Summary of National Guidelines on Airborne
Infection Control in Healthcare Settings
Dr. K. Sachdeva
CMO, Central TB Division
Overview
• Importance of airborne infection control
• Summary of (draft) national guidelines
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Managerial activities (National, State, Facility)
Administrative controls
Environmental/Engineering controls
Personal respiratory protection
• Next steps
Airborne infection control:
Why should you care?
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Transmission – TB and other resp. pathogens
Protection – patients and staff
Preparedness – pandemic viral disease
Accreditation – NABL, MCI and others
Evidence shows airborne transmission happening
in health care facilities
• Objective:
– Estimate incidence/prevalence of
TB in HCWs in Low/Middle income countries
• Methods:
– Search of medical literature electronic databases
– Review and analysis of 42 articles, 51 studies
• Findings:
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LTBI prevalence:
Annual risk of LTBI:
Annual incidence TB disease:
Attributable risk for TB disease:
54% (33 – 79%)
0.5 – 14.3 %
69 – 5,780/100,000
25 – 5,361/100,000
Joshi R et al. PLOS Medicine 2006; 3(12):2376-2391
People in health care facilities are exposed to
airborne transmission, as shown by example of
high TB rates in HCW
Work Location
Outpatient facilities
General medical wards
Inpatient facilities
Emergency rooms
Laboratories
TB Incidence
Rate Ratio
4.2-11.6
3.9-36.6
14.6-99.0
26.6-31.9
78.9
*relative to general population where study conducted.
Joshi R et al. PLOS Medicine 2006; 3(12):2376-2391
Impact of Airborne Infection Control Measures on TB
Transmission in Chiang Rai, Thailand, 1995 - 1999
Airborne infection control measures implemented (1996)
– Administrative
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Infection control plan and SOPs
HCW education and training (including laboratory staff)
HCW TST testing, with isoniazid preventive therapy
TB patient education
– Environmental
• Natural ventilation maximized in high-risk areas
• Negative pressure ventilation in TB isolation rooms
• Class II biosafety cabinet for laboratory
– HCW respiratory protection (N-95 masks)
• Known exposure to infectious TB patient
• Laboratory staff processing TB cultures
Yanai H, Limpakarnnanarat K, Uthaivoravit W, et al. Int J Tuberc Lung Dis 2003;7:36-45.
Impact of Airborne Infection Control Measures on
TB Transmission in Chiang Rai, Thailand (cont)
• Implementation of IC package was followed by decreased
health care worker TST conversion rates, even though
more TB cases detected in Chiang Rai overall
– HCW TST conversion rate (1995–7):
9.3 /100 py
– HCW TST conversion rate (1999):
2.2 /100 py
• Showed that implementation of IC package can reduce
airborne transmission
Yanai H, Limpakarnnanarat K, Uthaivoravit W, et al. Int J Tuberc Lung Dis 2003;7:36-45.
What to do?
National Guidelines on Airborne Infection
Control
• Purpose: to provide up-to-date
information about recommended
methods of reducing the risk of
airborne infections in health care
facilities.
• Target audience
– Health officials (general, not just TB)
– Health facility administrators and
infection control focal points
• Elements now included in NABH
hospital accreditations
Contributors
• NAICC Chair Prof SK Jindal
• Committee members – Dr D Behra, Dr R Sarin, Dr R
Singla (LRS), Dr A Agarwal (PGI), Dr V Chandrashekar
(DGHS), Dr Gupta (NCDC), Dr Thakur (NACO), Dr
Solanki (BJMC), Dr Rajesekaran (Chennai), Dr Anand
(NTI), Dr Mahilmaran (GHTM)
• CTD - Dr LS Chauhan, Dr K Sachdeva, Dr D Gupta, Dr
M Parmar, Dr S Chadha
• WHO – Dr S Sahu, F Wares
• CDC – Dr M Pearson & Dr P Jensen
Managerial activities
(National, State, Hospital administration and local health
officials)
National level: Plan, establish policy, train,
coordinate, evaluate
State/District level: Promote IC focal points at
facilities, develop coordination mechanisms, Plan,
train, monitor
Facilities: Develop local plan, implement,
supervise
Facility-Level Management Activities
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Designate focal points for the facility-level activities
Conduct a facility-risk assessment
Develop a facility plan for airborne infection control
Rethink the use of available spaces and consider
renovation and/or construction, e.g. waiting areas
Support trainings
Ensure proper implementation of the administrative
controls – especially relocation of waiting areas,
implementation of systems for queing, screening, fast
tracking
Keep adequate budget for maintenance of any controls
Supervise and monitor infection control activities
Education & training of staff is the key to
infection control
• Principles & practices of
infection control – standard
precautions
• Issues about airborne infection
risk and prevention
• Realities about personal
respiratory protection
• Responsibilities of personnel
and institution should be clear
Specific controls recommended in National
Guidelines
• Administrative controls
– Reduce potential opportunities for exposure
• Environmental controls
– Reduce concentration of infectious particles that
may be present
• Personal respiratory protection
– Further reduce risk to staff (not other patients) in very
high-risk settings where exposure not avoidable
What is meant by
administrative controls?
