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No. 3, 2010

International Research and Programs Branch Update

Vladimir Center of Excellence for Tuberculosis Infection Control

A nurse in Vladimir Oblast TB dispensary providing DOT: combination of TB infection control interventions (administrative controls, environmental controls, and respiratory protection).
Photo 1. A nurse in Vladimir Oblast TB dispensary providing DOT: combination of TB infection control interventions (administrative controls, environmental controls, and respiratory protection).

In October 2008, the Vladimir Center of Excellence for Tuberculosis Infection Control (Vladimir Center) was established.  The Vladimir Center is a partnership that includes the Vladimir Oblast Administration, the Central TB Research Institute (CTRI–Moscow), USAID, CDC/DTBE, and WHO–Moscow, and is located at the Vladimir Oblast TB Dispensary.  The Vladimir Center is involved in monitoring and implementing infection control (IC) measures, and serves as an IC training hub for Russia and other Russian-speaking countries.  Training topics include the airborne concept of TB transmission; the hierarchy of TB IC measures; the TB transmission risk assessment; the cost effectiveness of various environmental controls, the development of a prioritized, structured TB IC plan; the development of TB facility floor plans for (re)construction with ventilation requirements; the upper-room ultra-violet gamma irradiation (UVGI) concept; the measurement and assessment of ventilation and UVGI parameters; the testing and safe practices of biosafety cabinet use; the design, installation, and use of sputum collection booths; respiratory protection program development and respirator fit-testing; and costing, budgeting, advocacy, and resource mobilization issues for TB IC.

TB IC course participants and Vladimir TB laboratory technician during the practical exercise on laboratory biosafety: discussing specimen flow and SOPs.
Photo 2. TB IC course participants and Vladimir TB laboratory technician during the practical exercise on laboratory biosafety: discussing specimen flow and SOPs.

The risk of TB among health care workers in the Russian Federation exceeds the risk in the general population by more than 20-fold. Further, the Russian Federation has among the highest levels of multidrug-resistant (MDR) TB in the world.  The occurrence of TB among health care personnel and prison guards in Vladimir heightens anxiety about institutional transmission. 

In response, CDC, WHO, and Russian Federation partners implemented the Vladimir Center of Excellence for Tuberculosis Infection Control to adopt infection control measures that will protect health care staff, patients, homeless shelter personnel, prison staff, and prisoners from institutional or nosocomial TB transmission. We know that institutional transmission of TB is prevented by a three-tier hierarchy of control measures: administrative (organizational and managerial) controls, environmental (engineering) controls, and personal respiratory protection. High quality infection control practices prevent TB transmission and provide a safer environment for all. 

The Vladimir Center strives to sustain and build upon its success through its emphasis on training and, especially, on developing local sites as examples and training centers for other territories of Russia and the Commonwealth of Independent States (CIS). Currently, the Vladimir Center will be the only location in Russia capable of providing such high-level training.

The goals of the Vladimir Center are to

  1. Decrease occupational TB among institutional staff, so as to substantially decrease the spread of nosocomial (re)infection in TB institutions.
  2. Disseminate the infection control experience of the Regional TB Dispensary to other TB institutions in the Russian Federation and the CIS.
  3. Assist in the development of TB infection control programs in the CIS and the Russian Federation, through the Vladimir Center.
  4. Train others to implement new IC recommendations, including administrative controls, environmental and engineering controls, and personal respiratory protection, and any other recommendations applicable to facilities with a high risk for TB transmission.
  5. Provide training courses for Russian Federation and CIS health care professionals at the Vladimir Center, using the Vladimir Oblast TB dispensary as a working classroom, also using a state-of-the-art lecture hall and state-of-the-art engineering control laboratory.
  6. Develop and offer new training courses on TB laboratory biosafety, to include the certification of biological safety cabinets, as well as the design, commissioning, operation, and maintenance of ventilation systems.
Viktor Pronkov, pioneer TB infection control ventilation expert in Russia and former Soviet Union states, lecturing on environmental controls.
Photo 3. Viktor Pronkov, pioneer TB infection control ventilation expert in Russia and former Soviet Union states, lecturing on environmental controls.

Several IC interventions have been implemented at the Vladimir Oblast Tuberculosis Dispensary. Infection control training, including respirator fit testing, was initially conducted in 2002 by CDC specialists. After the training, the Dispensary staff developed an infection control program for their new location.  Included in the plan were administrative measures, engineering measures, and respirators. Three key administrative control measures included: patients separated according to smear status and drug susceptibility test (DST) results; limited access to high risk zones; and transfer of patients from other facilities to the TB hospital immediately upon receiving smear positive test results. The key engineering control measures included updated and improved ventilation systems to meet current Russian and international standards; biosafety equipment; shielded upper-room UVGI fixtures that allow for 24-hour usage; and sputum collection booths.  A respiratory protection program, including training and fit testing, was initiated.  Staff working in areas with significant risk of occupational exposure to airborne TB were given N95/EU FFP2 (European Union filtering face piece class 2) respirators.

Paul A. Jensen, CDC, teaching course participants on BSC design, routine testing, maintenance, and safe working practices
Photo 4. Paul A. Jensen, CDC, teaching course participants on BSC design, routine testing, maintenance, and safe working practices.

As a result of these IC interventions, a remarkable reduction in the rate of occupationally acquired TB was achieved in the Oblast TB dispensary (from 1,083 new cases per 100,000 to 166 during the first 5 years of the program, and no new cases of occupational TB in 2008–2009). Funds from the Oblast budget were allocated in 2005 for the ventilation reconstruction and for the purchase of respirators. Infection control measures were incorporated as a major component of the targeted regional TB control programs (2004–2006, 2007–2009, and 2010–2012). However, district-level TB institutions lack the resources and expertise needed for the effective protection of staff and patients from the risk of nosocomial TB.  Although completely eliminating the risk for transmission of M. tuberculosis infection in all health-care facilities may not be possible, implementation of and adherence to the internationally recommended measures in other places has dramatically reduced the risk of nosocomial transmission of TB.

—Reported by Paul Jensen, PhD, PE, Div of TB Elimination, and
Grigory Volchenkov, MD, Vladimir Center of Excellence
 

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