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Guiding Principles to Reduce Tuberculosis Transmission in the WHO European Region

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Guiding Principles to Reduce Tuberculosis Transmission in the WHO European Region Guiding Principles to Reduce Tuberculosis Transmission in the WHO European Region Giovanni Battista Migliori, Lia D'Ambrosio, Rosella Centis, Martin Van Den Boom, Soudeh Ehsani, Masoud Dara ABSTRACT Evidence-based guidance is needed on (i) how tuberculosis (TB) infectiousness evolves in response to effective treatment and (ii) how the TB infection risk can be minimized to help countries to implement community-based, outpatient-based care while reducing TB-related suffering and improving TB treatment outcomes. This document aims to 1) review the available evidence on how TB infectiousness evolves in response to effective treatment and which factors can lower or boost infectiousness; 2) present policy options on the infectiousness of TB patients relevant to the WHO European Region; 3) define the limitations in the available evidence and 4) provide recommendations for further research. The document aims to target all professionals dealing with TB (e.g. TB specialists, pulmonologists, infectious disease specialists, primary health care professionals, and other clinical and public health professionals), as well as health staff working in settings where TB transmission may occur. Keywords Tuberculosis - diagnosis, drug therapy, epidemiology, prevention and control, transmission Tuberculosis, Multidrug-resistant - diagnosis, drug therapy, epidemiology, prevention and control, transmission Antitubercular agents Infectious Disease Transmission - prevention and control Occupational Diseases - prevention and control Europe Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). ISBN 978 92 8 905341 9 © World Health Organization 2018 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. i Contents Abbreviations ................................................................................................................................. iv Contributors .................................................................................................................................... v Executive summary ....................................................................................................................... vii Introduction .................................................................................................................................... 1 Scope, purpose and target audience .............................................................................................. 1 Background ................................................................................................................................. 2 Methodology ................................................................................................................................... 3 Literature search .......................................................................................................................... 3 Limitations .................................................................................................................................. 4 Probability of TB transmission ........................................................................................................ 4 Current WHO guidance on TB infection control ............................................................................. 5 Administrative controls ................................................................................................................ 6 Environmental controls ................................................................................................................ 6 Personal protection ...................................................................................................................... 8 Need for national/subnational and facility planning ...................................................................... 9 Question 1. Which patients are infectious and which factors favour disease transmission? ............ 10 The actors: patients, health staff and visitors .............................................................................. 10 Who is infectious? ..................................................................................................................... 10 Exposure time needed to generate infection? .............................................................................. 12 Features that influence transmission ........................................................................................... 14 Features of the index case .......................................................................................................... 15 Question 2. When does an infectious patient become non-infectious after starting treatment?........ 16 What is the effect of treatment on infectiousness? ...................................................................... 16 Which tools do we have to monitor treatment and assess infectiousness? ................................... 20 Question 3. What can render the patient non-infectious more rapidly? ........................................... 22 Question 4. What can limit the rapid decline in a patient’s infectiousness? .................................... 23 Question 5. Which patients need hospital admission (and respiratory isolation) because of their infectiousness? .............................................................................................................................. 24 Criteria for hospital admission ................................................................................................... 27 Features of an hospital admitting TB and MDR-TB patients ...................................................... 27 Question 6. What are the research needs? ...................................................................................... 28 Conclusions .................................................................................................................................. 29 References .................................................................................................................................... 30 iii Abbreviations ACH air changes per hour EQA external quality assurance DOT directly observed therapy DST drug-susceptibility testing FAST Find cases Actively by cough surveillance and rapid molecular sputum testing, Separate safely and Treat effectively based on rapid drug-susceptibility testing HBC high-burden countries IGRA interferon gamma release assay LPA line probe assay MDR-TB multidrug-resistant tuberculosis OR odds ratio PAS para-aminosalicylic acid TB tuberculosis TST tuberculin skin test UV ultraviolet UVGI upper room ultraviolet germicidal irradiation XDR-TB extensively drug-resistant tuberculosis iv Contributors Authors Giovanni Battista Migliori WHO Collaborating Centre for TB and Lung Diseases, Maugeri Care and Research Institute, Tradate, Italy Lia D'Ambrosio WHO Collaborating Centre for TB and Lung Diseases, Maugeri Care and Research Institute, Tradate, Italy Rosella Centis WHO Collaborating Centre for TB and Lung Diseases, Maugeri Care and Research Institute, Tradate, Italy External peer reviewers Edward Nardell Division of Global Health Equity, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, United States of America Marina Tadolini Unit of Infectious Diseases, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy Giovanni Sotgiu Clinical Epidemiology and Medical Statistics Unit, Department of Clinical and Experimental Medicine, University of Sassari, Italy Askar Yedilbayev Partners In Health, Boston, Massachusetts, United States of America Masoud Dara Joint Tuberculosis, HIV and Viral Hepatitis programme, WHO Regional Office for Europe, Copenhagen, Denmark v Martin van den Boom Joint Tuberculosis, HIV and Viral
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