Evidence for the Use of Triage, Respiratory Isolation, and Effective Treatment to Reduce the Transmission of Mycobacterium Tuberculosis in Healthcare Settings: A Systematic Review

Abstract

Evidence is limited for infection prevention and control (IPC) measures reducing Mycobacterium tuberculosis (MTB) transmission in health facilities. This systematic review, one of seven commissioned by the World Health Organization to inform the 2019 update of global tuberculosis (TB) IPC guidelines, asked: do triage and/or isolation and/or effective treatment of TB disease reduce MTB transmission in health care settings? Of 25 included articles, 19 reported latent TB infection (LTBI) incidence in health care workers (HCWs; absolute risk reductions 1%–21%); five reported TB disease incidence in HCWs (no/slight [high TB burden] or moderate [low burden] reduction) and two in HIV-positive in-patients (6%–29% reduction). 23/25 studies implemented multiple IPC measures; effects of individual measures could not be disaggregated. Packages of IPC measures appeared to reduce MTB transmission, but evidence for effectiveness of triage, isolation, or effective treatment, alone or in combination, was indirect and low quality. Harmonising study designs and reporting frameworks will permit formal data syntheses and facilitate policymaking.

Reducing the risk of tuberculosis transmission for HCWs in high incidence settings

“…The evidence for effectiveness of IPC recommendations, alone and in combination, remains generally indirect and of low quality. Many studies are observational in nature, some with a high risk of bias and confounding, including design specific issues and heterogeneity of the results [40][41][42]. Overall assessment and guidance is further constrained by the limited availability of data from high TB burden healthcare settings.…”

“…Overall assessment and guidance is further constrained by the limited availability of data from high TB burden healthcare settings. Of the 25 selected primary research reports, 76% were conducted in high-income, low TB burden countries, predominantly in the United States [42]. Although there is limited evidence for effectiveness of IPC measures, overall, the implementation of multiple controls demonstrated an absolute risk reduction for TB incidence among HCWs and individuals attending the healthcare facilities [42,43].…”

“…Of the 25 selected primary research reports, 76% were conducted in high-income, low TB burden countries, predominantly in the United States [42]. Although there is limited evidence for effectiveness of IPC measures, overall, the implementation of multiple controls demonstrated an absolute risk reduction for TB incidence among HCWs and individuals attending the healthcare facilities [42,43]. The extent of the risks of acquiring TB has also been carefully assessed, and a strong priority was assigned to the systematic introduction of core practices alongside other IPC recommendations [3,41].…”

“…Current control measures are strongly recommended by the national health authorities and must be adopted in all healthcare settings that pose a high risk of nosocomial TB transmission [4,42]. Implementation of good infection control policy and practice requires buy-in at not only a healthcare facility level, but also a subnational and national level.…”

Waiting times, patient flow, and occupancy density in South African primary health care clinics: implications for infection prevention and control

“…[14,15] Several initiatives to reduce frequency of clinic visits have been tested and deployed, primarily with the intention of providing 'differentiated care'. [16,17] However, interventions that focus on the movement of people around the facility ('patient flow') have received less attention than individual-focused IPC interventions, such as mask-wearing, triage, and prompt initiation of treatment, [18,19] and 'passive' interventions, such as structural changes to improve ventilation. [20] This is partly because of the complexity of intervening to change patient flow or waiting times in busy facilities, which can vary widely in size, layout, internal organisation, and patient load.…”