3 i

MESY. TWG BIL 2/2014, CROWN GARDEN HOTEL, KELANTAN

DR. ASMAH RAZALIPUBLIC HEALTH PHYSICIANDISEASE CONTROL DIVISION (TB/LEPROSY)MOH PUTRAJAYA

MESYUARAT PENCAPAIAN NEGERI JAN-SEPT 2014 & PERBINCANGAN HALATUJU PROGRAM KAWALAN TB/KUSTA 2015

17-19 NOVEMBER, 2014CROWN GARDEN HOTEL, KELANTAN

PENGENALAN 3I

November 17, 2014


November 17, 2014


INTRODUCTION

• The Three I’s, Isoniazid Preventive Therapy (IPT), Intensified Case Finding (ICF) for

active TB, and TB Infection Control (IC),

are key public health strategies to decrease the impact of TB on people living with HIV.

November 17, 2014


INTENSIFIED CASE FINDING (ICF)• Intensified Case Finding (ICF) is an activity, recommended

by the WHO, intended to detect possible TB cases as early as possible among people living with HIV – usually by using a simple questionnaire for the signs and symptoms of TB.

• ICF: Intensified Case Finding for TB means regularly screening all people with or at high risk of HIV or in congregate setting for the symptoms and signs of TB, followed promptly with diagnosis and treatment, and then doing the same for household contacts.

November 17, 2014


ICF Goals• Reduce morbidity and mortality

More intensive case-finding leads to fewer TB deaths and less severe post-TB complications

Focus on those most at risk of severe morbidity

• Reduce TB transmission General community Institutional settings Marginalised populations

• Increase case-finding Target high risk groups Community-wide approach

November 17, 2014


November 17, 2014


ICF OPPORTUNITY• Screening of high risk groups

Symptomatic out pt,

PLHIV,

Diabetes,

HCW

• Screening in institutions

Prisons

PUSPEN

Old folk homes

• Screening in community

High prevalence TB locality

November 17, 2014


November 17, 2014


What factors determine the yield and cost-effectiveness of ACF?

Factor 1. TB prevalence among the targetHigher prevalence – higher yield

Factor 2. Diagnostic algorithmsMore comprehensive screening- higher

cost &yield

November 17, 2014


November 17, 2014


3 Ì= Intensified case finding

November 17, 2014


ICF OBJECTIVES

1. To increase CASE DETECTION RATE among the high risk group of TB

2. To identify suspected TB cases (symptomatic) among the high risk group of TB

3. To collect and analyse sputum from symp. Individu

4. To provide health education

5. To treat symptomatic TB

November 17, 2014


ICF ACTIVITY I(3)T

IDENTIFY

TRAIN

TRACE

TREAT

• Identify the localities with high burden of TB

• Conduct training to the staff & community volunteers

• House to house visit- TB screening & refer for positive symptoms

• Ensure treatment is given for positive TB

November 17, 2014


ICF-PROCESS1. Survey your data

2. Analyze -? High TB burden district- ? Localilities

3. Start planning your ICF project –

- Approval fr. TKPK KA, PKD, Local leaders

-Conduct meeting with local leaders

-Design your action plan- Gantt chart, budgetting, training,

ICF form

4. Conduct the training course

5. Start ICF- house to house visit, TB screening, refer positive symptoms to nearby clinic.

6. Writing the report

November 17, 2014


INFECTION CONTROL

November 17, 2014


DEFINITION

•Infection control refers to policies and procedures used to minimize the risk of spreading infections, especially in hospitals and human or animal health care facilities

November 17, 2014


WHY DO WE NEED INFECTION CONTROL?

