Tuberculosis infection control guidelines

Objectives

Namibia’s tuberculosis infection-control framework aims to minimise tuberculosis transmission in health facilities, congregate settings, households and other community environments, particularly where people with infectious tuberculosis, including drug-resistant tuberculosis, may expose patients, visitors, healthcare workers and other staff.[1][2][3][4]It gives particular emphasis to protecting people living with human immunodeficiency virus, children, immunodeficient patients and healthcare workers, in view of their heightened vulnerability or occupational exposure.[1][5][6][7]

• Implement appropriate tuberculosis infection-control measures across health facilities, prisons and police holding cells, military barracks, hostels, transport services, households and other congregate or community settings.[2][8][3]
• Reduce exposure through early identification of presumptive tuberculosis, rapid diagnosis, prompt effective treatment, safe separation of infectious patients, cough etiquette and reduced time spent in facilities.[9][5][10][6]
• Apply a hierarchy of controls in which administrative measures reduce exposure, environmental measures reduce airborne droplet nuclei, and personal protective equipment provides additional protection where other measures are insufficient.[11][9]
• Use the FAST strategy, meaning Finding TB cases Actively, Separating safely and Treating effectively, to accelerate diagnosis and initiation of effective treatment for infectious patients.[9]
• Strengthen integration between tuberculosis, human immunodeficiency virus and infection prevention and control services, alongside staff competence, community awareness, surveillance, operational research and accountability.[12][13][14]
• Tailor measures to transmission risk, local epidemiology, facility design, climatic conditions, available resources and the needs of specific settings.[1][7][13]

Implementation

Implementation combines facility risk assessment, written infection prevention and control planning, setting-specific service reorganisation, environmental safeguards, respiratory protection, workforce measures and multi-level oversight.[14][3][15][16]Administrative controls are prioritised as the first line of defence and should be supported by ventilation, ultraviolet germicidal irradiation where indicated, and respirators for staff facing residual airborne risk.[11][9][17][18]

• Screen patients at the first point of contact for cough, weight loss, fever, night sweats, current tuberculosis investigation or treatment, and relevant exposure history; register presumptive cases, collect sputum safely outdoors or in well-ventilated areas, and expedite laboratory testing and treatment.[5][14]
• Separate and fast-track people with presumptive or confirmed infectious tuberculosis in well-ventilated areas, protect high-risk patients from exposure, provide surgical masks when infectious patients must move through facilities, and limit unnecessary admission or movement.[9][5][10][19]
• Manage drug-resistant tuberculosis through designated services where possible, separation by infectiousness and resistance profile, single-patient airborne-precaution rooms for suspected or diagnosed extensively drug-resistant tuberculosis, and referral when safe separation cannot be achieved.[10][20]
• Improve airflow through natural cross-ventilation, open windows and doors where feasible, fans, extractor systems or mechanical ventilation, ensuring that contaminated exhaust air does not expose people or re-enter buildings.[17][21][19]
• Use upper-room ultraviolet germicidal irradiation in high-risk spaces where ventilation cannot be adequately improved, with engineering support, safety safeguards, routine cleaning, lamp replacement, performance checks and maintenance records.[22][18]
• Establish respirator programmes covering procurement, supply continuity, selection, training, fit testing, storage, inspection, disposal and hand hygiene; use respirators for staff caring for known or suspected multidrug-resistant or extensively drug-resistant tuberculosis and during aerosol-generating procedures.[18][23][7]
• Protect healthcare workers through tuberculosis risk education, screening at entry, periodically, on transfer or exit, confidential record keeping, prompt investigation and care, contact investigation, and access to human immunodeficiency virus prevention, treatment and isoniazid preventive therapy where eligible.[6][24][17]
• Conduct risk assessments jointly with relevant institutional staff in congregate settings, develop written plans assigning measures and responsibilities, promptly screen detainees and new inmates, and maintain continuity of treatment when people are transferred or released.[8][12]
• Train clinical, laboratory, cleaning, maintenance, management and volunteer staff through induction and refresher activities, supported by public education materials and tuberculosis and human immunodeficiency virus communication campaigns.[13][25]

Governance is organised through national and sub-national tuberculosis and leprosy programme structures, regional and district management, facility infection prevention and control focal persons, laboratory managers and hospital infection-control committees.[3][4][26][27]Facility committees bring together management, clinical, nursing, laboratory, pharmacy, cleaning, maintenance, occupational health and safety, quality-assurance and other relevant representatives to identify risks, set priorities, coordinate activities, recommend equipment and funding, and review implementation.[3][25]Each facility should maintain a written plan based on risk assessment and available resources, while facility leaders prepare costed annual and quarterly plans; no monetary budget amounts or funding allocations are specified in the supplied material.[14][3]

Monitoring links infection prevention and control to continuous performance improvement.[4][28]Facilities use risk-assessment and review checklists or dashboards at baseline and quarterly, monitor cough-register data monthly, document referral outcomes, assess diagnostic and treatment-initiation delays, and maintain records for staff screening, environmental maintenance and respirator fit testing.[28][29][30][31]National annual indicators include written tuberculosis infection-control plans, nurse screening and diagnosis, staff training, and the availability of outside waiting areas in human immunodeficiency virus care facilities.[4]Facility heads submit quarterly reports to regional management, Quality Assurance and the Directorate of Special Programmes, while routine monitoring, surveillance and special-study findings are analysed and shared with the tuberculosis infection-control committee to guide remedial action.[4][28][32]

