Summary of National Guidelines on Airborne Infection Control in Healthcare Settings

1. Summary of National Guidelines on Airborne Infection Control in Healthcare Settings Dr. K. Sachdeva CMO, Central TB Division

2. Overview • Importance of airborne infection control • Summary of (draft) national guidelines • Managerial activities (National, State, Facility) • Administrative controls • Environmental/Engineering controls • Personal respiratory protection • Next steps

3. Airborne infection control: Why should you care? • Transmission – TB and other resp. pathogens • Protection – patients and staff • Preparedness – pandemic viral disease • Accreditation – NABL, MCI and others

4. Evidence shows airborne transmission happening in health care facilities • Objective: • Estimate incidence/prevalence of TB in HCWs in Low/Middle income countries • Methods: • Search of medical literature electronic databases • Review and analysis of 42 articles, 51 studies • Findings: • LTBI prevalence: 54% (33 – 79%) • Annual risk of LTBI: 0.5 – 14.3 % • Annual incidence TB disease: 69 – 5,780/100,000 • Attributable risk for TB disease: 25 – 5,361/100,000 Joshi R et al. PLOS Medicine 2006; 3(12):2376-2391

5. People in health care facilities are exposed to airborne transmission, as shown by example of high TB rates in HCW Work Location TB Incidence Rate Ratio Outpatient facilities 4.2-11.6 General medical wards 3.9-36.6 Inpatient facilities 14.6-99.0 Emergency rooms 26.6-31.9 Laboratories 78.9 *relative to general population where study conducted. Joshi R et al. PLOS Medicine 2006; 3(12):2376-2391

6. Impact of Airborne Infection Control Measures on TB Transmission in Chiang Rai, Thailand, 1995 - 1999 Airborne infection control measures implemented (1996) • Administrative • Infection control plan and SOPs • HCW education and training (including laboratory staff) • HCW TST testing, with isoniazid preventive therapy • TB patient education • Environmental • Natural ventilation maximized in high-risk areas • Negative pressure ventilation in TB isolation rooms • Class II biosafety cabinet for laboratory • HCW respiratory protection (N-95 masks) • Known exposure to infectious TB patient • Laboratory staff processing TB cultures Yanai H, Limpakarnnanarat K, Uthaivoravit W, et al. Int J Tuberc Lung Dis 2003;7:36-45.

7. Impact of Airborne Infection Control Measures on TB Transmission in Chiang Rai, Thailand (cont) • Implementation of IC package was followed by decreased health care worker TST conversion rates, even though more TB cases detected in Chiang Rai overall • HCW TST conversion rate (1995–7): 9.3 /100 py • HCW TST conversion rate (1999): 2.2 /100 py • Showed that implementation of IC package can reduce airborne transmission Yanai H, Limpakarnnanarat K, Uthaivoravit W, et al. Int J Tuberc Lung Dis 2003;7:36-45.

8. What to do?

9. National Guidelines on Airborne Infection Control • Purpose: to provide up-to-date information about recommended methods of reducing the risk of airborne infections in health care facilities. • Target audience • Health officials (general, not just TB) • Health facility administrators and infection control focal points • Elements now included in NABH hospital accreditations

10. Contributors • NAICC Chair Prof SK Jindal • Committee members – Dr D Behra, Dr R Sarin, Dr R Singla (LRS), Dr A Agarwal (PGI), Dr V Chandrashekar (DGHS), Dr Gupta (NCDC), Dr Thakur (NACO), Dr Solanki (BJMC), Dr Rajesekaran (Chennai), Dr Anand (NTI), Dr Mahilmaran (GHTM) • CTD - Dr LS Chauhan, Dr K Sachdeva, Dr D Gupta, Dr M Parmar, Dr S Chadha • WHO – Dr S Sahu, F Wares • CDC – Dr M Pearson & Dr P Jensen

11. Managerial activities(National, State, Hospital administration and local health officials) • National level: Plan, establish policy, train, coordinate, evaluate • State/District level: Promote IC focal points at facilities, develop coordination mechanisms, Plan, train, monitor • Facilities: Develop local plan, implement, supervise