November 17, 2014


Need for infection control

November 17, 2014


Overburdened health services

November 17, 2014


Notification Rate per 100,000 (NR) and Cases of TB Among HCW, 2002-2013

November 17, 2014

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

50

100

150

200

250

300

0.0

20.0

40.0

60.0

80.0

100.0

120.0

3377 88 93 103 92

119 124

182 192221

248

111.9

81.0

TB Cases among HCWKadar Notifikasi (NR) Anggota KKM (100,000 Anggota KKM)Kadar Notifikasi(NR) Penduduk ( 100,000 Penduduk)

Cases

NR


MDRTB MALAYSIA (2004-2013)

November 17, 2014

2004 2005 2006 2007 2008 2009 2010 2011 2012 20130

20

40

60

80

100

120

140

160

180

200

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

13 17 42 41 56 55 64 141 74 124

0.3 0.3

0.70.6

0.9

0.8

0.9

1.3

0.80.7

Notified MDR Cases Propotion MDR (%)

Cases %


Risk factors for TB infection

•Concentration of infectious droplet nuclei in the air produced by index case when coughing.

•Duration of exposure - How long did the exposure last?

•Proximity to source -How close was the person to the TB patient? Household, workplace, congregate setting..

November 17, 2014


Standard Precautions

• Use with every patient, at every health care visit• Main elements include:

• Hand hygiene • Respiratory hygiene, cough etiquette• Use of personal protective equipment to avoid direct

contact with patient’s blood, body fluids, secretions, and non intact skin

• Prevention of needle stick/sharp injury• Cleaning and disinfection of the environment and

equipment

November 17, 2014


STANDARD PRECAUTIONSHealthcare workers must treat all blood & body fluids as infectious.

November 17, 2014


Airborne vs. droplet transmission

Airborne•Small droplet nuclei <5 microns diameter•Stay suspended in air•When inhaled, can reach the alveoli and cause infection

Droplet •Large droplets > 5 microns in diameter. •Do not remain suspended in the air, so no special air handling or ventilation is required

• If inhaled, do not reach alveoliNovember 17, 2014


Number and size of organisms

Number of organisms released

Talking 0-200Coughing 0-3,500Sneezing 4,500- 1,000,000

Size of the droplets (function of air velocity)

Sneeze ~3-10 m/s 75% are ~10 μm in diameter < 25% are droplet nuclei (1-5 μm in

diameter).

Wells 1955, Duguid 1945, Wells/Riley 1961, et al.November 17, 2014


Who can infect whom?

Patient to Worker to Visitor to

Patient Worker Visitor

November 17, 2014


AIRBORNE PRECAUTIONS

• Airborne precautions are required to protect against airborne transmission of infectious agents.

• Diseases requiring airborne precautions include, but are not limited to: Measles, Severe Acute Respiratory Syndrome (SARS), Varicella (chickenpox), and Mycobacterium tuberculosis.

• Airborne precautions apply to patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei.

• Preventing airborne transmission requires personal respiratory protection and special ventilation and air handling.

November 17, 2014


AIRBORNE PRECAUTIONS

•Place patients in airborne precaution room which has:•12 or more air changes per hour•Control of airflow direction

•Limit the movement of the patient•Ensure patients wear a surgical mask if outside their room

•Use a particulate respirator whenever entering and providing care

November 17, 2014

Factors affecting the risk of transmission

•Patient •Recipient•Bacterial •Institutional

November 17, 2014MESY. TWG BIL 2/2014, CROWN GARDEN HOTEL, KELANTAN


November 17, 2014


What are managerial activities?

Activities used by programme managers to support and facilitate the

• implementation • operation • maintenance • evaluation

of TB infection control at the national, sub-national and facility levels

November 17, 2014


MANAGERIAL ACTIVITIES

1. Identify and strengthen a coordinating body, and develop an IC plan

2. Ensure health facility design, construction, renovation and use are appropriate

3. Conduct surveillance of TB disease among health care workers, and assessment of health and settings at all levels

4. Address advocacy, communication and social mobilization (ACSM)

5. Conduct monitoring and evaluation of the set of IC measures

6. Enables and conduct research

November 17, 2014


Administrative controls1. Promptly identify

people with TB symptoms (Triage)

2. Separate infectious cases

3. Ensure patients cover their cough

4. Minimize time in health care facilities

5. Health worker protectionNovember 17, 2014


Administrative controls are first priority because they:

•Block the first step in the pathway of TB transmission

•Stop TB at the source: prevent release of droplet nuclei in the first place

•Have been shown to be effective•Are less expensive•Can be readily implemented by managers and health care workers

November 17, 2014


ISTC of Administrative controlsIdentify people with TB symptoms

(triage)Separate infectious casesTime is minimized in health care

facilities (also ensure effective Treatment)

Cough etiquette

(ISTC is also International Standards for TB Care)

November 17, 2014


B. Clinics: Identify people with TB symptoms

Ask screening questions at intake: • Do you have a cough? If yes, for how

long?• Are you being evaluated or treated for

TB?

