Hey...
Now that we have some background on what TB is and the threat it poses, let's begin to think about the ways that its spread and the spread of other infectious diseases can be controlled.
For an article about the spread of XDR-TB in a South African town where several people were infected (including health care workers) at the clinic where TB patients were being treated, see here.
For a presentation from the UIA-PHG conference about how to design hospitals to prevent TB transmission, see here.
For a report from the CDC about how to prevent and control TB transmission, see here.
For this assignment, I'd like you to think about the spread of TB within the health care setting. Pretend that you are the head administrator of a small hospital in South Africa which sees patients with HIV/AIDS, TB, malaria, bacterial infections and a range of other complaints.
Answer the following:
What policies and protocols would you put in place to protect your patients from contracting infections at the clinic? How would you enforce and sustain these policies, given that you are in a resource-poor setting? You can suggest protocols pertaining to (but not limited to) the physical design of the clinic, the use of equipment, and the distribution and behavior of staff and patients.
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Some important aspects of a TB clinic would IDEALLY include:
ReplyDelete-natural ventilation, with different systems for TB patients and other patients
-as much protection as possible (masks, at least) for health care workers
-complete training of patients and health care workers about what kind of behavior carries a higher likelihood of infection- but only information, no rules, since different traditions might be related to the spread of infectious diseases; for example, cheek-kissing as a greeting
-separate areas of the clinic for HIV and TB patients- separate hallways, waiting lines, etc.
-within the TB area, separate MDR, XDR, and reg TB cases, too
-for clinics in areas with high incidences of TB, have EVERYONE wear a protective mask when enter clinic
-prevent incomplete treatment at all cost- if not enough/inadequately protected health care workers to carry out DOTS, don't treat patients (in theory, but i don't know if this could ethically be perpetrated)
-screen people who have had contact with infected patients- if not feasible to do this with all TB cases, screen contacts of people with MDR or XDR
-clean facility every day with disinfectant
Anna Ruth
Most of the points, especially in the last article, seemed impossible in a resource-poor setting. Identifying people with high risk factors or people who have been exposed to TB is a good idea in countries like the US, but in countries with high incidences of TB, practically everyone has been exposed at some point. Here are some measures I think can be taken with relatively few resources:
ReplyDelete·Increasing education about the importance of following through with all the drugs, how TB is spread, etc, especially in areas of congregate living.
·Taking measures to reduce the stigma surrounding TB so that checking into a health clinic isn’t socially damaging. Ideally, everyone should acknowledge the danger of TB and other diseases so that health care workers could wear masks and gloves without scaring patients and intensifying the stigma.
·Boosting confidence in local health centers: that clinics will respect their patients’ confidentiality, and that going to a clinic won’t actually make you sicker (as was the case at the hospital in South Africa, where 100 people walked out because they were afraid of contracting HIV)
·Quick lab examination of TB tests so that effective treatment can be given to people who test positive as soon as possible.
·Obtaining legal rights for health care workers to detain patients (given a system of checks and balances) who refuse to follow safety protocol or to follow through with their treatment. Forcefully quarantining all TB patients would dramatically reduce instances of TB, but this does not seem feasible legally, logistically, or financially. Nonetheless, patients should not be given the choice to develop dangerous strands of TB.
As stated in the responses before me, many of the points made throughout the Times Magazine, and the other articles lead to me think many of them are near impossible goals to reach without the help of other countries, more resources, and money. Though even though the points seem unrealistic to this setting, they still have a chance of happening, which include:
ReplyDelete• Enable quicker lab results for seeing if the treatment is going to be resisted by the strand or not, and give quick second hand treatment to those whose strands are resisted by the first line drug.
• Allow higher education for the knowledge of transmission of TB, and education on the issues with previously having HIV/AIDS, and being susceptible to catching TB.
• Being able to prevent cases where first line treatment doesn’t work, causing more time to elapse between treatments. Even if the DOTS method needs to be enforced, all measures will be taken.
