DYPJHS Volume 2, Issue 1 : Jan-Mar. 2014 D Y Patil Journal of Health Sciences

ISSN (Print) 2347-3665 ISSN (Online) 2347-8020

EDITORIAL

Prevention of Tuberculosis Among Medical Resident Trainees: Save the Future Saviors!! Vaidya Preyas1, Kate Arvind1, Chhajed Prashant2* performance and quality of working life. They are at an increased risk of contracting diseases due to poor immunity resulting from work stress, disturbed sleep patterns and irregular food habits. The risk of contracting a new infection is proven to be more than the risk of reactivation of an old infection. [3,4] In a study from North India,15 TB developed in 2% of the resident doctors already working in the hospitals, giving an incidence of 11.2 new cases per 1000 person-years of exposure. The estimated incidence of TB among resident doctors was 10-fold higher than the incidence for the country.

Introduction Tuberculosis (TB) is one of the lethal communicable diseases known to mankind since centuries before. One of the most important physicians dedicated to the study of tuberculosis (phthisiology) was René Laennec, who died from the disease at the age of 45, after contracting tuberculosis while studying contagious patients and infected bodies. Many physicians and nurses throughout the 19th and early 20th centuries succumbed to the White Plague in the industrialized world. However, with the advent of effective chemotherapy, improved diagnostic services, and enhanced environmental controls, the risk of transmission of TB to health care workers has largely subsided in high-income countries.[1] The risk of transmission of Mycobacterium tuberculosis from patients to health-care workers (HCWs) is a neglected problem in many low- and middle-income countries (LMICs), where there is increased prevalence and lack of effective control programs and patient burden. The prevalence of latent tuberculosis infection (LTBI) among HCWs was, on average, 54% (range 33% to 79%).[2] Estimates of the annual risk of ranged from 0.5% to 14.3%, and the annual incidence of TB disease in HCWs ranged from 69 to 5,780 per 100,000. The attributable risk for TB disease in HCWs, compared to the risk in the general population, ranged from 25 to 5,361 per 100,000 per year.[2] The risk as compared with general population is highest among workers in TB inpatient facilities; laboratories, general medicine wards, and emergency rooms.[2] Workers in out-patient medical facilities have an intermediate risk, while workers in surgery, obstetrics, administration and operating theaters have the lowest risk. [2]

Factors that may facilitate transmission of tuberculosis in hospitals in India are enumerated in Table 2. [6] Infection control strategies As per guidelines laid by WHO and government of India, [7, 8] there are three levels of infection control (IC) measures: administrative (Managerial), environmental, and personal respiratory protection. Administrative controls are the most important since environmental controls and personal respiratory protection will not work in the absence of solid administrative control measures. Administrative controls reduce HCW and patient exposure

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Environmental controls reduce the concentration of infectious droplet nuclei

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Personal respiratory protection protects HCWs in areas where the concentration of droplet nuclei cannot be adequately reduced by administrative and environmental controls.

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Medical residents and fellows are the backbone of our health care system. They regularly work overnight, in emergency situations and with workload and stress which can affect their

Administrative controls Administrative controls are to identify persons with respiratory symptoms, separate them into appropriate environment, fasttrack them through the health care facility to reduce exposure time to others, and diagnose/treat them with minimal delay. Hospitalization should be reduced or avoided to the greatest extent possible. Triaging at waiting areas of outpatient offices and isolation of infective patients with the non-infective ones is essential at an outpatient as well as indoor services. At facility

*Corresponding author: Chhajed Prashant, E-mail: [email protected] 1 Institute of Pulmonology, Medical Research and Development, Department of Lung Care and Sleep Center, Fortis Hiranandani Hospital, Vashi, India 2 Institute of Pulmonology, Medical Research and Development, Department of Lung Care and Sleep Center, Fortis Hiranandani Hospital, Vashi; Department of Respiratory Medicine, Dr. Balabhai Nanavati Hospital and Lilavati Hospital, Mumbai, Maharashtra, India

