Implementing TB Infection Control in Out-patient Settings

As a healthcare professional, you have a vital role to play in tuberculosis infection
control in your clinic. If you see HIV positive patients
in your clinic, you know that they’re at
increased risk for getting TB because they’re very susceptible
to certain infections. In fact,
TB is the leading cause of death in people with HIV/AIDS. TB is different from other
opportunistic infections because it’s spread
by the respiratory route, and infected patients
can spread the disease to others in crowded clinics,
including you. This video is designed to
give you practical information to help you stop the spread
of TB in your clinic by improving
TB infection control practices. It’s based on the
World Health Organization Policy on TB Infection Control
in Health-Care Facilities, Congregate Settings
and Households. Use this video as a supplement to training
you’ve already received along with other
training materials, including the guidelines,
assessment and planning tools, posters and monitoring
and evaluation forms included with this video. Topics include how TB is spread,
who’s at most risk, and how to control TB. We’ll give you practical ideas
on how to make simple changes in your clinic set-up
and in your practices that can have a large impact
on your health and the health of your patients. TB is usually spread
when an infected person coughs and produces small droplets
which contain TB bacilli. The droplets remain suspended
in the air for hours. When someone
breathes in these droplets, he or she can become infected
with TB. There are several factors that can affect the likelihood
of TB transmission: The number of infected droplets
generated by a person with TB, the amount of time
a TB-infected person is in contact with others, the amount of ventilation in the area where the exposure
takes place, and the immune status
of the person exposed. TB is usually spread
by coughing patients who haven’t been recognized
as having TB and aren’t receiving treatment. So, it’s up to you
to notice coughing patients and get them diagnosed
and treated quickly. At the highest risk
of getting TB are those living with HIV/AIDS, people living in crowded,
poorly ventilated settings such as correctional facilities, military barracks
or refugee camps, patients with medical conditions such as diabetes,
cancer or renal failure, and those taking
immunosuppressive medications like steroids or chemotherapy and children
under the age of five. Who is most likely to interact
with all of these people? You are! Because of your job, you are very likely
to come into contact with many people who have TB and that puts YOU at high risk
of getting TB, too. To control TB there are four types
of infection control measures: Managerial Control Measures, Administrative Control Measures, Environmental Control Measures and Personal Protective
Equipment, or PPE. Remember, whatever your role
in the clinic, you are critical in carrying out these TB infection control
measures. Let’s take a closer look how. Facility administrators
and managers should provide leadership
by promoting a culture of safety and advocating
for necessary resources to conduct
infection control measures. This includes establishing
an infection control committee for the facility
that meets regularly, appointing someone to conduct
a facility assessment and developing an infection
control plan and policies. The basic building blocks
of infection control are the administrative
control measures and should be implemented
by all members of the team. These measures include prompt identification
of coughing patients, promoting cough etiquette, separating coughers
from other patients, and “fast-tracking” for prompt
diagnosis and treatment. They also include monitoring
the time it takes to get laboratory results back
(such as sputum smear results) and assuring the routine
evaluation of clinic personnel for TB. It is the undiagnosed
and untreated TB patient that presents the greatest risk
to others. It’s up to you to act
as early as possible to identify people coming into
the clinic who might have TB– and as you know, the most
visible sign is coughing. In a busy clinic, early identification
of coughing patients may be done
by the admissions clerk, a community health worker,
an educator or nurse. Work with your team to designate
the most appropriate staff for this critical task. Cough Etiquette
refers to the practice of covering all coughs
and sneezes to contain
respiratory secretions. All patients, visitors,
and clinic staff should be encouraged to cover
their coughs and sneezes with a handkerchief,
or a tissue. When a handkerchief or tissue
is not available coughing or sneezing
into the upper arm or elbow is the preferred technique for preventing the spread
of infection. This may seem strange, but infection control experts
recommend this technique as safer than coughing
or sneezing into the hands. Those who cough or sneeze
into their hands should wash them
with soap and water or use
an alcohol-based hand rub. If disposable surgical masks
are available, have coughing
or sneezing patients wear them to contain
respiratory secretions. Ask patients to dispose of masks
in the waste bin after use. A poster on cough etiquette
