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Research Support IPC
Evidence Based
Matsie Mphahlele, MPhil, MSc
MDR-TB Program
Jhpiego-SA
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Why is TB Infection Control
Important
� High burden of undiagnosed TB in health care settings and other
congregate settings
� Prevalence of undiagnosed PTB in VCT/ART clinics 8-27%
� (Mohammed et al. Int J Tuberc Lung Dis. 2004; 8(6):792-5, Edwards et al. 16th
Conference on Retroviruses and Opportunistic Infections. Montreal; 2009,
� Prevalence of undiagnosed PTB in mines
� Day et al. IJTLD. 2006;10:523-9, Corbett et al. Am J Respir Crit Care Med
2004;170:673-79)
� High rates of TB infection and disease in HCWs demonstrated in
studies implicating nosocomial transmission
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The problem
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The problem
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Guidelines and recommendations:
International guidelines to reduce TB transmission in resource-limited settings are available
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Evidence of the efficacy of TBIC interventions
� It not possible to measure infectiousness of TB or MDR-TB directly, nor can the efficacy of environmental infection control interventions to reduce or prevent transmission be measured directly.
� Lack of evidence on efficacy of most interventions is due to:
� inability to culture Mtb from air under real life conditions
� Molecular amplification methods
� detect nucleic acid from tubercle bacilli in the air, but cannot distinguish living from dead organisms
� nor quantify those with infectious potential.
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Evidence of the efficacy of TBIC interventions
� IPC guided by research, studies and evidence-based practices developed to facilitate safe and effective clinical interventions
� Easy to use, reliable, and evidence based strategies appropriate for resource-limited, high TB-HIV prevalence settings are needed
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Hierarchy of TB-IC
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Prevention of nosocomial
transmission in Russia
• Separation of TB patients according to sputum smear status, drug resistance and treatment regimen •
• Upper Room UVGI fixtures in high and medium risk areas
• Mechanical ventilation designed, installed, commissioned and maintained
• Personal respiratory protection program
• Laboratory biosafety program
Dr. GRIGORY VOLCHENKOV, Vladimir Oblast TB Dispensary
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How infectious is MDR-TB, and can it be interrupted?
Results from the field
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Purpose of the AIR Facility
To develop an evidence base for
affordable and effective
transmission control
interventions for TB (including
MDR and XDR TB) in
congregate settings within the
context of dual TB and HIV
epidemics.
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The AIR Facility
Witbank, Mpumalanga Province, SA
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AIR Facility, Experimental Plan
A B
Odd days Even days
Patient room intervention on/off on alternate days
Guinea pig air sampling
UVGI or
other
intervention
Air sampling
from breathing zone
3 2-bed rooms,
corridor and
common room
Infection rate with
patient room
Intervention on
Control infection
rate, patient room
Intervention off
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Tuberculosis, 2011. 91(4): p. 329-38.
Reported:
1)High rates of transmission from patients to guinea pigs
2)Transient TB infection
3)Reinfection
4)Limited disease progression
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74% guinea pigs infected
� Many guinea pigs reverted their skin test back to 0 mm
0
20
40
60
80
100
TST1 2 3 4 5
0
5
10
15
20
0 4 8 12 18
GP 8
0
5
10
15
20
0 4 8 12 18
GP 33
Timing of TST (weeks)
Timing of TST (weeks)
TST size in mm
TST size in mm
AIR Pilot Study
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Effects of natural ventilation in health care settings
� Used CO2 clearance� Naturally ventilated rooms – 28 ACH� Pre-1950’s – 40 ACH
� Mechanically ventilated negativepressure rooms - 12 ACH
� Calculated risk of TB transmissiono 39% in mechanically ventilated –vepr roomso 33% in naturally ventilated modernroomso 11% in naturally ventilated pre-1950’s rooms
Escombe AR et al; PLoS Medicine 2007
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Two predominant types of traditional home construction in Tugela Ferry. A. Round-shaped
home with thatched roof B. Box-shaped home with metal roof.
