reduce the production of TB particles in health facilities. The following
administrative controls should be implemented in all health facilities,
including in sections that do not specifically address TB.
Screening of clients for cough as they enter the
In order to reduce the production of TB particles
into the environment, clients who are coughing need to be identified as early
as possible. Clients can be asked for a history of coughing, or can be
observed. The sooner coughing clients are identified, the fewer TB particles
will be released into the facility.
The best place to identify coughing clients is in the
client reception or waiting area. A staff member, such as the reception clerk
or triage person, should be assigned responsibility for this task. Clients
should be asked in a gentle manner if they cough and a poster promoting client
disclosure of coughing should be placed in the reception area.
Coughing patients can be given priority to receive
faster medical consultation or investigations in order to reduce their time in
the waiting areas. If not possible, a separate,
well-ventilated or open area should be made available for coughing clients.
They should be instructed on cough hygiene (see below).
TB is a highly stigmatised disease and this should be
kept in mind when identifying coughing patients. Client confidentiality should
Education of clients in cough hygiene
When you cough into the air or into your hand, germs
(including TB) are likely to spread. If someone is coughing, it is better if
they cough into a piece of cloth, a
tissue or a paper mask to trap the TB droplet. Tissues and paper masks should
be made available in the waiting room. These should be disposed of once used in
a dustbin. If such physical barriers are not available,
the mouth and nose should be covered during cough with the bend of the elbow or
hands, which must then be cleaned immediately. Such cough hygiene also
applies to health workers, visitors and families. All clients should be educated on proper cough hygiene in the health
facility, in public and at home.
of coughing patients
Triaging involves the separating and fast-tracking of
people who are coughing and may have pulmonary TB. All patients should be
screened routinely upon arrival for coughs lasting longer than two weeks,
fever, weight loss and night sweats. People suspected of having pulmonary TB
should be "fast-tracked" for rapid diagnosis and any health services
which they need. This means that the coughing person leaves the clinic earlier
and fewer TB or other germs will be released into the air.
If the main reason for the person visiting the healthcare facility is not because of their cough (such as infant immunisation,
family planning etc.), they should receive these first without waiting and then
be investigated for cough.
Healthcare workers should explain to patients that
the fast-tracking system is for the safety for all people and that the goal is
to reduce the chances of the transmission of TB and other diseases. Posters in
the waiting area should encourage patients to let staff know if they are
coughing and indicate that waiting times will be shorter. This will decrease
frustration when coughing clients appear to ‘jump’ the queue.
Sputum collection can be very risky in terms of TB
transmission and should be done in a safe environment. The safest environment
is outdoors, as this provides the best ventilation and natural sunlight. The client should have access to a private
space to cough sputum, and to running water for washing their hands afterwards.
Sputum booths can provide privacy but should be well ventilated.
HIV and TB prevention and care
Provide a package of
prevention and care interventions for health workers including HIV prevention;
antiretroviral therapy and isoniazid preventive therapy for health
workers living with HIV.
health workers should be given appropriate information and encouraged to
undergo TB diagnostic investigation if they have signs and symptoms suggestive
of TB. Similarly, all health workers should be given appropriate information
and encouraged to undergo HIV testing and counselling. If diagnosed with HIV,
they should be offered a package of prevention, treatment and care that
includes regular screening for active TB and access to antiretroviral therapy.
Based on the evaluation, health workers should be put on either isoniazid
preventive therapy (IPT) or a full regimen of anti-TB treatment, should they be
diagnosed with active TB. Health workers with HIV should not be working
with patients with known or suspected TB (in particular, they should not be
working with patients with multidrug-resistant TB and extensively drug-resistant TB), and they should be relocated
from positions where risk of exposure to untreated TB is high to a lower risk area.