Expert views on TB infection control measures

TB screening and IPT as an essential part of infection control

“Intensified TB case finding (ICF), isoniazid preventive therapy (IPT), all of these are in the service of infection control,” Dr Miller said in Cape Town.

"Health care workers should be aware that the most powerful intervention to reduce transmission of TB is to reduce the diagnostic delays," Dr Fabio Scano of WHO's Stop TB programme told HATIP. Intensified case finding, prompt diagnosis and rapid initiation of appropriate treatment could make a big difference. According to WHO’s 1999 guidelines, “the greatest risk of transmission occurs when patients remain undiagnosed and untreated”.

Diagnosis has its hazards - collection of sputum samples is often carried out without consideration for the health carew worker and others in the facility.

“Sputum collection always should be done outside (open environment) and away from other people," WHO recomends, "not in small rooms such as toilets or other enclosed areas. When outdoor sputum collection is not possible, sputum should be collected only in well ventilated areas where the risk of exposing HCWs and other patients is low.”¹

TB screening is the first step towards diagnosis and treatment. TB case loads and transmission could be reduced even further by enhanced uptake of HIV testing and counselling, routinely screening those people testing for HIV for TB and offering isoniazid preventive therapy (IPT) to those without signs and symptoms of TB.

Cough etiquette

Questions linger about the best way to encourage good cough etiquette. Facemasks can help prevent the spread of TB from the patient wearing them to others — but many people feel they stigmatise the patients who wear them.  

“We are experimenting with the four possible ways of practising cough hygiene (hand /upper arm /handkerchief or tissue /surgical mask). At present, using the hand is the most accepted,” according to Robin Smith, an Infection Control Practitioner working for MSF in Khayelitsha. “There is still a great deal of stigma attached to surgical masks. We have considered giving all patients surgical masks on entry into the clinic to overcome this.”

Good adherence to a less than optimal barrier may be better than poor adherence to a good one. However, using a handkerchief has generally been thought to be less effective than a facemask, but according to research by Prof Mehtar “using a handkerchief or cloth to cover the mouth and nose was effective in reducing aerosol to 0.25 m, and surgical masks effectively reduced aerosols to 0.5 m.” As a result, Tygerberg is emphasising using handkerchiefs and cloths. 

Facemasks may be useful for patients who do not adhere to good cough etiquette or who have drug-resistant TB. Even then, it is impossible to force anyone to keep it on.

“I visited one of the smaller hospitals in Cape Town recently,” said Dr Corbett, “with TB patients just mixed in with everyone else. One of the TB patients had a mask on because she’d been recognised as drug resistant. While we were there, her kids came in to see her and straight away she took her mask down. And people laughed but they didn’t do anything about it. So I think it’s very hard.”

Other healthcare workers working at very busy clinics in South Africa told HATIP that they were not currently teaching any cough hygiene to their clients.

In contrast, Chris Green, a treatment educator at Spiritia Foundation in Jakarta, Indonesia told HATIP that facemasks are insisted upon within their HIV community support groups:

“In our support group meetings, we encourage participants to discuss the probability of peer group members coming to a meeting with a cough. We note that if they are just excluded, or asked to wear a mask, they may feel discrimination - particularly if they have recently joined. We encourage groups to discuss this in advance, and develop a group rule, to be posted on a notice board, that anybody attending with a chronic cough will be asked to wear a mask and encouraged to visit a clinic. This will also increase awareness.”

He added that in some parts of Indonesia, there’s another problem besides poor cough etiquette: “In Papua, many of the indigenous people chew betel-nut, and spit out the residue. A recent report raised concerns that this is contributing to TB infection in Papua New Guinea, and the same is extraordinarily true in Indonesian Papua. I remember as a lad the notices in the public conveniences in England: ‘Spitting causes Consumption’. I think those campaigns were effective; we urgently need to emulate them in Papua.”

