This document is an evidence-based policy for the implementation of sound tuberculosis (TB) infection control by all stakeholders.
TB infection control is a combination of measures aimed at minimizing the risk of TB transmission within populations. The foundation of infection control is early and rapid diagnosis, and proper management of TB patients.
TB infection control requires and complements implementation of core activities in TB control, HIV control and health-systems strengthening. It should be part of national infection prevention and control policies because it complements such policies – in particular, those that target airborne infections.
The evidence base for the policy was established through a systematic literature review. The review highlighted some areas where evidence supports interventions that add value to TB infection control. A number of recommendations were developed, based on this evidence and on additional factors, such as feasibility, programmatic implementation and anticipated cost.
Set of control measures
TB infection control requires action at national and subnational level to provide managerial direction, and at health facility level to implement TB infection control measures. The recommended set of activities for national and subnational TB infection control is necessary to facilitate implementation of TB infection control in health-care facilities, congregate settings and households, as shown in Box 1. These activities should be integrated within existing national and subnational management structures for general infection prevention and control, if such structures exist. Recommendations on TB infection control in health-care facilities are shown in Box 2.
In contrast to previous WHO guidelines (1, 2), which were aimed at health facilities, this document provides guidance to WHO Member States on what to do and how to prioritize TB infection control measures at national level.
The recommended set of measures are needed because TB infection control is at an early stage of development in most countries, based on reports to WHO from Member States in 2008. No country provided information or data on implementation of measures, although 66% (131/199) of countries stated that they had a policy on TB infection control (3).
In the past, TB infection control in health-care facilities and congregate settings was largely neglected in the policy and practice of TB control. However, recent outbreaks of multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) with high mortality – in particular in high HIV-prevalent settings – have led to a stronger focus on TB infection control in such settings. This document includes recommendations on TB infection control in health-care facilities, as shown in Box 2, below, as well as in congregate settings, as described in Chapter 4. It also provides guidance on how to reduce TB transmission in households, as shown in Chapter 5.
Implementing control measures
All health-care facilities, public and private, caring for TB patients or persons suspected of having TB should implement the measures described in this policy. The measures selected will depend on the infection control assessment (Activity 3 in Box 1, above), which is based on the local epidemiological, climatic and socioeconomic conditions, as well as the burden of TB, HIV, MDR-TB and XDR-TB.
The literature review suggests that implementation of controls as a combination of measures reduces transmission of TB in health-care facilities. However, administrative controls should be implemented as the first priority because they have been shown to reduce transmission of TB in health-care facilities. Administrative controls are needed to ensure that people with TB symptoms can be rapidly identified and, if infectious, can be separated into an appropriate environment and treated promptly. Potential exposure to people who are infectious can be minimized by reducing or avoiding hospitalization where possible, reducing the number of outpatient visits, avoiding overcrowding in wards and waiting areas, and prioritizing community-care approaches for TB management.
The administrative controls should be complemented by the environmental controls and personal protective equipment, because evidence shows that these measures also contribute to a further reduction of transmission of TB.
The environmental controls implemented will depend on building design, construction, renovation and use, which in turn must be tailored to local climatic and socioeconomic conditions. However, installation of ventilation systems should be a priority, because ventilation reduces the number of infectious particles in the air. Natural ventilation, mixed-mode and mechanical ventilation systems can be used, supplemented with ultraviolet germicidal irradiation (UVGI) in areas where adequate ventilation is difficult to achieve.
Personal protective equipment (particulate respirators) should be used with administrative and environmental controls in situations where there is an increased risk of transmission.
Congregate settings range from correctional facilities and military barracks, to homeless shelters, refugee camps, dormitories and nursing homes. In such settings, there is a need for coordination with policy makers responsible for such settings beyond the purview of ministries of health. Reduction of overcrowding in any congregate setting, and in particular in correctional services, is one of the most important measures to decrease TB transmission in such settings.
To reduce the transmission of TB in households, any information, education and communication activity for prevention and management of TB should include behaviour and social change campaigns. Such campaigns should focus on how communities and, in particular, family members of smear-positive TB patients and health service providers can minimize the exposure of non-infected individuals to those who are infectious. This will ultimately translate into healthier behaviour of the entire community in relation to prevention and management of TB.
Changes in focus of current policy
In addition to recommendations for national managerial activities and a focus on health-care facilities and congregate settings, as well as households, this policy differs from previous guidelines on TB infection control in having a greater focus on:
- design of buildings and use of space
- the role of communities, which have a right to be able to attend a clinic or hospital without fear of contracting TB, and for health workers to work in safer environments (this policy includes provision of a package of HIV prevention, treatment and care measures for health workers)
- the need for health workers to undergo TB diagnostic investigation if they have symptoms or signs suggestive of TB, and to be given appropriate information and encouraged to undergo HIV testing and counselling
- the need for health workers found to be HIV-positive to be given support, and for measures to be implemented to reduce their exposure to TB (particularly MDR-TB and XDR-TB)
- awareness-raising activities in the community to garner social support for decreasing TB transmission in the community, to contribute to sustainable change toward healthy behaviour, and to minimize the associated stigma through community education
- the role of advocacy for improved TB infection control, through the removal of obstacles that impede wide implementation of TB infection control activities
- minimizing time spent in health facilities, including clinics, and prioritizing models of community-based approaches in a context of proper case management and a patient-centred approach.
This document does not cover recommendations for laboratory biosafety, because these are being addressed elsewhere (4).
The literature review undertaken for this policy:
- identified major knowledge gaps in terms of the efficacy and effectiveness of infection control measures
- showed the need for TB infection control research to be scaled up and to be considered a crucial component of TB, HIV and general infection control research efforts.
The success of this policy depends on its rapid implementation. For this to happen, costs for the implementation of all the elements of the policy will need to be defined and adequate resources will need to be identified. In addition, scale-up of TB infection control will require simple indicators to monitor success in working towards safer health services for all.
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World Health Organization, Geneva
WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households. Geneva: World Health Organization; 2009. Executive summary.