Elma de Vries Discussion: • Have you thought about the occupational risk of getting Drug Resistant TB as a health worker? • How do you feel about it? • More scary than risk of getting HIV from a needlestick injury? • What else can one get from a needlestick injury apart from HIV? • Have you all had your Hep B boosters?
Risk of getting HIV from a needlestick injury is
0.3%, and that is reduced by 81% if you take AZT – now we take triple therapy, so risk very low. How do most health workers get HIV? • Have you all had your Hep B boosters?
Risk of getting HIV from a needlestick injury is
0.3%, and that is reduced by 81% if you take AZT – now we take triple therapy, so risk very low. How do most health workers get HIV? Like anyone else – through sex! • It is estimated that Health workers have 10x the risk of getting TB compared to the general population.
• Which one are we more at risk for (drug
sensitive TB or drug resistant TB)?
• Is your chance of getting DR TB bigger if
exposed than getting drug sensitive TB? • It is estimated that Health workers have 10x the risk of getting TB compared to the general population. • Which one are we more at risk for (drug sensitive TB or drug resistant TB)? • There is much more drug sensitive TB around, so bigger chance of getting it. • Is your chance of getting DR TB bigger if exposed than that of getting drug sensitive TB? • Same organism, just different resistance pattern to antibiotics, so same risk if exposed. History of TB • A hundred years ago, 20% of the population in some parts of Europe died of TB, including well known figures like the composer Chopin.
• What is the natural history of TB without
medication? • What is the natural history of TB without medication?
• 25% will cure even without medication
• 25% will die • 50% will develop chronic lung disease and die later DRTB • Drug resistant TB is simply TB that needs to be treated with different drugs, for longer. • It has been shown in Peru to be curable, but need scale up of the TB program, and patient support. Can do home based care as part of TB program. • We need to take precautions for transmission for all TB, not only when we suspect DRTB. DRTB Definitions • MDR: resistant to Rifampicin and INH • Mono resistance: resistant to only Rif or INH • Poly resistance: resistance to other 1st line drugs (not Rif/INH) • XDR: resistant to Rif and INH and an injectable and a quinolone Epidemiology • World wide the countries with the biggest burden of DRTB are China, India and the Russian Federation (62% of cases world wide in 2004) • Because such a high TB burden in Africa, even though lower MDR incidence per population, Africa has the same burden as Russia! • Around 425 000 cases annually - not lucrative to develop new drugs for a disease that only affects half a million people a year… Distribution of MDR in previously treated TB cases (WHO 2006) What is the MDR prevalence in SA? • For first time TB?
• For retreatment TB cases?
Prevalence in SA First treatment Re-treatment SA 2001 1.6% MDR 6.6% MDR Khayelitsha 2009 5.2% Rif resistant 11.1% Rif resistant Mozambique 3.5% MDR 11.2% MDR Swaziland 7.7% MDR 33.4% MDR
• Of MDR patients in SA, around 5-8% are XDR
• Around 9000 new cases of MDR in SA in 2009 (Western Cape >2000) • Around 600 new cases of XDR in SA in 2009 What is TB infection control? • TB infection control is prevention of transmission • TB is an airborne infectious disease • How can we prevent TB transmission? Hierarchy of infection control measures • Administrative controls to reduce risk of exposure, infection, and disease through policy and work practice
• Environmental controls to reduce concentration
of infectious bacteria in the air
• Respiratory protection to protect personnel who
must work in environments with droplets (large and small) (at the bottom of the hierarchy) 1. Administrative controls • Prevention of droplet nuclei containing M.tuberculosis from being generated • Prevention of TB exposure to staff and patients • Implementation of rapid and recommended diagnostic investigation and appropriate treatment for patients and staff suspected or known to have TB Diagnose more TB cases and start them on effective treatment! Administrative controls include… • Assigning responsibility for TB infection control • Prompt detection and timely diagnosis • Conducting a TB risk assessment of the setting • Developing and instituting a written TB IC plan • Adjusting patient flow and waiting areas in facilities (minimising overcrowding, and time spent in facilities) • Provision of face masks or tissues for cough hygiene • Training and educating HCW and patients • Screening and evaluating HCWs who are at risk for TB or who might be exposed to TB Sputum collection – ideally outside! To consider: •Infection risk •Privacy •Convenience •Supervised sputum 2. Environmental control • Naturally ventilated rooms mostly adequate, air conditioned areas often inadequate • Need at least 12 air changes per hour to decrease concentration of bacilli in air (WHO) • Keep the windows open campaign! • Can use ultraviolet light to kill bacilli Environmental control if patient treated at home • Separate room, keep kids away, masks, educate patient and family • Biggest risk of transmission is before diagnosis and treatment! 3. Personal Protective Equipment • Respirators for staff (e.g. N95 respirator) • Tiny pores which block droplet nuclei and an airtight seal around the edge Personal Protective Equipment • Face masks for patients • Large pores and lacks airtight seals around the edges; but prevent aerosolization Apart from masks, how can we decrease our risk of getting TB? Apart from masks, how can we decrease our risk of getting TB? • Look after our own immunity – enough sleep, exercise, not smoking • A study of the common cold showed that people who sleep less than 8 hours per night are more at risk than those who sleep more… • If a health worker is HIV+, to use INH prophylaxis and start HAART at CD4=350 Occupational Health Policy • Annually: – HIV testing and counseling strongly recommended
• Any active health worker with cough > 2
weeks: – Sputum smear microscopy, sputum culture and sensitivities – CXR not always indicated Where can students go for TB investigation? Where can students go for TB investigation? • Student Health • Staff health
• First test is sputum – can have a normal CXR
and have active TB • Because of exposure, request culture and sensitivities Take home messages • DRTB is a treatable disease • Early diagnosis and treatment important • Universal TB infection control measures needed – highest risk is undiagnosed patients! • Health workers should be tested if they have TB symptoms, and sensitivities requested