good shepherd hospital (swaziland) tb infection control policy dec 2014

8/9/2019 Good Shepherd Hospital (Swaziland) TB Infection Control Policy Dec 2014

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GOOD SHEPHERD

HOSPITALTuberculosis Infection Prevention AndControl Policy

December 2014

Policy development supported by COMDIS-HSD. Funded with UK aid from the UKgovernment.

This policy describes the infection control procedures that should be in place to preventthe spread of tuberculosis (TB) to healthcare workers, patients and visitors within Good

Shepherd Hospital (GSH). It is the responsibility of all hospital staff to read this policy andwork towards improving TB infection control in their department.



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DOCUMENT INFORMATION

Title Good Shepherd Hospital: Tuberculosis Infection Prevention and ControlPolicy

For use by: Good Shepherd Hospital: All departments

Authors

Helen McAuslane, Clare Humphreys, James Elton, David Mc Conalogue,Bongekile Nxumalo(COMDIS-HSD), Dr Fred Busuulwa, Vusani Ndzimandze,Soko Zakhele (Good Shepherd Hospital)

OtherContributors

TB Team, Infection Control Committee, Lubombo Regional MDR TBDecentralisation Committee

Approved by Good Shepherd Hospital, Senior Medical Officer Approved Date November 2014Version 1.0

AccompanyingGuidelines

1. Good Shepherd Hospital MDR TB Service Guidelines2. Swaziland National Tuberculosis Infection Control Policy3. WHO Policy on TB Infection Control in Health - Care Facilities,

Congregate Settings and Households

DOCUMENT REVIEW PLAN Responsibility forreview Infection Control Committee, supported by the TB TeamNext Review Date November 2015



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Foreword by Dr Kiron Koshy, Good Shepherd Hospital Senior Medical

Officer

GSH provides essential health services for the people living in the Lubombo region. Akey part of our work is caring for people with tuberculosis through screening,diagnosis and treatment of the disease. It is through these services that we also havean important role in halting TB transmission in this region.

The inpatient TB ward and development of an MDR - TB treatment service means thatwe are now able to treat more people, more effectively. However, the continuing

development of TB services at GSH also means that we need a detailed and up-to-dateinfection control policy that covers the entire hospital.

This document is the infection prevention and control policy and providesdetailed information on what hospital staff can do to protect themselves andothers from infection.

Protecting all staff and patients from TB infection is our priority and is everyone’sbusiness, from senior management to the most junior members of staff.

All staff should read these guidelines and put them into practice. Discuss the contentsof these guidelines with your colleagues and managers to see how you can makechanges where you work. Don’t be afraid to challenge staff or patients who may beputting others at risk.

These guidelines have been developed with the input of the National TB Control Team,the hospital infection control team and staff working in the TB clinic. Please read themin detail and use the information contained within to help GSH become a centre ofexcellence for TB care.



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2 ContentsSECTION 1: Policy Background ....................................................... ....................................................7

1 Introduction ........................................................................................................................................................... 7 2 Background ............................................................................................................................................................. 7 3 Latent TB Infection .............................................................................................................................................. 7 4 Active TB Disease ................................................................................................................................................. 8

4.1 Diagnosis ....................................................................................................................................... 8

4.2 Duration of Infectious Period ........................................................................................................ 8

5 Drug Resistant TB ................................................................................................................................................ 8 6 TB and HIV .............................................................................................................................................................. 9

SECTION 2: TB Infection Control ..................................................... .................................................. 10

1 Introduction ......................................................................................................................................................... 10 2 Principles of TB Infection Prevention and Control .............................................................................. 10

2.1 Early detection and treatment of new cases ................................................................................. 10

2.2 The use of prophylactic antibiotics such as IPT .............................................................................. 10

2.3 The use of infection control measures ........................................................................................... 10

3 Rapid Detection and Treatment of TB ....................................................................................................... 11 3.1 Prompt identification of people with TB symptoms (triage).......................................................... 11

3.2 Sputum sample collection, storage and testing ............................................................................. 11

3.3 Contact tracing ............................................................................................................................... 12

4 Administrative and Work Practice Controls ........................................................................................... 13 4.1 Infection control team & committee .................................................................................... 13

4.2 TB Infection Control Plan ................................................................................................................ 13

4.3 Staff training ................................................................................................................................... 14

4.4 Separation of Infectious Patients ................................................................................................... 15

4.5 Information for patients and visitors ............................................................................................. 15

4.6 Cough hygiene education ............................................................................................................. 15

4.7 Minimise time spent in healthcare facilities .................................................................................. 16

5 Environmental Measures ................................................................................................................................ 16 5.1 Natural ventilation.......................................................................................................................... 16

5.2 Mechanical ventilation ................................................................................................................... 17

6 Personal Protective Equipment ................................................................................................................... 17 6.1 Patients ........................................................................................................................................... 17

6.2 Healthcare workers ........................................................................................................................ 17



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7 TB Infection Control in Areas with Increased Risk .............................................................................. 17 7.1 Male and female TB wards ......................................................................................................... 18

7.2 Paediatric TB ward ...................................................................................................................... 18

7.3 Outpatients Department............................................................................................................. 18

7.4 X-ray department ........................................................................................................................ 19

7.5 GSH Outreach Teams .................................................................................................................. 19

7.6 Transporting TB patients ............................................................................................................. 19

8 MDR-TB .................................................................................................................................................................. 19 8.1 TB clinic ....................................................................................................................................... 20

8.2 X-ray department ........................................................................................................................ 20

8.3 GSH outreach teams ................................................................................................................... 20

9 Staff TB Screening and Surveillance ........................................................................................................... 20

