Video: Implementing TB Infection Control in Outpatient Settings
Through PEPFAR funding, CDC provides support for HIV care and treatment in over 1,300 HIV/ART clinics in resource-limited countries, primarily in Africa. CDC has recognized that in some countries guidelines for infection control related to Tuberculosis, have not yet been translated to facility level action. This video is part of an implementation package developed to address that need. It is based on the WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households (2009) and emphasizes basic, simple activities that can be performed at the facility level to begin implementation of TB infection control.
As a healthcare professional, you have a vital role to play in tuberculosis, or TB, infection control in your clinic. If you see HIV positive patients in your clinic, you know that they’re at increased risk for getting TB because they’re very susceptible to certain infections. In fact, TB is the leading cause of death in people with HIV/AIDS. TB is different from other opportunistic infections because it is spread by the respiratory route, and infected patients can spread the disease to others in crowded clinics, including you.
This video is designed to give you practical information to help you stop the spread of TB in your clinic by improving TB infection control practices. It’s based on the World Health Organization Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households.
Use this video as a supplement to training you’ve already received along with other training materials, including the guidelines, assessment and planning tools, posters and monitoring and evaluation forms included with this video.
Topics include how TB is spread, who’s at most risk, and how to control TB. We’ll give you practical ideas on how to make simple changes in your clinic set-up and in your practices that can have a large impact on your health and the health of your patients.
TB is usually spread when an infected person coughs and produces small droplets which contain TB bacilli. The droplets remain suspended in the air for hours. When someone breathes in these droplets, he or she can become infected with TB.
There are several factors that can affect the likelihood of TB transmission: The number of infected droplets generated by a person with TB, the amount of time a TB-infected person is in contact with others, the amount of ventilation in the area where the exposure takes place, and the immune status of the person exposed.
TB is usually spread by coughing patients who haven’t been recognized as having TB and are not receiving treatment. So, it’s up to you to notice coughing patients and get them diagnosed and treated quickly.
At the highest risk of getting TB are those living with HIV/AIDS, people living in crowded, poorly ventilated settings such as correctional facilities, military barracks or refugee camps, patients with medical conditions such as diabetes, cancer or renal failure, those taking immunosuppressive medications like steroids or chemotherapy and children under the age of five.
Who is most likely to interact with all of these people? You are! Because of your job, you are very likely to come in contact with many people who have TB and that puts YOU at high risk for getting TB, too.
To control TB there are four types of infection control measures: Managerial Control Measures Administrative Control Measures, Environmental Control Measures and Personal Protective Equipment, or PPE.
Remember, whatever your role in the clinic, you are critical in carrying out these TB infection control measures. Let’s take a closer look how.
Facility administrators and managers should provide leadership by promoting a culture of safety and advocating for the necessary resources to conduct infection control measures. This includes establishing an infection control committee for the facility that meets regularly, appointing someone to conduct a facility assessment and developing an infection control plan and policies.
The basic building blocks of infection control are the administrative control measures and should be implemented by all members of the team. These measures include prompt identification of coughing patients, promoting cough etiquette, separating coughers from other patients, and “fast-tracking” for prompt diagnosis and treatment. They also include monitoring the time it takes to get laboratory results back (such as sputum smear results) and assuring the routine evaluation of clinic personnel for TB.
It is the undiagnosed and untreated TB patient that presents the greatest risk to others. It’s up to you to act as early as possible to identify people coming into the clinic who might have TB-- and as you know, the most visible sign is coughing.
In a busy clinic, early identification of coughing patients may be done by the admissions clerk, a community health worker, an educator or nurse. Work with your team to designate the most appropriate staff for this critical task.
Cough Etiquette refers to the practice of covering all coughs and sneezes to contain respiratory secretions. All patients, visitors, and clinic staff should be encouraged to cover their coughs and sneezes with a handkerchief, or a tissue. When a handkerchief or tissue is not available coughing or sneezing into the upper arm or elbow is the preferred technique for preventing the spread of infection. This may seem strange, but infection control experts recommend this technique as safer than coughing or sneezing into the hands.