is included in the materials
accompanying this video. Promote cough etiquette every
chance you have in the clinic– at the entrance,
at registration, and every time you interact
with a patient or visitor. Remember you are a role model
for behavior in the clinic, so cover your own cough, too. A key method
for reducing TB transmission is to separate coughing patients
from non-coughing patients. A trained clerk, nurse or anyone that has contact with patients
as they enter the clinic can make
this initial separation. Ideally, coughing patients should wait in a separate,
outdoor area. This minimizes contact and takes advantage
of natural ventilation. You should explain to patients that no one will lose
their place in line and that this is
for their own protection. Once separated, coughing
patients should be fast-tracked or quickly examined
for additional symptoms to determine if TB
diagnostic tests are needed. Finally, as part of
administrative control measures, lab staff and the infection
control point person should monitor the time it takes
to get the lab results back, such as sputum smear results and assure there is routine
evaluation of clinic personnel for TB. Environmental Control Measures are the third major type
of infection control measures. They include the use of natural
and mechanical ventilation and ultraviolet
germicidal irradiation. These measures are used to reduce the number of
infectious droplets in the air. If your facility is planning a
renovation or new construction, it will be important to consider these environmental
infection control measures in the building design. Using natural ventilation in overcrowded waiting areas
and hallways is a relatively easy way to decrease the risk
of TB transmission. In warmer climates, building a covered outdoor
waiting area is an inexpensive and a good way
to maximize ventilation and reduce clinic congestion. Opening windows and doors
to maximize cross-ventilation reduces the number of infectious
TB droplets in the air. This works
in the home settings too, so instruct patients
to do this at home if a family member
is undergoing treatment for TB. In clinics, consulting rooms
should be arranged so airflow moves away
from the clinician toward the patient
to the outside. Electric fans can be used to assist in producing
this airflow pattern. Mechanical ventilation systems
designed for optimal airflow with the help of an engineer
can reduce TB transmission. But remember that ordinary
air-conditioning units do not reduce the risk
of TB transmission. Where available, ultraviolet
germicidal irradiation also known as UV lights or lamps placed in the upper parts
of a room help to clear the air
of infectious droplets. To be effective, UV lamps
need to be properly installed and regularly cleaned
and maintained. There are some environmental
control measures you can use to make sputum collection
less risky. Ideally, sputum collection
should be done outside in a designated location
away from other patients. When performed indoors, it should be done in
a well-ventilated room or booth designed to extract air
to the outside. Small,
poorly ventilated bathrooms should not be used
for sputum collection because they offer no safety to
other patients or staff members. The last TB infection control
measure we’ll discuss is Personal Protective Equipment
or PPE, which refers to the use
of particulate respirators and surgical masks. Particulate respirators
known as N-95’s or FFP2’s are worn by healthcare workers and are different
from surgical masks because they filter out
TB-infected droplets as you breathe in. If available, respirators
should be worn by staff when doing procedures
such as bronchoscopy and when caring for infectious
TB patients or suspects, especially when multi-drug
resistant TB is suspected. Surgical masks are not effective in preventing the inhalation
of TB droplets, but when worn by patients they can contain the majority
of droplets produced by coughs or sneezes, thus reducing the risk
of transmission. Staff and patients often have concerns about stigma
during triaging or when using particulate
respirators or surgical masks. It’s important for you
to be aware of these issues and discuss ways to approach
and communicate with patients to minimize stigma. In summary, we’ve covered the
basics of TB infection control including; how TB is spread,
who is at most risk for TB; and the managerial,
administrative, environmental and personal protective
equipment measures that can be used to control TB. You personally
are very important in preventing TB transmission — from one patient to another, from a patient to a visitor
in your clinic, and to yourself and your family. If you think
you may be infected, it’s important to get screened
and seek care immediately. Although tuberculosis
is a serious disease, it can be treated and cured. People coming into the clinic
look to you as a knowledgeable
health professional. You are in the best position to educate them about
TB infection control and to demonstrate
good infection control habits. You CAN make a difference
in TB infection control in your facility,
in your community, and in your country.

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