At the Stop TB Partnership, TB/HIV Core Group Meeting in New York in April, both Dr. Jeroen van Gorkom of KNCV and Dr Miller said similar campaigns around cough hygiene are needed.

“Even 80 years ago in the Netherlands - we had campaigns about cough hygiene, not spitting in public and so on,” said Dr van Gorkom. (You can view some good examples of early 20^th century anti-TB posters here).

Dr Miller said that within months, she would like to see cough etiquette and other TB IC printed on posters and put up in thousands of clinics, as was done in the past.

Separate TB suspects - but where do they go?

Separating TB suspects may be difficult in facilities where space is a major concern.

One solution, said Dr Miller, “in climates that allow for it, is to have as many covered outside waiting areas as possible. With regard to housing MDR patients, I know in our community many years back, we had trailers that our patients were living in. So each community comes up with a make-shift answer.”

But Dr Corbett said that many clinicians aren’t keen on putting people with HIV who are coughing together with people with TB during triage or when admitted into hospital.

“There’s an increase in the number of HIV-positive patients who have cough but do not have confirmed TB. What do we do with these people?  Do you isolate them with the TB patients? It just doesn’t seem right and people don’t do it, so in many places this basic separation of TB in-patients and non-TB patients, has completely fallen apart. That’s certainly true in Zimbabwe.”

She suggested moving to a “red/amber/green” approach to separating patients. However, this could wind up disclosing a patient’s HIV status.

But at his talk in Cape Town, Dr Jensen said that a well ventilated room where TB suspects have been instructed on cough etiquette is probably much safer than the waiting room — where, chances are, both groups of patients have been sitting together for hours anyway.

Why? Because we’re too busy to triage

“Some of the HIV partners have discussed with us the fact that even the concept of triage is not well accepted or well understood. Patients queue up and even if they're coughing blood, if they're number 15, they're seen after number 14,” said Dr. Miller.

“With the establishment of HIV care and treatment clinics we’ve tried to re-introduce the concept of triage, which was never implemented in many of our clinics,” Dr Eric Van Praag, Country Director of Family Health International in Tanzania, said at the Three I’s meeting. “Triage to get better patient flow, triage to sort out who needs emergency care or not, and triage in order to start implementing some IC components. It offers a lot of advantages. But we were not very successful. It’s very difficult - that concept of triage — not to train it but to implement with the current work load in our clinics.”

Task shifting might help. Some are using ‘cough monitors.’

“We have just introduced the concept of a 'Cough Officer' in Site B Ubuntu TB/HIV clinic,” said MSF’s Mr Smith. “The guys in KZN Church of Scotland Hospital [in Tugela Ferry] had good results with this.”

Written infection control plans for the facility

WHO’s guidelines emphasise the importance of having a written facility-based plan. However, it may be a challenge to convince large tertiary hospital administrators and staff to prioritise infection control.

“When you speak with people about it, the eyes roll and the fingers sort of twiddle, and people try to leave the room, so there has to be some way of conveying the message in a way that is more interesting and more gripping,” Dr Gerald Friedland of Yale University, and the Tugela Ferry team.

“We're going to need to sensitise a variety of persons including hospital administrators of the overall issue,” said Dr. Miller in Cape Town.

Dr Jagui agreed. “The directors, who are often something like a surgeon or a neurosurgeon, don't want to put money in infection control,” he said. But he suggested that whenever outbreaks, such as SARS, bird flu, etc, occur, to use the opportunity to get the hospital director’s attention.

Environmental controls: windows and buildings

“In many hospitals aspects of environmental controls and respiratory protection are prioritised neglecting the implementation of administrative controls,” Dr. Jagui said in Cape Town

Many of these are expensive, mechanical interventions that move air out of a room, or try to “clean” the air via filtration, or inactivate under UV lights. But lots of things can go wrong with these systems — especially in a resource-limited setting without reliable electricity. Prof Mehtar concluded that, with the exception of some window fans to blow air out of some rooms, mechanical engineering-based environmental solutions are impractical and exorbitantly expensive to install and maintain. And Dr Jensen stressed that even having a fan in the window will do no good if there is another open window right next to it, or if the door is closed.

