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Hi All,

I did not contribute to the 10 essential IC discussion but I wanted to share with you what I believe is a good (but not perfect) basic triage strategy used in our Haiti facility for many years.

It is based on smear and HIV status and requires 3 areas: 1) general medical ward, 2) TB ward, and 3) several isolation rooms. It is captured in this presentation with photos available in the community here: http://www.ghdonline.org/ic/resource/transmission-of-mdr-mtb-infection-contro...

Most TB in Haiti is treated in the community with paid community workers.

When patients require hospitalization, smear negative patients go to the general medical ward regardless of HIV status - presumably no one is very infectious. Smear positive/HIV negative patients go to the TB ward which has extra ventilation and UV lamps. Patients who are smear positive and HIV + cannot go to the general or TB ward, and require one of 6 isolation rooms.

It is not perfect because smears are not perfect indicators of infectiousness, and unsuspected TB patients and HIV infected patients may result in patients where they should not be, but it is probably better than what I have seen in many parts of the world and it is workable in our experience.

I offer this for discussion. Please share other examples.

Ed

Attached resource:

Link leads to: http://www.stoptb.org/wg/tb_hiv/assets/documents/10%20Essential%20Actions%20for%20Effective%20TB%20Infection%20Control.pdf

Summary: This list of 10 essential actions for effective TB IC was developed by the TB Infection Control Subgroup of the Global TB/HIV Working Group in collaboration with the HIV/AIDS and Stop TB Departments at WHO. Below is a summarized version with bullet points. Download PDF for full version.

1. Include Patients and Community in Advocacy Campaigns

* Raise awareness and education within the community and among patients about:
- TB infection, prevention and control: TB can be spread by coughing - persons coughing should cover their mouths (ref. #4).
- Patients HIV status and eligibility for Isoniazid Preventive Therapy (IPT).
- Right and access to rapid TB diagnosis and treatment.
- Themes like “Our community is TB-Safe” or “Our health facilities are stopping TB.”

* Health Care Workers (HCWs) may wear personal respiratory protection to protect themselves and others.

* Promote a safer clinic and care for everyone: Safety without stigma should be the goal.
- Avoiding unnecessary admissions to health care facilities is another way of increasing safety.


2. Develop an Infection Control Plan

* Facilities should have an infection control (IC) plan and a facility person or team responsible for IC:
- Identify high risk areas for TB transmission.
- Provide information on TB and HIV rates among HCWs and patients.
- Provide area-specific IC recommendations.
- The laboratory should have its own specialized standard safety procedures.


3. Ensure Safe Sputum Collection

* Sputum collection can be potentially hazardous for HCWs and patients:
- Remember: safety without stigma is the goal.
- Sputum should be collected outside (if feasible) or in specially designed rooms with adequate ventilation, and should be done away from other people.


4. Promote Cough Etiquette and Cough Hygiene

- Hang poster on TB IC and cough “etiquette” in at least the outpatient department waiting area, admissions area, and casualty department.
- When coughing: cover mouth and nose with hands, cloth such as handkerchief, clean rag, tissues, or paper masks.
- Staff are responsible for safety and should ensure patients adhere to these practices.


5. Triage TB suspects for "fast-track" or separation

- All patients should be screened upon arrival for chronic cough (i.e. >2-3 weeks), fever, weight loss, night sweats, haemoptysis, or contact with a person with TB.
* HCWs message to patients: screening is part of quality care.
* HIV status inquiry/information about testing for patients

- Fast-track suspected cases:
* Rapid diagnosis and care services
* Patients suspected of TB infection should wait near an open window or in a comfortable area separate from the general waiting room (outside when possible).
* Community-based treatment models should be encouraged.
* When in-patient settings: TB suspects should be placed in a room or area separate from general wards.
* Patients suspected or known with Drug-Resistant TB should be isolated from general public and other TB patients.


6. Assure Rapid Diagnosis and Initiation of Treatment

- Move suspected TB patients to the front of the queue for all services and provide prompt evaluation for TB:
* Use quality-assured laboratory for Acid-Fast Bacillus (AFB) smear and culture when possible. Turn-around time for smear results should be no more than 24 hours.
* If patient is AFB smear-negative: provide additional procedures (e.g. chest x-ray and referral visits) or treatment as quickly as possible.
* Use a tracking system whenever possible.

- DOTS treatment begins immediately after positive diagnosis
* Develop and follow a plan for assuring adherence with treatment.


7. Improve Room Air Ventilation

- Waiting areas should be open and well-ventilated (all this weather permitting):
* Windows and doors should remain open to maximize cross ventilation.
* Appropriately placed simple fans can assist ventilation.
* Open-air shelters with a roof to protect patients from sun and rain are recommended.

- New buildings and renovations should include TB IC in plans.
* Plan for separate patient wards or rooms with good ventilation for in-patient DR TB services.


8. Protect Health Care Workers

- Provide HCWs with health assessments inc. screening for TB and HIV at least annually:
* Encourage “know your HIV/TB status” policies and culture.

- For HIV-positive HCWs:
* Minimize exposure to persons with TB, for example offer a change of duties.
* Screen for IPT.
* Provide appropriate personal respiratory protection to HCWs in high-risk settings for transmission of TB such as bronchoscopy suites.


9. Capacity Building

- Provide training on TB IC practices: hand washing, other respiratory and blood borne infection control trainings.
* IC practices require a system-wide approach.


10. Monitor Infection Control Practices

- Supervision of IC practices should be a part of every supervisory visit.
* Facility Tour: check that IC is being implemented and that all essential supplies for IC are available.
* Develop a facility IC Plan.

- Monitoring:
* Annual TB cases among HCWs can provide useful information on transmission of TB in facilities.
* Medical records of a sample of TB patients looking at the time interval from admission to suspicion of TB, suspicion of TB to ordering sputum for AFB, time from ordering to collection of sputum, collection of sputum to reporting of results, to initiation of TB treatment and interviewing patients to discuss understanding of infection control, safety and stigma.

Source: Stop TB Partnership

Publication Date: June 1, 2008

Language: English

Keywords: Fact Sheet, General Resources, TB IC Guidelines

 
S. Mehtar
Replied at 6:12 AM, 2 Nov 2008

Dear Ed
I agree. What we need to do in low resource countries is to concentrate on triaging (separating) as soon as possible the potentially infectious cases from the rest. I like the Haiti model. At TBH we are going to start trying triaging based on any history of cough (it is really difficult in a high endemic area to do anything else) especially in OPD and clinics. Will let you know how it goes.
How can access some of the previous presentations? I am at home and need to get hold of the presentations here?
Talk soon
Shaheen

Sophie Beauvais
Replied at 10:22 AM, 3 Nov 2008

Dear Prof. Mehtar,

I'm looking forward to reading more about your new triage strategy based on cough when it is implemented, and thanks again for your contributions to this discussion and all others.

If you wish to view all the presentations available in the TB Infection Control community, you can click on a topic and then select “Resource” in the filter navigation menu on the left, or do a search with a keyword (or several) in the "Search" bar at the top of the page in "All Communities".

You can then refine results by languages, organizations (the source of the document) or the document type (PDF – a lot of the presentations are saved in that format, PowerPoint, Word, etc.). All files can then be downloaded and saved on your computer for future reference for example.

Last, a lot of the recent presentations published in the community, including the ones from the July 2008 Engineering Methods course and from The Union conference, are saved under the "Training" topic: http://www.ghdonline.org/get/search/?N=0+700132+100002.

I hope this answered your question but please let me know if you need more clarification and I’d be happy to help.

Best, Sophie

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