INFECTION CONTROL PRACTICES Rebecca O. Sanchez, RN, BSN, MPH Texas Department of State Health Services Texas Center for Infectious Disease Rebecca O. Sanchez, BSN., RN., MPH. has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity 1
INFECTION CONTROL Is In Your Hands! CENTER FOR DISEASE Makes the recommendations for all Infection Control Programs Implementation of these recommendations will prevent and control numerous types of communicable diseases and infections Updating your current Infection Control Policies with the guidelines is a must to accomplish and attain Healthy People 2010 2
INFECTION CONTROL Chain Of Infection Infections can spread when chain is broken opportunity for exposure Adhere to good Infection Control practices Always observe precautions as to disease and its spread Know the Causal Pathway of Disease CAUSAL PATHWAY OF DISEASE OR DISABILITY Environment (pre-exposure) Hazard/agent Behavior/risk factor Exposure Pre-symptomatic phase Apparent disease Death 3
PUBLIC HEALTH SURVEILLANCE Ongoing, systematic collection, analysis, and interpretation of healthrelated data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control. Passive PASSIVE VS. ACTIVE SURVEILLANCE - Provider-initiated Active - Health Department-initiated 4
PUBLIC HEALTH APPROACH Surveillance: What is the problem? Problem Risk Factor Identification: What is the cause? Intervention Evaluation: What works? Implementation: How do you do it? Response PUBLIC HEALTH SURVEILLANCE Systematic, ongoing Collection Analysis Interpretation Dissemination Link to public health practice 5
INFORMATION LOOP OF PUBLIC HEALTH SURVEILLANCE Public Reports Summaries, Interpretations, Recommendations Health Care Providers Health Agencies Analysis CDC GUIDELINES CDC Guidelines has three major components of Infection Control: Administrative Controls Environmental Controls Respiratory Controls 6
ADMINISTRATIVE CONTROLS Reduce risk of exposure to persons who might have TB disease Policies and procedures Safe work practices Education and training Employee screening programs ADMINISTRATIVE CONTROLS Screen all employees-employees can be: Low-risk Pre-placement: TB screening questionnaire and TST (2-step) or interferon gamma release assays (IGRA) Periodic: none, unless unprotected exposure occurs Medium-risk Pre-placement: TB screening questionnaire and TST (2-step) or IGRA Periodic: annual TB screening questionnaire and TST or IGRA, if negative Pre-placement CXR if documented past positive TST/IGRA or normal CXR no more than 6 months prior to hire Routine periodic CXR s no longer recommended Medical evaluation, as indicated 7
ENVIRONMENTAL CONTROLS Environmental: physical or mechanical measures that prevent spread and reduce concentration of droplet nuclei Ventilation General Local exhaust AIIR s (negative pressure) Filtration UVGI ENVIRONMENTAL Prevent spread by Controlling the source of infection thru local exhaust ventilation /air exhaustoutdoors Diluting/removing contaminated air by general ventilation (circulate the air) Cleaning the air by HEPA filtration or Cleaning the air by ultraviolet germicidal irradiation (UV Light) 8
ENVIRONMENTAL CONTROLS VARY WITH THE SETTING When local exhaust ventilation is not available perform cough inducing procedures outdoors, away from people IN THE CLINICS Early identification and triage is key: Encourage all clinic personnel (registration clerks) to identify persons who are coughing, or have upper respiratory symptoms and Refer to clinic nurse for quick triage. Persons with: Persistent cough (> 3 weeks) plus 1 or more other symptoms of TB disease Positive AFB sputum smear Recent initiation of anti-tb therapy (< 2 weeks) or has not demonstrated clinical response to therapy Any person coughing up blood Any person with unexplained fevers 9
ADMINISTRATIVE MEASURES TO TAKE Early identification in triage requires to: Mask patient (surgical mask) and temporarily isolate or segregate by placing in (exam room/closed door) Explain reason for masking and separation Monitor to ensure compliance Change masks when damp or torn Provide tissues if unable or unwilling to wear mask ADMINISTRATIVE CONTROLS In the clinic trained staff must use: Appropriate NIOSH-certified N-95 respirators In presence of a suspected or confirmed infectious TB patient who is unable/unwilling to wear a mask Entering a room that has been occupied by a person with suspected or confirmed infectious TB Transporting or accompanying a person with suspected or confirmed infectious TB in an enclosed vehicle In the presence of high-risk procedures, e.g., sputum collection 10
