TB Infection Control within the palliative care context

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TB Infection Control within thepalliative care context

Kath Defilippi

Patient Care Portfolio ManagerHospice Palliative Care Association of South Africa (HPCA)

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During this presentation:

• TB infection control will be discussed in relation to the disease transmission cycle

• Additional interventions implemented by HPCA will be shared

• Although drug resistant TB will be specifically mentioned, the focus is on general infection control iro TB in the palliative care context and includes both adults and children

MYCOBACTERIIUMTB

1. RESERVOIR5.SUSCEPTIBLE

HOST

4. PLACE

OF ENTRY

2. PLACE OF EXIT

3. METHOD OF TRANSMISSION

Disease-producing agent

How the agent moves from place-to-place or person-to-person

Where the agent leaves the host

Place where the agent lives

Where the agent enters the next host

Person who can become infected

Adapted from JHPIEGO, 2003

Disease Transmission Cycle

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The agent – mycobacterium tuberculosis• Has been active in humans for hundreds of years

• Acid fast slightly curved rod shaped bacillus 0.2-0.5 microns in diameter; 2-4 microns in length

• Thick lipid cell wall

• Multiplies slowly (every 18-24 hours)

• Aerobic – pulmonary TB most common variety

• One cough can release 3,000 droplet nuclei – one sneeze can release tens of thousands

• Initial infection – can remain dormant for decades as latent TB Infection (LTBI)

CDC Training, Pretoria University, August, 2010

Granuloma

Control of replication

Latent TBinadequate control of replication

ACTIVE TB

No disease(control of replication)

Bacterial replication

Immunosuppression

REACTIVATION

COURSE OF INFECTION

fibrosis

G Kaplan, CDC Training, University of Pretoria, Aug, 2010

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Conditions that promote progression of LTBI toactive TB disease• Overcrowding• Malnutrition• Age very young – immature immune system • very old – deteriorating immune system

• HIV infection – immune suppression - A healthy person with a strong immune system has a

10% chance per lifetime of developing TB disease - An HIV+ person has a 10% chance per year of developing TB

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“Everywhere in the world, whenever a new case of infectious tuberculosis emerges, the diagnosis and commencement of treatment are usually only made after that case has already infected one or more other persons”. JD Klausner, CDC Training , Pretoria University, August , 2010

Given the HIV/TB co-infection rate, statistics collected from HPCA member organizations suggest that there are a large number of undiagnosed TB patients already on palliative care programmes in South Africa.

In Sept 2010 out of a total of 31,685 HIV+ patients there were only 4,831 diagnosed with TB (15.2%)

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1. Decreasing the reservoir • Screening and referral for further investigation of TB:

• all new patients admitted to the pall care programme

• all existing patients who develop any of the signs and symptoms on TB screening tool

• all staff and volunteers on appointment and thereafter at least annually

• all staff and volunteers developing any of the signs and symptoms listed on TB screening tool

NB for palliative care programmes to liaise with DOH partners

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Contacts who are at risk of contracting TB in the home care setting where 99% of palliative care patients are to be found

• 9Health Care

Workers

Neighbours

Family*

Person with

infectiousTB

* Especially children under 5 years

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Indicators of probable TB disease in severely immune-suppressed patients

According to studies done by Hardman and Ong the most important indicators are:

• Significant recent weight loss• Persistent low grade fever• Night sweats• Cough

Only 60% of patients had a cough in Ong study

CK Ong et al Tuberculosis -HIV Coinfection: The relationship between manifestation of tuberculosis and the degree of immune-suppression le JSME: 2(2): 17-21

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HPCA TB Screening Tool

• All newly admitted patients to IPU and HBC programmes

• Visitors and family members

• All new staff /annual screening

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1.1 Decreasing the reservoir iro of patients/families

• Information regarding TB disease included in the health education given to all HIV+ patients and their families

• A person-centred approach to the provision of treatment adherence support and the management of side effects of TB drugs

• Promoting the relevant rights and responsibilities from the Patients Charter for Tuberculosis Care (p15 HPCA Guidelines)

• Advocating for all HIV+ patients with TB to commence with ART asap, including those on TB treatment

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Photo South Coast HospiceKwa-ZuluNatal

Photo St Bernard’s Hospice E Cape

Challenging environment in which infection control is implemented in HBC setting

Open air support group

Photo Msunduzi Hospice KZN

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1.2 Decreasing the reservoir iro staff and volunteers

• Staff wellness programme to promote and maintain optimal immune status

• Mandatory training on TB including infection control, for all categories of staff and volunteers

• Creating an organisational environment conducive to disclosure of HIV and TB status

• INH preventive therapy for HIV+ staff without signs of active TB

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Training community caregivers on infection control

Photo St Bernard’s Hospice, East London

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2.0 Infection control linked to place of exit of MTB

