TB Infection Control

Dear All
I have been away on a well deserved break and joined the discussion today. I did not realise that fencing was one of the strategies suggested by the gurus of TB control. I am intrigued- how does it work?
Best Regards and a prosperous and kind 2011!
Shaheen

Prof Shaheen Mehtar
MBBS, FRC Path (UK), FCPath (Micro) (SA), MD (Lon)
Head of Academic Unit for Infection Prevention and Control
Tygerberg Hospital & Stellenbosch Uni
PO Box 19063,
Tygerberg 7505, Cape Town
Tel: +27 21 938 5051
Fax: + 27 21 938 5065
Mobile: +27 82 852 3697
http://www.sun.ac.za/uipc
Infection Prevention and Control Africa Network
Visit website: www.ipcan.co.za. for information on
3rd IPCAN Conference, Namibia- 29th Oct-2nd Nov 2011
 followed by the WHO SIGN meeting 3rd-5th Nov, 2011

Dear Merid,

Thankyou for introducing this question. I can only speak of the 'vices' of fencing, since I see no virtues at all. I have no scientific proof of this, but I can state that the more succesful TB programmes that I have worked with in Africa and Asia never erected fences around their patients.

Fencing off (DR)TB patients has several adverse effects:
- It creates a detention centre atmosphere, which is detrimental to the recovery of the patients and encourages them to default from treatment, presenting significant risks for infection control
- It discourages suspect TB cases from presenting themselves to a clinic for fear of incarceration, thereby driving the disease underground and leaving infectious TB patients undiagnosed and untreated - the worst possible scenario in terms of infection control
- It stigmatises TB by reinforcing the public opinion that all those with TB should be forcibly segregated from the rest of society, a misconception that is thankfully being slowly but surely dispelled by the success of community based (DR)TB programmes

Having said this, an important administrative TB infection control is cohorting (Strong recommendation - WHO POlicy on TB Infection Control 2009): Identifying individuals according to risk factors in order to be ...

Dear Merid,

Thankyou for introducing this question. I can only speak of the 'vices' of fencing, since I see no virtues at all. I have no scientific proof of this, but I can state that the more succesful TB programmes that I have worked with in Africa and Asia never erected fences around their patients.

Fencing off (DR)TB patients has several adverse effects:
- It creates a detention centre atmosphere, which is detrimental to the recovery of the patients and encourages them to default from treatment, presenting significant risks for infection control
- It discourages suspect TB cases from presenting themselves to a clinic for fear of incarceration, thereby driving the disease underground and leaving infectious TB patients undiagnosed and untreated - the worst possible scenario in terms of infection control
- It stigmatises TB by reinforcing the public opinion that all those with TB should be forcibly segregated from the rest of society, a misconception that is thankfully being slowly but surely dispelled by the success of community based (DR)TB programmes

Having said this, an important administrative TB infection control is cohorting (Strong recommendation - WHO POlicy on TB Infection Control 2009): Identifying individuals according to risk factors in order to be able to separate those with a high risk of transmitting TB (e.g. Smear-positive patients) from those with a high risk of developping TB disease if exposed to TB infection (e.g. children). However, this can be done for example by having consultations in different spaces or at different times for separate risk catagories. It can be successfully achieved without fencing.

I hope that this helps. I look forward to thoughts from other colleages.

Kind regards,

Robin Vincent-Smith
TB Infection Control Practitioner
Medecins sans Frontieres

Great discussion!

How does one define "fencing"? Fencing, as in a chain-link fence, is offensive, stigmatizing, and ridiculous. How large are the "holes" in fences? Are they used to contain TB or contain (offend) people? Obviously, the latter is the answer. Now, let's talk about privacy fences. As the name implies, privacy fences allow privacy and will also provide some potential organization to patient, HCW, and visitor flow.

I believe the key here is to first define what you want and why . . . Then allow the patients and architects propose to the clinicians a solution . . . Then see if this is Okie Dokie for the clinicians . . . Then ask the question "Is this good for public health?" Why did I say "public health" and not IC or TB IC? Because public health includes more than just IC; public health is person-centered, not just HCW-centered.

Please note that I am NOT advocating fencing in (or out) TB patients!!!

 
Regards,
 
Paul J

Dear Robin
I could not agree with you more! Such severe measures may lead to the patients NOT presenting for care- the consequences of which are self evident. I do not think that is the way one should practice medicine, especially in LMI countries.
Regards
Shaheen

Prof Shaheen Mehtar
MBBS, FRC Path (UK), FCPath (Micro) (SA), MD (Lon)
Head of Academic Unit for Infection Prevention and Control
Tygerberg Hospital & Stellenbosch Uni
PO Box 19063,
Tygerberg 7505, Cape Town
Tel: +27 21 938 5051
Fax: + 27 21 938 5065
Mobile: +27 82 852 3697
http://www.sun.ac.za/uipc
Infection Prevention and Control Africa Network
Visit website: www.ipcan.co.za. for information on
3rd IPCAN Conference, Namibia- 29th Oct-2nd Nov 2011
 followed by the WHO SIGN meeting 3rd-5th Nov, 2011

Interesting topic. Opposite to Robin Vincent-Smith observation, I have seen some fenced in wards / health facilities in Africa. Very often, this has been done to control flow of patients within these areas, most of the time with an adverse effect. Patients feel locked up and try to escape prison.
One thing we have to keep in mind is the area we talking about. Health facilities in Africa might need more protection as a public building than for example a hospital in Boston, USA. Hence, the big fences you find around most of the facilities. This also leads to the fact that people on different continents have a different perception of a fence. A fence can protect you and a fence can lock you in.
When we talk fencing, one of the first questions we have to ask our self is, "What is the purpose of the fence?" Do we want to protect the people on the inside from the people on the outside, or the other way around? Do we want to restrict the flow of patients with in a certain area? Do we want to protect the building and the things it contains from "long term borrowing"? A fence ...

Interesting topic. Opposite to Robin Vincent-Smith observation, I have seen some fenced in wards / health facilities in Africa. Very often, this has been done to control flow of patients within these areas, most of the time with an adverse effect. Patients feel locked up and try to escape prison.
One thing we have to keep in mind is the area we talking about. Health facilities in Africa might need more protection as a public building than for example a hospital in Boston, USA. Hence, the big fences you find around most of the facilities. This also leads to the fact that people on different continents have a different perception of a fence. A fence can protect you and a fence can lock you in.
When we talk fencing, one of the first questions we have to ask our self is, "What is the purpose of the fence?" Do we want to protect the people on the inside from the people on the outside, or the other way around? Do we want to restrict the flow of patients with in a certain area? Do we want to protect the building and the things it contains from "long term borrowing"? A fence has many different functions. Depending of the function we can replace the fence with landscaping, a hedge, a water future, low walls, etc. all can direct the flow of people or even restrict them going somewhere.
Other options are to integrate "fencing" in the design of the building self. Well-located entrances, with receptions or nurse stations and proper signage will restrict flow of people in and out of the building. Other option for in patients might be the creation of a courtyard building. Inpatients can move freely within the courtyard, without the feeling of being fenced in.
Even so, try at least to avoid a fenced in ward with a two-meter high barbed wire fence.

Regards,

Hans