Policy update on TB infection control. Fabio Scano STB, WHO. T B I C. Outline. Where we stand Literature review Formulation of the recommendations Finalization of the document Next steps Policy dissemination Scale up. Timeline and progress. Questions for systematic reviews.
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Where we stand
Formulation of the recommendations
Finalization of the document
Where does TB transmission happen?
2. What is the efficacy of TB IC interventions
Triage & co-horting
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
LMICs: Low- & Medium- Income countries (World Bank ranking)
HICs: High- Income countries (World Bank ranking)
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?
Triage and cohorting:
2095 articles from two databases
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)
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.
4593 articles from six databases
103 articles on respirators, from which only 13 articles contained relevant
data after full-text review
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.
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.
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
Any HCF within a congregate setting should be considered as an health care setting.
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
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?
Essential package for airborne infections:
well ventilated rooms
Package of interventions based on the burden of TB, HIV and MDR-XDR TB.
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
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.