9.1 New staff ..................................................................................................................................... 219.2 Existing Staff .......................................................................................................................... 21

9.3 Staff TB screening events ...................................................................................................... 21

9.4 Surveillance of TB among staff ............................................................................................. 22

10 Ethical and Legal Considerations ................................................................................................................ 22 10.1 Universal free TB services ....................................................................................................... 22

10.2 Informed patients ................................................................................................................... 22

10.3 Healthcare worker protection ................................................................................................ 23

10.4 Involuntary isolation ............................................................................................................... 2311 Monitoring and Policy Review ...................................................................................................................... 23

Appendices ................................................ .................................................... .................................. 24

Appendix 1: TB screening tool ...................................................................................................................................... 24 Appendix 2: TB Infection Control Quarterly Reporting Tool ........................................................................... 25 Appendix 3: Measuring and Maximising Natural ventilation .......................................................................... 27 Appendix 4: Putting on and storing a N95 Respirator ........................................................................................ 29 Further Reading .................................................................................................................................................................. 30



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BoxesBox 1: Definitions of drug resistance

Box 2: Instructions for patients giving a sputum sample

FiguresFigure 1 Seating arrangements in naturally ventilated consultation room 1

AcronymsART ................................................................................................................. Anti Retroviral TherapyGSH ................................................................................................................ Good Shepherd HospitalIPT ........................................................................................................ Isoniazid Preventive TherapyLTBI ..................................................................................................... Latent Tuberculosis InfectionMTB ....................................................................................................................... Miliary Tuberculosis

NTCP.............................................................................................. National TB Control Programme

OPD ................................................................................................................. Out Patient DepartmentPPE ................................................................................................... Personal Protective Equipment SMT ............................................................................................................. Senior Management Team TB .......................................................................................................................................... TuberculosisTB IPC ............................................................... Tuberculosis Infection Prevention and ControlURC .........................................................................................................University Research CouncilUVGI........................................................................................... Ultra Violet Germicidal Irradiation



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SECTION 1: Policy Background1 IntroductionGSH is committed to providing the best possible environment for promoting the health andwellbeing of staff, patients and visitors to the hospital. This policy describes the infection

control measures that should be in place to prevent the spread of TB to healthcare workers,patients and visitors.

All staff within the hospital, including those involved in outreach services, should befamiliar with these guidelines and be able to apply them to their day to day work.

2 BackgroundTB infection is caused by Mycobacterium tuberculosis (M. Tuberculosis ) which mostfrequently affects the lungs, although it can affect other organs. Pulmonary TB istransmitted via droplet inhalation of M. Tuberculosis bacilli when the infected personcoughs, sneezes or spits. The droplets can remain suspended in the air for long periods,facilitating transmission to susceptible individuals.

The risk of transmission is dependent on the closeness and duration of the contact with aninfected person, the number of bacilli in the sputum and the susceptibility of the contact toacquiring the infection. The risk of infection is greatest in those with prolonged, closehousehold exposure to a person with infectious TB, although anyone who is in closeproximity with an infectious person, such as in a hospital environment, may be at risk. Onlya small number of mycobacterium needs to be inhaled to cause an infection.

The incubation period for TB disease is around 3 – 8 weeks and approximately 5 - 10% ofthose infected develop clinical symptoms of TB disease. Of the rest some will clear theinfection and some will have a latent form of the disease which may reactivate in later life.Those with pulmonary TB are those that transmit the disease and patients are infectiousfor as long as bacilli are present in the sputum.

The presence of HIV infection increases the likelihood of becoming infected andprogression to active disease. Without treatment TB can be fatal, especially in persons withHIV, however with good adherence to treatment most patients will be cured.

3 Latent TB InfectionLatent TB infection (LTBI) occurs when the individual has been infected with M.Tuberculosis but does not have active disease. Latent infection has the potential toreactivate, the risk of which increases with age, immunosuppression and chronic disease.It is thought that around 5% (1 in 20) of those with latent infection will develop active TBwithin 5 years of infection and around 10% (1 in 10) will develop it in their lifetime. This



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risk increases in persons with dual HIV and TB infection in whom 1 in 10 will develop TBdisease in a year. Isoniazid preventive therapy (IPT) reduces the risk of developing activeTB disease.

4 Active TB Disease

Active TB disease occurs when the person is infected with M. Tuberculosis and shows signsand symptoms of disease. TB disease can affect any organ or be disseminated through thebody.

Symptoms of pulmonary TB (TB disease in the lungs) include a persistent cough lastingthree weeks or more, fever, sweating at night, loss of appetite, weight loss, and fatigue.People with TB in other organs or with disseminated TB may have similar symptoms,depending on the site of the infection.

4.1 Diagnosis

In symptomatic cases and contacts pulmonary TB is diagnosed by considering symptomhistory alongside a chest x-ray and the presence of acid fast M. tuberculosis bacilli onsputum smear microscopy. GeneXpert is used to rapidly confirm the diagnosis and detectresistance to Rifampicin. Following this, samples are sent to the national TB hospital forculture and further drug sensitivity testing.

Smear positive cases (i.e. TB cases where TB is visible under a microscope) are moreinfectious than smear negative cases.

4.2 Duration of Infectious PeriodA person with TB of the lungs or larynx should be considered infectious until 2 consecutivesputum samples are smear negative on microscopy. A TB suspect should be consideredinfectious until TB is ruled out through sputum smear microscopy and chest x-ray.

People with drug sensitive TB are infectious for approximately 2 weeks after commencingtreatment. Those with significant lung disease, immunosuppression and drug resistant TBwill remain infectious for significantly longer (6 months for most patients with drugresistant TB).

