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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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Presentation Transcript
outline
Outline

Where we stand

Literature review

Formulation of the recommendations

Finalization of the document

Next steps

Policy dissemination

Scale up

questions for systematic reviews
Questions for systematic reviews

Where does TB transmission happen?

2. What is the efficacy of TB IC interventions

Cough etiquette

Triage & co-horting

Hospital stay

Ventilation

UVGI

Respirators

quality of evidence grade approach
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

slide7

Pooled estimates (reference general population)

LMICs: Low- & Medium- Income countries (World Bank ranking)

HICs: High- Income countries (World Bank ranking)

*with outliers

conclusions
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?

study selection
Study Selection

Triage and cohorting:

2095 articles from two databases

results for triage and co horting 12 studies
Resultsfor 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.
conclusions13
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
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.

study selection respirators
Study Selectionrespirators

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
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 cost-effective, and costs have decreased with time
  • Low compliance by HCWs
  • User seal check should not be used as surrogate fit test
recommendation20
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
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 settings22
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
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 community24
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
Prioritization

Essential package for airborne infections:

cough etiquette

patient placement

well ventilated rooms

Package of interventions based on the burden of TB, HIV and MDR-XDR TB.

targets
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
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