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TB INFECTION CONTROL Reconceptualizing the Approach PowerPoint Presentation
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TB INFECTION CONTROL Reconceptualizing the Approach

TB INFECTION CONTROL Reconceptualizing the Approach

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TB INFECTION CONTROL Reconceptualizing the Approach

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  1. TB INFECTION CONTROL Reconceptualizing the Approach Dr. Jessica Justman Dr. Wafaa El-Sadr Dr. Doris Macharia Director, UTAP Program Director, ICAP Country Director, ICAP-South Africa ICAP, Columbia University September 24, 2007 PEPFAR Track 1.0 Meeting, Atlanta

  2. Background • High rates of undiagnosed, untreated TB in HIV settings • Motherwell Community Health Centre, SA • 573/597 HIV pts screened for TB • 129 (22%) with TB disease • Gisenyi Day Hospital in Rwanda: 22% of HIV-infected inpatients found to have TB disease • Role of nosocomial transmission, esp MDR/XDR

  3. Updated Figures from Tugela Ferry From January 2005 to March 2007: • 433 TB cases resistant to at least INH and RIF • 239 (55%) XDR TB cases • 199 (84%) confirmed dead • 194 (45%) MDR TB cases (not XDR TB) • 119 (65%) confirmed dead • Greater than 90% of MDR and XDR TB patients found to be HIV infected • If no new interventions are introduced, a total of ~1,300 cases of XDR tuberculosis predicted • Over half nosocomially transmitted G. Friedland, MD

  4. What can be done to avert nosocomial XDR TB cases?Modeling of strategies Administrative measures Environmental measures Combinations of strategies Personal protective measures Impact of Preventing Nosocomial Transmission of Extensively Drug-Resistant (XDR) Tuberculosis in Rural South African District Hospitals Basu, S, Andrews A, Poolman E, Gandhi N, Shah S, Moll A, Galvani A, Friedland G (Lancet ( in Press )

  5. Efficacy of Rapidly Available Strategies to Reduce Nosocomial Transmission • Individual strategies reduce transmission but available ones have small-moderate effects • Administrative 2-5%, • Environmental 30-40%, • Personal < 10% ( hospital staff infections reduced by 67%) • Combinations of strategies are synergistic and can avert 48% (625 cases) in next 5 years • Decreased length of stay + rapid dx + increased natural ventilation + patient isolation + VCT + masks Impact of Preventing Nosocomial Transmission of Extensively Drug-Resistant (XDR) Tuberculosis in Rural South African District Hospitals Basu, S, Andrews A, Poolman E, Gandhi N, Shah S, Moll A, Galvani A, Friedland G (Lancet ( in Press )

  6. TB Prevention and Infection Control • Limited infection control in resource-limited settings • Environmental controls—expensive ventilation systems • Administrative controls—often lacking • Personal protective devices—seldom used • New approach needed

  7. Primary Objective To minimize nosocomial transmission of TB • help health care workers to reduce source infectiousness • HCW to promote rapid identification of patients with active TB • HCW to rapidly initiate TB treatment • HCW to promote adherence to treatment • Simple designs of renovated facilities

  8. Proposed activities • Select two sites for study • Motherwell Community Health Centre and Cecelia Makiwane Hospital proposed • Assess TB infection prevention and control knowledge and procedures to identify needs • Renovate facilities to minimize TB transmission • Establish work practice, clinical management and administrative procedures at each site • Assess uptake of interventions • Develop implementation manuals and tools

  9. Eastern Cape,SA Third most densely populated SA province 14% of total SA population Predominantly rural Declines in mining industry HIV prevalence estimate 23% Smear positive case rate ~300/100,000

  10. Cumulative enrollment in HIV care (pre-ART and ART) & ART care at ICAP-South Africa supported facilitiesJuly 2004 – June 2007 HIV care (pre-ART & ART) ART care ART patients retained* Source: ICAP URS, July 2007 *Includes ART patients who are not known to have died, transferred or lost to follow-up.