All policies developed by infection control
team to decrease risk
Procedures for implementing, enforcing,
monitoring, evaluating, and revising
infection control plan
Recommended outpatient administrative
controls
• Patient screening
• Cough hygiene IEC for patients
• Segregation of respiratory symptomatics
(where possible)
• Fast-tracking of respiratory symptomatics
– Jumping the queue
– Alternate evaluation pathway
Triage
• Identify people with respiratory symptoms
Respiratory Infection Control in Health
Care Facilities
18
Separate
• Where possible, separate persons with
respiratory symptoms in a separate wellventilated waiting area
• The specific criteria for separating patients will
depend on the local settings and patient
population
• Guiding priorities
– Minimize opportunities for transmission
– Protect immuno-compromised patients
– Keep drug-resistant TB from spreading
Examples of waiting areas
Fast-track respiratory symptomatics to
minimize time in health care facilities
• Example: Screening and marking OP tickets for
fast-tracking PTB suspects through diagnosis
Inpatient administrative controls
• Minimize hospitalization as per current practice
under DOTS
• Educate patients and attendants on cough hygiene
• Routine segregation of patients to separate wards (or
separate areas in same ward) so to reduce risk of
transmission, particularly to immune-compromised
– Where possible, isolate infectious patients
• Maintain spacing, ward decompression
Segregation
• 1. Keep HIV+ persons safe from
– Persons with MDR TB
– Known S+ patients
• 2. Keep the most infectious patients (any S+
newly-starting treatment) away from others
Segregation does not happen without
both policy and enforcement
• Designating
appropriate areas
• Routine
(voluntary) HIV
testing at
admission
• Automatic
procedures to
move patients
when indicated
Safe sputum collection
• Keep aerosol generating
procedures away from
other patients
– Sputum collection
– Sputum induction
Environmental controls
• Indoor patient segregation and bed spacing
• Ensure effective ventilation at all times and
seasons
• Special attention for high-risk areas
Segregation and Spacing
• Keep infectious patients away from vulnerable
patients using whatever approach is feasible:
– Airborne precaution areas
– Individual rooms
– Designated wards or ward areas
Ventilation
• Health-care facilities should seek to achieve
minimum standards for air exchange.
• High-risk settings should be prioritized for
immediate assessment and implementation of
improved ventilation.
Minimum air-changes per hour (ACH) required
for various health care settings
Type of Health care setting
Minimum ACH
Registration/Waiting
> 6 ACH
Outpatient departments
> 6 ACH
Inpatient departments
> 6 ACH
High-risk settings
> 12 ACH
ART centres
TB / Chest departments (outpatient and inpatient)
Bronchoscopy procedure rooms
MDR-TB wards and clinics
Airborne isolation rooms
Natural Ventilation
• In most settings, natural
ventilation is the preferred
method for ensuring
adequate air exchange.
• Ensure effective
ventilation at all times and
in all climatic conditions
through proper operation
and maintenance, and by
regular checks to ensure
fixed, unrestricted
openings.
Example: Use of louvered shutters
instead of glass windows to ensure
ventilation day and night
Assessing if natural ventilation is adequate
• Where ACH is not able to be measured, as is usually
the case in rooms with natural ventilation, the
following standards for ventilation should be
followed to ensure that air exchange is safely >6 ACH
under all climactic conditions.
– Natural ventilation should be "controlled", with fixed,
unrestricted openings that are insensitive to climactic
conditions
– Openings should constitute >20% of floor area
– Openings should be on 2 sides, preferably opposite sides.