5 Drug Resistant TB Drug resistant TB is associated with a history of failed or inappropriate treatment, eitherdue to poor treatment adherence, limited access to health services, or interruption of drugsupply. Drug resistant strains of TB can also be transmitted person to person in the sameway as drug susceptible TB. Definitions of drug resistance are shown in Box 1.



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Box 1: Definitions of drug resistance

Without treatment the mortality rate of MDR-TB is high, particularly if there is co -

infection with HIV. Failure of MDR-TB treatment increases the risk of developingextensively drug resistant TB (XDR –TB) which presents an even higher risk of death.Treatment for MDR - TB takes at least 20 months and starts with an intensive phase duringwhich the patient receives daily injections.

MDR-TB is not more infectious than drug sensitive TB, but the result of having the diseasecan be worse. GSH as an MDR-TB treatment initiation site must make infection controlacross the hospital the highest priority.

6 TB and HIVPeople living with HIV are 30 times more likely to develop TB than those who are not, TB isalso a major cause of death in HIV patients, therefore early detection and treatment isextremely important.

The Anti-Retroviral Therapy (ART) team and TB team should work together to detect andtreat patients with both TB and HIV infections. Newly diagnosed TB and HIV patientsshould be initiated on TB treatment for 2 weeks before starting ARTs, or as soon aspossible after this.

GSH provides an integrated service and all patients attending the hospital should be

screened for TB and encouraged to know their HIV status.

Mono - Resistant TB (DR-TB): Resistance to any first line anti-tuberculosis drug

Poly - Resistant TB (PR-TB): Resistance to more than one drug, other than rifampicin andisoniazid

Multi - Drug Resistant TB (MDR-TB): Resistance to at least rifampicin and isoniazid

Extensively Drug Resistant TB (XDR-TB): Resistance to isoniazid and rifampicin, anyfluoroquinolone and one of the second-line injectable drugs.



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SECTION 2: TB Infection Control1 IntroductionStrong infection control policies and procedures will help to protect staff, patients andvisitors at GSH from TB. This section describes the principles of TB infection control and

how to apply these throughout the hospital.

2 Principles of TB Infection Prevention and ControlThere are 3 important elements to reducing the number of new TB infections. These are: 1)early detection and treatment of new cases; 2) the use of prophylactic antibiotics such asIPT; and 3) the use of infection control measures in healthcare and other high risk settings.

2.1 Early detection and treatment of new casesThe most important measure for preventing the transmission of TB is prompt detectionand treatment of cases. Left untreated, each person with active TB will infect about 10 to

15 people every year. Early identification, referral and treatment of people with symptomsof TB is essential to halt the spread of disease, hence the importance of integrated TBscreening in all areas of GSH. Close contacts of patients with TB should be screenedpromptly. People living with HIV & AIDS should be screened regularly and as a priority ifthey are known to be a contact of someone with TB.

2.2 The use of prophylactic antibiotics such as IPTIPT can prevent the progression from latent to active disease and is an important measureto help stop the transmission of TB. Current Swaziland guidelines 2 suggest that all HIVpatients over 12 months of age should be initiated on IPT if they screen negative for TB.

HIV positive infants aged less than 12 months should be initiated if they are a contact of aTB case. Other high risk groups who should be offered IPT are children aged less than 5years who are contacts of a TB case, individuals in institutional settings such as prisonersor miners, and healthcare workers in contact with TB patients. Healthcare Workers whoare HIV+ and/or those assessed to be working in high risk areas such as medical wards orTB clinic should be prioritised for IPT. IPT should be repeated every 2 years as indicated,following a repeated negative TB screen. IPT is not recommended for contacts of MDR-TBpatients.

2.3 The use of infection control measures

Healthcare workers and others in the hospital environment are at a higher risk of TBinfection due to their close proximity to infectious TB patients. This risk is increasedfurther where there is also a high prevalence of HIV infection. Staff at particular riskinclude those working in outpatient departments (OPD), TB wards or clinics, laboratory

2 Ministry of Health, Kingdom of Swaziland . National Guidelines for implementing tuberculosis intensified case finding, isoniazid preventive therapy and infection control in health care and congregate settings . January 2012.Swaziland National Tuberculosis Control Programme/ Swaziland National Aids Programme.



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staff handling sputum samples, and community outreach teams who visit patients at home.Patients and visitors, including children, are at risk in busy waiting areas and inpatientwards.

3 Rapid Detection and Treatment of TB

3.1 Prompt identification of people with TB symptoms (triage)All patients must be screened at OPD and in the ART clinic at the start of every visit toidentify patients with TB symptoms. Children should be screened at Prevention of Motherto Child Transmission Clinic.

Screening will be conducted using the appropriate Swaziland National Screening Tool(Appendix 1). Screening results must be recorded in the national screening register and inthe patient ’s notes.

Those with a positive screen should be prioritised to see the doctor and be referred to theTB clinic to give a sputum sample immediately after this consultation.

3.2 Sputum sample collection, storage and testingSputum collection is best undertaken away from other patients and preferably outside.There are 2 cough booths available for patients to use:

Booth 1: outside the TB clinic for outpatient use Booth 2: outside the TB ward for inpatients and those in a wheelchair

To ensure good ventilation the door to cough booths must be kept open during the day and

only shut and locked at night when they are not in use.

For bed bound patients in the TB ward sputum samples should be taken under bed clothesto avoid coughing in the open space of the ward.

Sputum collection should be organised by the TB unit for outpatients and by the ward forinpatients.

Collection of early morning specimens is preferred because of the overnight accumulationof secretions, although specimens can be collected at any time for patients who have aproductive cough.

