5.1 TB IPC in congregate settings
Congregate settings are places where people reside in close proximity to each other, but which are not primarily meant to provide health care. Examples of such settings are prisons, homeless shelters, refugee camps, army barracks, hospices, dormitories, nursing homes and workplaces (e.g. factories and mines). TB can spread rapidly in congregate settings, sometimes even more rapidly than in health facilities, given the long duration of exposure, crowded environment, poor ventilation, delayed diagnosis and treatment, and (sometimes) limited access to health services. Individuals living in such settings should be protected against the risk of acquiring potentially life-threatening infections such as TB. Therefore, TB IPC measures should apply in these congregate settings as they do in health care facilities. However, it may be challenging for the MoH to access these facilities or services, particularly prisons and army hospitals, because they are managed by other public entities, such as the ministries of defence or justice. In the spirit of Pillar 2 of the End TB Strategy, a strong all-government approach to TB prevention should be established, to pave a way for collaboration and the provision of systematic access to TB services including chest X-ray, rapid TB diagnostics and TB IPC interventions. Possible steps for implementing TB IPC interventions in congregate settings are as follows (12):
- establish appropriate mechanisms for the implementation of administrative, environmental and respiratory protection measures;
- undertake TB risk assessment and identify areas with a higher risk for M. tuberculosis transmission, then prioritize those areas for stringent IPC actions;
- develop and provide access to educational materials and TB IPC interventions for residents, and train the facility staff and supervisors on TB IPC;
- promote cough etiquette and ensure supplies of PPE for both residents and staff;
- create a culture within the institution that encourages people who have a cough to seek health care; support prompt identification of such individuals through systematic TB screening at entry and at regular intervals during their stay;
- ensure that residents or inmates who are diagnosed with TB are started on TB treatment promptly and are separated from others and isolated in a well-ventilated space until they achieve bacteriological conversion; if eligible, individuals who have been in contact with these inmates should be screened for TB and offered TPT; and
- offer HIV testing to staff and residents, and counsel them, then link them to the package of HIV prevention, care and treatment services, as needed.
Key point: Collaboration between the Ministry of Health and other public and private authorities is necessary for the systematic implementation of TB IPC measures in congregate settings, as it is in health care facilities.
5.2 TB IPC in households
TB IPC measures in patient households are important to minimize transmission of both DS-TB and DR-TB to family members, given their high risk of acquiring M. tuberculosis infection or developing TB disease. Prompt initiation of appropriate TB treatment for the index patient is the critical first step towards cutting the chain of M. tuberculosis transmission. Contacts of those with DR-TB are at higher risk than contacts of those with DS-TB because an index case with DR-TB may take longer to access effective treatment and become noninfectious. In addition, morbidity and mortality are greater if the contacts are living with HIV. Thus, rapid implementation of IPC measures within the households of TB patients is important after the diagnosis of TB or DR-TB. Patients’ residences should be adequately ventilated, particularly the room where the person with infectious TB spends most of their time. Some basic enhancements to the living space to improve natural ventilation may substantially lower the risk to others. Patients should be educated on cough etiquette and should follow such practices at all times. If feasible, the bacteriologically positive TB patients should spend as much time as possible outdoors; sleep alone in a separate, adequately ventilated room; and spend as little time as possible in public places or on public transport.
Ideally, health care providers should wear respirators when attending bacteriologically positive TB patients in enclosed spaces. Once the patient is bacteriologically negative, respirators are no longer necessary. Family members living with HIV should not be directly involved in the care of infectious TB or DR-TB patients, but if there is no alternative, HIV-positive family members should wear respirators. Children aged below 5 years and pregnant women should spend as little time as possible in the same living spaces as patients with bacteriologically positive TB or DR-TB. All family contacts, and particularly children, should be screened regularly for TB disease and TB infection; if they test positive for TB disease, they should be offered DST and TB treatment. All contacts of patients with bacteriologically positive TB should be considered for TPT once TB is ruled out.
Implementation steps
Considerations for implementing TB IPC are as follows:
- Key stakeholders who could support effective implementation of TB IPC in households include staff at the health care facility, members of community-based organizations providing health services, community health workers or volunteers, as well as TB patients themselves and their close contacts.
- NTPs should build the capacity of the health workers to educate and counsel the TB patients and household members. Health education should start even before the patient is discharged from the hospital or referred for TB treatment after TB diagnosis and should continue during the course of treatment and follow-up.
- Community health workers and volunteers should be trained on how to implement TB IPC when a patient is discharged from the hospital, or referred for TB treatment, or during patient home visits.
- Household members should be educated on IPC measures, the importance of adherence to TB treatment, cough etiquette, natural ventilation and safe disposal of sputum. Annex 10 provides a country example of a tool used for imparting education to patients and families.
- Additional precautions are required for caregivers of DR-TB patients. NTPs should facilitate the provision of targeted counselling and tools for respiratory protection, preferably respirators, for as long as the DR-TB patient remains infectious.
- The use of rapid TB diagnostic tests and the prompt start of treatment for TB or DR-TB should be assured.
- HIV testing and counselling should be offered to all household members, and TB screening and TPT to all contacts of the TB patient.
- The TB patient should be encouraged to follow cough etiquette, sleep in a well-ventilated room and minimize travel to public places or on public transport.
- Community leaders and representatives should be engaged to implement risk reduction strategies in communities with a high TB burden; such strategies include keeping windows open and providing TPT for contacts, particularly children and people living with HIV.