Transcript Introduction

Policy update on TB infection control
TBIC
Fabio Scano
STB, WHO
Outline
1. Where we stand
1. Literature review
2. Formulation of the recommendations
3. Finalization of the document
2. Next steps
1. Policy dissemination
2. Scale up
Timeline and progress
Oct 07-April 08
1. Questions formulation
2. Systematic review
3. Drafting of the
recommendations
4. Sharing with the panel
5. Finalization
May 2008
Sept 2008
Nov 2008
Dec 08-Jan 09
Questions for systematic reviews
1. Where does TB transmission happen?
2. What is the efficacy of TB IC interventions
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Cough etiquette
Triage & co-horting
Hospital stay
Ventilation
UVGI
Respirators
Quality of Evidence – GRADE approach
• Grading approach to assess the quality of
evidence.
• To inform the strength of the public health
intervention
• Low quality evidence does not mean weak
recommendation
• Public health recommendation to also
consider programmatic issues.
BMJ 2004;328; 1490–98
Where does TB transmission happen
Pooled estimates (reference general population)
population
Outcome
Settings
Health care
workers
TB infection
Low income
9
5.77*
TB infection
High income
40
10.06
TB
Low income
37
5.71
TB
High income
15
1.99
TB infection
High income
5
2.74*
TB
High income
18
21.41*
TB infection & TB
Low income
7
1.73*
TB infection & TB
High income
15
3.19
Congregate
Household
LMICs: Low- & Medium- Income countries (World Bank ranking)
HICs: High- Income countries (World Bank ranking)
Studies Risk Ratio
*with outliers
Conclusions
• Clear higher risk for health care workers
• Need for a careful and further analysis for household and
congregate settings
• RR is higher in all the observed settings. Impact at
population level?
Package for infection prevention and control of TB in health care settings
Programmatic interventions
1 To identify and strengthen coordinating systems for planning and implementation at
all levels
2 To conduct surveillance and assessment at all levels of the health system
3 To address ACSM, HR requirements and capacity building and engage the civil
society
4 To conduct monitoring, evaluation
5 To enable and conduct research
Administrative strategies
6 To develop strategies to:
a) promptly sort TB suspects (triage) and
b) cohort them
c) implement cough etiquette practices
d) reduce hospital stay
Engineering and environmental control strategies
7 Natural Ventilation
8 Mechanical Ventilation
9 UVGI lights
10 Health facility revitalization
Personal protective interventions
11 Respirators
12 Package of prevention and care for HCWs including IPT for HIV-infected health
care workers
Efficacy of cohorting
Study Selection
Triage and cohorting:
2095 articles from two databases
50 articles on triage from which only 12
articles contained data
Results for triage and co-horting
(12 studies)
• Two studies from LMIC show significant reduction
• One study from LMIC shows little impact.
•
In 11 studies, indicators of nosocomial transmission decline
following implementation of IC measures
• Two studies show that implementation of administrative
interventions alone reduced TB transmission.
• One study shows great benefit of isolation.
• Implementation of administrative interventions alone reduced
nosocomial transmission of MDR in HIV ward.
Conclusions
• The quality of evidence available is low
• Always part of a package of interventions.
• Evidence suggests that reduction in the risk of TB infection is
possible with simple administrative control
• Strong theoretical benefit to implement these interventions
TBIC
Recommendation
Implementation of strategies to separate patients (cohorting) after triage are
recommended in health care and congregate settings.
The specific criteria for cohorting patients may vary depending on the local settings
and patient population.
HIV infected patients should be physically separated from those with suspected or
confirmed infectious TB.
Drug resistant TB suspects/patients should be separated from other patients including
other TB patients.
Strong recommendations, low quality evidence (see annex 6b,and chapter VI: table
6b)
Remarks
These recommendations place high value on avoiding exposure of non-infected patients
(in particular if immunocompromised) to infectious ones irrespective of the drug
susceptibility testing pattern.
Recommendation: physical separation of suspected and known infectious cases
Population: patients accessing Health Care and Congregate Settings
Factor
Decision
Quality of evidence
Low
Benefits
or desired effects
Strong
Disadvantages
or undesired effects
Values and preferences
Costs
Feasibility
Overall ranking of
recommendation
Research gap
Explanation
The quality of the evidence available is low. Only one study shows a direct impact of physical
separation as an individual intervention on reduction of TB transmission.
Early diagnosis and initiation of proper treatment
Reduction of transmission among individuals attending HCFs
Reduction of transmission among HCWs and families
PLWH (TB suspects) might be separated together with smear positive TB patients.
Strong
Moderate
(will increase cost
but not much)
Conditional to
country
Setting
HCWs will like measures that reduce their exposure
Communities will like measures that will make HCFs a safer place
But..
Increase workload for HCWs and Stigmatization
Reduced by:
Diagnostics costs of suspected new cases
Averted cases
Break chain of transmission
Increased by:
Staff training
Infrastructures (separated waiting area, isolation rooms…). This may require major capital investment.
