TB Infection Control

Dear Nardel,
Thanks for this interesting discussion platform.
Well we appretiate the New WHO TB IC Policy. It comes with many advantages for TB Control and management.it is intended for use at the national and sub-national level, not for institutions, and more details are promised for institutions thats not so bad too for the promise, but my advise is that since in this era where the stop TB partnership is pushing all efforts so that we can achieve the 2015 TB wipe out goal, i think some of these policies should come with a intention of implementation right from the grass roots(institutional level) to the national level. So what i mean is when ever these policies are being designed, the policy designers should take off some time and make sure that they prepare policies that will cover all levels rather than promises. Thanks Nyende Ali, DEF Uganda

Thank you Nyende Ali for that perspective. While national and subnational buy-in and support are essential, I agree with you that the real challenge is implementing transmission control at the institutional level. Clearly the next challenge is to find ways to help institutions all around the word implement fundamental changes in how TB, especially MDR TB, are managed, in particular where HIV is also common. There is growing evidence that globally we are generating more MDR and XDR TB than we are treating and a large portion of that is through institutional transmission - often due to reinfection. For that reason, I believe, MDR case rates are still increasing in places like Peru and Tomsk, Siberia where effective MDR-TB treatment has been long established.

Dear Ed,

This is very interesting while some countries in Eastern Europe are reporting universal access to MDR-TB such as Georgia. The Global Fund is investing massively in management of MDR particularly in the region of Eastern Europe and Central Asia.

Could you share with us the "growing evidence that globally we are generating more MDR and XDR TB than we are treating"? This would be particularly useful to determine how successful we are at the beginning time of massive investment.

Philippe Creac'h, Dr

Fund Portfolio Manager

Country Programs Cluster


The Global Fund to Fight AIDS, TB and Malaria

Chemin de Blandonnet 8 | 1214 Vernier, Geneva

Dear All,

I agree with the previous comments that 2009 WHO TB IC Policy does not provide detailed guidance on TB transmission preventions on facility level. It looks more like attempt of available evidence analysis on various TB IC interventions. 

I think this gap should be filled by country or regional level TB IC guidelines, which are now being developed in numerous countries with support of WHO and CDC.

Regarding Dr. Nardell's remark regarding generation of new drug resistant TB - I absolutely agree: without appropriate sustainable TB IC measures new DR TB cases are generated even in successful in terms of MDR TB treatment projects.

Dr. Grigory V. Volchenkov


Head Doctor
Vladimir Oblast TB Dispansery

Sudogodskoe shosse, 63
Vladimir 600023 RUSSIA

As a medical IPC practitioner of more years than I care to remember, I believe in applying IPC principles to local practice- thus looking at a sustainable IPC programme. I have worked on the ground in several LMI countries and the basic story is always the same- IPC systems and provisions, traditions, cultures and understanding differs.

In Africa, I think the issue around ventilation has been addressed in a very sensible manner. We have certain technical shortcomings- none or very few well trained engineering staff, no maintenance of electrical equipment, very little money for engineering provision, lack of trust in the current systems and therefore mechanical ventilation systems are not for us. Perhaps only certain designated areas such as operating theatres or similar but otherwise I think we can cope with less sophisticated systems.

We have over come these problems at our hospital but we are no where near what is expected of us- we do have selected isolation rooms with extraction fans to provide negative pressure ventilation. We do not use much mechanical ventilation since it is rather pointless in our setting. However in the Bronchoscopy, Respiratory ICU and other places at high risk from TB we have considered ...

As a medical IPC practitioner of more years than I care to remember, I believe in applying IPC principles to local practice- thus looking at a sustainable IPC programme. I have worked on the ground in several LMI countries and the basic story is always the same- IPC systems and provisions, traditions, cultures and understanding differs.

In Africa, I think the issue around ventilation has been addressed in a very sensible manner. We have certain technical shortcomings- none or very few well trained engineering staff, no maintenance of electrical equipment, very little money for engineering provision, lack of trust in the current systems and therefore mechanical ventilation systems are not for us. Perhaps only certain designated areas such as operating theatres or similar but otherwise I think we can cope with less sophisticated systems.

We have over come these problems at our hospital but we are no where near what is expected of us- we do have selected isolation rooms with extraction fans to provide negative pressure ventilation. We do not use much mechanical ventilation since it is rather pointless in our setting. However in the Bronchoscopy, Respiratory ICU and other places at high risk from TB we have considered and will be installing negative pressure ventilation-- our TB-IPC policy has these areas clearly defined.
For the winter, we open the top windows and place heaters under the main window allowing air currents to rise. This is for the healthcare facilities with hospitalised patients.

Our revised community TB-IPC programmes are just taking off and we cannot report much on the outcome of our new programme for some time. It is very community people based- we shall see in about 6 months.

I do hope this helps.

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

In two of the longest and largest MDR treatment sites - with excellent
treatment outcomes - Peru and Tomsk, Siberia, MDR rates continue to
rise. In Bull WHO (see Gelmanova) we have shown that re-infection in
hospitals is the biggest factor - and more than half of all MDR now
occurs in previously untreated patients - the result of transmission.

Correction: Since my last response, quoting data indicating that there had been no decrease in MDR in some of the longest standing MDR treatment sites, in Peru, Orel and Tomsk (Russia) I have become aware of the 2010 update on MDR surveillance issued in March (http://www.ghdonline.org/drtb/resource/multidrug-and-extensively-drug-resistant-tb-mxdr-t/). In this report there is now a downward trend for the last 2 years for both Orel and Tomsk. Although cases in Tomsk are up again this year, I suspect that the downward trend is real - reflecting many years of effective treatment. Peru trends are not mentioned and are presumably still upward. My point about the importance of transmission in fueling the epidemic still stands. Effective treatment is the most important way to reduce transmission.