Module 12: Infection Control in

Health Care Settings

*Image courtesy of: World Lung Foundation

 It may seem a strange principle
to enunciate as the very first requirement
of a hospital
that it do the sick no harm

Florence Nightingale, Notes on Hospitals, 1863

 Infection Control in the ERA of HIV

• More PLWAs are attending health care and community facilities

– VCTs
– Primary care and ART clinics (IDCCs)

• Patients and HCWs who are immunosuppressed may be

vulnerable to TB as a result of exposure

• Some settings may have higher prevalence of TB/HIV, both

known and undiagnosed
– jails/prisons
– mines
 Why TB is a Problem
in Healthcare Settings

• Persons with undiagnosed, untreated and

potentially contagious TB are seen in health care
facilities
• 30-40% of PLWAs will develop TB in the absence of
IPT or ART
• PLWAs can rapidly progress to active TB and may
become reinfected
• HIV-infected HCWs are particularly vulnerable due
to occupational exposure
 What is Infection Control?

Patient to Worker to
Worker Worker
Visitor Visitor
Patient Patient
Visitor to
Worker
Visitor
Patient
 Infectiousness

Patients should be considered infectious if they

• Are coughing

• Are undergoing cough-inducing or aerosol-generating

procedures, or

• Have sputum smears positive for acid-fast bacilli and they

• Are not receiving therapy

• Have just started therapy, or

• Have poor clinical response to therapy

 Infectiousness (cont.)

Patients no longer infectious if they meet all of these criteria:

• Have completed at least two weeks of directly-observed ATT;
and

• Have had a significant clinical response to therapy and

• Have had 3 consecutive negative sputum-smear results;

Retreatment /MDR cases may take longer to convert

The only objective criteria is negative bacteriology

 Fate of Droplets

Organisms Liberated
Talking 0-200
Coughing 0-3500
Sneezing 4500-1,000,000

Droplets can remain

suspended in the air for
hours.
 Hierarchy of Infection Control

•Administrative controls to reduce risk of

exposure, infection and disease thru policy and
practice;

•Environmental (engineering) controls to reduce

concentration of infectious bacilli in air in areas
where air contamination is likely; and

•Personal respiratory protection to protect

personnel who must work in environs with
contaminated air.
Hierarchy of Infection Controls

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 Administrative Controls

• Prevent droplet nuclei containing M. tuberculosis from

being generated;

• Prevent TB exposure to HCWs, other patients and

visitors;

• Implement rapid diagnostic evaluation and treatment

for TB suspects
 Specific Administrative Controls

Reduce risk of exposing uninfected persons to infectious disease:

• Develop and implement written policies and protocols to ensure
- Rapid identification of TB cases

- Isolation

- Diagnostic evaluation

- Treatment

• Implement effective work practices among HCWs

• Educate, train, and counsel HCWs about TB
 Administrative Controls (cont.)

Perform risk assessment and

classification of facility based
on:

• Profile of TB in community

• Number of infectious TB
patients admitted
 Engineering Controls

To prevent spread and reduce concentration of

infectious droplet nuclei

In clinics
• Maximize airflow in outpatient clinics settings by
opening doors and windows, using fans

In hospitals
• Use ventilation systems in TB isolation rooms

• Use HEPA filtration and ultraviolet irradiation with

other infection control measures
 What is Ventilation?

• The movement of air

• “Pushing” or “pulling” of vapor or

particles

• Preferably in a controlled manner

 Ventilation Control

Types of ventilation
– natural
– local
– general
Simple Measures Can Be Effective!
Personal Respiratory Protection

• Respirators can protect health care workers;

• Respirators may be unavailable in low-resource

settings;

• Face/surgical masks act as a barrier to prevent

infectious patients from expelling droplets

• Face/surgical masks do not protect against

inhalation of microscopic TB particles
 Masks and Respirators

Respirators rely on an
airtight seal and have tiny
pores which block droplet respirators
nuclei

Masks have large pores and

do not have an airtight seal
to around the edge,
permitting inflow of droplet
nuclei
Face/surgical mask
Personal Respiratory Protection

Use of respirators should be encouraged in high risk

settings:

• Rooms where cough-inducing procedures are

done (i.e., bronchoscopy suites)

• TB “isolation” rooms

• Referral centers or homes of infectious TB

patients

• CDC/NIOSH-certfied N95 (or greater) respirator

should be used
N95 Respirator Dos and Don’ts

*Image courtesy of: CDC Image Library

Do
Be sure your respirator
is properly fitted!

[Should fit snugly at

nose and chin]

*Image courtesy of: CDC Image Library

Note poor fit at the bridge
of nose

Note poor fit at the chin-

Respirator should cover
chin and create a seal
Don’t forget to WEAR it!

*Image courtesy of: CDC Image Library

 Efficacy
Respiratory protection is effective only if:

• The correct respirator is used,

• It's available when you need it,
• You know when and how to put it on and take it off,
and
• You have stored it and kept it in working order in
accordance with the manufacturer's instructions

• http://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respfact.html
 Summary: Infection Control for TB

To reduce risk of TB to HIV positive patients and health workers,

you can:
– Develop IC plan and identify responsible health workers
– Train staff on TB and TB infection control
– Screen HIV positive clients for TB symptoms and refer
promptly
– Provide separate waiting areas and expedited care for TB
suspects
– Use personal respiratory protection when indicated
– Use simple environmental control measures, like opening
windows, turning on fans, etc.
Cough Etiquette
Common-sense Prevention

*Image courtesy of: World Lung Foundation

 Infection Control (IC) for TB

To reduce risk of TB to HIV positive patients and health

workers, you can:
– Screen HIV positive clients for TB symptoms and refer
promptly
– Provide separate waiting areas and expedited care for
TB suspects
– Provide surgical masks or tissues to TB suspects
– Use simple environmental control measures, like
opening windows, turning on fans, etc.
– Screen health workers periodically for TB symptoms
5-Steps to Prevent TB Transmission
1 SCREEN Early recognition of subjects with
suspected or confirmed TB

2 EDUCATE Instruct patients on cough hygiene when

sneezing or coughing; provide tissues or
mask
3 SEPARATE Request patients to wait in a separate and
well-ventilated area
4 PROVIDE HIV Triage symptomatic patients to front of line
SERVICES for services sought, so they spend minimal
time around other patients
5 INVESTIGATE TB diagnostics (sputum smear) should be
FOR TB completed ASAP
 Infection Control (IC) for TB

• Risks to Patients and Health Care Workers Alike!

– Patient to patient
– Patient to providers
• Nurses, doctors, pharmacists, FWEs
– Provider to patients

• Reduce TB transmission in health care settings

• Devise an Infection Control Plan with your clinics

• Teach your colleagues to protect themselves

 References
Core Curriculum on Tuberculosis, What the Clinician Should Know. Fourth Edition,
2000. US Dept. of Health and Human Services, Centers for Disease Control and
Prevention.
hhttp://www.cdc.gov/nchstp/tb/pubs/corecurr/Chapter1/Chapter_1_Introduction.htm
hhttp://www.cdc.gov/niosh/npptl/topics/respirators/factsheets/respfact.html

Guidelines for Prevention of TB in Healthcare Facilities in Resource-Limited Settings.

World Health Organization, 99.269.
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