Transcript New 2005 Infection Control Guidelines

New
WHO Policy on TB Infection
Control in Healthcare Facilities,
Congregate Settings and
Households
Michele L. Pearson, MD
International Research and Programs Branch
Division of TB Elimination
Outline
• Global global TB trends and healthcareassociated TB transmission
• Process/methods used to develop WHO TB
IC policy
• Summary of new TB IC recommendations
and policy changes since previous
document
• Recommended practices for biosafety
Rationale of TB IC
• Co-existing HIV pandemic
• Emergence of MDR/XDR-TB strains
• Documented TB transmission and
outbreaks in healthcare settings
• Implementation of recommended TB
infection control interventions terminated
or reduced facility TB transmission
Wells, C et al. JID 2007;196:S86–S107
Importance of TB Infection Control
• Subcomponent of WHO’s updated Stop TB
Strategy, contributing to health system
strengthening
• Element of WHO’s 12 collaborative activities for
TB and HIV control
• One of WHO’s “Three I’s for HIV/TB”
• Essential component of sound HIV control
programs in countries with high HIV prevalence
Status of Global TB IC Efforts, 2008
• 66% (131/199) of WHO Member States
reported having TB IC plan
• None reported data on implementation
WHO Policy on TB IC
• Objective: Provide member States with guidance on
how to reduce TB transmission in healthcare facilities
and how to prioritize TB IC measures
• Target audience:
– Policy makers (national and subnational)
– Managers of TB and HIV/AIDS programs
– IC and quality assurance programs/personnel
– Occupational health
– Documented TB transmission and outbreaks in healthcare
settings
What’s New
• Guidance on how to prioritize TB IC measures at
National level, including national managerial
activities
• Update on facility-level measures
• Considers facility-level managerial activities as a
separate element, rather than a component of
administrative controls
• Emphasis on appropriate administrative and
environmental controls and personal protective
equipment
What’s New?
• Special focus on building design and use of space
• Increased emphasis on certain activities:
– Integration of TB IC with other healthcare system efforts
– Greater involvement of civil society in design, development,
implementation, and monitoring and evaluation of TB IC
– Greater emphasis on selective administrative controls (e.g.,
reduction in time spent in healthcare facilities)
– Provision of HIV prevention, treatment and care services for
health workers
Policy Formulation Process
Policy Formulation Process
• Systematic review panel reviewed science on efficacy
and effectiveness of TB IC measures
• Collaborative effort of WHO Department for Epidemic
and Pandemic Alert and Response, HIV/AIDS
Department and the Patient Safety Programme
• Draft reviewed by various stakeholders, including
systematic review panel, WHO regional office staff, TB
IC sub-group of WHO TB/HIV working group,
implementation working group of Stop TB Partnership
• Recommendations expected to remain valid until 2013
Recommendation Rankings
• Strong--desirable effects outweigh
undesirable effects
• Conditional—desirable effects probably
outweigh undesirable effects)
• Recommendations also informed by expert
opinion, climatic, cultural, cost and
programmatic factors
Factors that Influence
Recommendation Rankings
• Quality of evidence
• Benefits
• Values and preferences
• Costs
• Feasibility
Other Outcomes of Systematic Review
• Identified gaps in science on efficacy and
effectiveness of TB IC measures
• Need for scale-up in TB IC research
• Highlighted importance of simple
indicators to monitor success in
implementing TB IC programs/activities
WHO TB IC Policy for Healthcare
Settings
• Policy complements:
– General infection control efforts
– Airborne infection control efforts
• Describes how to prioritize TB IC measures
based on burdens of TB, HIV and MDR-TB
• Does not provide recommendations on
laboratory biosafety
• Stresses importance of sustained political,
institutional, and financial commitment and
multidisciplinary involvement
National and Subnational
Activities
National and Subnational TB IC
Activities
• Describes six activities that provide the
managerial framework for implementation
of TB IC in healthcare settings
• Targeted to policy makers at national and
subnational levels
National and Subnational TB IC
Activities
1.
Identify and strengthen a coordinating body for TB IC and develop
comprehensive budgeted plan that includes necessary human
resources for program implementation
2.
Ensure appropriate facility design, construction, renovation and
use
3.
Conduct surveillance of TB among HCWs and conduct assessments
at all levels of the healthcare delivery system
4.
Address TB IC advocacy, communication, social mobilization
(ACSM), including civil society engagement
5.
Monitor and evaluate TB IC measures
6.