Lygizos et al. BMC Infectious Diseases 2013 13:300 doi:10.1186/1471-2334-13-300
Natural ventilation reduces high TB transmission risk in traditional homes in rural KwaZulu-Natal, South Africa
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Natural ventilation reduces high TB transmission risk in
traditional homes in rural KwaZulu-Natal, South Africa
Table 1
ACH and estimated TB risk in predominant home types
All homes Box-shaped, Metal-roofed
Round-shaped, Thatch-
roofed
ACH Mean (SD) Mean (SD) Mean (SD)p-value
Closed 3 (2.9) 3 (2.7) 3 (3.3)0.50
Windows Open 9 (7.1) 13 (8.1) 5 (2.9)0.01
Windows & Door
20 (13.1) 27 (9.7) 13 (12.8)0.01 Open
*TB Risk (10h exposure)
Closed 55.4 (27.8) 58.3 (24.7) 52.5 (31.5)0.62
Windows Open 21.5 (14.1) 24.7 (18.1) 18 (8.4)0.32
Windows & Door
9.6 (4.7) 8.9 (3.6) 10 (5.6)0.44 Open
Wells Riley equation: C = S(1 − e− Iqpt/Q) where C = number of new cases, S = number of susceptible individuals, I = number of infectors (presumed to be 1 per household), q = number of infectious quanta produced per hour per infector (assumed to be 13 based on previous studies) [22], p = pulmonary ventilation rate of susceptible individuals (0.6 m3/h, previously established), t = exposure time of susceptible individuals, Q = absolute room ventilation (ACH*room volume). The probability of a new case was C/S.Lygizos et al.
Lygizos et al. BMC Infectious Diseases 2013 13:300 doi:10.1186/1471-2334-13-300
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Wind-driven turbine roof ventilators
Wind-Driven Roof Turbines: A Novel Way to Improve Ventilation for TB Infection Control in Health Facilities. HCox, R Escombe et al. PLoS One 2012
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UPPER ROOM-ULTRAVIOLET GERMICIDAL IRRADIATION
(UVGI)
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UVGI
WHO recommendations:
� Priority should be given to achieving adequate air changes per hour using ventilation systems
� If not possible, UVGI is a complementary intervention
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- Escombe AR et al. Plos Med 2009 (March) ; 6
Lima Peru- Escombe et al
73% efficacy
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EXPERIMENTAL DESIGN:
ODD DAYS:
EVEN DAYS:
ANIMAL ROOM 1
ANIMAL ROOM 2
254 nm Irradiance: 250µµµµW/ cm2
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Ventilation ducts in patient rooms Paddle Fans Assure Good Air Mixing
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Results
UV1 Intervention Control
TST-1 0 1TST-2 0 3TST-3 0 5TST-4 0 0TOTAL 0 9
UV2
TST-1 3 17TST-2 12 30TST-3 0 1TOTAL* 15 48
*p<0.0005
Combined hazard ratio 4.9 (CI.95: 2.8, 8.6)
Efficacy:80%
Hazard
of becom
ing infe
cte
d
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EFFECT OF ACH AND
MIXING FAN ON UV
EFFECTIVENESS
AIR MIXING
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Personal Respiratory Protection
Special filters in place to prevent inhalation ofdroplet nuclei
• N95 (or greater) or FFP2 (or greater)• Evidence based on:Mathematical modelingLaboratory testing using surrogate particlesExpert opinion
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Personal Respiratory Protection
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EXPERIMENTAL DESIGN:
ODD DAYS:
EVEN DAYS:
ANIMAL ROOM 1
ANIMAL ROOM 2
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Results
2.3-fold (95% CI, 1.5–3.4; P , 0.0005) lower risk among guinea pigs exposed to air exhausted from the ward whenpatients wore face masks.
*56% (95% CI, 33–71%) risk reduction in transmission
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While the evidence-base has grown, there are several challenges...
� Lack of expertise and experience in ventilation design, construction, commissioning and maintenance
� Practical implementation and application
� Long term hospitalization with poor isolation tradition; neglect of administrative infection control principles is quite common
� Investments for TB control often lack prioritization
� Sustainability of IC interventions
� Critical gaps related to knowledge and skills in TB IC among HCW
� Enforcement of community supported treatment and management of patients
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Summary
� Health care workers are at risk for contracting TB and need much higher levels of protection than they currently receive.
� Experiments have demonstrated that MDR TB transmission can be interrupted through implementation of existing transmission control strategies and technology.
� Experiments have demonstrated that standardized treatment of patients for MDR-TB rapidly suppresses MDR-TB transmission.
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THANK YOU