TB Infection Control

Dear Susan,

I would like to tackle this difficult problem that you presented so
effectively. We had an international UVGI meeting at Harvard last
December, and application guidelines is supposed to be one of the
results, so a very timely issue for this forum.

Let's consider the issues, one by one:
1) If you accept our claim, based on old and new data, that effective
treatment stops transmission almost immediately, I am greatly assured
by your statement that all patients have had DSTs and are on the
appropriate therapy. However, I am confused by high rates of
non-adherence if all treatment is supervised, and that there are high
rates of treatment failure - not consistent with fully supervised
treatment based on DSTs. Can we assume that patients just don't show
up for treatment? Presumably, then, when they return, having been off
therapy, they could be infectious.
2) Agree, UVGI WITH MIXING FANS, is the most appropriate engineering
option in this harsh climate. I emphasize the need for mixing fans to
get the most out of fixtures.
3) Based on point #1, any treatment center could have non-adherent
infectious patients, and from that perspective fixtures for all
centers would be ...

Dear Susan,

I would like to tackle this difficult problem that you presented so
effectively. We had an international UVGI meeting at Harvard last
December, and application guidelines is supposed to be one of the
results, so a very timely issue for this forum.

Let's consider the issues, one by one:
1) If you accept our claim, based on old and new data, that effective
treatment stops transmission almost immediately, I am greatly assured
by your statement that all patients have had DSTs and are on the
appropriate therapy. However, I am confused by high rates of
non-adherence if all treatment is supervised, and that there are high
rates of treatment failure - not consistent with fully supervised
treatment based on DSTs. Can we assume that patients just don't show
up for treatment? Presumably, then, when they return, having been off
therapy, they could be infectious.
2) Agree, UVGI WITH MIXING FANS, is the most appropriate engineering
option in this harsh climate. I emphasize the need for mixing fans to
get the most out of fixtures.
3) Based on point #1, any treatment center could have non-adherent
infectious patients, and from that perspective fixtures for all
centers would be ideal. With limited funds, the numbers of patients
treated is as good a surrogate for risk as any I can think of. I
would start with the busiest treatment centers and work down as far as
funds will allow.
4) No one can say with any scientific rationale that treatment centers
with 20 patients need UVGI and that those with 10 do not - or any
other arbitrary number. TB infectiousness is highly variable. A TB
"disseminator" could easily appear at a small clinic, but just
statistically less likely.
5) I would be sure to include room paddle fans in the plan even if
that means fewer treated sites - at least those done should work well.
However, paddle fans are cheap and long-lasting with little or no
maintenance. Priority areas would be any common waiting areas -
essentially based on time-motion considerations and exposure of other
patients or staff. It is hard to be more specific without seeing
these set-ups.
6) I would cost out all sites and propose that budget. I would start
top-down based on utilization, as discussed, until the funds granted
run out - and continue with additional funding when available. No
plan with an arbitrary cut-off makes sense to me.
7) as you imply, maintenance is critical
8) do you have a source of fixtures tested to be safe and effective?
Grigory Volchenkov may have some recommendations for you.

I hope this helps,

Ed

On Fri, Jul 20, 2012 at 7:42 AM, GHDonline (Susan Adolph)
<> wrote:
> Susan Adolph added a new discussion to the TB Infection Control community.
>
> Title: Criteria for installation of upperroom UVGI systems in ambulatory TB treament locations
>
> Discussion contents:
> "Hello all,
>
> I would like to open a discussion on what criteria to use before deciding to install upper room UVGI in ambulatory TB treatment settings. Previously we were considering to install in all locations with more than 20 TB patients and then we lowered that to 10. Here is some info on the context.
>
> 1. Most of these locations do not have patients present 24 hours a day, in fact, the majority of them will only have them in the mornings.
> 2. Segregation is difficult given lack of HR capacity (usually there is only one nurse to deliver treatment, which makes segregation difficult even if you have the space). So there is quite a bit of mixing between DS, DR, S-ve and S+. (yes, we are working on this, no it is not possible to get some patients to come in the afternoons)
> 3. We have commitment for regular maintenance and cleaning.
> 4. We have SEVERE winters, gas shortages, lack of heat. As a result most facilities seal windows with plastic, completely eliminating natural ventilation. It is not possible to change this; it is so cold in our treatment locations that it is already an adherence issue. All of this makes UVGI one of our ONLY options for environmental measures during winter months.
> 5. Although these locations will not have TB suspects, they often start their treatment from these locations from the very 1st day of treatment. That said, we also have a fair amount of adherence issues, treatment failures, and patients slow to convert, although I don’t have stats off the top of my head (other than our 25% defaulter rate for DR…)
> 6. All patients have had DST and are on appropriate treatment.
> 7. We have a separate plan for TB hospitals and I would prefer not discuss it in this discussion.
> 8. Patients take anywhere between 20 minutes and 1 hour to take their medications. (which are administered to 3 patients at a time so that is correctly observed.)
> 10. We currently support approximately 80 of these ambulatory sites, which is why we need to develop criteria, as we cannot afford to install it everywhere. However, if I can provide good justifications, budget is not that big of a problem.
> 11. All sites consist of between 1 and 3 rooms which are separate (with their own entrance) from all other non-TB health services.
> 12. Mechanical ventilation is not an option for these locations for various reasons that I don’t want to go into in this post.
>
> So my biggest issue is if upper room UVGI is justified for 10 patients who are likely on effective treatment but for whom there are only a few other IC measures in place and natural ventilation is not possible for 4 months of the year.
>
> What criteria do you think I should use to choose locations for installation?
>
> Best Regards,
> Susan Adolph, RN
> ICO MSF Uzbekistan/Tajikistan"
>
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