Essay on Infection, Prevention & Control of Tuberculosis

Question: With reference to infection prevention and control theory critically discuss the challenges of managing one of the following in the workplace or the community.
                 Tuberculosis OR Surgical Site Infection OR Clostridium Difficile

Answer: Essay on Infection, Prevention & Control of Tuberculosis

Introduction

The aim of this paper is to choose a specific disease and understand how such is spread and what the control measures of it are. For this paper, Tuberculosis is chosen as the infectious disease. The paper is divided into three core segments – the first segment being the introduction; the second segmenting presenting the nature of the disease and its epidemiology, the impact of such and will highlight the prevention and control measures. In this stage, we would also present the Hong Kong Government’s specific role and policies in infection prevention and control of Tuberculosis. The challenges of prevention and control would be mentioned, and recommended strategies would be presented. Lastly, the summarization of the key findings will be presented in the third segment Conclusion. Prevention of infection and control of such is a scientific and comprehensive approach teamed with practical solutions, designed for preventing harm caused by different infections to patients as well as health workers (Slingenbergh, Hogerwerf, & Engering, 2013). World Health Organization has a systematic framework in place named Infection Prevention & Control (IPC), which is based out of infectious diseases, its epidemiology, and social science and strengthening of health systems (WHO, 2018). This IPC occupies a significant position in the field of patient safety and quality of universal health services as it is relevant for health workers as well as patients at every single encounter of health care in each and every country worldwide. No countries, no matter how much advanced its healthcare systems are, are free of these specific healthcare related infections. As per a recent report by Centers for Disease Control and Prevention (CDC), 24% of the total global population is presented infected with TB and in 2016 alone, more than 10.4 million individuals globally became sick with the disease (CDC, 2018). Hence, the need for having IPC Programmes installed for different contagious diseases should be place. WHO identified the need for having IPC Programmes in every nation and the level of facility is clearly reinforced within the “100 Core Health Indicators List” by WHO (World Health Organization, 2018). 

