Infection Control Guidelines in Tuberculosis [compatibility mode]

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The aim today is to cover three focus areas

MANAGEMENT OF SUSPECTED / CONFIRMED CASES OF INFECTIOUS TUBERCULOSIS

Tracing HCWs exposed to patient with active pulmonary tuberculosis

1stArea

2ndArea

3rdArea

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Spread of infection within the hospital requires three essential elements, a source of infecting organisms, a susceptible host and a mode of transmission. Each element is being equated to a link in a chain.

This chain analogy is used to represent the series of interactions which are necessary to produce an infection process. To prevent transmission of infection, it is important to understand the role each element (link) plays.

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How are infections transmitted?How are infections transmitted?

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Standard PrecautionsStandard Precautions Expanded PrecautionExpanded Precaution

Primary strategy for Primary strategy for preventing transmission preventing transmission

of microorganisms to of microorganisms to patients, They are patients, They are

applied to all patientsapplied to all patientsHand hygiene &Hand hygiene &

Appropriate use ofAppropriate use ofPPEPPE

Transmission Based Transmission Based Precautions for patient Precautions for patient

with suspected orwith suspected orconfirmedconfirmed

communicable communicable diseasedisease

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Pulmonary TBMesealsChickenpox

MeningitisInfluenza A

H1N1Mumps

MDR

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TB

TB

TB8

MANAGEMENT OF SUSPECTED / CONFIRMED CASES OFINFECTIOUS TUBERCULOSIS

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Identify patients who have active TB at the time of triage. HCWs who are the first point of contact in facilities that serve populations at risk for TB should be trained to ask questions that will facilitate identification of patients with signs and symptoms suggestive of TB.

Evaluate promptly patients with signs or symptoms suggestive of TB to minimize the amount of time spent in the Emergancy Room or Ambulatory Care areas.

Follow airborne TB precautions while the diagnostic evaluation is being conducted for such patients. These precautions include:

Placing such patients in a separate area apart from other patients, and not in open waiting areas ( ideally, in a room or enclosure meeting TB isolation requirements).

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Provide patient with surgical masks to wear and instructing them to keep their masks on.

Giving these patients tissues and instructing them to cover their mouths and nose with the tissue when coughing or sneezing.

Schedule appointments for such patients for health care clinics in order to avoid exposing other patients and HCWs.

Place patient in appropriate room, i.e negative pressure room. Ideally, ambulatory- care setting in which patients with TB are frequently examined or treated should have a TB isolation room(s) available.

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Place patient in a single, negative pressure room. Maintain patient in his/ her room at all times. If must

leave the room he/she must wear a mask, see comments for type of mask.

Ensure that doors and windows are closed at all times to maintain negative pressure.

Limit number of individuals entering the room. Use N 95 filter mask prior to entering the room. Educate HCWs and visitors regarding the importance

of adherence to these policies.12

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•• Select a fit tested respirator• Place over nose, mouth and chin• Fit flexible nose piece over nose bridge• Secure on head with elastic• Adjust to fit• Perform a fit check – Inhale – respirator should collapse Exhale – check for leakage around face

How to Don a Particulate Respirator

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• Lift the bottom elastic over your head first

• Then lift off the top elastic

• Discard

Removing a Particulate Respirator

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•• Select appropriate type and size

• Opening should be in the back• Secure at neck and waist• If gown is too small, use two

gowns Gown #1 ties in front Gown #2 ties in back

How to Don a Gown

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•• Unfasten ties• Peel gown away from

neck and shoulder• Turn contaminated

outside toward the inside• Fold or roll into a bundle• Discard

Removing Isolation Gown

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HAND HYGIENEDr. Nahla Moustafa

MD, PhD. Public HealthInfection Control Director, MCH ,Najran

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Waterless Hand Rub “alcohol-based hand

rub

Routine Hand Washing

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~ Use soap and water for visibly soiled hands ~~ Do not wash off alcohol handrub ~

Apply to palm; rub hands until

dry

Wet hands, apply soap and rub for

>10 seconds. Rinse, dry & turn

off faucet with paper towel.

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Isolation Precautions

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•Maintain patient with protective apparel in place.•Expedite procedure to minimize patient stay.•Observe specific isolation techniques. •Wash hands before and after contact with patient.•Arrange for patient’s return to ward as soon as possible.•Change linen, clean equipment and environmental surfaces as indicated before the next patient.

