Unit 5

Infection Control Practices

Training of Nurses on Tuberculosis Care & Control in

India
GFATM Round 7

Unit Objectives
Participants will be able to understand
the
occupational risk of TB infection among
Health Care Providers(HCPs)
various strategies for TB Infection Control in
Health Facilities
Bio Medical Waste Management under
RNTCP for Health Facilities
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Goals of Infection Control Program

The main goals of a TB infection-control
program are to ensure early and prompt
Detection of TB disease
Isolation of people who have or are
presumed to be having TB disease(airborne
precautions)
Treatment of people who have or are
presumed to be having TB disease
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Prevention of Drug Resistant TB(DR TB)

A direct consequence of lack of implementation of
Infection Control Practices ( e.g. Spatial Separation)
Difficult Task as:
No separate symptoms from susceptible patients
Takes long to diagnose DR TB

Unknowingly DR TB patients get mixed with other

patients
As a result
Deteriorate faster
Infect other patients
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Large Group Discussion

Occupational Transmission of TB
Possible measures to prevent
transmission of TB infection at
workplace

Risk of Nosocomial Transmission of TB to HCPs

Increased risk among nurses, physicians, nursing &
medical students and laboratory workers who have:

frequent and direct patient contact

have longer duration of employment
contact with undiagnosed TB patients & not
placed on therapy
employment in facilities with no IC measures/
limited resources in place
performing cough-inducing procedures on patients
HIV + Status
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Strategies For TB Infection Control

Administrative controls (Ist Priority)
reduce HCW and patient exposure

Environmental controls ( 2nd Priority)

reduce the concentration of infectious droplet nuclei

Respiratory Protection Controls (3rd Priority)

protects HCWs in areas where the concentration of
droplet nuclei cannot be adequately reduced by
Administrative and Environmental controls

Administrative Controls
Developing and implementing a written TBinfection control plan
Ensuring the availability of prompt
laboratory processing, testing, and
reporting of results
Ensuring proper cleaning and sterilization
or disinfection of equipment that might be
contaminated
Educating, training, and counseling health
care workers about TB
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Administrative Controls
Early identification and diagnosis
Giving priority for patients with cough for clinical and lab
investigations
for early detection of smear-positive PTB patients
Reducing delay in starting appropriate RNTCP treatment
once diagnosed
Avoiding unnecessary admission for inpatient care

Patient education
Sputum collection
Triage and evaluation of probable TB patients
Reducing exposure in the laboratory
In patient management and Isolation Policies

Administrative Controls
Special Areas
Radiology
Sputum induction and coughinducing procedures
Surgical and autopsy suites
Intensive care areas
10

Administrative Controls
Special Areas
MDR TB Wards
ART Centres
Designated Microscopy Centres
(DMCs)
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Administrative Controls
Immunosuppression and TB
HCPs and Patients are at increased
risk of
reactivation of previous TB infection
rapid progression to disease after infection

Prompt Evaluation & Treatment

Avoid postings in TB settings
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Case Scenario I
Nurse A, on duty, in a crowded TB OPD,
observes a middle age man, coughing
frequently and is appearing weak & sick
He tells her that his mother is suffering from
TB and the MO asked him to get evaluated for
TB.
What steps should Nurse A take in this
situation?

Answer
Nurse A should presume that the man has
infectious TB
She should ensure that he is evaluated
quickly
He should be provided with a Surgical
mask and be told to cover his mouth while
coughing/ sneezing
Nurse should ask him wait in an area away
from other patients

Environmental Controls
Placing TB wards in well ventilated areas
Allocating different areas for efficient
patient separation
Reduce concentration of infectious
droplet nuclei through following
technologies
Natural ventilation
Mechanical ventilation
Ultraviolet germicidal irradiation (UVGI)
15

Environmental Controls -Spatial Separation

Separate Smear + TB and HIV + Patients

Risk of TB Transmission:
HIV - and HIV + ( No. TB)
Smear + TB and HIV +
MDRTB smear + and HIV+
MDRTB smear + and HIV -

Low Risk
High Risk

Greatest Risk!
High Risk
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Environmental Controls
Natural Ventilation
Simplest and least expensive technique
Maximizing natural ventilation through open
windows

Mechanical Ventilation
more complex and costly method
Use of window fans, exhaust ventilation
systems
Dilution / Removal of contaminated air
Use of Negative pressure to control airflow
patterns in patient/procedure room or setting
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Environmental Controls
Ultraviolet Germicidal Irradiation (UVGI)
Less expensive alternative to more expensive
environmental measures
Consists of special lamps that give off
ultraviolet light
Must be installed in the upper part of rooms
or corridors or placed in exhaust ducts
Particularly useful in larger wards, TB clinic
waiting areas
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Example of Types of UVGI

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Respiratory Protection Controls

Implementing a respiratory
protection program
Training health care workers on
respiratory protection
Educating patients on respiratory
hygiene and the importance of
covering their cough
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Respiratory Protection Controls

Instructions For the use of Masks
When caring for patients with
TB/other airborne diseases

While transporting or doing

procedures on patients
with TB
When suffering from a
respiratory infection yourself
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Respiratory Protection Controls

Instructions For the use of Masks
A paper or cloth mask gets wet in <10 minutes,
allowing bacteria to pass
Specially designed paper
masks with synthetic material
designed for filtering out
aerosols are protective
Fit testing is essential for
the correct functioning
of the masks
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Respiratory Protection Controls

Fit Testing

Performed to ensure that the appropriate

respirator (size and shape) for each HCW is used
involves the use of an aerosol which may be
tasted
usually saccharin or a bitter-tasting material

If the HCW tastes the aerosol, the respirator must

be adjusted (i.e., the nose clip) and retested
Any leak between the face and the mask is a
potential entry point for infectious droplet nuclei
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Ill Fitted Respirator