Analysis

Tuberculosis

Tuberculosis is an infectious disease which usually impacts the lungs. Tuberculosis is responsible for the 2nd largest number of deaths caused by a single infection agent in the world (CDC, 2018). In 2016, it was identified that 1.3 million people died from the disease globally and approximate 10.4 million people fell ill (World Health Organization, 2017). It is caused by the bacterium Mycobacteriumtuberculosis (MTB). Though it generally impacts lungs but it can also affect different parts of the body (Moller & Hoal, 2010). Most of the infections are not associated with any symptom, and such situation is known as Latent Tuberculosis, when the individuals carry the bacterium but infection doesn’t not manifest (CDC, 2018). In cast of active diseases, which account for around 10% of total latent infections, if left without treatment can be fatal for half of the patients (World Health Organization, 2017). The typical symptoms of the disease are – chronic cough which may be tinged with blood, night sweats, fever and drastic weight loss (CDC, 2018). Tuberculosis was traditionally known as “consumption” and it stemmed from the weight-loss the disease brings about in infected patients (Moller & Hoal, 2010). 
Tuberculosis is spread through the air, just as flu or a simple cold is spread. When someone infected by the bacterium, and the infection is in active stage, coughs, talks, sneezes, laughs or releases tiny fluid droplets of liquid in the air, the germs are spread. Individuals containing or carrying latent TB in their bodies do not spread the disease (Horsburgh, 2014). It has been observed, that active infection tends to occur more in people who smoke or in people having HIV / AIDS. Diagnosis of latent TB can be detected through TST or Tuberculin Skin Test and a series of blood tests and the diagnosis of the active TB can be done through chest X rays and the culture of body fluids along with microscopic investigations (Ananthan, et al., 2009). 
The problem with Tuberculosis still existing and dominating in developed and developing nations are the various challenges associated with identification, diagnosis and treatment of TB. Example can be taken of India, and this example is valid for a number of countries. Indians have a notion that TB is a disease which is associated with poor people and this disease does not exist in affluent causes. This acts as a major challenge as these individuals do not realize that their servants, cooks, derivers can very well be asymptomatic carriers of this disease and they themselves can get infected in their own houses (Sandhu, 2011). Along with this, in countries where unpasteurized milk or dairy products are consumed, TB spreads rapidly in humans (Chi C. Leung et al., 2003). The apparent lack of initial symptoms which can disguise as common cough and cold, and the lack of symptoms for latent infections and for asymptomatic carriers become one of the most critical challenges for identification and diagnosis of TB. 
Individuals having frequent and prolonged contact with people infected with TB are at a very high risk of getting infected (World Health Organization, 2017). An individual with untreated and active TB may infect more than 15 individuals per year (Zumla, Raviglione, Hafner, & von Reyn, 2013). He probability of such transmission depends on a number of aspects – number of infectious water aerosol ejected from the infected person, the ventilation aspects of the room, virulence of the MTB strain, the duration of such exposure, immunity of the uninfected individual and etc (Phillips, et al., 2010). 
90% of the infected individuals with MTB have a chance of asymptomatic latent version of the infection with very small chance of such latent infection progressing to active disease (WHO, 2017). When the bacterium reaches the pulmonary alveoli and invades the endosomes result in infection. The alveolar macrophages identify the bacterium as foreign objects and try to get rid of them by doing phagocytosis. However, tuberculosis bacterium survives the body’s natural attempts to destroy it and eventually kills the host cell and spreads further (WHO, 2017). 
Tuberculosis is a terrifying illness which plagued Hong Kong decades back, and is considered as one of the 50 notifiable diseases which are infectious by Prevention and Control Board of Disease Ordinance (Vynnycky, Borgdorff, Leung, Tam, & Fine, 2008). The disease which was much feared in Hong Kong, started making an exit in the middle of 1950s when – the cure was discovered; the hygiene aspects of Hong Kong improved; and third the colonial government started the vaccination procedure of the cure in newborns (Noertjojo, Tam, Chan, Tan, & Chan-Yeung, 2002). However, outbreaks kept on occurring from time to time and as per the Department of Health, approximately 10 school outbreaks have been recorded each year. In the recent time, experts have shown fear about a global comeback of the disease, and that will be even complex, as a rise has been observed in the drug resistant cases and recurrent travels between the disease hotspots with that of cramped living areas of the region (South China Morning Post , 2017). It is worth mentioning that the latest case of TB in Hong Kong has been identified in September 2017, where 8 individuals in a public school were infected with the disease (SCMP, 2018). Hence it is of critical importance, that focus be presented on prevention and control measures to prevent the outbreak of such an infectious disease in the population. 
In Hong Kong, Tuberculosis posed a serious health threat for many decades. A series of studies had been conducted in Hong Kong as a result of such and these are a few mentioned (Ho, Ho, & Chong, 2006; C. C. Leung et al., 2015; Chi C. Leung et al., 2003; Noertjojo et al., 2002; Vynnycky et al., 2008). The government of Hong Kong also implemented a number of control and prevention policies are strategies for management of Tuberculosis. Namely, mass screening strategies, active screening techniques amongst the high risk groups, identification of passive cases etc were implemented fully. HK Government followed the technique of DOTS (Directly Observed Treatment, Short Course) as recommended by WHO, which had five following components – commitment of government to control TB, detection of cases by testing the sputum smear of the patients showcasing symptoms, standardized treatment of 6 – 8 months, regular supply of the essential drugs for TB and the recording and reporting of the overall TB control program and the patient treatments. (Info Gov, 2016). Today the government of Hong Kong, follows a framework of seven services for controlling tuberculosis and chest services. These are surveillance of and the control of tuberculosis; services provided to outpatients with chest diseases and tuberculosis; provision of the DOTS to patients of tuberculosis; health awareness and several promotional activities; BCG vaccination made compulsory for the newborns; identification, prevention, curation and the rehabilitative services for the clients suffering from pneumoconiosis and lastly conducting research on TB and several related chest problems to develop better treatment facilities (Info.Gov.HK, 2018).   