November 17, 2014


Identify people with TB symptoms

If the patient reports cough > 2 weeks and/or being evaluated or treated for TB, then:

• Suspect the person may have infectious TB• Instruct patients to cover cough• Triage (next slide)

November 17, 2014


Separate potentially infectious patients

• In a well-ventilated area away from others

•Requires rational design and use of buildings, attention to patient flow

•Provide care for infectious TB patients in clinics separated space from clinics for people living with HIV/AIDS

How do (or can) you accomplish separation in your countries’ facilities?

November 17, 2014


Minimize Time to expose others

If suspect TB:• Quickly provide the services originally requested (fast track instead of queue)

• Initiate a TB diagnostic evaluation, or facilitate referral for diagnostic services

• Separate from other patients

November 17, 2014


November 17, 2014

Promote Cough etiquette

Among patients, visitors, and health workers

• Use tissue or cloth to cover nose and mouth when coughing or sneezing

• Use surgical mask if patient unable to cover own cough, or patient is moving through facility

• If no physical barrier available, cover mouth and nose with bend of the elbow

• Posters in all patient care and staff areas• Staff vigilance to identify coughing patients in

waiting areas (if missed by screening)


PROTECTION OF HEALTH CARE WORKERS

•Appropriate information and education

•Encourage HIV testing•Encourage screening •Training

November 17, 2014


Environmental controls—facility level

Reduce the concentration of infectious particles in the air via:

• Ventilation• Natural, mechanical, or mixed mode• Can direct the flow of infectious air away from health care

workers and other patients

• Ultraviolet germicidal irradiation (UVGI)

November 17, 2014


A. What is ventilation?• Movement of air• “Pushing” and/ or “pulling” of particles and vapours• Preferably in a controlled manner

November 17, 2014


THE BETTER VENTILATED THE AREA,

THE LOWER RISK OF TRANSMISSION OF TB

AND OTHER AIRBORNE INFECTIONS

November 17, 2014


November 17, 2014


Window openings

November 17, 2014


Sputum collection outside: a simple solution!

Sputum collection

Don’t!Do!

November 17, 2014


Air Changes Per Hour (ACH)

•Calculating ACH is the most simple way to assess ventilations

•ACH = Volume of air moved in one hour•One ACH means that the volume of air in the room is replaced in one hour

•WHO recommends at least 12 ACH to prevent airborne infection

•The higher the ACH, the better the dilution and the lower the risk of airborne infection

•But too much airflow can be uncomfortable

November 17, 2014


ACH = air flow rate divided by room volume

November 17, 2014


What do you need to measure ACH?

1.A tape measure

2.Vaneometer

3.Smoke tube

4.Calculator

5.Note pad

November 17, 2014


Measure dimensions of the opening to calculate area

Area of window opening = length x widthExample 1: Area = 0.5 m x 0.5 m = 0.25 m2

November 17, 2014


Use the vaneometer to measure velocity, direction

Speed = metres per second = m/s

November 17, 2014


Room volume = width x depth x height

Example 1:

3 m wide x 5 m deep x 3 m high = 45 m3

Calculate room volume

November 17, 2014


Example : ACH calculation

•Window area = length x width = 0.25 m2

•Air velocity through window= 1 m/s•Air flow rate = window area x air velocity = 900 m3/h

•Room volume = width x depth x height = 45 m3

•ACH = Air flow rate divided by room

volume = 900 m3/hour = 20 ACH

45 m3 November 17, 2014


Ventilation is more effective if:

1. Directional airflow2. There is good air-mixing (no stagnant or short circuiting)

November 17, 2014


Directional airflow

•Air flows from “clean” to “contaminated”

•Locate the health care workers (or other patients) near the clean air source

•Locate the person who may be infectious near a place where the air is exhausted away

November 17, 2014


Natural ventilation

Open Window

Open Window

Door C D E F

BDirection of air flow

Beds

A

Beds

Health care worker (HCW) is near the clean air source

November 17, 2014


Natural ventilation• Created by the use of external

airflows generated by natural forces such as:

• Wind

• Differences in temperature (stack)

• Naturally ventilated rooms can achieve very high ventilation rates (ACH) under ideal conditions

November 17, 2014


Stack ventilation• Stack ventilation is another

type of natural ventilation• It is driven by differences in

temperature.• When the room air is

warmed, it is lighter and rises.