Instructions for patients about how to give a sputum sample are given in Box 2



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Box 2: Instructions for patients giving a sputum sample

Sample storage

Sputum sample should be stored in a cool box and transported to the refrigerator in the TBlaboratory within 2 hours of collection. At weekends or holidays samples should bedelivered to the laboratory and placed in the specimen fridge by the member of TB clinicstaff on duty. The TB clinic should have a key to the TB laboratory so that they can do this.

Testing and results

Sputum samples are tested using sputum smear microscopy and Xpert MTB/RIF(GeneXpert). The results should be available within 24 hours. If the result showsRifampicin resistance the TB clinic should be contacted immediately and the patient shouldfollow the MDR –TB patient pathway. Further details can be found in the MDR –TB ServiceGuidelines.

3.3 Contact tracingContact tracing is extremely important in reducing onward transmission and identifying TBsuspects. Systematic contact tracing should be conducted for all pulmonary (or laryngeal)TB patients. This is organised by the TB clinic. Please see TB contact tracing guidelines andSwaziland National Guidelines for implementing TB intensified case finding, IPT andinfection control in health care and congregate settings for more information. Staff inhealthcare and other congregate settings (e.g. prisons) should be offered regular screening

for TB symptoms.There are 3 levels of TB infection control in healthcare settings. These are: 1)administrative and work practice controls, 2) environmental measures, and 3) the use ofpersonal protective equipment. Each of these is described below.

1. Administrative and work practice measures aim to reduce staff and patientexposure through comprehensive policies, training and infection control plans.

1. Gargle with water to rinse out your mouth, ensure you have not smoked,eaten or taken a drink before providing the sample.

2. Breathe deeply several times and cough from deep down in the lungs.

Sputum is the mucous or phlegm coughed up from the lungs, it is notsaliva or mucous from the back of the throat. A large spoonful is a goodamount.

3. Open the collection pot and hold it close to your mouth. Spit the sputuminto the pot without getting any on the outside and screw the lid ontightly.

4. Wash your hands.



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2. Environmental measures aim to reduce the concentration of infectious particles

3. Personal protective equipment protects staff that work in high risk areas, includingthe use of N95 masks.

This policy describes the administrative, environmental and personal protective measuresthat should be implemented to protect staff, patients and visitors from TB.

4 Administrative and Work Practice ControlsAdministrative and work practice control measures have the greatest impact on preventingTB transmission and serve as the first line of defence within health care settings. The aim ofthese measures is to:

Prevent TB exposure to staff and patients through reducing contact with infectiouspatients

Reduce the spread of infection by ensuring rapid diagnosis and treatment.

4.1 Infection control team & committeeThe infection control team, under the leadership of the Clinical Matron, is responsible forleading infection control in the hospital, including TB infection control. The team aresupported by an infection control committee who are responsible for the development andimplementation of infection control plans and policies and monitoring and evaluating oftheir impact.

The infection control team consists of a nurse and a nursing assistant, and is led by thesenior Clinical Matron. The team is supported by a doctor.

The infection control committee should consist of representatives from each area of thehospital, including the TB clinic. The committee meets on the first Wednesday of eachmonth to discuss infection control issues, implement infection control measures, supportbest practice and monitor infection control rates.

The TB clinic nurse on the infection control team should monitor the infection controlmeasures described in this policy using the Infection Control Quarterly Reporting Tool inAppendix 2 and report back to the committee every quarter. All staff should identify anyproblems with TB infection control and promptly report this to a senior manager.

4.2 TB Infection Control PlanThere should be a TB Infection Prevention and Control (TB IPC) plan for the hospital thatdescribes how this TB infection control policy will be put into practice. Each area within the



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hospital should also have their own plan with named leads for TB infection controlactivities.

The TB plan should also have clear guidelines for monitoring and reporting on this. Thedevelopment of plans should be overseen by the infection prevention and controlcommittee, led by the infection prevention and control lead. Staff should be informed of theplan through training and a copy should be available to everyone employed at GSH. Theplan in each area should be kept in the staff office.

The National TB Control Programme (NTCP) infection control regional co-ordinator cansupport the development of infection control plans.

4.3 Staff trainingAll staff should be trained regularly on infection prevention and control. This should

include specific education about TB infection control, this policy and the TB IPC plan.

Educational materials on TB prevention and cough hygiene should be available at the staffWellness Clinic.

New staff should receive educational material and training on TB infection control duringtheir orientation to the hospital. In-service training should be held annually to coincidewith staff screening ( see section below on in-service training). In addition, staff at theWellness Clinic should screen staff and talk about TB risk reduction strategies every timethey visit the clinic.

The NTCP regional infection control officer can support staff training and should becontacted when planning any training. Please contact the TB clinic for more details.

In-service trainingStaff training should include the following: Basic information about TB disease and how it is transmitted Risk of TB transmission to health care workers, staff and visitors Cough hygiene

Symptoms and signs of TB HIV and TB co –infection Details of the TB IPC plan and the responsibility that each staff member has to

implement and maintain infection prevention and control practices Specific infection prevention and control measures and work practices that reduce TB

transmission



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Staff should be screened for TB as part of their in-service training

4.4 Separation of Infectious Patients Outpatients suspected of having TB disease should be provided a surgical mask (if

coughing) and taken to the front of the queue for urgent review by the doctor. After review by the doctor, the TB patient should be taken to the TB department for TB

suspect follow up as this is a well ventilated area and will minimise the potential spreadof infection.

Care should be taken when infectious cases such as TB suspects and patients arescheduled for procedures like chest radiography. Measures e.g. triaging, should beadhered to as much as possible to minimise risk of mycobacterium exposure to highrisk groups including immuno-suppressed persons (this applies to laboratory servicesalso).

