14.2 Administrative measures in health facilities

14.2.1 Evaluation of the risk of M. tuberculosis transmission

The first step is to perform an initial TB risk assessment. This assessment should be performed by the IPC practitioner (Section 14.2.3).

 

For an example of risk assessment tool, see Appendix 23.

14.2.2 Infection prevention and control plan

Based on the initial assessment, each facility should develop a detailed, written, specific TB-IPC plan for implementing measures to reduce TB transmission.

 

The TB-IPC plan should be re-evaluated and updated based on periodic (at least annual) TB risk assessments.

A simplified version of this TB-IPC plan should be accessible to staff, i.e. healthcare staff, but also staff not directly involved in the management of patients.

 

A floor plan indicating the risk of TB transmission in each area should be drawn up and displayed.

 

Box 14.2 – Levels of risk in TB facilities

 

High risk Sputum and other respiratory specimen collection areas Laboratory (areas for specimen preparation) Wards or rooms of infectious TB patients Rooms used for TB diagnosis (clinical consultation, medical imaging) Waiting rooms in high TB prevalence areas   Limited risk Pediatric wards Wards or rooms for patients with extrapulmonary TB (EPTB) and no concomitant pulmonary TB (PTB) or smear- and culture-negative PTB Laboratory (areas other than those used for specimen preparation, e.g. for specimen reception, smear reading)   Low risk (non-TB zones) Kitchen Administration Pharmacy Technical services

 

14.2.3 Infection prevention and control practitioner and committee

An IPC practitioner with the authority, budget, and human resources for implementing TB-IPC measures and conducting TB risk assessments should be assigned.

 

According to the context, a multidisciplinary TB-IPC committee may be established to assist the IPC practitioner in the development of the TB-IPC plan and ensure its dissemination within the facility. This committee can include doctors, nurses, laboratory technicians, logistic officers, housekeeping staff, transport staff, administration staff.

14.2.4 Training of staff

Training on TB symptoms, TB transmission and TB-IPC measures (including respirator fit testing) should be provided to staff when:

• The TB-IPC plan is implemented.
• A TB-IPC measure is introduced or modified.
• A new staff member is hired.

In addition, continuous training sessions should be provided to all staff at least once a year.

14.2.5 Patient triage

In waiting rooms in high TB prevalence settings, patients with cough should be quickly identified.

These patients should be promptly isolated and referred/transferred to a unit or facility where TB can be diagnosed and treated.

14.2.6 Early diagnosis and treatment of tuberculosis

Patients with PTB are no longer considered as infectious after 2 weeks of effective treatment [1] Citation 1. Centers of Diseases Control and Prevention. Core Curriculum on Tuberculosis: What the Clinician Should Know. Seventh edition, 2021.
https://www.cdc.gov/tb/education/corecurr/pdf/CoreCurriculumTB-508.pdf [2] Citation 2. Migliori GB, Nardell E, Yedilbayev A, et al. Reducing tuberculosis transmission: a consensus document from the World Health Organization Regional Office for Europe. Eur Respir J 2019.
https://doi.org/10.1183/13993003.00391-2019 .

Therefore, it is essential to promptly:

• Screen patients at risk of TB (Chapter 6).
• Diagnose TB using rapid diagnostic tests (Appendix 5). 
• Start effective treatment.

14.2.7 Separation and isolation

All health facilities

• Patients with TB (presumed or confirmed): place in isolation; no movements to areas where they could contaminate other patients. 
• Patients without TB: no movements to areas where they could be exposed to the bacillus.

Outpatient TB facilities

• Favour home-based treatment.
• Limit the frequency and duration of visits to the TB facility.

Inpatient TB facilities

• Hospitalise only severely ill patients who cannot be diagnosed or treated as outpatients.
• Group patients according to their infectiousness (Box 14.1) and resistance profile (drug-susceptible/drug-resistant TB, e.g. isoniazid resistance, rifampin resistance, multidrug resistance, extensive drug-resistance).
• Place patients in single rooms if possible.
• If the number of single rooms is limited, they should be given in priority to patients pending diagnosis (potential infectiousness and resistance profile unknown) and patients likely to be the most infectious and/or with the most difficult-to-treat resistance.
• If there are no single rooms, place patients in rooms with 2 to 4 beds max., respecting the principle of separation according to their infectiousness and resistance profile.
• Provide gathering areas for patients to socialize, according to their infectiousness and resistance profile.
• Assign dedicated staff to provide care for patients in isolation.
• Maintain isolation of infectious patients if ambulance transport is required.
• Limit number of attendants.
• Allow visits in dedicated and clearly signaled areas. Limit number of visitors and duration of visits. Avoid visits by children if possible.

14.2.8 Respiratory hygiene and cough etiquette

Patients, attendants, visitors and health staff should cover their mouth and nose when they cough or sneeze.

Posters to remind respiratory hygiene and cough etiquette should be displayed in various places within the facility.

14.2.9 Information for patients, attendants and visitors

Information on the risk of TB transmission and on precautions to be observed (cough etiquette, use of respirators/surgical masks) should be provided by the health staff, using appropriate educational material.

Staff should make sure that patients, attendants and visitors adhere to TB-IPC measures.

14.2.10 Health facility hygiene

All standard precautions (hand hygiene; gowns, gloves, facial protection when required; cleaning of floors and surfaces; handling of soiled linen or equipment, and waste) apply in TB facilities, as they do in any health facility.

 

Sputum containers of inpatients should be replaced daily. Used sputum containers (from wards and laboratory) should be collected in a leak proof trash bag. They should not be filled with chlorine solution before incineration (this can produce toxic gases).

 

After patient's discharge, the patient's room should be adequately ventilated (Section 14.3.1 and Appendix 24).