• Higher level of cleanliness throughout the hospital, taking all precautions into account; having a daily cleanse of all rooms. (higher employee rate is needed)
• Though the main issue I can think of is ventilation. As high tech ventilation could be quite costly, I believe thinking of an alternative natural solution to ventilation is in order. Such as using natural wind sources to power the ventilation system.
• Also, to go along with the second bullet, allowing there to be separate wings for TB, and HIV/AIDS ridden patients, this lowers the risk of the two getting interchanged within ones body.
• Lastly, as there is only one prevention method known as of now for TB, those who work/visit the clinic must take the newly enforced precautions seriously. If the precautions are taken loosely, and doctors/nurses think their immune system is strong enough to fight TB, they are wrong. No risks can be taken against this disease.
The architecture of the hospital needs to be appropriately designed with the patients in mind. It need to be a clear environmental where patients can recover mentally and emotionally as well as physically. Open spaces, as well as smaller confined rooms for quarantined patients, should ensure that air moves freely through out the hospital, preventing stale air. However, one must be careful to keep fresh air, rather than a breeze ways inside, where TB and other bacterial diseases can flourish and be carried.
ReplyDeleteIt is essential that the employees are educated not only in terms of drug dosage and symptoms, but how to sterilize needles and other equipment. Even if hygiene can't be kept up at an ideal rate (because of lack of resources etc.), some level must be taught and maintained. For example: if there is little available water, give the water to the patients to drink, keeping them hydrated. Use alternate ways to sterilize equipment, like extreme heat or even fire!
There should be distinguished areas for patients with one disease rather than another, so a patient with HIV are less likely to contract TB from the patient in the next bed over, etc. Like wise, waiting rooms must be separated from the wards.
Special attention and care must be paid to the staff. If the staff is not healthy, patients can't be helped. It is hard to do this in resource poor settings, but the staff must be adequately paid and have good working conditions as incentive for staying at the hospital. I agree with Paul Farmer that a hospital must have additional worker, not just the doctors, employees who don't require the full doctors education. These people can help the doctor so he is able to see more patients. They too, however must be educated sufficiently at least in hygiene, and given alternate methods depending on the resources available.
Over all, I believe that the hospital must employ and surround itself with people who want to be there. Either because they are making good money, because they want to help the sick, or ideally, both.
When working within a health care setting ideally you would have everything you need or the option to get it. However working in a health care setting that does not have enough resources means that you will have to cut corners and work with things that might not be as effective but still help. There are some key things that are involved with making a type C facility like a type A facility.
ReplyDelete• One thing that you would need would be clean medical supplies so that you would not cross contaminate anyone.
• Having an organized association where it co exits with other organizations trading ideas, statistics and facilities. So that instead of having three different facilities that do the same thing you could combine all three and organize it so that it makes it easier and safer for patients and staff.
• Training staff so that they know what they are doing and keep everyone safe.
• Training patients so that they know how to keep themselves in shape. They would also need to know how important it is to keep taking their medicine even if they feel better.
• Keeping HIV/AIDS, TB, malaria, and other infectious diseases patients away from each other so that someone with TB will be less likely to spread TB to someone with HIV/AIDS.
• Keeping the building and people maintained with the appropriate Ventilation, Filtration, Masks, and Respirators.
• Quick and effective care so that patients can be treated quickly with less of contaminating other people.
• Being honest and upfront with everyone about everything. Doctors need to be honest to their patients and not baby them so that they feel better.
In my hospital, there would need to be a number of things:
ReplyDelete- Separate wards or even floors for various diseases. For example, a floor for HIV/AIDS treatment.
-Throughout the whole hospital, there needs to be proper ventilation to prevent the further spreading of diseases.
-I also think that there needs to be information seminars for both patients and employees about how to keep people already sick from getting other diseases and how to keep the staff safe.
-I would use the DOTS strategy, but within the hospital, there would be a couple of people designated to each ward, and that's the only they would work.
-In an ideal situation, there would be enough drugs for every patient, but we all know that it's not the case in most places. Before I opened my hospital, I would make sure there were enough drugs for a full course of treatment for ever bed, with extras.
