TB INFECTION CONTROL

Reconceptualizing the Approach

Dr. Jessica Justman Dr. Wafaa El-Sadr Dr. Doris Macharia Director, UTAP Program Director, ICAP Country Director, ICAP-South Africa

ICAP, Columbia UniversitySeptember 24, 2007

PEPFAR Track 1.0 Meeting, Atlanta

Background

• High rates of undiagnosed, untreated TB in HIV settings– Motherwell Community Health Centre, SA

• 573/597 HIV pts screened for TB• 129 (22%) with TB disease

– Gisenyi Day Hospital in Rwanda: 22% of HIV-infected inpatients found to have TB disease

• Role of nosocomial transmission, esp MDR/XDR

Updated Figures from Tugela Ferry

From January 2005 to March 2007: • 433 TB cases resistant to at least INH and RIF

– 239 (55%) XDR TB cases• 199 (84%) confirmed dead

– 194 (45%) MDR TB cases (not XDR TB)• 119 (65%) confirmed dead

• Greater than 90% of MDR and XDR TB patients found to be HIV infected

• If no new interventions are introduced, a total of ~1,300 If no new interventions are introduced, a total of ~1,300 cases of XDR tuberculosis predicted cases of XDR tuberculosis predicted

– Over half nosocomially transmittedOver half nosocomially transmitted

G. Friedland, MD

What can be done to avert nosocomial XDR TB cases?Modeling of strategies

Administrative measures Environmental measures Administrative measures

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staff mask staff +pt mask staff enforce staff +pt enforce VCT+ARV

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Combinations of strategies Personal protective measures

Impact of Preventing Nosocomial Transmission of Extensively Drug-Resistant (XDR) Tuberculosis in Rural South African District Hospitals Basu, S, Andrews A, Poolman E, Gandhi N, Shah S, Moll A, Galvani A, Friedland G (Lancet ( in Press )

– Individual strategies reduce transmission but available ones have small-moderate effects

• Administrative 2-5%,

• Environmental 30-40%,

• Personal < 10% ( hospital staff infections reduced by 67%)

– Combinations of strategies are synergistic and can avert 48% (625 cases) in next 5 years

• Decreased length of stay + rapid dx + increased natural ventilation + patient isolation + VCT + masks

Efficacy of Rapidly Available Strategies to Reduce Nosocomial Transmission

Impact of Preventing Nosocomial Transmission of Extensively Drug-Resistant (XDR) Tuberculosis in Rural South African District Hospitals Basu, S, Andrews A, Poolman E, Gandhi N, Shah S, Moll A, Galvani A, Friedland G (Lancet ( in Press )

TB Prevention and Infection Control

• Limited infection control in resource-limited settings– Environmental controls—expensive ventilation

systems– Administrative controls—often lacking– Personal protective devices—seldom used

• New approach needed

Primary Objective

To minimize nosocomial transmission of TB

• help health care workers to reduce source infectiousness– HCW to promote rapid identification of

patients with active TB– HCW to rapidly initiate TB treatment– HCW to promote adherence to treatment

• Simple designs of renovated facilities

Proposed activities• Select two sites for study

– Motherwell Community Health Centre and Cecelia Makiwane Hospital proposed

• Assess TB infection prevention and control knowledge and procedures to identify needs

• Renovate facilities to minimize TB transmission• Establish work practice, clinical management

and administrative procedures at each site• Assess uptake of interventions• Develop implementation manuals and tools

Eastern Cape,SAThird most densely populated SA province14% of total SA population

Predominantly ruralDeclines in mining industry

HIV prevalence estimate 23%Smear positive case rate ~300/100,000

7,632

9,60811,255

13,91515,569

18,017

22,746

29,696

36,737

9068683,626

4,264 5,8747,844

20,551

15,273

0

10,044

24585 2,0221,193

2,846 5,1986,872

8,855

13,363

17,479

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

Jul-Sep2004

Oct-Dec2004

Jan-Mar2005

Apr-Jun2005

Jul-Sep2005

Oct-Dec2005

Jan-Mar2006

Apr-Jun2006

Jul-Sep2006

Oct-Dec2006

Jan-Mar2007

Apr-Jun2007

Nu

mb

er o

f p

atie

nts

Cumulative enrollment in HIV care (pre-ART and ART) & ART care at ICAP-South Africa supported facilities

July 2004 – June 2007HIV care (pre-ART & ART)

ART care

ART patients retained*

Source: ICAP URS, July 2007*Includes ART patients who are not known to have died, transferred or lost to follow-up.

