These principles should be applied in all health facilities, public spaces and homes. All people living in South Africa are exposed to TB. Most of us were vaccinated against TB as babies and our natural immunity means that we do not develop TB disease.
Transmission of TB in healthcare settings to both patients and healthcare workers is a well-documented phenomenon in every country, regardless of the local TB incidence. In South Africa, contracting pulmonary tuberculosis in healthcare setting is known and recognized as an occupational hazard. A study by University Research Co. LLC (URC) and the Desmond Tutu Tuberculosis Centre in five provinces in South Africa found that the average burden of TB in HCWs was 2% compared to 0.9% in the general population while O’Donnell et al. also found that HCWs had a 5 to 6-fold increased rate of hospital admission with MDR-TB or XDR-TB compared to non-HCWs. The national incidence of TB infection attributable to healthcare work is 5.8% (range 0-11%).
Despite the risk that HPCA member hospice staff dealing with TB patients are exposed to, effective implementation of infection control measures has ensured that the incidence of infection stays low.
The following factors play a role in the transmission of Mycobacterium tuberculosis:
·The environment in which the exposure to the TB bacillus takes place. TB is more easily transmitted in dark, cramped spaces that are poorly ventilated.
·The length of exposure to the air containing TB bacilli
·The concentration of TB bacilli in the air
INFECTION CONTROL MEASURES
As in all healthcare settings, the three main methods of reducing transmission of TB in hospices are administrative, environmental and personal. Annual audits are conducted to assess the extent to which these measures are implemented by hospices.
These measures have the greatest impact in preventing the spread of TB. HPCA member hospices are required to draw up and implement policies and procedures that, amongst others, deal with screening of all hospice patients, screening of staff, procedure for safe collection of sputum samples and referral for treatment and education of patients and staff on cough etiquette.
Environmental controls are the second line of defense in reducing TB transmission. Good natural ventilation can help reduce the risk of infection by diluting and/or removing infectious particles in the air. Therefore, it has to be standard practice that, if weather permits, doors and windows should be left open as much as possible. However, in the use of available spaces, care should be taken regarding the direction of air flow. Natural ventilation can be increased by using fans. Home Based Caregivers need to encourage their TB patients to sit outside as much as possible.
Hospice staff, like all healthcare personnel, are at an increased risk of contracting TB. Educating all hospice staff and volunteers on TB, regular screening, encouraging early recognition of symptoms, referral, follow-up and support in line with workplace policy helps to protect personnel.
Using personal protective equipment such as N95 respirators, gloves, gowns, aprons, protective eyewear, as recommended by the World Health Organisation Universal Precautions, can reduce the risk of exposure of healthcare professionals to potentially infective materials and certain airborne germs. The HPCA provides all hospices with N95 respirators to be used by staff and volunteers. Hospices, in turn, encourage newly diagnosed TB patients to wear surgical masks.
Success of infection control measures in SA hospices
The number of hospice staff and volunteers that were reported to have been infected with TB in 2012 was 232, in 2013 it was 178 and for 2014 so far it is 127. What is more important than the fact that the incidence of infection is decreasing, is the fact that none of the staff have been reported to have been infected with Drug Resistant TB. We do not have information of volunteers at hospices but the number of staff working at member organisations on the TB programme are 6155 staff so conversion rate in 2014 was 2% which is lower than the national incidence of TB infection attributable to healthcare work of 5.8%.
This figure will be even less if we include the volunteers in hospice services. If there are equal numbers of volunteers to staff in hospices the infection rate would be 1% which is equivalent to the risk of the general population in South Africa.
We would like to congratulate hospice management and staff in implementing effective infection control measures.