TB Infection Control

Dear Dan,

Thanks very much for the feedback on GHDonline and for sharing your case study which itself will be quite instructional for others.

We all respond to the questions posted here and are never sure that those responses are read or that they are at all helpful, so getting this kind of feedback is incredibly helpful.

Your responses seems sound. I have a question: how were you sure that the laboratory worker was infected in the lab and not in the community? Certainly both are possible. In resource-rich settings we might prove the point (as much as one can) by matching the worker strain with a strain (uncommon, so identifiable) being processed in the lab. But under high prevalence conditions matching may not be available and if it were the strain could be common in the lab and in the community. So how did you work this out?

Thanks again, and happy holidays.

Ed

Edward A. Nardell, MD
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
FXB Building, 709c
651 Huntington Ave.
Boston, MA 02115 ...

Dear Dan,

Thanks very much for the feedback on GHDonline and for sharing your case study which itself will be quite instructional for others.

We all respond to the questions posted here and are never sure that those responses are read or that they are at all helpful, so getting this kind of feedback is incredibly helpful.

Your responses seems sound. I have a question: how were you sure that the laboratory worker was infected in the lab and not in the community? Certainly both are possible. In resource-rich settings we might prove the point (as much as one can) by matching the worker strain with a strain (uncommon, so identifiable) being processed in the lab. But under high prevalence conditions matching may not be available and if it were the strain could be common in the lab and in the community. So how did you work this out?

Thanks again, and happy holidays.

Ed

Edward A. Nardell, MD
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
FXB Building, 709c
651 Huntington Ave.
Boston, MA 02115

617 432-6937 617 877-9412 (Cell)
(preferred) or

Dear Dr. Nardell,

Thank you for the reply.

Regarding your question, you are correct: we do not know for sure that it was a nosocomial infection. There is certainly the possibility that our lab manager was infected outside the lab, but we feel that given the circumstances, it is quite probably a nosocomial infection:

* He lives at the hospital in the quarters with several other
people, all of whom are healthy.
* Our hospital is extremely remote in the foothills of the Himalayas
and he has very very little occasion to leave the hospital complex.
* He only very rarely (1-2 times per year) visits his family, in
another part of the country.
* No other known TB contacts.

Nonetheless, your point is very important of course. From our perspective though, the most important thing was to assume that it was nosocomial, address all possible weaknesses in our infection control policies, and hope that, regardless of the specific etiology or management of his TB, that our future infection control would be better.

Thank you once again for your insights.
Regards, -Dan

--
Dan Schwarz
Executive Director | Nyaya Health
http://www.nyayahealth.org

p: +977 975.101.7136
e:
Skype: dschwarz0

Dear Dan,
This is truly an interesting case. Lab personnel are at high risk of TB infection, especially if the sputum collection facilities were deficient. Where is the sputum collection performed now? In Africa, we try to encourage Health Care Facilities to do it outdoors, but I am not sure how cold it gets where you are. In Mozambique, we find that training on how to use respirators are much needed to guarantee some protection, and I would advise you to do it regularly in Nepal as well.
We also facilitated a Respiratory Infection Control course with WHO last year in India, and two people from Nepal were present. We also heard our colleague from WHO trained a few others in Kathmandu last year. I can find contacts for you if you need material.
Luciana Brondi
HIV/TB and IC Advisor, Jhpiego, Mozambique

Dear Dr. Brondi,

Thank you for your email. I'll try to respond to your questions:

The sputum collection is performed by the patients in an open area, normally outside the outpatient clinical area. They are given the sputum containers and then they bring them back to the lab personnel. Then the lab staff take it to the new sputum examination room. The cold is very much a factor in our setting, as is the rain during the monsoon season, so having it at least somewhat inside is a priority. That being said, our new sputum examination space is as open as is possible, with an open
door on one end of the small room and a big window at the other end. The dimensions are about 3m long, and 1.5m wide, and we place a fan at the one end of the room to suck air in from outside and funnel it out the other side.

The respirator training, as you highlight, is very important. We are trying to work on this right now. If you happen to have in-country (Nepal that is) contacts for this, please send them to me. You can email me directly at

Dear Dr. Brondi,

Thank you for your email. I'll try to respond to your questions:

The sputum collection is performed by the patients in an open area, normally outside the outpatient clinical area. They are given the sputum containers and then they bring them back to the lab personnel. Then the lab staff take it to the new sputum examination room. The cold is very much a factor in our setting, as is the rain during the monsoon season, so having it at least somewhat inside is a priority. That being said, our new sputum examination space is as open as is possible, with an open
door on one end of the small room and a big window at the other end. The dimensions are about 3m long, and 1.5m wide, and we place a fan at the one end of the room to suck air in from outside and funnel it out the other side.

The respirator training, as you highlight, is very important. We are trying to work on this right now. If you happen to have in-country (Nepal that is) contacts for this, please send them to me. You can email me directly at if you prefer.

Thank you once again for your insights. Best regards, -Dan

--
Dan Schwarz
Executive Director | Nyaya Health
http://www.nyayahealth.org

p: +977 975.101.7136
e:
Skype: dschwarz0