XDR TB - National Resource for TB Infection Control [PDF]

May 7, 2013 - XDR TB (extreme or extensively drug resistant TB). Where there is resistance to ..... Used as part of PPE

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Idea Transcript


Tuberculosis in SA today as a Healthcare Challenge

Breathe Easy. Worry Less.

7/5/2013

National Core Standards for Health Establishments in South Africa The main purpose of the National Core Standards is to:  Develop a common definition of quality care which should be found in all health establishments in South Africa, as a guide to the public and to managers and staff at all levels;  Establish a benchmark against which health establishments can be assessed, gaps identified and strengths appraised; and  Provide for the national certification of compliance of health establishments with mandatory standards

2

National Core Standards for Health Establishments in South Africa 2011 Domain 2: Patient Safety, Clinical Governance and Clinical Care  Sub-domain 2.6 Infection prevention and control  Standard 2.6.2 Specific precautions are taken to prevent the spread of respiratory infections  Criteria 2.6.2.1 A programme for the prevention and control of respiratory infections is in place (eg for tuberculosis)

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Definitions

(multidrug resistance) Where there is resistance to both INH and Rifampacin XDR TB (extreme or extensively drug resistant TB) Where there is resistance to INH and Rifampacin as well as any fluroquinalone in addition to one of the injectable TB agents (kanamycin and amikacin and capreomycin) (but excluding streptomycin)

 MDR TB



 TDR (Totally Drug Resistant): Resistant to > 9 drugs in the absence of clinical response  Mono-resistance

Resistance to one of the first line TB drugs.  Poly-resistance

Resistance to more than one first line TB drug. (but not both INH and RIF)

When is the HCW (Health Care Worker) at risk? 1. High risk  Prolonged close contact with infectious ( smear positive)  Aerosol producing procedures  HCW with HIV+ who are involved in regular TB pts management.

2. Medium risk  Sputum collection  Prolonged closed contact with retreatment pts 3. Low risk  HCW in PHC(primary health centre) centre's involved in management of TB pts  Porters, cleaners, administrative staffs  HCW in general hospitals & community health centre's.

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Environmental Factors Increase Risk for Transmission

    

Exposure in small, enclosed spaces Inadequate ventilation Recirculated air containing infectious droplets Inadequate cleaning and disinfection of equipment Improper specimen-handling procedures

Treatment  Goals  To cure the individual patient  Minimize the transmission of Mycobacterium tuberculosis to other persons

 Directly observed therapy (DOT)  Assure adherence.  DOT involves the provision of anti-tuberculosis drugs directly to the patient and watching him/her swallow the medication

Drug Cost – 30 days - Cost per patient per month) PAS (4g BD) Capreomycin (1g 5x) Moxifloxacin (400mg OD) Terizidone (250mg tds) Cycloserine (250mg tds) Klacid (500mg BD) Amikacin (1g 5x) Kanamycin (1g 5x)

2008

2009

R1600

R 2360

R2358

R800

R 1300

R2391

R 800

R911

R650

R 579

R566

R600

R 522

R522

R 228

R123

R400

R 216

R223

R250

R 200

R239

Clofazamine (300mg) OD

Ethionamide (250mg tds) Ofloxacin (800mg OD) Augmentin (625mgs BD) Rifafour (4 BD) PZA (1,5gm OD) Rifanah (300 – 2 BD) EMB (1,2 OD) Ciprobay (1,5gm) OD

2010

2012

R204 R130

R 177

R60

R

54

R191 R349

(R135)

R 112

R74

R80

R

67

R67

R50

R

42

R33

R

40

R42

R

38

R43

R

32

R36

R36

Drug Costs

Drug (> 50KG)

Cost (per patient per month) 2010

STD TB (intensive phase)

R67

STD TB (continuation phase)

R42

MDR (intensive phase)

R1207

MDR (continuation phase)

R968

XDR (intensive phase)

R6654

XDR (continuation phase)

R4263

Infection Control is the KEY

You may have the newest or best facility, structurally but if appropriate infection control measures and mechanisms are not in place you are failing staff and patients

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Fundamentals of Infection Control