• This building is designed to let the warmed air escape near the top, which is then replaced by fresh air entering through the lower opening.

November 17, 2014


Turbine driven ventilation (whirly bird)

• A whirly bird (turbine) can draw even more air once it starts spinning.

• These take advantage of the stack effect.

• Photo courtesy of Hans Mulder

November 17, 2014


November 17, 2014


Maximize Natural Ventilation• Openings on opposite walls (cross ventilation)• Openings are unrestricted (stay open)• 10% of floor space should be openable

window area on each wall• Upper levels of the building (higher from the

ground floor)• Building and openings are oriented to use the

prevailing wind, without obstruction by other nearby buildings

November 17, 2014


Mechanical and mixed mode ventilation

November 17, 2014


Mechanical ventilation

• Is created by using a fan to force air exchange and to drive air flow

• Works by generating negative pressure in the room to drive airflow inward

To be effective, it is essential that:• All doors and windows kept closed• A minimum of 12 ACH is maintained• The ventilation system is well-designed,

maintained and operated

November 17, 2014


Principles of ventilation

Which is an easier way to extinguish the flame?• Inhale (pull, exhaust)• Exhale (push, supply)

November 17, 2014


Two ways to dilute and remove contaminated air

First choice: Single pass

Re-circulation + HEPA filtration

Rooms in a health facilityNovember 17, 2014

Designs to provide air mixing

Airflow patterns are affected by:

•Air temperature•Location of furniture

•Space configuration

•Movement of health care workers (hcw)

hcw

supply

exhaust

hcw

exhaustNovember 17, 2014


Short circuiting

•Clean air is removed before it is mixed with room air

•Contaminated air in the room is not effectively diluted or removed

supply

exhaust



Negative pressure keeps droplet nuclei in the room

•Air flows from a higher pressure area to a lower one

•A room under negative pressure has a lower pressure than adjacent areas, so air is drawn into the room; negative pressure directs the airflow

•Negative pressure is achieved by exhausting more air from a room than is supplied

November 17, 2014


225

m3 /

h

200

m3 /

h

25 m3/h

200

m3 /

h

225

m3 /

h

135

m3 /

h

135

m3 /

hPatient room(Negative)

Nurse room(Positive)

What is negative pressure?

November 17, 2014

Negative pressure room

•Air flows into room, from higher to lower pressure

•10% flow differential is minimum required

•Keep doors and windows closed•Monitor to ensure negative pressure is maintained



Mixed mode ventilation

• Combines the use of mechanical and natural ventilation

• Is done through the installation of an exhaust fan to increase the rate of air changes in the room

• Can be useful in places where• natural ventilation is not suitable (e.g. very

cold weather) • fully mechanically ventilated rooms are

not available

November 17, 2014


Fans• Fans can be used to mix

the air in a naturally ventilated area.

• A ceiling fan - circulates air but doesn’t move it in a particular direction. This type of fan mixes the air, and is more effective with an open window to dilute and remove droplet nuclei

• The other fans can direct the air, and be positioned to enhance air movement into and out of a room to remove droplet nuclei.

November 17, 2014


Window exhaust fan

• Fan used for exhaust ventilation.

Photo courtesy of Paul JensenNovember 17, 2014


Corridor

Patient room

Window fan

Airflow with window exhaust fan

•Exhausted air is expelled through the fan.• The exhaust fan has generated negative pressure in the patient room. • This difference in pressure allows the air to enter the room from the corridor. • The directional airflow prevents droplet nuclei from escaping into the corridor.November 17, 2014


Window exhaust fan

• A window exhaust fan with a window open directly below it.• The picture is taken outside the room. We are standing outdoors looking into the room.• The fan is exhausting contaminated air to the outside, right above an open window.• Air is flowing into the room through the window. Photo courtesy of Paul Jensen.