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Table 2. Factors that may facilitate nosocomial transmission of tuberculosis (TB) in hospitals in India Area Factor Factors that increase risk for Overwhelming numbers of TB patients and repeated exposure to smear-positive TB patients nosocomial exposure Unnecessary or prolonged hospitalization of smear-positive TB patients Delays in intiating anti-TB treatment for those with TB Poor adherence to treatment, use of suboptimal treatment regimens, and lack of adequate patient support to improve adherence Interruptions in supply of TB medications in healthcare facilities Lack of effective infectionFailure to recognize and isolate patients with active pulmonary TB control procedures Laboratory delays in identification of TB, and poor use of tests such as sputum microscopy to identify infectious TB cases Clustering patients with TB with susceptible and vulnerable patients (e.g., HIV-positive patients) Lack of HIV testing services and delayed recognition of TB in HIV-infected patients because of atypical Lack of HIV testing services and delayed recognition of TB in HIV-infected patients because of atypical presentation and low level of clinical suspicion Inadequate respiratory isolation facilities and engineering controls Overcrowded hospital wards and outpatient departments Poorly ventilated wards and rooms Lack of adequate sunlight in hospital wards and departments Lack of airborne infection isolation rooms Lack of personal protection equipment (e.g., respirators) Lack of screening programs to detect and treat TB among healthcare workers Lack of commitment on the part of hospitals to invest in infection control programs Lack of national guidelines on nosocomial TB tailored to the Indian healthcare environment Gaps in knowledge and Lack of awareness about nosocomial TB transmission in healthcare settings in India awareness Healthcare workders’ belief that nosocomial infection is an occupational hazard that cannot be avoided Lack of educational programs on occupational safety and hygiene Poor patient education regarding cough etiquette and sputum disposal

level, administrative controls play a major role in reducing the risk of TB transmission and are essential for the implementation of other controls (i.e. environmental controls and personal protective equipment).

should use a surgical mask and observe cough etiquette. The use of surgical mask by residents and physicians do not prevent them from inhaling aerosols. They should use respirators for prevention of infection before seeing the patient.

Environmental Controls

Early diagnosis and treatment

The choice of environmental controls is largely determined local factors and resources. Ventilation should be prioritized to reduce the number of infectious particles in the air. Effective ventilation may be achieved by natural ventilation where possible. In high-risk settings where optimal ventilation cannot be achieved through natural or mechanically-aided means, properly designed, placed and maintained shielded ultraviolet germicidal irradiation devices should be considered as a complementary control. Use of HEPA filters in small closed settings should be encouraged. Proper placement of patients in the indoor setting so as to facilitate the air current away from the uninfected patients should be made certain.

Education of the residents so as to identify the early symptoms and diagnosis should be done on a regular basis. Screening of residents with Tuberculin skin testing or chest radiograph annually is controversial. Pre employment testing to identify individuals at high risk like those suffering from diabetes, immunosuppressive disorders or on immunosuppressants should be done. Sputum microscopy and newer gene based tests should be asked so as to prevent delay of treatment and further transmission. A confidential register must be maintained about residents with TB and treatment status. Ensuring recoveries by providing rest/leave from work, good nutrition and complete treatment options. Everyone including department heads, administration is concerned about health of their resident doctors. Policies are being devised and implemented to provide adequate nutrition to medical residents. Even though this subject has always stirred the medical community it is of utmost importance that residents at their individual level observe preventive measures and abide by taking rest and good nutrition. Young doctors

Personal protective equipment Personal protective equipment (e.g. particulate respirators certified as N95 or FFP2) should be available as required in high-risk situation, especially drug-resistant tuberculosis, and during high-risk aerosol-generating procedures such as bronchoscopy or sputum induction. The infective patient 4

plays pivotal role in health care delivery and patient management. Prevention of tuberculosis transmission in these health care professionals is vital as they are going to cure and save many more lives and thus effectively reducing burden of these diseases in the community.

5.

Rao KG, Aggarwal AN, Behera D. Tuberculosis among physicians in training. Int J Tuberc Lung Dis 2004; 8:1392-4.

6.

Pai M, Kalantri S, Aggarwal AN, Menzies D, Blumberg HM. Nosocomial tuberculosis in India. Emerg Infect Dis 2006; 12:1311-18.

7.

WHO Guidelines for prevention of tuberculosis in health care facilities in resource-limited settings. (1999) Available from: http://www.who.int/tb/publications/ who_tb_99_269.pdf

8.

Guidelines on Airborne Infection Control in Healthcare and Other Settings In the context of tuberculosis and other airborne Infections, April 2010,Directorate General of Health Services Ministry of Health & Family Welfare, Nirman Bhawan, New Delhi. Available from: http://www.tbcindia.nic.in/pdfs/Guidelines_on_Airborne _Infection_Control_April2010Provisional.pdf

References 1.

Fennelly KP, Iseman MD (1999) Health care workers and tuberculosis: The battle of a century. Int J Tuberc Lung Dis 3: 363–364.

2.

Joshi R, Reingold AL, Menzies D, Pai M. Tuberculosis among health-care workers in low- and middle-income countries: a systematic review. PLoS Med 2006; 3: e494.

3.

Geiseler P J, Nelson K E, Crispen R G, Moses V K. Tuberculosis in physicians: a continuing problem. Am Rev Respir Dis 1986; 133: 773–778.

4.

Bonifacio N, Saito M, Gilman R H, et al. High risk for tuberculosis in hospital physicians, Peru. Emerg Infect Dis 2002; 8: 747–748.

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