Administrative Controls Environmental Controls Respiratory Protection 1 1

Way Forward 



Administrative Measures – must be introduced in all facilities  Reduce risk of exposure via effective IC program  Infection control teams & policies  Triaging of Patients  Training of staff Environmental Measures (Prevent spread and reduce concentration of droplet nuclei)  New Hospitals, clinics and waiting areas built must be designed to provide good ventilation & infection control.  Existing facilities must be reviewed and revitalized to facilitate ventilation & infection control  Possible interventions  UV lights – if affordable  Fans (extractor + Normal)

 Mechanical ventilation systems  Create new windows to improve natural ventilation

1 2

Our responsibility to infection control  We need to reduce exposure of staff, patients and visitors to TB  We need to ensure necessary measures are in place  Have proper infection control guidelines in place  Implement these guideline  Educate everyone  Assess facility for problems  Do formal risk assessments  Implement triaging of patients  Improve ventilation  Implement air exchange assessment  Implement fit testing  Have personal protection available  Have regular staff wellness monitoring 13

Infection Control Program  Patient education  Cough hygiene (turn head/cover mouth)  Surgical masks – are used on patients coughing excessively or during transport.  Isolation of Patients  Isolation of TB from MDR from XDR patients (in ideal circumstances)  Good ventilation  Natural ventilation (open window policy) in multi-storey  Mechanical Ventilation - Negative pressure ventilation  Individual Protection - N95 respirators  Respirators – (filter small enough to stop TB / need tight fit).  Implemented fit testing.  Ultraviolet lights Require proper maintenance and monitoring  Cost implication  Certain risk to staff 14

Respiratory Protection Controls

 Reduce the risk of exposure  Implement Respiratory Protection program  Train HCWs in RP  Respirator masks  Correct donning  Correct removal  Correct disposal  Train patients in respiratory hygiene

Respiratory Protection Controls Personal protection for staff Personal particulate respirators (N95 or FFP 2 masks) are very different than surgical masks. Protects the wearer of from Airborne particles that are 1 – 5 µm in diameter Surgical mask not effective to prevent TB transmission. Can be worn continuously for 8 hours. N95 masks are single use only, discard into medical waste directly after removal, decontaminate hands. Make sure of mask fit

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What is a surgical N95 respirator ? A surgical N95 respirator is a NIOSH-approved N95 respirator that has also been cleared by the Food and Drug Administration (FDA) as a surgical mask Who is NIOSH? The National Institute for Occupational Safety and Health (NIOSH) is the U.S. Government agency responsible for the certification and approval of respiratory protective devices for occupational use.

Who is the FDA? The Food and Drug Administration (FDA) is the U.S. Government agency that oversees most medical products, foods, and cosmetics. This includes surgical masks and surgical N95 respirators

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NIOSH Standards Oil resistance

Rating

Description

Not oil resistant

N95

Filters at least 95% of airborne particles

N99

Filters at least 99% of airborne particles

N100

Filters at least 99.97% of airborne particles

R95

Filters at least 95% of airborne particles

R99*

Filters at least 99% of airborne particles

R100*

Filters at least 99.97% of airborne particles

P95

Filters at least 95% of airborne particles

P99

Filters at least 99% of airborne particles

P100

Filters at least 99.97% of airborne particles

Oil Resistant

Oil Proof

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If a particulate filtering face piece respirator does not have these markings as identified above and does not appear on one of the NIOSH lists, it has not been certified by NIOSH for occupational use.

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Reference: Rengasamy,S.,W.P.King, B.C.Eimer and R.E. Shaffer.(2008). Filtration performance of NIOSH-approved N95 and P100 filtering facepiece respirators against 4 to 30 nanometer-size nanoparticles. Journal of Occupational and Environmental Hygiene 5(9):556-564

Approval holder’s business name or manufacturers business name

Filter designation: NIOSH filter series ie N95 TC# xxx-xxxx Approval number The name NIOSH or the logo Model # xxxx

Lot # xxxxx

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European Standards EN 149:2001

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Class

Filter penetration limit (at 95 L/min air flow) Inward leakage

FFP1

Filters at least 80% of airborne particles

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