TB Infection Control

Dear Alexi,

By PHC I presume you mean primary health care, but abbreviations sometimes vary. I am unaware of any recommendation that suggests that respirators be used routinely in PCH facilities, although depending on TB rates in some countries, it might be justified in encounters with coughing patients. Certainly respirators ought to be available should a TB suspect come into clinic. Ideally, they would be fit tested for maximum benefit, but if the institutional risk assessment suggests that TB rate in the population served is low, my opinion is that non-fit tested respirators available for occasional use would be better than no respirators at all.

Remember that even with fit testing, there may be 10-15% face seal leak, so not absolute protection. Moreover, the greatest exposure in the PHC setting is the unsuspected, undiagnosed patient where no respirator is likely to be used, fitted or otherwise.

The onset of effective treatment stops TB transmission almost immediately. It follows that the most important protective strategies to prevent TB transmission in PHC settings are:
1. Finding cases - Actively - through cough surveillance (i.e., ideally by a paid cough officer) followed by a rapid diagnostic test for TB and drug resistant TB, i ...

Dear Alexi,

By PHC I presume you mean primary health care, but abbreviations sometimes vary. I am unaware of any recommendation that suggests that respirators be used routinely in PCH facilities, although depending on TB rates in some countries, it might be justified in encounters with coughing patients. Certainly respirators ought to be available should a TB suspect come into clinic. Ideally, they would be fit tested for maximum benefit, but if the institutional risk assessment suggests that TB rate in the population served is low, my opinion is that non-fit tested respirators available for occasional use would be better than no respirators at all.

Remember that even with fit testing, there may be 10-15% face seal leak, so not absolute protection. Moreover, the greatest exposure in the PHC setting is the unsuspected, undiagnosed patient where no respirator is likely to be used, fitted or otherwise.

The onset of effective treatment stops TB transmission almost immediately. It follows that the most important protective strategies to prevent TB transmission in PHC settings are:
1. Finding cases - Actively - through cough surveillance (i.e., ideally by a paid cough officer) followed by a rapid diagnostic test for TB and drug resistant TB, i.e., Xpert TB, or sputum smear if drug resistance is low.
2. Separation of coughing patients under safe conditions while awaiting diagnostic tests.
3. Treatment based on rapid DSTs, that is, EFFECTIVE treatment.

We are calling these core components "F-A-S-T" and they apply equally to PHC in the in-patient or out-patient setting. Full implementation of this approach awaits the general availability of rapid diagnostics, but active cough surveillance, quick sputum smears, and rapid treatment can be effective today in most places where MDR rates are low.

Ed

Edward A. Nardell, MD (note: new address below, effective immediately)
Associate Professor
Harvard Medical School (Medicine; Global Health and Social Medicine)
Harvard School of Public Health (Environmental Health; Immunology and Infectious Diseases)
 
Brigham and Women's Hospital
Division of Global Health Equity
Partners In Health
641 Huntington Avenue, 3A-03
Boston, MA 02115
 
617 432-2080 (academic office)   617 877-9412 (cell)

Dear Ed, thank you for your response and clarifications. PHC is Primary Health Care, as you have presumed correctly. It seems maybe that at primary health care level HCW protection mean of respirators is more psychological. However I share opinion that limited amount for each HCW is needed. In my view this also gives health care worker feeling of protection and security which is important and may also contribute to the profession prestige. So far we do not see possibility to supply fit-tester to each facility. At initial stage simple training/orientation meeting on respirator use might be offered.
Best regards.
Alexei

In the US it is an OSHA requirement that every person that has the potential to come in contact with an infected person be fit tested every year. When we fit test hospital employees we test everyone but administration. Because this is a financial burden we keep our costs down.

Depending on the job we can test up to 30 people at a time and only charge $3 to $10 per fit test and is based on the number of fit tests.

Hope this helped coming from someone that tests thousands of people a year.

Good Luck, Kevin Best
Owner
Respiratory Protection Testing
www.bestfittest.com

Dear all
In addition to all previous important inforamation, National TB control Program conduct case Findings . This can be either:
a. Passive case finding that is done when patients themselves on their own initiatives come at a health facility with symptoms suggestive of Tuberculosis. Investigations are done and patients received DOTS treatment

b. Active case finding: which is limited to high risk groups as contacts of cases, elderly, expatriates , workers of high risk occupations (e.g. Health care workers, persons exposed to silica dust), prisoners and handicapped living in confined places and immune-compromised patients as HIV patients.

In addition, strengthening TB epidemiological surveillance by strengthening recording & reporting system is very important.