Any inpatients suspected to have pulmonary TB should have their sputum tested

immediately. They should be placed near the window for good ventilation and shouldspend the daylight hours outside the ward where possible. They must be educated oncough hygiene and given a surgical mask if necessary. If confirmed they should bemoved to the TB ward.

4.5 Information for patients and visitorsEducational materials on TB prevention and cough hygiene should be available for patientsand visitors at each outpatient clinic and for visitors on the ward.

Educational posters should be visible at strategic points at Wellness Clinic, outpatientdepartment, beside the TB ward and in TB OPD.

The infection control lead and lead person in the TB clinic are responsible for ensuring thatposters and leaflets are restocked regularly from the NTCP and University ResearchCouncil (URC).

4.6 Cough hygiene educationAll coughing patients should be educated about cough hygiene. Cough hygiene includes thefollowing when sneezing, coughing or during any other forced expiration: Turning the head to the side

Covering the nose and mouth with a tissue or surgical mask Disposing of tissues appropriately Regular handwashing, particularly after disposing of tissues or providing a sputum

sample

Patients should be supplied with tissues and a waste receptacle. If patients cannot or willnot use appropriate cough etiquette they should wear a surgical mask when moving about



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the hospital. Patients should be encouraged to wash their hands after giving a sputumsample.

Healthcare workers should always use proper cough etiquette and encourage its use byfamilies and visitors.

4.7 Minimise time spent in healthcare facilitiesSputum collection and the receipt of laboratory results should be as fast as possible. Initialreports for MTB and rifampicin resistance using Gene Xpert should be available within 24hours.

TB patients should, wherever possible, be treated in the community. If admission isrequired, doctors should encourage discharge at the earliest possible date to reduce risk oftransmission to other patients, visitors and staff.

5 Environmental MeasuresEnvironmental control measures aim to reduce the number of infectious particles in theenvironment by diluting contaminated air, removing particles and controlling airflow inpatient areas. This is done through increasing natural ventilation or installing mechanicalventilation.

Environmental controls are the second line of defence for preventing the spread of TB inhealth care settings. Environmental controls will not completely remove the risk of TBtransmission and they need to be used alongside administrative controls and Personal

Protective Equipment

It is the responsibility of the infection control lead nurse to regularly check environmentalcontrols in the hospital following the guidance in appendix 3.

5.1 Natural ventilation Each area in the hospital should make the most of natural ventilation so that airflow is

increased. This includes but is not limited to keeping doors and windows open. Tall or bushy trees near windows should be trimmed regularly to improve airflow

around buildings Installation of wind turbines to roofs of hospital wards, clinics, OPD and the laboratory

can help to increase airflow. The chairs for patients in consultation rooms should be position to ensure a good

airflow between the health care worker and the patient, as recommended by the WHO(see fig 1).

Outpatients waiting to be seen should wait in well ventilated waiting.



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Figure 2: Seating arrangements in naturally ventilated consultation room 3

5.2 Mechanical ventilation Mechanical ventilation is used to remove air from buildings, particularly where natural

ventilation is difficult. Examples include extractor fans and the use of air filters and Ultra Violet GermicidalIrradiation (UVGI) lights.

6 Personal Protective Equipment

6.1 PatientsA surgical mask should be worn by the TB patient if moving about the hospital and thepatient does not exhibit the use of proper coughing etiquette. Surgical masks prevent thewearer from spreading microorganisms by capturing large wet particles from the nose andmouth. They do not provide protection to the wearer from inhaling TB-containing dropletsin the air and therefore are not recommended for staff or visitor use for TB infectioncontrol. N95 respirators should not be given to TB patients.

6.2 Healthcare workersHealthcare Workers and other staff should use an N95 respirator mask to protectthemselves when close to a TB suspect or TB patient. This includes staff in the TB ward, TBclinic, OPD or other parts of the hospital, when transporting infectious cases or whencarrying out sputum inducing procedures such as gastric lavage or chest physiotherapy.

Instructions of how to store, put on, and take off the respirator are presented in Appendix4.

7 TB Infection Control in Areas with Increased Risk

3 USAID & CDC Implementing the WHO Policy on TB Infection Control in Health-Care Facilities,Congregate Settings and Households



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7.1 Male and female TB wardsThe male ward has 7 beds and 1 private/isolation room. The female ward has 9 beds and 1private/isolation room.

General information

Patients should be given a surgical mask which should be worn during any contact witha healthcare professional such as ward rounds, drug dispensing, bed bathing anddressing changes. Change surgical masks every day.

Make sure beds in the TB wards are 1.5m apart. Keep windows open at all times. Patients who need to produce sputum should use the cough booth outside the TB ward.

If they are not ambulatory they should cough under their blankets/sheets.

Visitors to TB wards

Visitors should report to the nursing station before the visit. All visitors should be screened for TB by staff on the TB ward using the form provided. Visitors to the TB wards should be strongly encouraged to meet the patient outside

with the patient using proper cough etiquette or wearing a surgical mask. In rare circumstances, visitors may need to go onto the ward; this should be for a

minimum time unless they have a N95 mask. If visitors are using a N95 mask theyshould be instructed on how to put on, remove and store the respirator (Appendix 4).

Children under 5 and people living with HIV should be prohibited from visiting the TB

ward.7.2 Paediatric TB wardChildren 13 and under with confirmed pulmonary TB should be admitted to the paediatricTB ward. Although children pose less of an infectious risk than adults, the same controlmeasures for the TB ward apply.

7.3 Outpatients DepartmentStaff working in the OPD are likely to be exposed to undiagnosed TB patients. Therefore itis extremely important that all patients attending OPD are screened immediately by thecough officer using the national screening tool.

