Administrative controls

Question:

How can administrative measures in health care facilities be used to prevent the spread of MDR- TB in those facilities?

Answer:

The first and most important level of infection control is the use of reduce the exposure of HCWs and patients to M. tuberculosis. Important administrative measures include: • Early diagnosis of potentially infectious MDR-TB patients.

• Prompt separation or isolation of infectious MDR-TB patients. • Prompt initiation of appropriate MDR-TB treatment.

The most important aspect of administrative control measures is the physical separation of

patients known to have or suspected of having MDR-TB (especially smear-positive cases) from

other patients, especially those who are immunocompromised.

Ideally, patients with MDR-TB should be treated in isolated (or at least separated) wards. If no facilities exist and it is necessary to manage MDR-TB cases in a general hospital setting, special measures are needed: Because of prolonged infectiousness and the consequent increased risk of nosocomial transmission, patients suspected of having MDR-TB should, whenever possible, be placed in a separate area or building in the facility, preferably in well-ventilated rooms where the possibility of contact with other patients is minimal. If this is not feasible and there are large numbers of patients suspected of having MDR-TB, then a dedicated MDR-TB ward or area of a ward should be established.

Patients who are seriously ill at diagnosis or develop MDR-TB complications may require prolonged hospitalisation, and many countries hospitalise MDR-TB patients for the first several months of treatment. These patients are often admitted to specialized MDR-TB wards. Para- doxically, the risk to HCWs may be lower in such facilities than in general hospitals since the diagnosis has been made at or prior to admission and many of the patients rapidly become non- infectious once placed on adequate MDR-TB therapy.

Known or suspected HIV-positive patients should be kept separate from MDR-TB patients at all times. Such patients have a particularly high risk of contracting MDR-TB and in many countries, explosive outbreaks of MDR-TB have occurred on wards containing HIV-infected patients.

Immunocompromised HCWs should be given opportunities to work in areas with a lower risk of exposure to M. tuberculosis. MDR-TB should be strongly considered as part

of a differential diagnosis for immunocompromised HCWs with respiratory complaints in close contact with confirmed MDR-TB patients. Immunocompromised HCWs suspected of having MDR-TB should be promptly evaluated and treated, preferably on an outpatient basis. They should be removed from work until infectiousness is ruled out or until they have become smear-negative.

Patients’ willingness to remain in isolation/separation may be facilitated by keeping them occupied through various activities such as the provision of television, books/magazines, billiards, crafts, etc. It should be remembered that the difficulties in enforcing isolation can be reduced by ensuring timely diagnosis and prompt treatment.

In hospital settings and for drug susceptible TB, isolation may be stopped after a patient has had three negative smears (at least one must be on an early-morning specimen) taken on three separate days, and shows maintained clinical improvement, including resolution of cough. While some facilities use the same criteria for patients with MDR-TB; however, many experts are more cautious about returning MDR-TB patients back to their homes, schools, work sites and congregate settings. The reasons for this are the more dire conse- quences of MDR-TB and the fact that there are not good prophylactic regimens for the treatment of latent TB infection due to MDR-TB. Patients with smear-negative, culture- positive sputum on treatment certainly can still transmit MDR-TB. The WHO guidelines consider patients with MDR-TB to be contagious until their sputa are culture-negative and forbids travel in public airplanes or other public transportation until their sputa are culture negative. Many institutions will not stop isolation until the patient is proven culture-nega- tive.

Infectious patients with XDR-TB, whether infected with HIV or not, should not be placed on open wards (even if the ward is designated for patients on MDR-TB treatment). Given the high mortality associated with XDR-TB, isolation until the patient is not longer infec- tious is recommended.

Community-based ambulatory MDR-TB treatment can reduce the risk of transmission

to patients and health care workers. Although most transmission is likely to have occurred before the diagnosis and start of MDR-TB treatment, ambulatory patients should be ad- vised to avoid contact with the general public, practice home isolation, and especially avoid contact with susceptible persons, such as young children or HIV-infected individuals. Other important administrative measures that should be in place in facilities treating MDR-TB patients include:

• Assessment of the risk of transmission in the facility;

• Development of an infection control (IC) plan that details in writing the measures that should be taken in a given facility;

• Adequate training of HCWs to implement the plan.

The appointment of a director of infection control for the institution, and an infection control committee representing key departments of the facility, are strongly recommended. The initial task of the committee is the formulation of a comprehensive infection control plan for the institution, including a program for the education of all staff on infection con- trol policies and procedures.

Module 14 Infection control • Page 171