TB Infection Control: What do we need to do?

Bess Miller, M.D. M.Sc.Chair, STOP TB Infection Control Subworking Group

TB/HIV Working Group

Ministerial Meeting of High M/XDR-TB Burden Countries

Beijing, China1-3 April 2009

Acknowledgements• Fabio Scano• Rose Pray • Ernesto Jaramillo• Paul Nunn• Haileyesus Getahun• Kenneth Castro• Virginia Lipke• Paul Jensen• Ed Nardell• Core Team of TB Infection Control Subworking Group

Outline

1. The problem

2. The solution

3. Conclusions

The Problem…

Is there an additional risk of TB to…

– Health workers?– Prisoners?– Household members of TB patients?

Increased risk of TB in Increased risk of TB in highhigh risk populationsrisk populations

Prisoners

Health care workers

Household Members

PopulationPopulation

High income

High income

High income

Low income

High income

Low income

High income

Low income

SettingsSettings

18

5

15

37

40

9

15

7

StudiesStudies

21.41TB

2.742.74TB infection

1.99TB

5.715.71TB

10.06TB infection

5.775.77TB infection

3.19TB infection & TB

1.731.73TB infection & TB

Risk RatioRisk RatioOutcomeOutcome

Source: WHO, 2008

Can you transmit MDR/XDR TB?

HIV-Associated MDR TB Outbreaks,1988-1995

Evidence of institutional MDRTB transmission

Wells CD, et al. HIV Infection and multidrug-resistant tuberculosis - the perfect storm.

J Infect Dis 2007;196:S86-S107

The truth is that…

• In these MDR TB outbreaks in NYC hospitals, it was deaths among health workers that brought attention to TB infection control.

• In the recent MDR TB outbreak in southern Africa, 6 health workers died of MDR TB and XDR TB.

At the global level…

• TB infection control (and infection control overall) has been neglected in health care, prisons, and other congregate settings.

• But now we are all listening.

The solution….

WHO Policy on TB Infection Control (2009)

• Promotes combination of controls.• Addresses health facilities, congregate

settings, and households• Adds managerial component • Promotes minimizing time spent as in-patient• Emphasizes community involvement • Promotes integrating TB infection control

with other infection control activities

What is needed to implement the policy?

• Leadership

• Technical expertise

• Financial and human resources

LeadershipWho? Ministries of Health

• Policies, guidelines• Systems developed to provide direction,

oversight, training, M & E• Assignment of responsible bodies• A campaign

Technical expertiseWho? Countries, technical agencies

• Infection control nurses (and other clinical staff)

• Architects, engineers • Community advocates

Financial and human resourcesWho? Ministries of Finance,

Infrastructure, Justice, Donors

• Infrastructure - hospitals, clinics• Commodities - supply chain management• Maintenance of equipment• Human resource development

A critical piece…

• Infection control elements need to be line items in National MDR TB action plans.

Safer health facilities for all.

We can do better!