D.TRANSPORTING PATIENTS ON AIREBORNE ISOLATION PRECAUTIONS

In The Receiving Department

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D.TRANSPORTING PATIENTS ON AIREBORNE ISOLATION PRECAUTIONS

•Notify the department to which the patient is to be transported of the isolation precautions that are in effect. •Instruct the patient of ways he/she can assist in maintaining appropriate precautions to prevent transmission of the infection.•Dress wounds with impervious dressings as required.•Dress the patient in a clean gown.•Explain to the patient the need for the protective apparel he/she is required to wear.•Put a mask on the patient who is in Airborne isolation. •Place the patient on a stretcher/wheelchair as appropriate and cover wheelchair/ stretcher with a sheet.•Cover the patient with a clean sheet.•Transport the patient to the area as required.•Return the patient to the isolation room as soon as circumstances allow. •Clean and disinfect wheelchair or strecher with the approved disinfectant.

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Once active disease has been ruled out OR

If diagnosed with active disease, must be on adequate therapy, recovering clinically,

and has had 3 negative sputum for AFB on 3

separate days. Consult with Infection Control Directorprior to discontinuing isolation

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Elective operative procedures on patients who have TB should be delayed until the patient is no longer infectious.

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Perform procedures if possible, in operating rooms that have anterooms. For operating rooms without anterooms, the doors to the operating room should be closed, and traffic into and out of the room should be minimal to reduce the frequency of opening and closing the door.

Attempts should be made to perform the procedure at a time when other patients are not present in the operative suite and when a minimum number personnel are present (e.g, at the end of the day).

Place a bacterial filter on the patients endotracheal tube.

Recover patient in the operating room.

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In general Sitters are not allowed for patients who are being treated in isolation for airborne, communicable or contagious diseases. Exception to this policy will only be allowed after consultation and upon approval of the Director, Infection Prevention and Control Program or designee.

Every patient and allowed sitter in isolation will follow isolation precautions.

It is the responsibility of every patient and his/her allowed sitter to abide with all infection control rules and regulations at his/her sign.

It is the responsibility of the Hospital Staff to educate the patient in isolation and his/her allowed sitter about all infection control rules and recommendations.

It is the responsibility of the Hospital Staff to monitor the compliance of the patient in isolation and his/her allowed sitter with infection control isolation recommendations.

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What the risk of exposure?How we can prevent the

exposure?If the exposure is already

done, what is the exposure management plan?

Employee HealthTracing of Exposed HCWs

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1.All employees must comply with the Employee Health tuberculosis screening program. 2.All employees must report to Employee Health if they have any symptoms suggestive of tuberculosis infection or if they have experienced exposure to smear-positive patients.3. BCG will not be given to those who are PPD test negative. 4.PPD Conversion Rate should be calculated annually

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Confirm TB Exposure

Exposure ControlPLAN

MANGEMENT OFTB

EXPOSED STAFF

TRANING IN EMPLYEE HAELTH & SAFTY

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The single most effective measure to control the transmission of Open Pulmonary TB:

Airborne Precautions

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MANAGING MYCOBACTERIUM TUBERCULOSIS EXPOSURES

1. Incubation Period2-10 weeks from exposure to detection of positive Purified Protein Derivative (PPD); risk of developing active disease is greatest in first 2 years after exposure.

2. Exposure CriteriaSpent time in a room with a person who has active disease without wearing an N95 respirator; packing or irrigating wounds infected with M. tuberculosis without wearing an N95 respirator.

3. Period of CommunicabilityPersons whose smears are AFB-positive are 20 times more likely to cause secondary infection than persons who are smear-negative; children with primary pulmonary TB are rarely contagious.

4. Employee HealthObtain baseline PPD if not done recently and if HCW previously negative; perform post exposure PPD at 12 weeks; prescribe prophylaxis if postexposure PPD is positive.

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5.Work Restrictionsa.Exposed

None for persons whose PPD becomes positive.b.Infected

Restrict HCWs with active TB until after they have taken 2-3 week of effective antituberculosis chemotherapy and they have had 3 negative sputum samples for AFB on 3 separate days.

6. Prophylaxis Isoniazid 300 mg daily for 6 mo, or 12 mo for HIV-infected persons and pyridoxine 20-40 mg daily.

MANAGING MYCOBACTERIUM TUBERCULOSIS EXPOSURES

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Person identified with possible active M ycobacterium tuberculosis

Notify ICP& Initiate airborne isolation PrecautionsS

StopNo

ICP and involved area(s) generate contact list of exposed HCW

Supervisor directs exposed HCW to Employee Health

Confirm diagnosis.Was M TB or AFB found in respiratory

secretions or wound drainage?

StopNo

Assess if HCWexposed. Did HCW share a ir space with

confirmed case while not wearing a respirator?

Yes

Employee Health assessesHCW, administers baselinePPD, repeats PPD in 12 weeks, prescribes prophylaxis

for PPD conversion

Complete documentation and reports as necessary

Yes

Yes

Abbreviations:AFB Acid-fast bacilliHCW Healthcar Worker

ICP Infection Control Professional

IgG Immunoglubulin GIgM Immunoglubulin MPt PatientPHN Public health nurseM TB M ycobacterium

TuberculosisPPD Purified Prote in Derivative * See Explanation

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