November 17, 2014


Where goes that air?Short-circuiting

• Locating the exhaust next to the supply of incoming air results in short circuiting of the air outside the building.

November 17, 2014


Respiratory protection

November 17, 2014

A. Risk of TB transmissionWork location TB incidence rate ratio

(relative to population TB incidence rate)

Outpatient facilities 4.2 – 11.6

General medical wards 3.9 – 36.6

Inpatient facilities 14.6 – 99.0

Emergency rooms 26.6 – 31.9

Laboratories 42.5 to 135.3

Joshi R, Reingold AL, Menzies D, Pai M [2006]. Tuberculosis among health-care workers in low- and middle-income countries: a systematic review. PLoS Med 3(12): e494.

Menzies D, Joshi R, Pai M [2007]. Risk of tuberculosis infection and disease associated with work in health care settings. Int J Tuberc Lung Dis 11(6): 593-605.November 17, 2014



WHO RECOMMENDATIONS

• When used with administrative and environmental controls, particulate respirators may provide health care workers (HCW) additional protection from TB

• Respirators • Must meet or exceed standards• Be properly used• Be part of a training programme

November 17, 2014

Surgical masks• Reduce the spread of microorganisms from the wearer to others, by capturing large wet particles

• Do not protect the wearer from inhaling small infectious aerosols.



Particulate respirators

• Protect the wearer from inhaling droplet nuclei

• Filter out infectious aerosols

• Fit closely to the face to prevent leakage around the edgesNovember 17, 2014


Surgical masks(yes for patients)

November 17, 2014


Surgical masksdo not protect staff from TB

November 17, 2014


USER SEAL CHECK

1. Exhale sharply• Should feel positive

pressure inside respirator• If leakage, adjust, re test

2. Inhale deeply• Negative pressure should

make respirator cling to face• If leakage, adjust, re test

Cover respirator with both hands

November 17, 2014


WHY IS FIT TESTING NECESSARY?

•Ensure a proper seal between respirator and wearer

•Determine appropriate make/model

•Determine appropriate size

November 17, 2014


WHEN SHOULD FIT TESTING BE DONE?Employees should pass a fit test:• Prior to initial use• Whenever a different respirator facepiece (size, type, model or make) is used

• Periodically thereafter• Whenever changes in the worker’s physical condition or job description that could affect respirator fit are noticed or reported

November 17, 2014


SOURCES OF FACEPIECE LEAKAGE

• Around facepiece/skin interface• Through air-purifying element• Through exhalation valve

November 17, 2014


HOME INFECTION CONTROL• Ensure adequate ventilation / open windows.• Isolating patients- own bedroom if possible• Promoting cough hygeine• Ensuring that patients use surgical mask during waking hours while at home or when meeting with others;

• Refraining from close contact with children; • Maximising time in open-air environment (e.g., receiving visitors outside);

• Minimising contact with known HIV positive patients; and

• Ensuring that household members are screened for TB and DR-TB

November 17, 2014


INFECTION CONTROL HCW

• Wearing an N95 respirator (health workers and DOTS supporters);

• Keeping HOME visits or clinical evaluations brief, and whenever possible, conduct these outside or in a well-ventilated room with as much distance as possible from the patient;

• Educating the patient on cough hygiene• Providing the patient with a surgical mask when close contact is required

November 17, 2014


IPT

November 17, 2014


• HIV is the strongest risk factor for developing tuberculosis (TB) disease in those with latent or new Mycobacterium tuberculosis infection.

• The risk of developing TB is between 20 and 37 times greater in people living with HIV than among those who do not have HIV infection.

• TB is responsible for more than a quarter of deaths in people living with HIV.

• A high rate of previously undiagnosed TB is common among people living with HIV.

TB/HIV

November 17, 2014


November 17, 2014

ESTIMATED TB INCIDENCE, 2012• WHO estimated that there

were 8.6 million new TB cases in 2012 and 1.1 million (13%) were HIV-positive.