  11. Number of ICAP-supported facilities by USG-funded activity, South Africa Source: ICAP South Africa Site Census, August 2007

  12. Motherwell and Cecilia Makiwane sites proposed Rietvlei Hospital & Clinics / Mzimkulu District ICAP Satellite Office, Port Edward St. Patrick’s Hospital / Qaukeni District Clinics / Holy Cross Hospital ICAP Main Office, East London ICAP Satellite Office, Port Elizabeth Frere Hospital & Clinics Ikhwezi Lokusa Wellness Center Empilweni TB Hospital Cecilia Makiwane Hospital & Clinics Dora Nginza Hospital Livingstone Hospital Nelson Mandela Metropolitan Municipality Clinics: Zwide, New Brighton, Chatty, Masakhane ProvincialClinics: Kwazakhele, Motherwell, Walmer 14th Ave

  13. Proposed activities • Select two sites for study • Motherwell Community Health Centre and Cecelia Makiwane Hospital proposed • Assess TB infection prevention and control knowledge and procedures to identify needs • Renovate facilities to minimize TB transmission • Establish work practice, clinical management and administrative procedures at each site • Assess uptake of interventions • Develop implementation manuals and tools

  14. Baseline site assessment • Standardized tool to assess knowledge and attitudes of health care workers regarding TB transmission, nosocomial TB, protective devices and infection control practices. • Observational assessment of health care practices including triage of TB patients, securing and dispatching sputum samples, time patient spends in clinic, time to receipt of results, laboratory procedures, etc.

  15. Design Of Renovated Facilities Develop simple guidelines for simple structural and design approached in renovation of HIV care and treatment sites to minimize nosocomial transmission of TB • Ventilation: open waiting areas, new windows, fans, UVGI • Isolation: separate waiting areas

  16. Work Practice Proceduresto promote HCW’s role in rapid identification of patients with active TB Develop training and mentoring materials • focused on active case finding of TB cases • tailored to HCW needs identified in baseline assessment Develop systems • for consistent use of TB symptom checklist • to obtain high quality sputum samples • to transport sputum samples and to obtain results • Linkages between HIV and TB services

  17. Specific Implementation Activities • Hire TB Prevention and Control advisors • Establish policy with multidisciplinary TB Prevention and Control team • Triage systems with dedicated triage staff • to screen all patients at every visit and refer TB suspects to separate, ventilated area. • Rapid diagnosis with sample tracking system • Rapid initiation of treatment • Adherence with DOT • Community education

  18. 1. Has the patient had a cough for > 3 weeks? • . Has the patient had night sweats for > 3 weeks? • . Has the patient lost > 3kg in the past 4 months? • . Has the patient had fever for > 3 weeks? • . Has the patient had recent contact with another person with active TB? • If “Yes” to question 1: The patient is a TB suspect, perform sputum collection for acid fast bacilli smear and continue evaluation for TB per the TB control program diagnostic algorithm for pulmonary TB • If “No” to question 1 but “Yes” to any other question: The patient is a TB suspect, continue evaluation for TB guided by clinical signs and symptoms. Refer to national reference hospital if necessary. • If “No” to all the questions: The patient is not a TB suspect at this time, stop investigations for TB and repeat screening with questionnaire every 3 to 6 months. • *modified from Mohammed et al, 2004.

  19. Specific Implementation Activities-2 • Training and mentoring • TB transmission, self-protection through rapid diagnosis and treatment of TB, effective triage of patients, diagnosis of TB, initiation of TB treatment and importance of retention of patients and adherence with treatment, linkage to the laboratory • routine mentoring and annual CME to reinforce • Confidential HIV counseling and testing • Adequate access to treatment • TB preventive therapy for HIV-infected health care workers will be provided

  20. Specific Implementation Activities-3 • Evaluate impact of interventions • Level of uptake of interventions • [Individual vs combinations of interventions] • Develop and distribute implementation manuals and tools (posters, flip charts)

  21. TB / HIV INTEGRATION (by site) Port Elizabeth

  22. Summary • Proposal focuses on reconceptualizing TB infection control by helping health care workers to reduce source infectiousness • 2 SA sites—health centre and hospital • Trainings and work practice interventions aimed at HCWs protecting themselves and their patients • Assess level of uptake