All patients seen in OPD who screen positive for TB symptoms should be: provided with a surgical mask; prioritised for assessment by an OPD doctor; and referred to the TB clinic for further investigations.



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Patients with TB symptoms should spend the minimum time possible in the OPD waitingarea.

7.4 X-ray departmentThe x-ray department should prioritise TB patients/suspects to reduce the risk oftransmission to other patients in the waiting area: All TB patients/ suspects sent for an x-ray should have the words 'TB' , ‘MDR - TB' or 'TB

suspect' clearly marked on their x-ray form. All TB patients attending x-ray should be encouraged to wear a surgical mask. The x-ray department should take all infection control precautions as outlined above,

including the use of N95 masks.

7.5 GSH Outreach TeamsAll hospital teams visiting patients at home (e.g. Home Based Care, Mental Health and

Epilepsy) should be aware that they may come into contact with known TB cases as well asundiagnosed TB patients. Outreach teams should take the following precautions: When visiting TB patients staff should wear N95 respirator masks and conduct the

consultation outside if possible. If collecting sputum samples, this should be done in a well ventilated area; preferably

outside and away from other members of the household. Patients should be encouraged to practice cough hygiene as described in section 4.6. Staff should be alert to TB symptoms in both patients and their contacts and encourage

anyone with symptoms to seek healthcare at GSH.

7.6 Transporting TB patientsTB patients may need hospital transport if they require urgent medical treatment or forreferral to the National MDR-TB Hospital. If hospital transport is used to make sure that: all people handling the patient should have an N95 respirator; if the driver’s compartment is sealed he/she does not need to wear the respirator; where possible people accompanying the patient should sit in the front with the driver,

but if they sit in the back with the patient they should wear the N95 respirator; and the windows in the part of the ambulance where the patient is travelling should be open

to allow airflow

8 MDR-TBGSH will be a treatment initiation site for MDR-TB patients not requiring hospitaladmission and will run an MDR clinic every Thursday. Although MDR-TB is not moreinfectious than drug sensitive TB the consequences of infection can be more serious.Therefore it is particularly important that contact with MDR patients is minimised. The



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Lubombo Region Drug Resistant Tuberculosis Decentralisation Service guideline providesmore details of the decentralised service in Lubombo.

All patients with Rifampicin resistance on Xpert MTB/ Rif should be contacted immediatelyand asked to attend the TB clinic accompanied by a family treatment supporter. To preventdelays in treatment initiation this appointment may not necessarily occur on a designatedMDR-TB clinic day. If the treatment initiation is not on a designated MDR-TB day, followthese procedures:

8.1 TB clinic When the patient arrives they should be identified as an MDR-TB patient and be

prioritised by clinic staff before any other patients that are waiting, so that they spendminimum time in the clinic.

If MDR-TB patients have to wait to be seen they should be provided with a waiting area

separate from other patients in the clinic and preferably outside. As with drug susceptible TB patients MDR patients should be encouraged to wear a

surgical mask. Staff should wear N95 masks.

8.2 X-ray departmentInfection prevention and control should be as outlined as for all TB, however in addition tothis, diagnosed MDR-TB patients should be escorted to x-ray by a member of the TB clinicteam to ensure they are seen immediately. MDR-TB patients should not spend any time in

the general waiting area with other patients.

8.3 GSH outreach teamsTeams that may be likely to visit MDR-TB patients at home include the TB Clinic HomeAssessment Team, Home Based Care and Mental Health teams. It is very important thatthese teams are aware of where MDR patients are so that they can take suitableprecautions. It is therefore the responsibility of the TB Team to ensure patient referrals aregiven to each of the GSH outreach teams.

All staff visiting patients at home should follow infection prevention and controlprocedures as outlined above, including the use of PPE and minimising the time spentinside the patient's home or in unventilated rooms with the patient.

9 Staff TB Screening and SurveillanceHealthcare workers have a high risk of developing TB and of transmitting the infection tovulnerable patients. In addition to adhering to the infection control measures described



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above all staff should also attend regular screening at the Staff Wellness Clinic. The purposeof staff screening is to rapidly detect and treat any staff that may have TB.

9.1 New staff All new staff members should be screened for TB on the pre-employment check.

Screening should include TB symptom screening, chest x-ray, HIV testing andcounselling, and base line blood test including LFTs and RFTs.

Staff who are HIV positive or otherwise immuno-compromised should avoid workingdirectly with TB patients and TB suspects. GSH should support this by avoiding theallocation of staff known to be immunocompromised to the TB Ward, TB Clinic orOutpatients Department.

All new staff that screen negative for TB should be encouraged to take a 6 month courseof IPT. This will be coordinated by the Wellness Clinic. Healthcare Workers who areHIV+ and/or those working in high risk areas such as the medical wards and the TB

clinic, should be prioritised for IPT.

9.2 Existing Staff

Any staff members who have TB symptoms should present to the Wellness Clinic. If staff identify colleagues with TB symptoms they should encourage that staff member

to present to the Wellness Clinic. If they do not present at the Wellness Clinic, thematrons’ office should be informed.

All healthcare workers should promptly be evaluated for TB disease if they have acough, bloody sputum, night sweats or weight loss.

Health care workers and other staff should be informed about the specific risks for TBinfection in people living with HIV.

All staff attending the Wellness Clinic for any reason should be screened for TB as partof their initial assessment.

9.3 Staff TB screening events

TB Screening events will be run by the Wellness Clinic every September and February. All staff are encouraged to attend staff TB screening events at least once per year.

It is the responsibility of senior managers, matrons and senior sisters to encourage staffto attend.