Prevention & Control Measures

There are seven countries that are responsible for 64% of the total global 10 million cases of TB in 2016, out of which five countries hail from Asia. These are China, Indonesia, India, Pakistan and the Philippines. Hence, having an adequately established prevention and control method for TB is of crucial importance herein (South China Morning Post , 2017). 
Individuals who work in healthcare are at a higher risk of becoming infected with the disease hence, it is necessary to have TB infection plan of control as part of the overall control program for prompt detection of the patients, airborne precautions and the treatment of the individuals who have been suspected of TB (ICMM, 2016). In every healthcare settings, especially in areas where people higher risk of getting exposed to TB, specific policies and procedures for control measures should be developed, reviewed in a periodic fashion and evaluated for the effectiveness to determine the specific actions necessary for reducing the risk of transmission of TB. 
As per the CDC, the TB prevention and control methods should ideally be of three level hierarchies – administrative actions, environmental control and use of protective gears. Amongst administrative control, a dedicated team must be assigned for the task, who will assess the setting, develop and implement a infection control plan, ensure the availability of the laboratory testing, implement the work practices required, educate and spread awareness amongst healthcare workers and patients and visitors, testing and evaluating, applying the epidemiology based principles of prevention, using visual aids and coordinating the efforts (CDC, 2018). The second hierarchy level is the use of environmental controls to reduce and prevent the spread of the infectious aerosol (CDC, 2018). Environmental control is of two types – primary controls which consist of controlling the infection source by using local ventilations and diluting and reducing the pollutant air by general ventilation and secondary controls which are aimed at controlling the airflow with the intention of preventing the contamination of air in areas next to airborne contagious disease isolation rooms and using HEPA filtration or ultraviolent irradiation to purify such air. Lastly, the third hierarchical control is the use of protective equipments and reducing the risk of exposure through – implementing a program of respiratory protection; training the healthcare workers on the importance of protection and educating and spreading awareness to patients and their families of cough etiquettes (CDC, 2018). 
For the purpose of this essay, three specific prevention and control strategies would be identified and further analyzed, and these are – auditing, surveillance and risk management. 
Auditing in healthcare is a procedure used by the professionals to effectively assess, evaluate and then improve the care of patients in a very systematic manner (Paton, Ranmal, & Dudley, 2015). The audit measures the present practices against a specific defined standard. Audit is a core part of clinical governance, whose main aim is to improve and sustain high quality of clinical care in patients. The utility of audit in tuberculosis management and prevention and control is of critical importance, as repeated audit will help understand the present status of prevention and control in a region and the gap between the present status and the desired status (Busch, 2012). 
Auditing is done in five stages- preparatory stage, whereby one specific topic is selected and identification of available resources; selection of criteria stage whereby, defining the criteria and defining the standard is conducted; measuring the performance level, through collection of data and analysis of the data thus collected; making strategies for improvements and conducting them and lastly maintaining the improvements made (Hargie & Tourish, 2009). 
Tuberculosis audit in cohorts, (TBCA) was introduced in the North Western region of England in 2012, as ongoing process to improve the clinical health practice and the public health practice (Wallis, et al., 2016). This study was one of the very first ones to evaluate perceptions of participants in any TBCA and it was found that, such TBCA actually acts as a effective strategy for quality improvement, which promotes identification of TB, care of TB and control measures and overall improves the patient safety. To sustain the success derived from TBCA, physicians and practitioners in public health must engage in such a secured and ongoing funding stream and clear mechanisms of reporting must be introduced in public health system (Wallis, et al., 2016). Surveillance in healthcare is a constant, systematic compilation, analysis and specific interpretation of the health associated data needed for the planning, implementation and further evaluation of the practices of public health (McSherry & Pearce, 2011). Surveillance in healthcare helps in serving as a system of early warning for different impending and unavoidable health emergencies; document the very impact of an intervention and helps in tracking the progress towards specific goals and lastly can monitor and effectively clarify the epidemiology of several health problems, in order for priorities to be set and to create general public awareness and development of health strategies and policies (World Health Organization, 2018). From itself, it can be understood how important surveillance tactics is for prevention and control of tuberculosis worldwide. 
The European TSN or the Tuberculosis Surveillance Network consists of experts in the field hailing from 53 countries of the WHO’s European region. The main function of this network is to collect, validate, analyse and further disseminate the surveillance data of Europe associated to TB. The main function of this network is the identification of patterns in the epidemiological studies of TB in this geographic region and to monitor the progress towards elimination of TB (ECDC, 2018). Effectiveness of surveillance as a strategy for prevention and control for an infectious disease like TB is huge, and can help any country in taking hold of the situation and devise effective strategies for improved prevention and complete control of the disease from spreading and repeated returning (European Centre for Disease Prevention and Control/WHO, 2011). Successful surveillance will help the public health agencies to – identify the contacts who might be infected along with identification of others who are at a risk of such; determine the prevalence and incidence of tuberculosis in any specific area and overall assist the healthcare workers and doctors to evaluate the illness in their patients and subsequent communities. Such tuberculosis surveillance thereby helps in controlling the spread of the disease, develop strategies to prevent the disease and respond to specific events associated to potential exposure to TB. Risk management is another strategy in prevention and control of infectious diseases (Scott, 2009). Risk management in healthcare helps in improvement of patient safety; ascertains that the mandatory national regulations pertaining to a specific disease is followed; assists in identifying potential medical errors; reviews and evaluates the existing and future policies and lastly, analyzes and updates the legislation impacting the specific field of healthcare regarding which risk management is being carried out (Murray, 2010). For tuberculosis to be controlled and prevented, risk management strategies must be adopted as such will help in detection of risk areas which are likely to give rise to incidents of TB. Risk management helps organizations understand the potential areas of risk before the occurrence of such risks in reality (Mossialos, et al., 2015). Hence, risk management strategies when followed in healthcare also will help in identifying the conditions which might give rise to TB, and will help the institutions to take preventive actions and specific control before the actual arrival of the outbreak. Risk management in healthcare subsequently is conducted by determining the factors and metrics of risks, environment scanning for detection of risks and providing information to the management about the present status of the pre-risk zones (European Centre for Disease Prevention and Control & WHO Regional Office for Europe, 2015).

