Enhancing TB Infection Control at Chorrillo Health Center, Panama

Background

Tuberculosis (TB) is an airborne infectious disease, transmitted by aerosolized droplet nuclei which are exhaled by a coughing person who presents active TB disease. The droplets can hang in the air and travel easily, increasing the probability that any person who visits or works at or near a TB clinic will inhale the droplets. While health workers at TB clinics are at particular risk to acquire TB, other personnel (e.g. administrative staff) who may perceive themselves as lower risk can also be exposed.

The World Health Organization (WHO) / Pan-American Health Organization (PAHO) state in the 2017 TB/HIV Co-infection Clinical Regional Guideline the importance of implementing TB infection control (TBIC) measures in settings with high risk for TB transmission, such as public health facilities. TBIC measures are classified into four categories: managerial, administrative, environmental control and personal protection. Research has shown that the implementation of TBIC measures can decrease TB annual incidence among health care workers between 27% and 81%, depending on the incidence rate.

 

Context

Chorrillo Health Center is a public health facility located in Panama City, with a catchment area of 19,486. In 2017, 45 new and relapsed TB cases were registered at this facility. In that year, based on local TB data, the TB incidence rate was 230.9 per 100,000 persons - four times higher than the national rate of 54 per 100,000 persons, according to the WHO 2017 TB Profile for Panama.

Despite the high level of risk, as of mid-2017 the health center was not implementing strong preventive measures to protect patients and staff. Some issues identified included:

  • Attending to TB patients in the emergency room, exposing a wide range of patients including pregnant women and children
  • No triage system for coughing patients
  • Sub-optimal ventilation in the at the emergency room (no cross-ventilation or a central ventilation system)
  • Lack of staff understanding on appropriate timing and use of personal protective equipment such as surgical masks and particulate respirators

 

Intervention

Through the PEPFAR/CDC-funded “HIV-Coinfection Strategies for Program Planning in Central America,” in August 2017, University Research Co., LLC (URC) coordinated with National TB Program (NTP) of Panama to introduce an infection control strategy. Over the course of the next two years, with technical assistance from the project, the Chorrillo Health Center took concrete steps to prevent the spread of tuberculosis (TB) among staff and visitors to the health facility. Strong leadership and staff engagement to introduce TB infection control measures (TBIC) enabled the clinic to reduce the risks or transmission.

Some of the steps taken to reduce the likelihood of TB transmission to other patients and staff included:

  • A rapid assessment of this facility to identify how the clinic functioned, as well as the existing strengths and limitations of infection control
  • Engagement with the clinic Medical Director and his team to prioritize issues and prepare a technical assistance plan based on the assessment results
  • Quarterly technical assistance and mentoring meetings focused on developing and implementing TBIC measures. This technical assistance was provided during onsite visits by URC or virtual meetings using the Zoom platform.
  • A series of on-line trainings for key TB clinic personnel. To ensure multi-level programmatic follow-up, regional and central-level personnel attended the trainings.
  • Provision of key TBIC equipment and supplies: ventilation smoke tubes, digital velocimeter, saccharose solutions to carry out sensitivity and fit tests, and N95 particle respirators
  • A three-day workshop including both theoretical and practical training on TBIC for Metropolitan Health Region facilities, including personnel from the Chorrillo Health Center

 

Using their greater understanding of the challenges and opportunities to improve TBIC, the Metropolitan Regional Health authorities and the Chorrillo staff used national and local funds to make several improvements, including (as of April 2019):

  • Providing clinical attention for presumptive and confirmed TB cases at a specific TB clinic, separated from the emergency room, where cross-ventilation has been established
  • Triage for coughing patients, monitored daily by TB staff
  • Coughing patients wear surgical masks and the attending health care workers wear an N95 particulate respirator
  • Key personnel are trained on why, when and how to carry out a fit test for N95 particulate respirators. TB clinic personnel will soon be required to pass a fit test.

 

The technical assistance we received has bolstered our knowledge about TB infection control. We are encouraged to believe in ourselves and take advantage of our potential to improve care for our TB patients and prevent the spread of TB to visitors, patients and staff.

Dr. Max Pinzon, Medical Director, Chorrillo Health Center, Medical Director

 

Conclusion

Implementation of TBIC measures at a public health facility is a very important strategy to prevent TB transmission to other patients, health care workers and visitors. Daily follow up of these measures will continue to reduce the risk of TB transmission.

 

Belkis de Moreno, nurse at the Chorrillo TB Clinic, wearing an N95 particulate respirator
Belkis de Moreno, nurse at the Chorrillo TB Clinic, wearing an N95 particulate respirator
Publication Date 
April 2019
Resource Type 
Success Stories
Regions/ Countries 
Language 
English