To improve and disseminate best practices for TB infection control, members draw on a diversity of backgrounds, including engineering, architecture, administration and medicine. Experts answer questions and practitioners share strategies for effective TB infection control.
The World Health Organization classifies sputum induction as a high risk aerosol-generating procedure (2009). When conducting the procedure at home while the patient is still infectious, the question of subsequent sputum disposal collection and safe disposal arises. The Stop TB Partnership recommends avoiding “indiscriminate spitting” during at-home sputum collection; thus patients and other residents should be cautious of where and how they keep potentially infectious sputum (2008).
In this discussion, GHDonline members and moderators exchange knowledge on the appropriate way to dispose of sputum collected in homes of infectious TB patients to control transmission.
Most institutional guidelines on TB transmission control focus on the known or suspected TB case already on therapy, but it has long been known that the greater risk in hospitals is from unsuspected, untreated case. […] Administrative controls are often said to be the least expensive and most effective interventions. (Nardell E., Dharmadhikari A. 2010)
In this discussion, members confer about useful interventions, especially triage strategies, to prevent the transmission of TB indoors and in congregate settings with few resources, such as makeshift TB-HIV clinics in local churches in sub-Saharan Africa.
According to the World Health Organization (2009), "Isolation precaution is an important strategy in the practice of infection control. [...] Although there is no single study showing the effectiveness of isolation, there are many reports documenting the efficacy of the various components of isolation, including use of private rooms." In this discussion, GHDonline members and moderators exchange knowledge on designing isolation rooms that maximize ventilation for patients with drug-resistant TB in areas with limited resources.
Fit testing and user seal checking have different uses and, as outlined in the preamble to the U.S. Occupational Safety and health Administration (OSHA) legislation for respiratory protection (Title 42, Code of Federal Regulations, Part 1910.134), one cannot be substituted for the other.
Started with a question on the relative effectiveness of “fit testing” and “user seal checking” (previously referred to as “fit checking”), members and moderators exchange information resources and discuss fit testing and user seal checking methods and uses for various respirators.
Ventilation plays a key role in tuberculosis infection control, and in resource-poor settings good ventilation is often achieved by opening windows and letting the wind move the air in and out of the building. However, in some climates it is too cold to keep windows open, and this presents a problem for infection control.
A member working with Médecins Sans Frontières in Lesotho in an HIV program where 80% of patients are also diagnosed with TB wondered how health facilities operating without electricity can reduce nosocomial TB infections in cold climates where the most common heat source is charcoal stoves. Practical recommendations to improve ventilation and other infection control measures were shared.
Smear microscopy of sputum, often obtained by inducing sputum, is a key tool for TB diagnosis in resource-limited settings as it is low cost and more feasible than other procedures (Menzies D. Sputum Induction: Simpler, Cheaper and Safer- But Is It Better? American Journal of Respiratory and Critical Care Medicine. 2003,167:676).
In this discussion, 15 members on four continents shared protocols and recommendations for outdoor sputum induction (OSI) that address environmental considerations, time needed between inductions, and precautions for health workers thus creating a comprehensive online “how-to” guide.
In areas where drug sensitivity testing (DST) and capacity for treating drug resistant tuberculosis is limited, patients suspected of having MDR-TB may need to be transported from their community to a regional or national facility for diagnosis or treatment. Likewise, sputum samples requiring culture or DST may need to be taken to a distant lab. This discussion covers the precautions that should be taken to prevent TB infection of people involved in transporting patients, and to maintain the integrity of the sputum sample during transportation.
The World Health Organization recommends that in addition to Administrative and Environmental Infection Control procedures such as proper cough etiquette and ventilation, personal protective equipment such as N95 and FFP2 respirators should be worn by health workers working with TB patients (Annex 7, 2009).
More than 100 resources and discussions have been posted so far by GHDonline members, raising important practical questions such as: Which respirators protect against TB and how effective are they? How should a respirator be worn? Can a respirator be re-used safely? How long can respirators be worn? What are the costs of various models and do members have recommendations for suppliers?
Especially relevant to community-based tuberculosis programs with patients in with single-room homes, this discussion covers a range of interventions to reduce risk of transmission between start of treatment and sputum culture conversion and highlights the need for new approaches for MDR and XDR cases in cold climate areas where home ventilation is very difficult (because of heat loss).
A number of common sense approaches have been advocated, although like most infection control interventions, high-level proof of efficacy is generally lacking.