• 75% of these HIV-positive TB cases were in the African Region.

• There were 1.3 million people died from TB in 2012 with 320,000 deaths from HIV-associated TB.


November 17, 2014

• Globally, 0.4 million TB patients living with HIV were enrolled on CPT in 2012.

• The coverage of CPT among TB patients with a documented HIV-positive test result was 80% in 2012, similar to the level of 2010 and 2011.

• In 2012, 4.1 million people enrolled in HIV care were reported to have been screened for TB, up from 3.5 million in 2011.

• Of the reported 1.6 million people newly enrolled increased, since about 50% of those newly enrolled in HIV care and screened for TB are likely to be eligible for IPT.

ESTIMATED HIV PREVALENCE IN NEW TB CASES, 2012


HIV SITUATION IN MALAYSIA

‘By end of 2013, Malaysia reported a cumulative figure of 101,672 HIV cases with 85,332 people living with HIV.

Cumulatifve HIV = 98,279Cumulative deaths = 15,688PLHIV = 82,591

November 17, 2014


0

5000

10000

15000

20000

25000

30000

35000

40000

2003 2004 2005 2005 2007 2008 2009 2010 2011 2012 2013 2014 2015

NO OF HAART

Expected coverage

ESTIMATED ARV COVERAGE , MALAYSIA

November 17, 2014


TBHIV (%) IN TB CASES, MALAYSIA (2000- June,2014)

No.of cases

%TBHIV

20002001

20022003

20042005

20062007

20082009

20102011

20122013

06'20140

5,000

10,000

15,000

20,000

25,000

0

4

8

12

16

11,945

692

5.8

No.TB Cases No.of new TB Cases with HIV Positive%TBHIV in TB cases

November 17, 2014


• In 2013, there were 24,071 cases of TB registered in Malaysia. About 20, 635 (86%) cases were tested for HIV at the same time of TB diagnosis.

• Off 20,635 TB patients tested for HIV, about 1,510 (7.3%) cases were recorded to be HIV positive.

• Off 1,510 patients with TB-HIV co-infection, 1,299 (86%) cases were pra- diagnoses and 211 (14%) post diagnoses of TB-HIV co-infection.

TB-HIV cases were first detected in 1990 and contribute to about 10% of the total TB cases reported in Malaysia.

November 17, 2014

TB HIV COINFECTION


TB-HIV DEATH, MALAYSIA

November 17, 2014


Impact of HIV on TB

• HIV increases risk of developing active tuberculosis• 5 -10% chance per year of re-activation • 9 times greater risk compared to HIV

negative people • 50% chance per lifetime of re-activation

Isoniazid prophylaxis treatment reduces risk of developing TB by 33% regardless of Mantoux status(relative effect 0.67; CI 0.51–0.87) (Cochrane review Level 1)

IPT

November 17, 2014


November 17, 2014


2 Ì = Isoniazid Prophylaxis Theraphy

November 17, 2014


Isoniazide 5mg/kg od (Max 300mg)

+Pyridoxine 50mg od

for 6 months

November 17, 2014


IPT

• A meta-analysis showed that there was no difference in development of active TB between six month and 12 month IPT (RR=0.58, 95% CI 0.30 to 1.12). (WHO, 2010)

• Thus, our local circular recommends that IPT to be given for six months. (Circular, 2011)

November 17, 2014


• TB-HIV collaborative activities started in Malaysia since year 1990.

• Approaches to engage TB and HIV programme in management of TB-HIV co-infection need to be improved.

• All cases diagnosed with TB should be screened for HIV and vice versa.

• There was decrease in ART coverage among HIV positive TB patients; 434 (32%) in 2012 compared to 407 (27%) in 2013.

• CPT coverage among TB-HIV patients was still low (<5%).

• There was encouraging increased in IPT coverage among HIV positive TB patients ; 459 in 2011, 1120 in 2012 and 1220 in 2013.

TBHIV MALAYSIA

November 17, 2014


THANK YOU ….

• • • 3 Ì

November 17, 2014

3 i

Health & Medicine

Transcript of 3 i