OpiniãoThis checklist was prepared for the express purpose of national tuberculosis (TB) programme reviews for TB infection prevention and control (IPC) (1,2). Such reviews typically consider multiple programmatic components; thus, a checklist helps the reviewer to focus on the critical areas of any particular component.
Objectives
By the end of the review, experts should be able to comment on how TB IPC measures are implemented at different levels of the health services (with the measures being administrative controls, environmental controls, respiratory protection and the core components of IPC as they apply to TB).
Note: TB laboratory biosafety is generally dealt with separately from TB IPC, and this review needs to be coordinated with the experts reviewing the laboratory services.
Background
The End TB Strategy calls for a 90% reduction in TB deaths and an 80% decrease in the TB incidence rate by 2030. The strategy emphasizes the need for prevention across all approaches, including TB IPC at health care facilities and other settings where the risk of Mycobacterium tuberculosis transmission is high. TB IPC measures and practices are vital to reduce the risk of transmission, by reducing the concentration of infectious particles in the air and the exposure of susceptible individuals to such particles.
Stakeholders
Various personnel are involved in implementation of TB IPC and may be encountered as part of the programme review:
- managerial staff at national, subnational and health facility level contributing to the national TB programme (NTP) and national HIV/AIDS programme; and other individuals such as engineers, managers at hospitals and primary health care facilities and at long-term residential facilities, prison health services and migrant facilities; and
- health care workers and community health workers involved in TB and HIV care; evaluations of household contacts; implementation of IPC; diagnostic services in health care facilities, both in public and private primary and secondary health sectors; and other services
Key questions to answer
Note: Questions marked by an asterisk are those that are most relevant at the national level.
Policies and core components of IPC
- Are guidelines and institutional arrangements for IPC adequate in scope? Do they focus sufficiently on airborne infection prevention and control (e.g. is there an IPC committee at the health facility level and does its mandate include airborne infection and TB)?
- Are there IPC risk assessments and plans for selected high-risk settings?
- Have staff been trained or sensitized on airborne infection prevention and control in last year?
Administrative controls
Are the following administrative controls and measures in place to reduce the transmission of M. tuberculosis by patients with infectious TB at facilities?
- Staff designated to oversee IPC activities in the health facility.
- Staff designated to implement triage, separation and fast tracking of individuals with TB symptoms
- Provision of respiratory protection equipment for staff and visitors (e.g. respirators for health workers and medical masks for patients).
- Policy in place to ensure early initiation of TB treatment among individuals diagnosed with TB.
- Provision of patient education material (e.g. audiovisual aids in the patient waiting area providing information on cough etiquette and respiratory hygiene, and posters and pamphlets providing key messages to reduce airborne infections).
- Are health care workers offered annual TB screening (e.g. chest X-ray and tests for TB infection) and provision of TB preventive treatment (TPT)?
Environmental controls
- Is the infrastructure of health care facilities adequate for the implementation of TB IPC?
- Are patient waiting areas well-ventilated?
- Is the seating arrangement in doctor or staff consulting rooms, hospital wards appropriate? Is there cross-ventilation?
- Does the facility use any form of mechanical ventilation (e.g. exhaust fans and high-efficiency particulate air [HEPA] filters) to ensure frequent air changes or does it use upper-room germicidal ultraviolet (GUV) systems?
- Is there a need for structural changes in the health facility to facilitate IPC for airborne pathogens? Who is responsible for health facility maintenance and renovation?
Respiratory controls
- Do staff use respiratory protection equipment appropriately (e.g. respirators and medical masks)?
- If respirators are used, is fit testing done before supply?
Indicators
Definition: The relative risk of developing TB disease among health workers employed in facilities providing care for TB or HIV expressed as a ratio of the TB case notification rate among health workers to the TB notification rate in the general population during the same period, adjusted for age and sex if appropriate.
Numerator: The TB notification rate among health workers; that is, the total number of patients with TB registered among health workers per unit number of health workers in the reporting unit during the reporting period.
Denominator: The TB notification rate in the general adult population; that is, the total number of TB patients registered per unit number of adult populations in the reporting unit during the reporting period.
Purpose: To estimate the relative risk of developing TB among health workers compared with the general population, providing an indirect measure of the impact of TB IPC activities implemented in health care facilities.
Rationale: Health workers share the background risk of TB in the population. Additionally, due to involvement in patient care, their exposure to infectious TB is higher than that of the general population. If TB IPC measures are effectively implemented in health care facilities, exposure can be minimized and the risk of acquiring TB reduced, and the relative risk of TB disease should be close to 1.
Methodology: TB among health workers should be registered in the occupational health programme in the country, and the occupational health records should provide information on the number of health workers detected having TB during the reporting period. Alternatively, and in the absence of occupational health records, information on TB among health workers may be obtained from the NTP. Health workers having TB should be registered in TB registers maintained at the basic management unit, and it is desirable to indicate occupation in the register or indicate “health care worker” and workplace in the remark’s column of the TB register. The definition of “health care worker” may be country specific, and it needs to be clearly defined and used universally and consistently to compare trends over time. Depending on the country, it may include only medical and nursing staff or all health workers.
Numerator: Calculate the notification rate of TB among health workers by dividing the total number of health workers reported to have TB by the total number of health workers in the reporting unit during a chosen period (most commonly 1 year, given the relatively low numbers of health workers with TB).
Denominator: Calculate the TB notification rate among the adult general population by dividing the total number of adult patients with TB registered during the reporting period by the total adult population in the reporting unit during the chosen period. The data used in the numerator and denominator may be adjusted for age and sex for further analysis.
Periodicity: Data should be collected continuously and reported annually to the national and subnational level, and also to WHO.
Strengths and limitations: This indicator attempts to measure the adequacy of IPC measures in health care facilities, but it should be interpreted carefully because occupational health records or registration in NTP records by occupation may be lacking. The data may further be lacking if health workers prefer TB treatment from non-NTP providers. This may underestimate the overall risk of TB among health workers. On the other hand, the risk may be overestimated if the probability of health workers accessing TB screening and diagnostic services from the NTP in a country is high.
Source of information: Occupational health records, TB register at the basic management unit.
Responsibility: NTP.
HIV: human immunodeficiency virus; IPC: infection prevention and control; NTP: national TB programme; TB: tuberculosis; WHO: World Health Organization
References for Annex 9
- WHO guidelines on tuberculosis infection prevention and control, 2019 update. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/handle/10665/311259).
- Tuberculosis laboratory biosafety manual. Geneva: World Health Organization; 2012 (https://apps.who.int/ iris/bitstream/handle/10665/77949/9789241504638_eng.pdf?sequence=1).
- A guide to monitoring and evaluation for collaborative TB/HIV activities – 2015 revision. Geneva: World Health Organization; 2015 (https://www.who.int/publications/i/item/9789241508278).