-I would try to train people from the community about proper sterilization and sanitation tactics, and I would also provide basic supplies so people could sterilize things in their own home.
-I agree with Alison. All of the staff at my hospital would have to be completely honest,and not baby their patients. I don't want them to think they're getting better, so they stop taking their medicine. Patients need to understand that if they stop taking the antibiotics or whatever, before they're supposed to, their condition will get worse.
In a resource poor setting I would need to prioritize the highest health factors first. I would first separate out the TB patients from the HIV patients, because this group is the most likely to become actively infected. If the facility was so small that there were not separate wards, then I would at least put a plastic sheet up to separate the two sides of the room. I would do the same for MDR- TB and XDR-TB, because having these groups reinfect each other would make the treatment useless. I would also keep the room as ventilated as possible, potentially an open window policy (with screens for mosquitoes and other insects). If masks were affordable, I would have all doctors wear masks at all times, and I would have the patient wear a mask for close up examinations. If masks were too expensive I would have the doctors wear a bandana or shirt around their mouth for these examinations, especially for drug resistant TB.
ReplyDeleteI would have bed nets on every bed and the walls spraying with insecticide. It is a fairly cost efficient way to keep the workers and the patients safe.
In order to help solve the problem of patients mingling in the waiting room, I would have people either wait outside of in a screened in porch so as to keep the air flowing.
Putting precious resources into stopping diseases spreading from patients seems worth the expense to me. If a hospital is less safe than a persons home, then he will not go seeking treatment at all. Also, if the few healthcare workers get sick, the whole hospital could collapse, and the clinic will have lost it’s most valuable resource.
There are many aspects to fighting TB in impoverished countries that are important. Ideally and with limited supplies, I think there are a few that deserve particular attention and effort.
ReplyDeleteMy first priority would be to separate patients with HIV/AIDS, TB, MDR-TB, and XDR-TB so as to minimize transmission of the most deadly and untreatable strains of TB to those who are most at risk towards developing an active case (and further spreading the condition).
Ventilation seems vital to improving the situation. I would utilize the impact of open spaces- screened in rooms, doors, and windows. I would push for a couple big rooms as opposed to many small ones. If there were not enough big rooms to separate people with varying strains of TB I would section them off from one group to another with curtains at least. I would have the waiting room be outside under a shelter, but with no walls to keep maximum air flow while patients still undiagnosed were interacting. Renovations might be costly, but the beneficial effects are lingering and help a multitude of people.
I would try to provide at least masks for all of the health workers to prevent them from getting infected. Anti-bacterial soap and other cleaning supplies would have to be widely used. I would train the health care officials to clean the clinic immaculately and often.
The biggest problem seems to be individuals refraining from seeking medical attention until they have had the opportunity to spread their infection to family and community members. I think active community involvement would be key- if the members of society have a policing system amongst themselves, where individuals who appear sick are encouraged to seek medical attention by their friends and family, I think all programs would yield improved results.
The DOTS program would be encouraged and highly regarded, as would the basic training of people who only need to make home visits or provide for the sanitation of the clinic.
Obviously collecting the medicines used to treat TB would be invaluable and a given.
• Well ventilated clinics- possibly open air if there is not a concern about Malaria or if bed nets can be acquired
ReplyDelete• Ensure all patients who start treatment continue seeking treatment until treatment is successfully concluded or patient dies. There must be minimal chance for drug resistance to develop.
• Patients infected with HIV are kept separate from patients with TB. Both sets of patients are educated on the risks of contagion for family members and other visitors.
• Medical supplies are sterilized as much as possible in the setting. New methods of sterilization are researched for use in resource poor environments using resources like the sun and limited electricity.
• Medical supplies designed to be disposable are not used at all unless a steady supply is procured. Supplies such as needles are not used if the supply is so small that they must be reused for separate patients.
• Nurses and community practitioners are well trained for both treatment of patients but also for prevention of infection of visitors and infection between patients.