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Respirator vs Surgical Mask

Respirator-has only tiny pores
which block droplet nuclei
and relies on an air tight seal
around the entire edge

Surgical Mask-has large

pores and lacks air tight
seal around edges

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Respiratory Protection Controls

Instructions For the use of Masks
Patients can be given surgical masks to wear
in order to reduce transmission
Remember:

A surgical mask protects others from the

wearer and the N95 mask or particulate
respirator protects the wearer

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Respiratory Protection Controls

Educating patients regarding Cough Hygiene
Instruct coughing/sneezing patients to
Turn their heads
Cover the mouth with a cloth
or rag
Wash hands
Wash / burn the cloth used
Visitors also need to be educated
regarding cough hygiene
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Group Exercise
State the type of TB infection control:
1. Use natural exhaust ventilation and mechanical
ventilation to remove contaminated air
2. Use personal protective equipment in situations that
pose a high risk for exposure to TB disease
3. Developing and implementing a written TB-infection
control plan
4. Ensure the availability of recommended laboratory
processing, testing, and reporting of results
5. Educating patients on the importance of covering their
mouth with cloth, while coughing/sneezing
6. Keeping Smear + TB and MDR TB Patients separately
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Use of Standard (Universal ) Precautions

Practicing Hand Hygiene
Using Personal Protective Equipment (PPE)
when handling blood, body substances,
excretions and secretions
Following Biomedical Waste Management
guidelines
Safe handling of sharp items
Safe handling of specimen (blood, etc.)
Safe handling of spillage of blood/body fluid;
and
Use of disposable/sterile items
32

Safe Handling of Specimens

Cover cuts in hands properly with water proof
adhesive bandages
Wear disposable gloves while collecting
blood/body fluids and maintain proper
asepsis
Wash hands thoroughly with soap and water,
particularly after handling specimens

33

Safe Handling of Sharps

Special precautions while
administering inj.
Streptomycin:

Use of disposable
/adequately needles
Used needles to be
destroyed by Needle
Cutters
Disposal according to Bio
Medical Waste
Management guidelines

Needle Cutter
Used Needle Container

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Protect Oneself
HCPs should:
Take three doses of hepatitis B vaccine
Follow standard precautions at all
times
Take Post Exposure Prophylaxis (PEP) in
the event of any occupational exposure
Consider periodic screening for TB
infection
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Bio Medical Waste Management (BMW)

Types of wastes generated under RNTCP
Human/biological waste
Sputum

Sharp waste
Needles, Glass slides etc.

General Waste
Used blister packs, drug packaging material

Plastic waste
Disposable syringes, cups and glasses

Laboratory waste
Liquid waste, broomsticks, and paper waste
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BMW Management
Guidelines of BMW for PHIs, under RNTCP

Waste to be discarded with the overall waste

of the health facility
LTs and DOT providers in PHIs will adopt
Infection control techniques as per RNTCP
Activities include
Organized waste collection
Information dissemination
Monitoring & Reporting of disposal of the waste
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BMW Management
Waste

Management

General Waste (Used

blister packs, drug
packaging material)

No prior treatment required

Disposal in Black bags

Sputum Container ,Lids,

Wooden Sticks & Left
over Specimen

Put in foot operated plastic bin/bucket, filled

with 5% Phenol/Phenol compound
Leave overnight/for 12 hrs.
Put in autoclave-able plastic Red bag
Put in Autoclave machine for 15-20 min(at
121 C)*
Shredded/mutilated, after cooling
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BMW Management
Waste

Management

Stained Slides

Put in a puncture proof container & Red Bag

Put in Autoclave machine for 15-20 min(at
121 C)*
Dispose in the Sharps Disposal pit , after
cooling
Slides should NEVER be BROKEN

Used
Syringes/Needles/Broken
Vials

Cauterize the needle, immediately after use

Cutting of the plastic hub, without detaching
needle
Put sharps in translucent ,puncture proof
container
Put Plastic syringes in Red, autoclave-able
bag
Autoclave for 15-20 min (at 121 C)*
Dispose in the Sharps Disposal pit,/shredding,
after cooling
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BMW Management

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Patient Education & Counseling

Nature of TB disease
Cough Hygiene
Sputum Disposal
Prompt screening of adult & Child(< 6 yrs.)
Maintaining Adequate Ventilation
Restriction on Immunocompromised CareTakers , Children ( 6 yrs.) & Visitors
Treatment Adherence Counseling

Case Scenario II
Ms B,diagnosed with infectious TB, is getting
discharged. Nurse C educates on the following
guidelines, to prevent the transmission of TB at
home:
1. Cover her mouth while coughing
2. Allow limited visitors at home
3. Sleeping with her 3 yr. old son
Which of the above guideline is not correct?

Role of Nurses in maintaining Infection

Control Practices
Use appropriate PPE while caring for TB
patients
Ensure proper ventilation in wards with TB
patients
Ensure evaluation of HIV + and patients
with > 2 wks. of cough for TB
Ensure Spatial Separation of HIV+ &
Infectious TB patients
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Role of Nurses in maintaining Infection

Control Practices
Segregate hospital wastes appropriately
Follow guidelines for safe handling of Sharps/
Spills/Specimens etc.
Teach, train and supervise junior
staff/students and cleaning & other staff in
the ward with regard to waste segregation
and disposal
Educate patients/families regarding following
various Infection Control measures at home
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Key Points
Poor implementation of Infection Control
Polices/Program put HCPs at risk of
acquiring TB in Health facilities
Broadly, Infection Control needs to be
addressed at 3 levels:
Administrative
Environmental
Personal

Nurses have an important role to play at all

these levels
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Thank You

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