out operational
research with the aim of enhancing the
programme’s performance.
 The university hospitals

 see patients referred by the intermediate

level
 The specialists who practice here help to
develop and apply the technical guidelines
of the NTP and participate in the tasks of
training and supervising health personnel
?