Additional AFB and CXR for positive TB triage
Generally feasible in HIC
Lack of human resources in MIC/LIC
Lack of infrastructures in MIC/LIC
Slow diagnostic process to exclude TB infection (turnaround time…lab facilities)
STRONG RECOMMENDATION
To develop and assess the impact on reduction of TB of different models of physical separation based on smear; HIV status
and suspected or confirmed TB sensibility pattern
Efficacy of respirators
Study Selection
respirators
4593 articles from six databases
103 articles on respirators, from which
only 13 articles contained relevant
data after full-text review
Results for Respirators (13 papers)
• 3 epidemiologic studies ( benefit of using respirators)
• Modeling studies (lower infection risk with better respirator
and use of masks/respirators can prevent XDR-TB cases)
• Better respirators cost more, HEPA respirators are not costeffective, and costs have decreased with time
• Low compliance by HCWs
• User seal check should not be used as surrogate fit test
Recommendation: Use
Population:
of respirators
health care settings
Intervention:
Respirators
Factor
Decision
Quality of evidence
Low
Benefits
or desired effects
Disadvantages
or undesired effects
Benefits not always
outweigh
disadvantages
Research gap
Not clear additional protection if environment is well ventilated
Requires training
Requires adherence
Affect HCW's performance on practices.
Allergies to material
moderate
HCWs will like measures that reduce their exposure
But..
Reduces comfort of HCWs
Generate stigma
moderate
Increased by:
Purchase
Training programme
Costs
Overall ranking of recommendation
Theoretical basis
low evidence
No clear guidance on the duration of use
Provide additional protection to the HCWs
Values and preferences
Feasibility
Explanation
Conditional to country
setting
Lack of expertise
Lack of training
Requires commitment to wear them from health care workers
STRONG RECOMMENDATION (MDR and high risk procedures)
CONDITIONAL RECOMMANDATION (susceptible TB)
1. To determine the effectiveness of the intervention on the reduction of TB transmission
2: To determine the programmatic role of fit testing versus fit checking
Recommendation
1. In addition to implementation of administrative and environmental
interventions, respirators should be used by HCWs when providing care for
patients/suspects with susceptible TB, whenever possible.
Conditional recommendation (see annex 11, and chapter VI: table 11)
2. Respirators should be used by HCWs during aereosol-generating procedures
associated to higher risk of TB transmission (e.g bronchoscopy, intubation,
aspiration of respiratory secretions and autopsy or lung surgery with high
speed device) and when providing care to MDR-XDR TB patients.
Strong recommendation (see annex 11, and chapter VI: table 11)
The use of respirators should be part of a comprehensive training programme.
Ideally, the training programme should also include fit testing.
Congregate settings
Include prisons, army barracks and homeless
shelters.
TB incidence exceeds the incidence among the
general population (complex transmission dynamics)
Recommendations cannot be too specific because
they cover such a wide range of settings.
Congregate settings
Recommendations:
• Programmatic and administrative interventions
– as per health care facilities
– high focus on case detection, cohorting and no overcrowding
• Environmental and personal protective
– Follow country legislation for public buildings
Remarks
Any HCF within a congregate setting should be considered as an
health care setting.
Infection control in the community
Background
1. Major risks for contacts lies in the exposure to the infectious case
before the diagnosis
2. Early case detection remains a pillar intervention
3. IC literacy messages should be part of any community
Infection control in the community
Guidance:
•
Shared space should be well ventilated (natural ventilation). If possible patients
should spend as much time as possible outside.
•
Patients should be educated and always respects cough etiquette
•
Ideally, patients should sleep in a separate room if smear positive.
•
Patients should avoid public transportation and congregate settings if smear positive.
DO we need specific recommendations for MDR patients?
Prioritization
Essential package for airborne infections:
1.
cough etiquette
2.
patient placement
3.
well ventilated rooms
Package of interventions based on the burden
of TB, HIV and MDR-XDR TB.
Targets
By 2009:
1) 50% of the countries, according to the prioritization, should have
developed a plan; set up surveillance activities; and assessed all the HCF
and congregate settings for TB IC
By 2010:
1) all countries, according to the prioritization should have developed a plan;
set up surveillance activities; and assessed all the HCF and congregate
settings for TB IC
5) 50% of countries should be reporting on the implementation of the
package of TB/IC interventions.
Next steps…to ensure safer health facilities,
congregate settings and household
• Dissemination of the policy (including the evidence)
• Development of an advocacy strategy for generating demand
and fund raising
• Working through regional and country offices (WHO and
partners) for changes in policy and regulations
• Budget the package for quantifying the costs of scaling up TB
IC
• At country level assess responsibilities for the implementation
of the package (TB, HIV, Occupational Health, Justice
department, health system and civil society)
TBIC