Prevention & Control of Tuberculosis in Hong Kong

As per a report by Centre for Health Protection, Department of Health of The Government of the Hong Kong Special Administrative Region, the individual strategies for prevention of tuberculosis is done by – maintaining an adequate personal as well as environmental hygiene; adopting a healthy lifestyle; washing hands repeatedly and adequately; covering the mouth and nose while sneezing or coughing; seeking treatment after symptoms occur and receive the BCG immunization. 
Hong Kong Tuberculosis, Chest and Heart Diseases Association were formed in the early twentieth century as a mean of keeping the disease under control. Under the guidance of Professor Chan, the mission of the institution if to promote research and experimental work for prevention, identification and treatment of tuberculosis and other chest and lung related diseases. Department of Health of Hong Kong has in place several prevention and control measures in its website and anyone can inform the Ministry about any occurrence of TB in their area through this website (Department of Health , 2018). They are also responsible for the following prevention and control measures; 
- Conducting surveillance and the control of tuberculosis
- Conducting services on out patients with tuberculosis or any other chest related diseases
- Providing treatment for patients suffering from active tuberculosis infection 
- Promoting educational and other awareness programs to control tuberculosis and overall health improvements
- Making the BCG vaccination programs for newborns compulsory 
- Conducting assessment, and other preventive, rehabilitative and curative services for the clients who suffer from the disease. 
- Conducting a research on the tuberculosis and other infections for designing better control strategies for improved fight against these diseases. 
As per a study by Vynnycky et al, in 2008, it was found that there is a high risk of tuberculosis outbreak in Hong Kong as the control measured adopted by the government and health department was limited (Vynnycky, Borgderff, Leung, Tam, & Fine, 2008). Hong Kong Government’s efforts to control and prevent TB from occurring have met with active criticism throughout. Experts and physicians found it slow and inadequate. This infectious disease is generally seen in offices, schools and nursing homes as the symptoms are often considered to be common cold and are overlooked by most. Early diagnosis is an aspect which must be done in war footing everywhere. BCG vaccination gives a partial protection from the disease, and early detection and treatment are the only means through which control can occur. 
In the Sha Tin School outbreak, one student with the disease infected seven other individuals. Though screening was done to find whether others were infected as well, but such screening occurred at a later date and by that time, those eight infected individuals could have affected 8 times more. Hence, this slow response by the HK government exposed flaws in their contact tracing and screening procedure and health authorities have failed to identify the individuals at risk. Also, the health authorities were reluctant to conduct massive screening techniques. 
Taiwan can be considered as an ideal and successful program for control and prevent tuberculosis. The island has in place a system to trace the contact of the patient, including those individuals who have come in contact with the infected patient and then screening is done. For each patient in Taiwan, approximate 15 close contacts are traced, then screened and then offered preventive treatment. This proactive approach by Taiwan has led to a massive reduction of its TB rates from a whopping 72.5 individuals in 100,000 in 2006 to that of 43 in 2017 (SCMP, 2018). In comparison to this, Hong Kong authorities only screens and identifies in the patient’s household, which means that they only track 2 – 4 individuals. The ones diagnosed with latent tuberculosis are given preventive pills for a 9 month old period, and only half of them complete the procedure, as per government data. Hence, this is a major gap, in the actual theory and procedures which HK government has in place and the reality (SCMP, 2018).  

Conclusion

Any government, who cares for its citizens, should improve its control and prevention techniques, as this is a serious public health hazard. Hong Kong government should adopt clinical governance strategies like auditing, surveillance and risk management to control the outbreak of the disease and must have in place effective follow up techniques to ensure that patients have undergone the required treatment and completed the treatment or else, drug resistant strains of Mycobacterium would be formed and such drug resistant TB outbreak cannot be stopped by anything. Directly observed treatment (DOT) must be followed to reduce the incidence of drug resistant diseases (Okoh, 2009). It is going to be a very challenging task for the HK Government as the population is very mobile and transient. Hence, the HK Health Ministry all the more should take more active measures in controlling and preventing the disease from recurrence. 

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