ADMINISTRATIVE CONTROLS In the field When conducting home visits and When appropriate, conduct visit outdoors If indoors provide and Ask patient to wear surgical mask Open a window or door; turn on fan, if available Sit near fresh air source (a door or window) Wear an N-95 respirator Reduce exposure time If supervising sputum collection, take patient outdoors HOME VISITS Provide patient and family education on Tuberculosis Inform patient to remain at home and avoid public places as much as possible (Home Isolation) The physician (Health Department) will determine and provide authorization to return to work, or and school, etc. 11
ADMINISTRATIVE CONTROLS Education in the field Patient and family education includes: How TB is transmitted, and how it is not Importance of adherence to treatment regimen Effectiveness of natural ventilation and fans for air mixing and removal Private space, if possible (sleep in separate room) Cough etiquette (cover mouth when coughing) Previously unexposed visitors (family, friends, etc.) are not allowed in the home and no small children ADMINISTRATIVE CONTROLS In the field as you conduct a visit: Assess patient for symptoms, clinic visits, educate and observe for: adherence to treatment regimens of both patients and contacts (friends or family member) Check all medication bottles and count the tablets Assess progress made in evaluation of previously identified contacts Identify new contacts and coordinate their evaluation with the local health department or clinic. Arrange transportation as needed 12
TRANSPORTING TB PATIENTS Instruct patient to wear a surgical mask Staff requires NIOSH N-95 respirator No additional passengers in the vehicle Set ventilation controls to fresh air or vent Set fan to high Open windows Leave windows open for at least 1 hour COMPONENTS OF A TB INFECTION CONTROL PROGRAM Written policies and procedures Medical screening Protect in situations that pose a high exposure riskannual training with Face Fit Testing Prevent the spread and reduce concentration of infectious droplet nuclei Reduce risk of exposure (user face seal checks) 13
PERSONAL RESPIRATORY PROTECTION PROGRAM Two critical elements along with Infection Control: Training of HCW The selection of appropriate, well-fitting respirators Respiratory protection: used when administrative and/or environmental controls fail to provide adequate protection or is not applicable: 14
PERSONAL RESPIRATORY PROTECTION PROTECT IN HIGH RISK SITUATIONS Should be used by persons: Entering areas of isolation Present during cough inducing/aerosol generating procedures In other settings during your home visits RESPIRATORY PROTECTION Use NIOSH-certified respirators, ONLY NIOSH approval label N-95 filters are rated at 95% efficiency or greater Respirators effective against TB Air purifying Atmosphere supplying 15
RESPIRATORY PROTECTION Nonpowered air-purifying Disposable particulate respirators Most common adequate for most circumstances Advantages Light weight Reasonably comfortable to wear Requires no cleaning or maintenance discard when damaged, wet or soiled Inexpensive Disadvantage: air leakage into facepiece RESPIRATORY PROTECTION Advantages Significantly reduces exposure to M. tb Protects HCW in the field when environmental controls are not available Requires no cleaning-disposable, light weight Disadvantages Barrier to emotional contact Impairs verbal communication May foster feelings of isolation or being stigmatized Can jeopardize patient s confidentiality Uncomfortable/ if not fitted air leakage can occur Interferes with vision when glasses are worn 16
ADMINISTRATIVE CONTROLS Respiratory tract disease Defining Infectiousness Suspected or Confirmed TB Disease Poor cough etiquette Cough lasting > 3 weeks Cavitation on CXR Positive AFB sputum smear results Cough-inducing or aerosol-generating procedures Untreated, nonstandard treatment, or early in course of treatment ADMINISTRATIVE CONTROLS Transmission of M. tb is most likely to result from exposure to persons who have Unsuspected/Undiagnosed pulmonary TB Diagnosed TB disease, but are receiving inadequate therapy Diagnosed TB disease, but are early in the course of therapy 1 st line of defense early identification and isolation of infectious cases 17
TRANSMISSION OF M. TUBERCULOSIS Person-to-person via airborne droplet nuclei Chain of transmission Infectious source Environment (air path) Susceptible host Infection control breaks the chain of transmission INFECTIOUSNESS OF TB Patient considered infectious if: Disease in lungs, airway, or larynx, or Coughing, or Undergoing cough inducing procedures, or Positive AFB sputum smears AND Not on anti-tb therapy, or Has just started therapy, or Has poor clinical or bacteriologic response to therapy 18
INFECTIOUSNESS OF TB Extrapulmonary TB is usually not infectious unless: Concomitant pulmonary disease TB in oral cavity or larynx Open abscess or lesion with high concentration of organisms Aersolization of organism during dressing changes A CHEST RADIOGRAPH IS ORDERED 19