4440 38

4 40

5

10

15

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25

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35

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45

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Total number offacilities

Care & treatment TB screeningamong HIV pts

HIV testingamong TB pts

Testing &counseling

Type of activity

Nu

mb

er o

f fa

cili

ties

`

Source: ICAP South Africa Site Census, August 2007

Number of ICAP-supported facilities by USG-funded activity, South Africa

Rietvlei Hospital & Clinics / Mzimkulu District

ICAP Satellite Office, Port Edward

St. Patrick’s Hospital /

Qaukeni District Clinics /

Holy Cross Hospital

ICAP Main Office, East London

Frere Hospital & Clinics

Cecilia Makiwane Hospital & Clinics

Ikhwezi Lokusa Wellness Center

Motherwell and Cecilia Makiwane sites proposed

Dora Nginza Hospital

Livingstone Hospital

Nelson Mandela Metropolitan Municipality Clinics:Zwide, New Brighton, Chatty, MasakhaneProvincialClinics:

Kwazakhele, Motherwell, Walmer 14th Ave

Empilweni TB Hospital

ICAP Satellite Office, Port Elizabeth

Proposed activities• Select two sites for study

– Motherwell Community Health Centre and Cecelia Makiwane Hospital proposed

• Assess TB infection prevention and control knowledge and procedures to identify needs

• Renovate facilities to minimize TB transmission• Establish work practice, clinical management

and administrative procedures at each site• Assess uptake of interventions• Develop implementation manuals and tools

Baseline site assessment

• Standardized tool to assess knowledge and attitudes of health care workers regarding TB transmission, nosocomial TB, protective devices and infection control practices.

• Observational assessment of health care practices including triage of TB patients, securing and dispatching sputum samples, time patient spends in clinic, time to receipt of results, laboratory procedures, etc.

Design Of Renovated Facilities Develop simple guidelines for simple

structural and design approached in renovation of HIV care and treatment sites to minimize nosocomial transmission of TB– Ventilation: open waiting areas, new windows,

fans, UVGI– Isolation: separate waiting areas

Work Practice Proceduresto promote HCW’s role in rapid identification

of patients with active TBDevelop training and mentoring materials• focused on active case finding of TB cases • tailored to HCW needs identified in baseline

assessment

Develop systems• for consistent use of TB symptom checklist• to obtain high quality sputum samples• to transport sputum samples and to obtain results• Linkages between HIV and TB services

Specific Implementation Activities• Hire TB Prevention and Control advisors• Establish policy with multidisciplinary TB

Prevention and Control team• Triage systems with dedicated triage staff

– to screen all patients at every visit and refer TB suspects to separate, ventilated area.

• Rapid diagnosis with sample tracking system• Rapid initiation of treatment• Adherence with DOT• Community education

1. Has the patient had a cough for > 3 weeks?2. Has the patient had night sweats for > 3 weeks?3. Has the patient lost > 3kg in the past 4 months?4. Has the patient had fever for > 3 weeks?5. Has the patient had recent contact with another person with active TB?

If “Yes” to question 1: The patient is a TB suspect, perform sputum collection for acid fast bacilli smear and continue evaluation for TB per the TB control program diagnostic algorithm for pulmonary TBIf “No” to question 1 but “Yes” to any other question: The patient is a TB suspect, continue evaluation for TB guided by clinical signs and symptoms. Refer to national reference hospital if necessary.If “No” to all the questions: The patient is not a TB suspect at this time, stop investigations for TB and repeat screening with questionnaire every 3 to 6 months.

*modified from Mohammed et al, 2004.

Specific Implementation Activities-2• Training and mentoring

– TB transmission, self-protection through rapid diagnosis and treatment of TB, effective triage of patients, diagnosis of TB, initiation of TB treatment and importance of retention of patients and adherence with treatment, linkage to the laboratory

– routine mentoring and annual CME to reinforce

• Confidential HIV counseling and testing• Adequate access to treatment• TB preventive therapy for HIV-infected health

care workers will be provided

Specific Implementation Activities-3

• Evaluate impact of interventions– Level of uptake of interventions– [Individual vs combinations of interventions]

• Develop and distribute implementation manuals and tools (posters, flip charts)

TB / HIV INTEGRATION (by site) Port Elizabeth

 TB x Rx VCT Prev CPT Link  CBO ART Tbreg Scr IPT Infec Staff Infra Grad

e

Port Elizabeth

Empilweni TB hosp x x x x x x x x x x x x x x  

Dora Nginza (adult) x x x x x x x x   x   x x x  

Dora Nginza (paed)  x x x x x x x x x x   x x x  

Livingstone hosp x x x x x x x x x x   x x x  

Kwazakhele x x x x x x x x x x   x  

Motherwell x x x x x x x x x x x  

Walmer 14th Avenue x x x x   x x x x x     x    

Zwide x x x x     x x x x     x    

New Brighton x x x x x x x x x x   x x x  

Chatty x x x x x x x x x x   x x x  

Masakhane x x x x x x   x x x          

 ACTIVITIES TIME-FRAME (August 2007 - July 2008)

O N D J F M A M J J A S

Hire TB control advisors for each site                        

Assessment of infection prevention and control knowledge and practices

                       

Establish infection prevention and control committees

With the ECDOH, formulate site specific infection prevention and control operational plan

                       

Procure and distribute equipment and supplies

                       

Develop and implement a capacity building and training strategy for the health care workers at the two sites

                       

Modify the existing physical infrastructure at sites to allow adequate natural and mechanical ventilation

                       

Educate patients, families and community on TB transmission

                       

Establish a M & E system for the project

                       

Conduct technical support supervision to the sites: ICAP-SA

Provide technical Assistance: ICAP New York

Summary

• Proposal focuses on reconceptualizing TB infection control by helping health care workers to reduce source infectiousness

• 2 SA sites—health centre and hospital

• Trainings and work practice interventions aimed at HCWs protecting themselves and their patients

• Assess level of uptake