Plan Beta for tuberculosis: it's time to think seriously about poorly ventilated congregate settings

Abstract

SUMMARYGlobally, the rates of decline in tuberculosis (TB) incidence are disappointing, but in line with model predictions regarding the likely impact of the DOTS strategy. Here, we review evidence from basic epidemiology, molecular epidemiology and modelling, all of which suggest that, in high-burden settings, the majority of Mycobacterium tuberculosis transmission may occur in indoor congregate settings. We argue that mass environmental modifications in these places might have a significant impact on TB control and suggest a research agenda that might inform interventions of this nature. The necessary technology exists and, critically, implementation would not be dependent on health care workers who are in short supply in the communities worst affected by TB.

Agents of change: The role of healthcare workers in the prevention of nosocomial and occupational tuberculosis

“…Poorly ventilated and overcrowded indoor congregate settings where there are people with infectious but unsuspected TB, such as healthcare facilities, may be responsible for a high proportion of TB transmission in HBCs 3 . To address the risk of nosocomial TB transmission, the World Health Organization (WHO) has proposed the adoption and rigorous implementation of TB-IC measures 28 .…”

“…In addition, all staff should receive TB-IC training at least every two years as recommended by the WHO 59 . Each facility should have administrative IC measures in place, such as FAST (Find cases Actively using cough screening and rapid molecular diagnostics, Separate temporarily and promptly Treat effectively) 30 and environmental control measures such as improving ventilation, decreasing overcrowding and the use of germicidal ultraviolet disinfection 3,31 . These measures should be considered at the outset during the health facility planning process and IC officers should thus be part of advisory committees to architects designing health facilities to give input on TB-IC measures.…”

“…The 2016 WHO Global TB Report estimates that, in 2015, the number of TB cases per 100 000 HCWs was more than double the notification rate in the general adult population 1 . The risk of TB transmission in healthcare and other congregate settings is high 2,3 and nosocomial outbreaks of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) are well documented 4,5 . TB infection control (TB-IC) is one of the key components of the second pillar of the WHO End TB Strategy 6 .…”

Effect of ventilation improvement during a tuberculosis outbreak in underventilated university buildings

“…1 Despite the advances in molecular diagnosis, effective drug treatment, and directly observed treatment, short-course (DOTS) program, the worldwide TB incidence declined very slowly, 2% per year at the present timebut is consistent with model predictions for the impact of the DOTS strategy. 1,2 Additional strategies are urgently required to achieve the global End TB target.…”

“…5 The role of ventilation in preventing TB transmission has been widely proposed in infection control guidance. 2,[6][7][8] However, conclusive evidence is lacking. 8,9 Theoretically, improving ventilation rate decreases the probability of TB transmission exponentially, but never to zero.…”