Other environmental controls, such as natural ventilation in a well-laid out building, are another matter entirely. A recent study by Ron Escombe and colleagues has shown that ventilating tuberculosis (TB) wards by opening windows is more likely to reduce the risk of infection than mechanical ventilation and should be practiced wherever the climate permits.³

Dr Jensen does like whirlybird roof vents however. Since hot air rises, if there is a breeze outside, these can move air out of a room pretty quickly.

MSF is using them, according to Robin Smith: “Electricity and maintenance are a problem here in Khayelitsha so we are working as much as possible with natural ventilation - covered outdoor waiting areas, windows, whirlybirds for example - which require neither electricity nor maintenance. This is not only in the waiting rooms, but also in the TB and HIV departments.”

“I’m preaching that ventilation is the answer and that we should all be thinking about it,” said Dr Venter.

However, just opening the windows won’t work in every building.

“We find that counselling rooms at TB clinics - even in hospitals - are often poorly designed, laid out and ventilated,” said Chris Green in Jakarta. “The older hospitals and clinics here are MUCH safer than the modern version. The older facilities tend to have higher ceilings, larger windows, better ventilation (no air conditioning), and waiting areas are often open. In contrast modern hospitals have low ceilings, are usually air-conditioned, have tinted, sealed windows, and waiting areas are closed and crowded.”

Some of the facilities Dr Venter worked in fell into that latter category.

“To improve ventilation in the waiting room, we rebuilt one of our ART facilities, and plan to renovate another, with specific instruction to improve ventilation and increase access to ventilation – part DoH, part Pepfar funding,” he said.

Building design is outside most healthcare workers' expertise. Health facilities will require airborne infection control assessments to determine whether opening the windows is adequate or whether renovations might be necessary. Thus, TB IC must also become integrated into national public health policy, with plans, supervision and inspections as a way to monitor and evaluate progress. These issues will be discussed in an upcoming HATIP report on the outcomes of the Three I’s meeting.

But even in a building with good natural ventilation, someone has to make sure that the windows stay open, that there is the right sort of air circulation, and that staff do these things consistently.

Training and supervision of staff

“There is urgent need for wide-spread training that is comprehensive and integrates HIV and TB, but is inclusive of all aspects of care including psychosocial right down to occupational safety and how and when to put on an N95 mask,” Dr Krista Dong of iTeach told HATIP.

“Lack of education was our biggest barrier,” Robin Smith of MSF told HATIP. “We started by running DR-TB training sessions for all healthcare workers, now we are busy doing the same for all home-based carers, and after that we will move onto the general population.”

This is a big job because people need to produce TB IC training materials and methods that are appropriate to the language and culture of the nurses and other health staff.

Prof Mehtar emphasised that English is not the first language for many and that: “The method of instruction had to be more practical than theoretical...and the local culture of communication was verbal and relied on talking, workshops and discussion with visual evidence.” 

These methods are time and labour-intensive.

PALSA PLUS has a wealth of experience using similar methods of training nurses who run primary care clinics in South Africa (published by the Knowledge Translation Unit at Cape Town University Lung Institute). According to Dr Ruth Cornick at the University of Cape Town Lung Institute, TB IC has been integrated into the TB section of this year's edition of PALSA PLUS, including how to take sputa safely, ventilation, and instructions on the appropriate use of facemasks and respirators.

“The guideline and training approach prioritises diagnosing and treating TB quickly and knowing the patient and health workers' HIV status which of course impact on the spread of TB. We also have several reminders about MDR and XDR TB where they would prompt appropriate action in the course of a clinical consultation,” she said. 

Soon this course should reach most primary care nurses throughout South Africa.

Another issue is that training generally requires supervision to ensure implementation.

