progress in the implementation of collaborative tb/hiv activities contribution of tb infection...

Progress in the Implementation of

Collaborative TB/HIV Activities

Contribution of TB Infection Control Subgroup

3 November 2009

Key contributions

• Ensure that health care facilities providing services for people living with HIV have infection control practices that include TB infection control

• Ensure prevention of TB transmission to health care workers, employed in facilities providing care for people living with HIV– IC indicators from A guide to monitoring and

evaluation for collaborative TB/HIV activities

2009 WHO TB infection control policy

• Online version found as follows:

http://whqlibdoc.who.int/publications/2009/9789241598323_eng.pdg

• Printed versions available and being distributed

• Policy being translated into different languages

• Aide memoires being prepared

2009 WHO TB infection control policy

• Addresses health facilities, congregate settings and households

• Adds a managerial component at the national and facility level

• Promotes the role of the civil society in designing, implementing and evaluating TB IC

• Promotes synergies between TB infection control and general infection control, and with the health system

• Emphasizes community involvement in raising awareness, promoting behavior change, reducing stigma

• Recommends a combination of controls based on facility assessments

Managerial activities

• Identify or strengthen a coordinating body• Develop a comprehensive and budgeted plan• Ensure health facility design, construction or

renovation• Conduct surveillance for TB disease among

HCWs• Address advocacy, communication and social

mobilization• Conduct monitoring and evaluation • Enable operational research

Health care facilities

• Health facility level managerial activities

• Administrative controls

• Environmental controls

• Personal protective equipment

Administrative controls

Strategies to promptly identify potentially infectious cases (triage), separate them, control the spread of pathogens (cough etiquette) and minimize time in health care settings1) Triage2) Separation3) Cough etiquette4) Minimize time in health care settings

TB triage for patients needing hospitalization, Haiti

Partners in Health

General wardSmear — HIV + or —

TB PavilionSmear +HIV —

6 isolation roomsSmear + and HIV +

Separation of respiratory patients

Cough hygiene

Protection of HCWs

• Encourage TB diagnostic investigation when signs and symptoms suggestive of TB occur or when exposed to smear-positive and culture-positive TB patients

• Encourage HIV testing

• If HIV-positive, make available a package of care, including IPT, ART, if needed, job relocation, and screening for TB

Environmental controls

• Use of ventilation systems

• Use of ultraviolet germicidal irradiation (UVGI) fixtures, at least when adequate ventilation cannot be achieved

Natural ventilation

Plan of Respiratory wards, Santa Rosa 3

General respiratory wardUnoccupied ward

Balcony

Balcony Balcony

Office

Nurses

Drug-sensitive TB

MDR-TB Isolation room

Plan of Respiratory wards, Santa Rosa 3

General respiratory wardUnoccupied ward

Balcony

Balcony Balcony

Office

Nurses

Drug-sensitive TB

MDR-TB Isolation room

Use of open air spaces

Personal protective equipment

• Use of particulate respirators is recommended for health workers when caring for patients or suspects with infectious TB

• In particular, health workers should use respirators:– during high-risk aerosol-generating procedures

associated with high risk of TB transmission (e.g. bronchoscopy, intubation, sputum induction procedures, aspiration of respiratory secretions, and autopsy or lung surgery with high-speed devices)

– when providing care to infectious MDR-TB and XDR-TB patients or people suspected of having infectious MDR-TB and XDR-TB.

Prioritization of TB IC measures

• Choice of controls or a combination of controls should be based on a comprehensive TB IC facility assessment

• Consider epidemiological, climatic, socioeconomic conditions, and estimated costs

• Specific recommendations for high HIV prevalent settings and for MDR-TB and XDR-TB.

Congregate settings

• Prisons, jails, military barracks, homeless shelters, refugee camps, dormitories and nursing homes.

• Each facility differs in type of population and duration of stay of the dwellers.

Congregate settings

Avoid overcrowding

Focus on DOT in prisons.

Be part of the national planning and assessment of facilities.

Recommendations are less specific than those for HCF.

Recommendations on medical services as per HCF.

Long-term stay (prisons) and short term stay (jails)

Households

Importance of early case detection and TB contact investigation

Emphasis on behaviour-change campaigns for patients and families of

smear/culture positive patients

Focus on cough etiquette and respiratory hygiene and to spend as

much time as possible outside

Use of respirators by HWs in specific situations

Renovation of houses for MDR and XDR TB

From policy to implementation

• Additional tools and guidance documents: work of the TB IC Subgroup– Implementation framework– Advocacy strategy– Costing of the TB IC policy recommendations– Standards and specifications of TB IC

equipment – Case design book

Framework

• How to implement the recommendations of the TB IC policy– Best practice examples– Example of roles and responsibilities– Tools – Checklists– Sample IEC materials

Advocacy

• Draft document with recommendations to support policy adoption and dissemination

• Contains detailed information on priority target groups

• Key messages for each audience

• Specific actions to be taken

• Opportunities to reach the target groups

Costing

• Estimates cover the period from 2009-2015

• Different scenarios for MDR-TB and TB in the 27 high burden MDR countries, plus an additional 9 TB HBCs, not already in the model

• Promotion of community care approaches• Budget estimates vary from 758 to 4,546

million USD

Costing cont.

• Assumptions underlying the model being validated by countries implementing TB IC activities

• Costing estimates to guide refinement of the WHO planning and budgeting tool

• Costing model to be made available for country adaptation and use

• Cost estimates to be included in the Global plan revision

Standards and specifications

• WHO prequalification does not apply to commodities

• Demand from countries for guidance on purchase of TB IC equipment (respirators, UVGI, fans)

• Document will enable countries to make informed choice on purchases

Case design book

• Being prepared by graduates from the Harvard course on engineering methods for the control of airborne infection..class of 2008– Examples of facility designs with adequate

ventilation, in different climatic conditions– Use of outdoor spaces, when feasible– Simple examples of the use of prevailing

winds, cross ventilation, and space.

27

TB INFECTION CONTROL IMPLEMENTATION EFFORTS - 2009

Peru, DR, Guyana

Armenia, Azerbaijan, Belarus, Ukraine, Turkey, Moldova, Romania, Portugal, Kyrgyzstan, Turkmenistan, Russian Federation

Benin, Burkina Faso, Cote d'Ivoire, Ghana, Guinea, Nigeria, Senegal, Togo, Cameroon, DRC, Rwanda, Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, Zambia

Myanmar, Bhutan, Nepal, Bangladesh

China, Viet Nam, PNG

Egypt, Djibouti, Pakistan,

Implementation activities

• Training of programme managers

• Situational analyses

• Development of TB IC policies and strategic plans

• Identification of infection control focal points

• TB IC representation on infection control coordinating bodies

Opportunities to scale-up

• Presentation at the 36th International Hospital Federation Congress – Rio

• Symposia at the 40th UNION World Conference on Lung Health – Cancun– TB Infection Control– TB and Migration– TB IC Subgroup meeting at Cancun– TAG

Synergies with the TB/HIV WG

• Promote TB IC in future meetings and events (IAS, UNAIDS, PEPFAR Implementers' meetings, ICAP)

• Incorporate the salient recommendations in the 3I's roll-out

• Insure that TB IC is reflected in country level TB/HIV work plans and funding proposals

• Maintain representation and participation in the TB IC Subgroup to foster common agendas and communication