12. Facility-Level Management Activities • Designate focal points for the facility-level activities • Conduct a facility-risk assessment • Develop a facility plan for airborne infection control • Rethink the use of available spaces and consider renovation and/or construction, e.g. waiting areas • Support trainings • Ensure proper implementation of the administrative controls – especially relocation of waiting areas, implementation of systems for queing, screening, fast tracking • Keep adequate budget for maintenance of any controls • Supervise and monitor infection control activities

13. Education & training of staff is the key to infection control • Principles & practices of infection control – standard precautions • Issues about airborne infection risk and prevention • Realities about personal respiratory protection • Responsibilities of personnel and institution should be clear

14. Specific controls recommended in National Guidelines • Administrative controls • Reduce potential opportunities for exposure • Environmental controls • Reduce concentration of infectious particles that may be present • Personal respiratory protection • Further reduce risk to staff (not other patients) in very high-risk settings where exposure not avoidable

15. What is meant by administrative controls? All policies developed by infection control team to decrease risk Procedures for implementing, enforcing, monitoring, evaluating, and revising infection control plan

16. Recommended outpatient administrative controls • Patient screening • Cough hygiene IEC for patients • Segregation of respiratory symptomatics (where possible) • Fast-tracking of respiratory symptomatics • Jumping the queue • Alternate evaluation pathway

17. Triage • Identify people with respiratory symptoms

18. Respiratory Infection Control in Health Care Facilities 18

20. Separate • Where possible, separate persons with respiratory symptoms in a separate well-ventilated waiting area • The specific criteria for separating patients will depend on the local settings and patient population • Guiding priorities • Minimize opportunities for transmission • Protect immuno-compromised patients • Keep drug-resistant TB from spreading

21. Examples of waiting areas

22. Fast-track respiratory symptomatics to minimize time in health care facilities • Example: Screening and marking OP tickets for fast-tracking PTB suspects through diagnosis

23. Inpatient administrative controls • Minimize hospitalization as per current practice under DOTS • Educate patients and attendants on cough hygiene • Routine segregation of patients to separate wards (or separate areas in same ward) so to reduce risk of transmission, particularly to immune-compromised • Where possible, isolate infectious patients • Maintain spacing, ward decompression

24. Segregation • 1. Keep HIV+ persons safe from • Persons with MDR TB • Known S+ patients • 2. Keep the most infectious patients (any S+ newly-starting treatment) away from others

25. Segregation does not happen without both policy and enforcement • Designating appropriate areas • Routine (voluntary) HIV testing at admission • Automatic procedures to move patients when indicated

26. Safe sputum collection • Keep aerosol generating procedures away from other patients • Sputum collection • Sputum induction

27. Environmental controls • Indoor patient segregation and bed spacing • Ensure effective ventilation at all times and seasons • Special attention for high-risk areas

28. Segregation and Spacing • Keep infectious patients away from vulnerable patients using whatever approach is feasible: • Airborne precaution areas • Individual rooms • Designated wards or ward areas

29. Ventilation • Health-care facilities should seek to achieve minimum standards for air exchange. • High-risk settings should be prioritized for immediate assessment and implementation of improved ventilation.

30. Minimum air-changes per hour (ACH) required for various health care settings

31. Natural Ventilation • In most settings, natural ventilation is the preferred method for ensuring adequate air exchange. • Ensure effective ventilation at all times and in all climatic conditions through proper operation and maintenance, and by regular checks to ensure fixed, unrestricted openings. Example: Use of louvered shutters instead of glass windows to ensure ventilation day and night

32. Assessing if natural ventilation is adequate • Where ACH is not able to be measured, as is usually the case in rooms with natural ventilation, the following standards for ventilation should be followed to ensure that air exchange is safely >6 ACH under all climactic conditions. • Natural ventilation should be "controlled", with fixed, unrestricted openings that are insensitive to climactic conditions • Openings should constitute >20% of floor area • Openings should be on 2 sides, preferably opposite sides. For example, a 100 ft 2 room should have >10 ft 2 fixed, unrestricted openings on two sites, for a total of 20 ft2

33. If natural ventilation not adequate… • Guidelines caution against use of technologically driven interventions (mechanical ventilation, UVGI) without sustained commitment and clear commitment for maintenance and budget Blocked air intake duct for ventilation of waiting area

34. Mechanical ventilation • Mechanical ventilation – with or without climate control – may be appropriate where natural ventilation cannot be implemented effectively or is inadequate given local conditions (e.g. building structure, climate, regulations, culture, cost and outdoor air quality) • If mechanical ventilation is used, the system should be well designed, maintained and operated, to achieve adequate airflow rates and fresh air exchange.

