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Infection Control and Tuberculosis in PerúLessons Learned
Dr. Martin Yagui Moscoso
(Dr. Paul Arthur Jensen)
1. Perú
Area: 1,285,215 km2
Population: 27 million
1. Health Services
7,501TOTAL
5,237Post Centers
1,778Health Centers
486Hospitals
NumberHealth Service
2. TB in Perú: Epidemiology
3. TB Transmission in Health Services in Perú
• 2000: A Study in Callao-Peru using tuberculin skin test (TST) among residents, measured incidence of TST conversion
• Of 98 residents that had been evaluated, 59% had a positive TST before the study
• Of 36 residents that were initially negative TST, 6 converted to positive TST
• Annual rate of TST conversion: 17%)
Bonifacio N.; Saito M., Gillman R et al. High Risk for Tuberculosis in Hospital Physicians, Peru. Letter in EmergInfect. Dis. 8:747-748. 2002
3. TB Outbreak in Health Services in Peru
• Outbreak in Almenara Hospital in 1996-1997. 44 health workers with TB infection.
• TB incidence 1994: 167 x 100,000
• TB incidence 1997:– Laboratory: 6,977 x 100,000
– Medicine: 932 x 100,000
Alonso Echanobe J et al. Transmision of M tuberculosis in Healthcare Workers University Hospital in Lima PeruClin Infec Dis 2001;33:589-596
3. TB Outbreak in Health Services in Peru
• 36 health workers with confirmed TB
• Multivariate analysis: Independent risk factor for TB infection in laboratory health workers was the use of common areas
Alonso Echanobe J et al. Transmission of M tuberculosis in Healthcare Workers University Hospital in Lima PeruClin Infec Dis 2001;33:589-596
Susceptibility and Resistance of M. tuberculosis in Health
Workers. Peru -2004
10065TOTAL
13.89Non-culturable or contaminated
23.115Poly or mono-resistance
6.24MDR
4.63Pan-resistance
52.334Pan-susceptible
%#Results
4. Chronology of IC in Perú
1990-1997 1998 2002 2004 2005 2006 2007
IC TB plans
In 10 Health
Centers and
hospitals
Global Fund
finance IC TB
Plans in
18 hospitals
Beginning of
Activities of
General IC
The first
guideline
of IC TB
in Peru
The first course
for engineers
Updated TB
Guidelines
Beginning
of the IC
TB
trainings
Organization
and
improvement
of NTP
5. Peruvian Guidelines of IC
• 1998: First Infection Control Guidelines (in general):
– Surveillance of Nosocomial infections (NI)
– Control and prevention of NI
– Sterilization
– Hospital Solids residues
5. Peruvian Guidelines of TB IC
• 2002: Specific guidelines for TB IC– Isolation Guideline (2002)
– Manual de prevenciòn de la transmisiòn de TB al interior de establecimientos de salud (2004)
– Manual de doctrina deTB (2006)
6. Training in Infection Control
• Since 1997: 70 hospitals were trained in surveillance of nosocomial infections, control and prevention, isolation and sterilization.
• 1997-2007: More than 2,000 health workers were training in general and specifics aspects of infection control.
6. Training in Infection Control
• 2002: Training in TB IC for health workers of Lima and Callao:– Doctors and nurses of TB programs
– Laboratorians
– Hospital directors
– Doctors and nurses of emergency, ICU and medicine departments
– Engineers and architects
6. Training in Infection Control
• The content of those courses included: general concepts about TB transmission, administrative controls, engineering controls (natural and mechanical ventilation, UV Light, HEPA filters) and respiratory protection (fit testing)
• Time: 4 or 5 days.
7. Implementation of TB IC Plans
• TB IC Plan implementation was subsequent to the training courses.
• We helped participants develop a TB IC Plan in the last day of the course and then selected the best TB IC Plans for presentation & expansion.
7. Implementation of TB IC Plans
• Criteria for selection are:– 3 control levels
(administrative, engineering, respiratory protection)
– political commitment of authorities of the hospital
– Health services that have high rates of TB and MDR
• Amount of money for each TB IC Plan:– Health centers: $5,000
– Hospitals: $15,000 – 20,000
Example of TB IC Plans in LimaBefore - After
9. Biosafety in MycobacteriaLaboratories
• 1996: National Health Institute of Peru developed the norms of biosafety for TB laboratories
• 2006: Norms were updated
• With the support of the State Laboratory of Massachusetts courses have been developed to train certifiers of biological safety cabinets
10. Future Activities in TB IC
• The Global Fund TB Project has planned Infection Control activities for 18 hospitals at national level, these include:
– Trainings for health workers in 18 hospitals
– Financing the implementation of 18 TB Infection Control Plans.
12. Lessons Learned: Guidelines
The existence of local and national guidelines on general aspects of Infection Control facilitates the introduction of TB IC measures
12. Lessons Learned: Guidelines
It's important to be careful in adopting recommendations of other countries with different prevalence of TB, more resources, etc.
12. Lessons Learned: Elaboration and Implementation of TB IC Plans
In many hospitals aspects of environmental controls and respiratory protection are prioritized neglecting the implementation of administrative controls.
12. Lessons Learned: Training
Frequent rotation of health workers forces to National TB program to have constant trainings in infection control
12. Lessons Learned: Training
It is important to include to engineers and architects who work in health services in these trainings.
12. Lessons Learned: Donors
• National TB programs must be able to supervise construction or remodeling TB areas (inpatient, laboratories, etc.) not to increase the risk of transmission
Donors not necessarily know about IC
Acknowledgements
• Peruvian National Tuberculosis Program
• Peruvian National Institute of Health
• CDC
• Socios en Salud (PIH)
• Harvard Medical School
• Brigham and Women’s Hospital
• Massachusetts State Laboratory Institute