CAVITARY DISEASE ADMINISTRATIVE CONTROLS Confirm TB disease hospitalize patient Patient should remain under airborne precautions until diagnosis is confirmed 3 consecutive sputum smears collected 8 24 hours apart; one early AM specimen Place on standard, multidrug anti-tb therapy (minimum of 2 weeks) once confirmed as directed Isolate patient until there is Demonstrated clinical improvement and patient is symptomatic free (no cough, no fever) 20
ADMINISTRATIVE CONTROLS Suspected TB disease hospitalized patient If suspicion of TB disease remains after 3 negative AFB sputum smear results, do not release from airborne precautions until Patient has had standard, multidrug, anti-tb treatment at least (5-7 days) Improving clinically (decreased cough, resolution of fever) Consider sputum induction if specimen in question, induce sputum or obtain a bronchoscopy INDIVIDUALIZED DECISION MAKING FOR ISOLATION AT HOME OR HOSPITAL Extent of illness Presence or absence of cavitary disease Degree of sputum smear positivity Frequency and strength of cough Likelihood of MDR infection Nature and circumstances of contact and compliance with medication 21
ADMINISTRATIVE CONTROLS Children with confirmed or suspected TB Less likely than adults to be infectious Low number of organisms Reduced tussive force Usually do not require infection control measures Evaluate for infectiousness as in adults Extensive pulmonary/laryngeal involvement Prolonged cough, cavitation on CXR, + AFB sputum smears Not on adequate anti-tb therapy or just started anti-tb therapy ADMINISTRATIVE CONTROLS Home isolation Negligible likelihood of MDR-TB Standard multi-drug anti-tb therapy for 2-3 weeks AFB smear negative or rarely positive: 5-7 days Complete adherence with treatment (DOT) Evidence of clinical and bacteriologic improvement All close contacts identified, evaluated and started on treatment, if indicated 22
ADMINISTRATIVE CONTROLS Effect of Chemotherapy on Infectiousness INH AFB smear positive, cavitary PTB: RIF 2 days > 90% decrease 10 6 10 7 organisms/ml. PZA EMB 14-21 days > 99% decrease ADMINISTRATIVE CONTROLS Effective anti-tb therapy Reduces frequency of cough Reduces amount of sputum produced Reduces number and viability of organisms in sputum 23
ADMINISTRATIVE CONTROLS Delayed response to anti-tb therapy Nonadherence to anti-tb drug regimen Unrecognized drug resistance Extensive TB disease Malabsorption Co-morbid conditions Diabetes mellitus HIV TUBERCULOSIS STATS CDC U.S. = 10,528 TB cases (a rate of 3.4 cases per 100,000 persons) Texas = Cases 1,325 16 MDR=Texas 24
CDC Updates for 2012 Tuberculosis Cases ADMINISTRATIVE CONTROLS Discharge to home A plan exists for health department follow-up Standard TB treatment started and tolerated; DOT has been coordinated No children < 4 years/immunocompromised contacts in the home All immunocompetent household members have been previously exposed to the patient The patient will not travel outside the home (except for healthcare follow-up visits) 25
Homeless Population ADMINISTRATIVE CONTROLS Discharge to congregate settings 3 consecutive negative AFB sputum smears collected 8 24 hours apart; one early AM specimen Receiving standard, multidrug anti-tb therapy Demonstrates clinical improvement MDR-TB Consider airborne precautions during entire hospitalization or until documented AFB culture conversion 26
ADMINISTRATIVE CONTROLS In the field: Conducting home visits Patient and family education Wearing of surgical mask if sharing air indoors with persons not previously exposed Home isolation: required to remain at home; cannot go out to public places with exception of medical care Health Department authorization to return to work, school, etc. Collecting sputum safely ADMINISTRATIVE CONTROLS In the field Transporting infectious patients Instruct patient to wear a surgical mask Provider(s) and driver(s) should wear N-95 respirator(s) Transport additional passengers and staff in separate vehicle Ambulance: negative pressure and HEPA filtration, if possible Open as many windows as possible Other vehicle Set ventilation controls to fresh air or vent setting; set fan speed to high setting Leave vehicle unoccupied with windows open for at least an hour after transporting patient 27
RESPIRATORY PROTECTION Components of a Respiratory Protection Program Written policies and procedures Medical screening Screening questionnaire Physical exam, PFT, etc., if further evaluation indicated Initial and annual training Initial fit testing Periodic fit-testing, if indicated User seal checks REMEMBER: We can prevent disease We can treat disease We can cure disease But unless we identify early and report and do follow up among cases Tuberculosis will continue to Consume US! 28
CONSUMPTION REFERENCES Heartland Educational Slides CDC Tuberculosis Educational Slides APIC Infection Control Guidelines MMWR - Epidemiology Program Office, Center for Disease Control American Thoracic Society/Center for Disease Control. Treatment of Tuberculosis, 1983 29