Each department will be invited to attend an information session and be given a specificday to attend the clinic.

Staff working in the following areas should attend TB screening every 6 months:1. Staff working in the TB clinic2. Staff working on the TB ward



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3. Staff working in the OPD where they are likely to come into contact withundiagnosed TB patients

4. Any other staff working in close contact with TB patients including those in the x-ray department , TB laboratory and Home Based Care team

The results of screening events should be reported to the Infection Prevention andControl Team and the Senior Management Team (SMT) and should include thefollowing information:

o Number and percentage of staff screened from each departmento Number/percentage that screened positiveo Number diagnosed with MDR-TBo Number commenced on treatmento Number commenced on IPTo Work history for previous year of those who have started treatment. This should be

a description of which areas of the hospital they have been working in and for howlong. Gathering this information may help to identify areas where infection controlcould be strengthened.

9.4 Surveillance of TB among staff It is the responsibility of the Wellness Clinic to work with the Infection Control Team to

monitor the number of cases of TB infection in staff to ensure that infection preventionand control measures are working.

The number of staff screened and the results of this should be reported to the InfectionControl Team on a monthly basis and reported to SMT at regular intervals.

The annual report should also provide information on treatment outcomes for all staffcommenced on TB treatment.

10 Ethical and Legal Considerations

10.1 Universal free TB servicesGSH has a responsibility to provide free and universal TB diagnostic and treatmentservices. This obligation is grounded in their duty to fulfil the human right to health. Notonly does TB treatment significantly improve the health condition of individuals, it alsobenefits the broader community by stopping the spread of a highly infectious disease.

10.2 Informed patientsPatients need to be fully informed and counselled about testing and treatment and shouldreceive comprehensive information about the risks, benefits and alternatives available tothem. As with any medical treatment, the voluntary and informed decision of the patient isnecessary to start TB treatment.



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10.3 Healthcare worker protectionHealth care workers have obligations to provide care, but also a right to adequateprotection. The hospital has a duty to protect its staff from infection and must provide asafe working environment and adequate personal protective equipment. Also, health-careworkers who are at heightened risk of contracting TB themselves, such as those who areHIV positive, should be accommodated by the hospital to work away from highly infectiousareas.

10.4 Involuntary isolationInvoluntary isolation is rarely justified and should be a very last resort. TB treatmentshould be provided on a voluntary basis. If a patient refuses treatment, this is likely to bedue to insufficient counselling or lack of treatment support. In very rare cases, where allefforts to engage a patient to adhere treatment fail, the rights of other members of thecommunity might justify efforts to isolate the contagious patient involuntarily. It is

essential that the manner in which a patient is involuntarily isolated complies with ethicaland human rights principles and in accordance with the law. In these cases, the regionalsocial worker, police and community leaders should be engaged to facilitate isolation in asensitive manner.

11 Monitoring and Policy Review

The responsibility for monitoring TB infection control is with the infection prevention andcontrol team with the support of the TB Team. The infection prevention and control team

will report to the infection prevention and control committee quarterly on theadministrative, environmental and PPE controls described here.

In addition, the Infection Control Team should include TB infection as a separate section intheir annual report to the SMT. Indicators for TB infection control are included in Appendix2.

This policy should be reviewed by the Infection Control Committee in November 2015.



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Appendices

Appendix 1: TB screening tool

Screening Tool for TB

The Swaziland Tuberculosis Screening Tool has 5 questions. Each patient on presentationat outpatients department, ART or at the Wellness Clinic should be asked:

1. Cough, any duration

2. Fever, 2 weeks or more

3. Night sweats, 2 weeks or more

4. Weight loss, 4 weeks or more

5. Chest pain, any duration

If a patient has any of these symptoms, the patient should be considered a TB suspect andreferred to the TB clinic for further investigation.

Screening Tool for Children

The following are questions which have been derived from the Tuberculosis ScreeningQuestionnaire for Children. For the full screening tool, please refer to the NationalScreening Tool for Children.

1. I s there a history of TB contact? (Y/N)

2. Has the child had a cough for two weeks or more? (Y/N)

3. Has the child had night sweats for 2 or more weeks? (Y/N)

4. Has the child lost noticeable weight in the last 4 weeks? (Y/N)

5. Has the child had a fever for 2 or more weeks? (Y/N

If a patient has any of these symptoms, the patient should be considered a TB suspect andreferred to the TB clinic for further investigation.



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Appendix 2: TB Infection Control Quarterly Reporting Tool

This reporting tool should be completed by the lead person for TB infection control in eacharea and collated by the infection control lead nurse. Please complete all fields that arerelevant, marking those that are not with N/A. The results should be reported at infection

prevention and control meetings once every quarter and a copy should be given to the SMT.

DATE:

DEPARTMENT

NAME OF PERSON CONDUCTING ASSESSMENT

TB Screening Checks

Indicator Total number Percentage

Number of patients screened for TB Number screened/totaloutpatients appointments x 100

Number of TB contacts screened n/a

Number of visitors to the TB wardwho were screened 4

n/a

Number of staff screened for TB Number screened/total numberof staff x100

Number of staff who screened

positive for TB

Number screening positive/

number screened x 100Number of cases of TB diagnosed instaff

PPE Checks

Indicator TotalNumber

Percentage

Staff who have been fit tested for an N95

mask

Staff who have an N95 mask Number fit tested/Staffwho have a mask x100

4 Visitors to the TB ward who are not already on TB treatment should be screened at regular intervals.



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Are N95 masks are being stored correctly (ina cool dry place and not in a plastic bag)?

Yes / No / Not Applicable.