Enable and conduct operational research
Reducing TB transmission in
health-care facilities
Facility-level TB IC Measures
• Managerial Activities (Facility-level)
– Identify and strengthen local coordinating bodies for TB IC and
develop facility implementation plan (including human resources,
and policies and procedures to ensure proper implementation of
controls)
– Conduct on-site surveillance of HCWs for TB disease and assess
facility
– Rethink use of available spaces and consider renovation of
existing facilities or construction of new ones to optimize
implementation of controls
– Address advocacy, communication and social mobilization
(ACSM) for HCWs, patients and visitors
– Monitor and evaluate set of TB IC measures
– Participate in research efforts
Facility-level TB IC Measures
• Administrative controls
– Prompt detection of patients w/ TB sxs (triage), separation of
infectious patients, cough etiquette and respiratory hygiene,
minimize time in facility, decrease diagnostic delays (use of rapid
diagnostics, decrease time for sputum testing and culture),
prompt treatment
– Package of prevention and care interventions for HCWs including
HIV prevention, ART and IPT for HIV-positive HCWs
• Environmental controls
– Use ventilation systems
– Use UV germicidal irradiation (UVGI) fixtures, at least when
adequate ventilation can not be achieved
• Personal protective equipment
– Use particulate respirators
Administrative Controls: Strength of
recommendation and Evidence Quality
Recommendation Evidence Quality
Promptly identify
patients w/ TB
symptoms
STRONG
LOW
Separate infectious
patients
STRONG
LOW
Triage is crucial and TB
suspects should be fasttracked
Control spread of
pathogens (cough
etiquette and respiratory
hygiene)
STRONG
LOW
Minimizes exposure of
non-infected patients to
infectious
Minimize time spent in
facility
STRONG
patients. Should be done
irrespective of likely or
known drug susceptibility
patter
LOW
Manage patients as
outpatients where possible
Administrative Controls: Strength of
recommendation and Evidence Quality
Recommendation
Provide
package of
interventions
for HCWs,
including HIV
prevention,
ART, and IPT
STRONG in HIV
prevalence HIV areas
CONDITIONAL in
Low prevalence HIV
areas
Evidence
Quality
HIGH
All HCWs should be
given appropriate info
and encouraged to
undergo HIV testing and
counseling.
HIV-positive HCWs
should not work with
know or suspected TB
patients and should be
reassigned to
areas/duties that pose
lower risk of TB
exposure.
HIV-positive HCWs
should receive regular
screening for active TB
and access to ART.
Environmental Controls: Strength of
recommendation and Evidence Quality
Evidence
Recommendation Quality
Use ventilation
systems
STRONG
LOW
Natural ventilation
CONDITIONAL
LOW
In existing facilities, depending on
climatic conditions, maximize use
natural ventilation before considering
other ventilation systems.
Mechanical
ventilation
CONDITIONAL
LOW
Useful when natural ventilation alone
cannot provide sufficient rates. May be
advisable in settings where natural or
mixed-mode ventilation systems are
inadequate given local conditions (e.g.,
building structure, climate, regulations,
outdoor air-quality, costs
UVGI
CONDITIONAL
LOW
Adjunct to, not replacement for,
ventilation. Upper UVGI devices
potential hazardous if not properly
designed, installed, used and
maintained.
Personal Protective Equipment: Strength of
recommendation and Evidence Quality
Evidence
Recommendation Quality
Particulate
respirators
STRONG
(in particular for
MDR-TB and highrisk procedures)
LOW
Should be accompanied by a
comprehensive training program for
HCWs and, if possible, fit-testing.
Prioritizing Measures and Setting
Targets for TB IC
Prioritization of TB IC Measures
1.
Identify and strengthen a coordinating body for TB IC and develop
comprehensive budgeted plan that includes necessary human
resources for program implementation
2.
Ensure appropriate facility design, construction, renovation and
use
3.
Conduct surveillance of TB among HCWs and conduct assessments
at all levels of the healthcare delivery system
4.
Address TB IC advocacy, communication, social mobilization
(ACSM), including civil society engagement
5.
Monitor and evaluate TB IC measures
6.
Enable and conduct operational research
Suggested targets: Global-level
implementation of TB IC
By
2102
50% of countries have:
•National TB IC plan
•National surveillance of TB disease among HCWs
•TB IC assessments of major healthcare-facilities and congregate
setting
Reports on TB IC implementation
By
2013
ALL countries:
•National TB IC plan
•National surveillance of TB disease among HCWs
•TB IC assessments of major healthcare-facilities and congregate
setting
•Reports on TB IC implementation
Summary
• TB transmission in healthcare settings poses risk to
patients and HCWs and undermines global TB control
efforts
• WHO TB IC policy
– provided evidence-based, cost-effective, feasible
recommendations for TB IC
– identified gaps in science on efficacy and effectiveness of TB IC
measures
– highlighted need for scale-up in TB IC research
– stressed importance of simple indicators to monitor success in
implementing TB IC programs/activities
– prioritized TB IC efforts
Research Gaps
• Administrative controls
– Impact of cough etiquette/respiratory hygiene on TB
transmission
– Rapid diagnostics to reduce time to diagnosis
– Screening criteria for triaging TB suspects in different
settings based on TB, HIV and MDR/XDR-TB burdens
– Effect of physical separation based on smear results,
HIV status and drug-susceptibility pattern
– Methods for screening HCWs
– Duration of preventive therapy
Research Gaps
• Environmental controls
– Effectiveness of ventilation systems in
different settings and climates and by design
– Efficacy and effectiveness of UVGI
• Personal Protective Equipment
– Impact of fit-testing on effectiveness
– Re-use guidance
WHO Policy on TB Infection
Control in Healthcare Facilities,
Congregate Settings and
Households
Muchas Gracias!
[email protected]