COUGH HYGIENE! COUGH HYGIENE!COUGH HYGIENE! Picture – G Kaplan, CDC Training, Pretoria University, August, 2010

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2.1 Infection control linked to place of exit• Policies in place regarding criteria for admission of TB patients

to palliative care programmes (HPCA Draft Guidelines p 12-14)

• Generally patients with TB in the lungs or larynx should be considered infectious until they have:• Completed 2 wks of TB treatment and show improvement in

clinical symptoms

• In the case of MDRTB:• Had two consecutive negative sputum smears on two

different days. At least one specimen should be an early morning specimen

• Safe sputum collection (HPCA Draft Guidelines p 23)

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3.1 Prevention of transmission

• Good ventilation can help reduce the risk of infection by diluting and/or removing infectious particles in the air

• A well-ventilated space has air constantly entering and leaving, allowing an effective mixture of air

• This effective mixture increases the dilution of infectious particles

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3.2 Promote good natural ventilation to prevent airborne transmission of MTB

• Keep doors and windows open especially in areas where people congregate inside a building

• Where electricity is available, use fans to blow air out of the room

• Hold support groups in the open air whenever the weather permits

• Encourage patients and family members to sit outside in the sun

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5.1 Susceptible children

• All children who have been exposed to an adult with infectious TB must be referred for investigation

• - they should then either receive first or second line treatment or be given INH preventive therapy (IPT)

• Young children with TB are usually not a risk to other children or adults

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4.0 Infection Control linked to place of entry - airborne mycobacterium tuberculosis

Personal Controls• Surgical masks

• No protection against infectious droplets

• May limit distribution of large particles

• Consider for coughing patients

• Respirators for caregivers• Filter >95% of infectious droplets (N95)• Fit-testing required• Valuable during aerosol-producing

procedures• May be re-used if handled properly

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4.1 Implement universal precautions linked to the prevention of HIV infection

• Hand washing and the wearing of gloves whenever there is contact with bodily secretions

• Covering any breaks in the skin

• Effective disposal of all potentially contaminated waste

• Safe disposal of sharps

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5.0 Protection of susceptible family membersIn the case of MDR TB • Assess home prior to admission of patient, prepare and

capacitate family to implement the necessary infection control measures

• Ensure that there are separate sleeping arrangements

• No children under 5 years in the household

• If possible no elderly relatives in the household

• Monitor response to second line treatment and liaise with MDR unit re management of side effects

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5.1 Protection of susceptible health care workers in palliative care teams• Provide effective facial masks and monitor their use

• As far as is possible do not allow immune compromised staff and volunteers to have direct contact very ill AIDS patients who could have undiagnosed TB or with MDR TB patients

• Promote disclosure of HIV and TB status

• INH preventive therapy

• Care for the caregiver programmes

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5.2 Personal Protective Equipment

In order for facial masks to be effective:-Must be large enough to fully cover the nose, lower face,

jaw, and facial hair-Must be made of fluid-resistant materials

All staff/volunteers caring for patients must begiven gloves and have access to aprons

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5.3 Infection Control Plan

Designated responsibility reflected on job description/s

Includes assessment of TB infection control risks

Written policies and procedures

In-service training for all categories of staff /volunteers

Forms part of Risk Management Programme which is evaluated annually

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5.6 Staff Training

Each staff person should understand the importance of infection control & their role in implementing infection control

Job descriptions should include specific infection control duties

Infection control should be included as part of staff orientation and in-service training, and include those not directly involved in patient care

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Additional interventions adopted by HPCA 2nd edition of the Hospice Palliative Care Standards include criteria on:

• Screening for TB as part of initial and ongoing assessments• TB infection control and training• Inclusion of TB in risk management and quality improvement

programmesSurveys are conducted to assess compliance with the standards on a

regular basis

Infection control guidelines distributed to all members• Implementation of infection control monitored via audit tool

Development of Guidelines for providing palliative care to patients with TB

Development of a specific 5-day training course for TB in the palliative care setting

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Topics included in TB master training course

Global, national and provincial overview

SA National TB programme (4 I’s)

Diagnosis and investigations (pulmonary and extra-pulmonary TB) adults and children

Palliative care principles within the context of TB

History of TBEpidemiology

Communication

Collaboration, referrals and networking

Special paediatric considerationsIPT

Monitoring evaluation and reporting

Prevention and Infection Control – adults and childrenTB as part of risk management

Treatment adherence supportPatient and family education

Drug resistant TB Integration of TB and HIV IRIS – implications for palliative careprogrammes

Providing care for TB patients, including end of life careLoss, grief and bereavement

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Sincere thanks to:HPCA TB Task Team and the reference group of TB

experts - in particular Prof David Cameron

Open Society Institute

Worldwide Palliative Care Alliance