Comments:

Are surgical masks for patients and suspectsare available and in use


Comments:

Environmental checks

Are all windows and doors open? Yes / No / Not Applicable.

Comments:

Is furniture in consultation rooms set upcorrectly? (see diagram in infection controlpolicy)


Comments:

Are fans in place and working? Yes / No / Not Applicable.

Comments:

General comments (please highlight any areas for improvement or training needs)



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Appendix 3: Measuring and Maximising Natural ventilation 5

A. Checking natural ventilation

People can usually feel the existence or lack of air movement in a space. A ventilated spacehas a slight draft. In the absence of ventilation, air will feel stuffy and stale and odours willlinger. Use the following checklist to assess natural ventilation in your waiting areas andexamination rooms. Check air mixing and determine directional air movement in all partsof rooms or areas. One way to visualise air movement is to use incense sticks as describedin these 4 steps.

1. Hold two incense sticks together and light them.2. As soon as the incense starts to burn, blow out the flame. Now the incense should

produce a continuous stream of smoke.3. Observe the direction of the smoke.

4. Observe how quickly the smoke dissipates. This is a subjective test that may requiresome practice it does not give a definite result but is useful for comparing one roomor area to another.

Alternatively refer to USAID & CDC Implementing the WHO Policy on TB Infection Controlin Health-Care Facilities, Congregate Settings and Households for more quantifiablemethods.

B. Controlled natural ventilation

Natural ventilation refers to fresh dilution of air that enters and leaves a room or other area

through openings such as windows or doors. Natural ventilation is controlled whenopenings are deliberately secured open to maintain air flow. Unrestricted openings (thatcannot be closed) on opposite sides of a room provide the most effective naturalventilation.

C. Propeller fans

Propeller fans may be an inexpensive way to increase the effectiveness of naturalventilation, by increasing the mixing of airborne TB as well as assisting in the direction ofair movement by pushing or pulling of the air.

Types of propeller fans

• Ceiling fans

• Small fans that sit on a desk or other surface

5 WHO. Guidelines for Infection of TB including MDR TB and XDR TB. Malawi July 2008.



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• Fans that stand on the floor

• Fans mounted in a w indow opening

Air mixing and removal

A propeller fan helps mix air in a room. Mixing of air will reduce pockets of highconcentrations, such as in the corners of a room or in the vicinity of patients where naturalventilation alone is not enough. The total number of infectious particles in the room willnot change with mixing; however, the concentration of particles near the source will bereduced, and the concentration in other parts of the room may increase. If this dilutioneffect is combined with a way to replace room air with fresh air, such as by openingwindows and doors, the result will be fewer infectious particles in the room. A room withan open window, open door, and a fan will have less risk than an enclosed room with nofan, an enclosed room with a fan, or a room with an open window but no fan. In addition,mixing may increase the effectiveness of other environmental controls.

Directional airflow

If placed in or near a wall opening, propeller fans can also be used to enhance airmovement into and out of a room. Consider fans installed in the windows or through wallopenings on the back wall of a building. The fans exhaust air outside, away from people orareas where air may come back into the building. If doors and windows in the front of thebuilding are kept open, the overall effect should be to draw in fresh air through the front ofthe building and exhaust air through the rear. Health care staff should be mindful of thedirection of airflow to ensure the patient is closest to the exhaust fans and the staff isclosest to the clean air source. With this arrangement, the risk that TB will be spread isgreater near the back of the building; however, once the contaminated air is exhausted,dilution into the environment will be fast.

D. Exhaust fans

There are a wide variety of exhaust fan systems. A system can be as simple as a propellerfan installed in the wall, or it could include a ceiling grille, a fan, and a duct leading todischarge on an outside wall or on the roof. Over time, dust and lint accumulate on exhaustfan blades. The fans, motors, blades, and ducts become dirty and less air is exhausted. Forthis reason, these systems should be cleaned regularly.



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Appendix 4: Putting on and storing a N95 Respirator

A. Putting on a N95 Respirator Wash hands with soap and dry hands.

Place the date and your name on the respirator as the respirator should not be worn byothers and used only for a month. Hold the respirator in front of your face and place the lower elastic band around the

lower part of your head or upper neck. Place the upper elastic band so that the respirator fits snugly. The elastic band should

be fairly horizontal for a tight fit. Bend the flexible nose piece. N95 Respirators need to fit snugly to be effective and

should not be worn with beards or unshaven faces. If glasses are worn fit the upper edge of the respirator under the glasses to prevent

fogging of glasses and a snugger fit. Gently shape the respirator to your face but do not crush it. Wash hands with soap.

B. Removing and storing a N95 Respirator

Wash hands with soap and dry hands. Remove the respirator by the elastic bands and minimise contact with the face

respirator itself. Do not crush the face respirator. Store in a cool dry location and not in a plastic bag (collects humidity). For example

hanging on a wall to avoid contamination . Discard the respirator as infectious wasteafter wearing for a month.

Wash hands with soap.



Further Reading1. WHO. Implementing the Stop TB Strategy: a handbook for national tuberculosis control

programmes (2008).http://www.who.int/tb/publications/2008/who_htm_tb_2008_401_eng.pdf?ua=1

2. The Tuberculosis Coalition for Technical Assistance. Implementing the WHO Policy onTB Infection Control in Health - Care Facilities, Congregate Settings and Households(2010).http://www.stoptb.org/wg/tb_hiv/assets/documents/TBICImplementationFramework1288971813.pdf

3. CDC Tuberculosis Infection Control and Prevention. Infection Control in Health CareSettings (online) http://www.cdc.gov/TB/topic/infectioncontrol/default.htm

good shepherd hospital (swaziland) tb infection control policy dec 2014

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