For example, a 100 ft 2 room should have >10 ft 2 fixed,
unrestricted openings on two sites, for a total of 20 ft2
If natural ventilation not adequate…
• Guidelines caution against use of
technologically driven interventions
(mechanical ventilation, UVGI) without
sustained commitment and clear commitment
for maintenance and budget
Blocked air
intake duct for
ventilation of
waiting area
Mechanical ventilation
• Mechanical ventilation – with or
without climate control – may be
appropriate where natural
ventilation cannot be
implemented effectively or is
inadequate given local conditions
(e.g. building structure, climate,
regulations, culture, cost and
outdoor air quality)
• If mechanical ventilation is used,
the system should be well
designed, maintained and
operated, to achieve adequate
airflow rates and fresh air
exchange.
Directional control of air-flow
• Directional control of air flow
(i.e, negative pressure) is
recommended in specific
high-risk settings where
infectious patients with drugresistant TB or other acute
respiratory diseases of
potential concern are likely to
be managed – i.e. airborne
isolation rooms, MDR-TB
wards and clinics, and
bronchoscopy suites
Arrangement of patients and staff
• Optimal arrangement of
patients and staff should
be implemented in all
outpatient departments,
DOT centers, microscopy
centers, and radiology
What’s wrong with this picture?
Chest clinic, Oct 2009
What’s wrong with this picture?
Very poor
ventilation,
blocked
windows, recirculating A/C
Ineffective
filtration
devices gives
false security
Exhaust fan would draw
air from waiting to
doctor’s chamber
Crowded waiting area
(wait outside!)
UVGI
• In high-risk settings where it is not possible
to achieve adequate air exchange using
natural ventilation, a complementary
option is to use upper room or shielded
ultraviolet germicidal irradiation (UVGI)
devices.
• Installation should seek to irradiate the
maximal air volume with the highest
intensity UV, while keeping staff and
patient exposure to less than 6.0 mg/cm2
over an 8-hour period.
• Emphasis on proper installation and
maintenance.
Personal Respiratory Protection
• Only N95 particulate respirator for
HCW, properly fitting and used,
provides some additional protection
to the user against airborne
infection
– Masks (including 3-layer surgical masks)
are effective primary for source control
of patient, to catch what is going out,
not what is coming in
– Masks for HCW may be useful for large
respiratory droplets and protection of
mucous membranes (i.e. catch the
spray from a sneeze before it hits your
face) and remain a part of droplet
precautions
Place of respirators in infection control
activities
• Proper implementation of administrative and
environmental controls is first and second line
of defense;
• Respirators only add a layer of insurance
where the risk to HCW is especially high.
• Guidelines address situations where
respirators appropriate, training, selection and
fit, and re-use
When should respirators be used?
Settings in India where particulate respirators are recommended
for protection against airborne infection
• 1) Laboratories: When manipulating cultures (solid or liquid
media), despite use of biosafety hood or negative pressure
facility
• 2) Bronchoscopy: for all staff in bronchoscopy suite
• 3) MDR Wards (opt): Respirators should be made available for
optional use by staff, with all staff receiving training and
sensitization on their use.
• 4) As recommended by MoH to contain spread of disease of
public health importance and unknown transmission (e.g.
Influenza H1N1)
Households
• Behaviour change campaigns for family
members of smear positive TB patients
– Maximize home ventilation
– Practice cough etiquette
– When smear positive, where possible sleep in
separate room & spend as little time as possible in
congregate settings
– Sensible, practical, yet hygienic sputum disposal
Next Steps
• Dissemination of national guidelines
• Large facilities should begin managerial activities
• Pilot testing of feasibility of interventions
– 40 facilities, various types (MC, DH, CHC/RH, B-PHC), West
Bengal, Gujarat, and Andhra Pradesh
• Development of IC capacity
– Managers, programme officers, facility administrators,
– Architects and engineers
– Engage with MCI / NCI / IPHS to integrate
recommendations into curriculum/standards
– Frontline healthcare workers on Standard Precautions,
including airborne/TB
Thanks
• NAICC Chair Prof SK Jindal
• Committee members – Dr D Behra, Dr R Sarin, Dr R
Singla (LRS), Dr A Agarwal (PGI), Dr V Chandrashekar
(DGHS), Dr Gupta (NCDC), Dr Thakur (NACO), Dr
Solanki (BJMC), Dr Rajesekaran (Chennai), Dr Anand
(NTI), Dr Mahilmaran (GHTM)
• CTD - Dr LS Chauhan, Dr K Sachdeva, Dr D Gupta, Dr
M Parmar, Dr S Chadha
• WHO – Dr S Sahu, F Wares
• CDC – Dr M Pearson & Dr P Jensen