35. Directional control of air-flow • Directional control of air flow (i.e, negative pressure) is recommended in specific high-risk settings where infectious patients with drug-resistant TB or other acute respiratory diseases of potential concern are likely to be managed – i.e. airborne isolation rooms, MDR-TB wards and clinics, and bronchoscopy suites

36. Arrangement of patients and staff • Optimal arrangement of patients and staff should be implemented in all outpatient departments, DOT centers, microscopy centers, and radiology

37. What’s wrong with this picture? Chest clinic, Oct 2009

38. What’s wrong with this picture? Very poor ventilation, blocked windows, re-circulating A/C Ineffective filtration devices gives false security Exhaust fan would draw air from waiting to doctor’s chamber Crowded waiting area (wait outside!)

39. UVGI • In high-risk settings where it is not possible to achieve adequate air exchange using natural ventilation, a complementary option is to use upper room or shielded ultraviolet germicidal irradiation (UVGI) devices. • Installation should seek to irradiate the maximal air volume with the highest intensity UV, while keeping staff and patient exposure to less than 6.0 mg/cm2 over an 8-hour period. • Emphasis on proper installation and maintenance.

40. Personal Respiratory Protection • Only N95 particulate respirator for HCW, properly fitting and used, provides some additional protection to the user against airborne infection • Masks (including 3-layer surgical masks) are effective primary for source control of patient, to catch what is going out, not what is coming in • Masks for HCW may be useful for large respiratory droplets and protection of mucous membranes (i.e. catch the spray from a sneeze before it hits your face) and remain a part of droplet precautions

41. Place of respirators in infection control activities • Proper implementation of administrative and environmental controls is first and second line of defense; • Respirators only add a layer of insurance where the risk to HCW is especially high. • Guidelines address situations where respirators appropriate, training, selection and fit, and re-use

42. When should respirators be used? Settings in India where particulate respirators are recommended for protection against airborne infection • 1) Laboratories: When manipulating cultures (solid or liquid media), despite use of biosafety hood or negative pressure facility • 2) Bronchoscopy: for all staff in bronchoscopy suite • 3) MDR Wards (opt): Respirators should be made available for optional use by staff, with all staff receiving training and sensitization on their use. • 4) As recommended by MoH to contain spread of disease of public health importance and unknown transmission (e.g. Influenza H1N1)

43. Households • Behaviour change campaigns for family members of smear positive TB patients • Maximize home ventilation • Practice cough etiquette • When smear positive, where possible sleep in separate room & spend as little time as possible in congregate settings • Sensible, practical, yet hygienic sputum disposal

44. Next Steps • Dissemination of national guidelines • Large facilities should begin managerial activities • Pilot testing of feasibility of interventions • 40 facilities, various types (MC, DH, CHC/RH, B-PHC), West Bengal, Gujarat, and Andhra Pradesh • Development of IC capacity • Managers, programme officers, facility administrators, • Architects and engineers • Engage with MCI / NCI / IPHS to integrate recommendations into curriculum/standards • Frontline healthcare workers on Standard Precautions, including airborne/TB

45. Thanks • NAICC Chair Prof SK Jindal • Committee members – Dr D Behra, Dr R Sarin, Dr R Singla (LRS), Dr A Agarwal (PGI), Dr V Chandrashekar (DGHS), Dr Gupta (NCDC), Dr Thakur (NACO), Dr Solanki (BJMC), Dr Rajesekaran (Chennai), Dr Anand (NTI), Dr Mahilmaran (GHTM) • CTD - Dr LS Chauhan, Dr K Sachdeva, Dr D Gupta, Dr M Parmar, Dr S Chadha • WHO – Dr S Sahu, F Wares • CDC – Dr M Pearson & Dr P Jensen