Those who cough or sneeze into their hands should wash them with soap and water or use an alcohol-based hand rub. If disposable surgical masks are available, have coughing or sneezing patients wear them to contain respiratory secretions. Ask patients to dispose of masks in the waste bin after use. A poster on cough etiquette is included in the materials accompanying this video. Promote cough etiquette every chance you have in the clinic-- at the entrance, at registration, and every time you interact with a patient or visitor. Remember you are a role model for behavior in the clinic, so cover your own cough, too.
A key method of reducing TB transmission is to separate coughing patients from non-coughing patients. A trained clerk, nurse or anyone that has contact with patients as they enter the clinic can make this initial separation. Ideally, coughing patients should wait in a separate, outdoor area. This minimizes contact and takes advantage of natural ventilation. You should explain to patients that no one will lose their place in line and that this is for their protection. Once separated, coughing patients should be fast tracked or quickly examined for additional symptoms to determine if TB diagnostic tests are needed.
Finally, as part of administrative control measures, lab staff and the infection control point person should monitor the time it takes to get lab results back, such as sputum smear results and assure there is routine evaluation of clinic personnel for TB.
Environmental Control Measures are the third major type of infection control measures. They include the use of natural and mechanical ventilation and ultraviolet germicidal irradiation. These measures are used to reduce the number of infectious droplets in the air.
If your facility is planning a renovation or new construction, it will be important to consider these environmental infection control measures in the building design. Using natural ventilation in overcrowded waiting areas and hallways is a relatively easy way to decrease the risk of TB transmission. In warmer climates, building a covered outdoor waiting area is inexpensive and a good way to maximize ventilation and reduce clinic congestion. Opening windows and doors to maximize cross-ventilation reduces the number of infectious TB droplets in the air. This works in home settings too, so instruct patients to do this at home if a family member is undergoing treatment for TB. In clinics, consulting rooms should be arranged so airflow moves away from the clinician toward the patient and to the outside. Electric fans can be used to assist in producing this airflow pattern.
Mechanical ventilation systems designed for optimal airflow with the help of an engineer can reduce TB transmission. But remember that ordinary air-conditioning units do not reduce the risk of TB transmission. Where available, ultraviolet germicidal irradiation also known as UV lights or lamps placed in the upper parts of a room help to clear the air of infectious droplets. To be effective, UV lamps need to be properly installed and regularly cleaned and maintained.
There are some environmental control measures you can use to make sputum collection less risky. Ideally, sputum collection should be done outside in a designated location away from other patients. When performed indoors, it should be done in a well-ventilated room or booth designed to extract air to the outside. Small, poorly ventilated bathrooms should not be used for sputum collection because they offer no safety to other patients or staff members.
The last TB infection control measure we’ll discuss is Personal Protective Equipment or PPE, which refers to the use of particulate respirators and surgical masks. Particulate respirators known as N-95’s or FFP2’s are worn by healthcare workers and are different from surgical masks because they filter out TB-infected droplets as you breathe in.
If available, respirators should be worn by staff when doing procedures such as bronchoscopy and when caring for infectious TB patients or suspects, especially when multi-drug resistant TB is suspected. Surgical masks are not effective in preventing the inhalation of TB droplets, but when worn by patients they can contain the majority of droplets produced by coughs or sneezes, thus reducing the risk of transmission. Staff and patients often have concerns about stigma during triaging or when using particulate respirators or surgical masks. It’s important for you to be aware of these issues and discuss ways to approach and communicate with patients to minimize stigma.
In summary, we have covered the basics of TB infection control including; how TB is spread, who is most at risk for TB; and the managerial, administrative, environmental and personal protective equipment measures that can be used to control TB.
You personally are very important in preventing TB transmission -- from one patient to another, from a patient to a visitor in your clinic, and to yourself and your family. If you think you may be infected, it is important to get screened and seek care immediately.
Although tuberculosis is a serious disease, it can be treated and cured. People coming into the clinic look to you as a knowledgeable health professional. You are in the best position to educate them about TB infection control and to demonstrate good infection control habits.
You CAN make a difference in TB infection control in your facility, in your community, and in your country.