For instance, following recognition of the devastating impact of nosocomial TB on healthcare workers in Malawi, infection control guidelines were written and distributed to each hospital and staff were trained.⁴ The emphasis was on rapid diagnosis of patients with smear-positive pulmonary TB, administrative attempts to isolate infectious patients, and the education of patients on cough hygiene. Hospitals were requested to consider offering confidential counselling and HIV testing to their staff and to advise those who were HIV-positive against working on general wards and TB wards.

However, a survey three years later showed no significant improvement and staff only reported scattered implementation of the policy. “The introduction of guidelines for the control of TB infection is an important intervention for reducing nosocomial transmission…, but rigorous monitoring and follow-up are needed in order to ensure that they are implemented,” wrote Dr Anthony Harries and colleagues

Dr Corbett recently conducted a survey rating 50 African facilities in Ethiopia, Kenya, Malawi, Mozambique and Zimbabwe on their infection control practices — and found most were lacking.

Survey of reported TB IC practice at 50 African facilities:

Someone needs to be accountable, and empowered

So having a plan and putting it into practice are very different things.

Dr Francois Venter told HATIP that some of his facilities’ TB IC plans were all on paper: “We have patients coughing routinely in crowded waiting rooms. What’s holding up TB IC implementation? No central person is responsible. ID nurses see their role as TB notification and little else; ward nurses don’t really see it as a priority.” To change this, he would like to “make it someone’s responsibility, and give them the resources - and the power - to implement!”

Which is exactly what MSF has done in Khayelitsha by employing Robin Smith.

“One of our largest barriers was that TB infection control currently falls under the responsibility of the facility managers and Health & Safety reps, where it gets lost in the plethora of other things that they have to worry about, particularly if they are not educated about it. Having a full time Infection Control Practitioner for the Khayelitsha sub-district has allowed us to attack the problem more cohesively and I would recommend that other sub-districts do the same.”

Turning panic into activism

Not every programme will appoint and train an infection control officer, and as a number of people have pointed out, responsibility is usually given to someone without much power to change things where they work.

Advocating for a national TB IC policy (integrated with other airborne IC measures) would provide support for teams trying to scale-up TB IC where they work.

“There is need to also have mechanisms for supervision or inspection of health facilities, enforcing the implementation of standards and clinical practice. That means that you must have national standards, national policy, national training programmes and guidelines, and a monitoring and evaluation system if you want to measure whether TB IC is having an impact,” Dr van Gorkom told HATIP.

In addition, the community should act as a watchdog, and draw attention to poor TB IC at their local facilities.

TB IC has to be made personal for both the healthcare community and the HIV community, because they are the ones most at risk.

There are some pretty basic things that programmes can implement and that healthcare workers can do to help protect themselves and their patients in the wards and waiting rooms, and that community members can do to make places where people with HIV gather safer (including demanding safety from their own health clinic). Just like treatment literacy efforts were used to help people understand some of the science around HIV, they can be used to help people protect themselves from TB.

Activists are beginning to mobilise around this issue and teach people the basics. But TB IC needs to be rolled out into community-based organisations as well. Incorporating good TB IC in their own organisations may further reduce TB transmission, and like the activists in Indonesia, also increases awareness of what to expect in their health care facilities.

Activism is what prompted the reaction to the MDR-TB crisis in New York — an event that resurrected TB as a global health priority — Dr Ken Castro of the CDC reminded the audience in Cape Town. “It was the healthcare worker unions who demanded to be protected, and the AIDS Coalition to Unleash Power, (ACT UP), doing protests and demonstrating in front of the Health Department. We need to bring out that sense of outrage in the community that’s most affected.”

“We need a bit of the same outrage that was associated with lack of ART in the developing world, a clarion call that says we have to roll-out ART responsibly - that means we can’t get people sick by visiting the clinics,” Dr Rene Ridzon of the Gates Foundation said at the Three I’s meeting in Geneva.