Monitoring & Evaluation

The tuberculosis infection-control framework links monitoring and evaluation to implementation improvement, using a strategic framework that covers inputs, processes, outputs, outcomes and impact at national and sub-national levels.[3][4]Monitoring is intended to support planning, coordination, efficient use of human and financial resources, service quality, accountability, problem-solving and resource mobilisation across facility, district, regional and community levels.[3]

• Assess facility risks using standardised TB infection-control risk-assessment checklists, applying assessments separately across relevant service settings and using findings to select controls according to transmission risk and available resources.[7][21][15][29]
• Use facility review checklists or dashboards at baseline and quarterly thereafter, with verification based on records, observed practice, training lists, stock records, registers, logs, maintenance records and fit-testing results.[28][30][31]
• Monitor cough screening daily to ensure that people with cough are screened, and use the number of diagnosed TB patients as an indicative measure of improved screening.[9]
• Document presumptive TB cases daily and evaluate them monthly against outpatient attendance, notified TB cases and bacteriologically confirmed cases.[5]
• Track diagnostic and treatment-initiation delays through registers recording specimen receipt, results and treatment-start dates; assess minimum, maximum and average intervals from initial contact to diagnosis and from diagnosis to treatment initiation at least quarterly.[6][30][31]
• Review a random sample of 20 patient records from the previous six months to assess delays across presentation, specimen collection, laboratory processing, diagnosis, treatment initiation, culture, drug-susceptibility testing and treatment adjustment.[29]
• Screen healthcare workers at entry, periodically, on transfer or exit, and maintain confidential screening and suspect-investigation registers.[6][24][17]Staff screening data should include symptoms, radiography, clinical examination, laboratory findings and follow-up actions.[24]
• Notify the district tuberculosis and leprosy coordinator and the Social Security Commission when a staff member is diagnosed with TB, and undertake contact investigations among household members and immediate colleagues.[24]
• Maintain environmental-control records, including airflow checks, maintenance dates, repairs, component replacement and next service dates.[17][22]Record ultraviolet germicidal irradiation inspection, cleaning and lamp replacement, and measure ultraviolet-C performance following lamp replacement and quarterly thereafter.[18]
• Maintain respirator fit-test registers containing worker identity, test date and outcome, respirator specifications and next test date; repeat testing ideally annually and when respirator type, physical condition or duties change.[7]

National annual indicators include the proportion of hospitals and health centres with written TB infection-control plans, nurses screened for TB, screened nurses diagnosed with TB, facilities with nurses trained in TB infection control, and HIV-care facilities with outside waiting areas.[4]Routine cough-register data should be monitored and reported monthly, while routine monitoring and surveillance should be reported quarterly.[28][32]Facilities should compile monthly or quarterly infection-prevention and control plan reports.[14][3]

Accountability is distributed across facility, district, regional and national structures. Infection-prevention and control focal persons, district tuberculosis and leprosy coordinators and district community coordinators complete monitoring checklists for submission to regional and national levels.[28]Heads of institutions prepare quarterly reports for Regional Management Teams, Quality Assurance and the Directorate of Special Programmes.[4]Regional management compiles annual reports for the National Quality Assurance Unit, while district management reviews facility surveillance reports and submits reports to regional level.[27]Hospital Infection Control Committees conduct regular monitoring, evaluation, surveillance and auditing, review progress in management meetings, and scrutinise reports for regional and national submission.[27][25]

Routine monitoring, surveillance and special-study findings should be analysed with current and historical statistics, survey results and inspection findings, then shared with the TB infection-control committee to inform remedial action.[28][32]Several operational sections do not provide outcome targets, detailed indicator definitions, or external accountability procedures beyond the specified tools, reports, registers and responsible structures.[33][18][8]

Costing & Financing

Costing information is limited. The guidance characterises tuberculosis infection-control measures as rational, affordable and cost-effective, but does not provide quantified implementation budgets, allocations, financing gaps, expenditure figures, currencies or economic assumptions.[2][3]

• Prepare costed annual and quarterly tuberculosis infection-control plans at facility level.[3]
• Develop an annual infection-control programme budget based on agreed priorities, resource needs and scheduled activities.[27][25]
• Recommend adequate funding through Hospital Infection Control Committees, which identify and prioritise infection-control needs and equipment requirements.[27][25]
• Provide budget and staffing for maintenance of environmental controls, including ventilation and ultraviolet germicidal irradiation servicing, repairs, cleaning, lamp replacement, monitoring and staff training.[17][22]
• Resource respiratory protection, fit testing, staff training, storage and replacement of respirators, although no monetary values are supplied.[18][23]
• Evaluate infection-control resource and training needs through regional and district management structures.[27]

The publication itself received financial support from the United States Agency for International Development through TB CARE I under agreement AID-OAA-A-10-00020.[1]This support is identified for the publication rather than as a quantified implementation-financing commitment.[1]