Drug resistant TB – what every

student should know

Elma de Vries
 Discussion:
• Have you thought about the occupational risk
of getting Drug Resistant TB as a health
worker?
• How do you feel about it?
• More scary than risk of getting HIV from a
needlestick injury?
• What else can one get from a needlestick
injury apart from HIV?
• Have you all had your Hep B boosters?

Risk of getting HIV from a needlestick injury is

0.3%, and that is reduced by 81% if you take
AZT – now we take triple therapy, so risk very
low.
How do most health workers get HIV?
• Have you all had your Hep B boosters?

Risk of getting HIV from a needlestick injury is

0.3%, and that is reduced by 81% if you take
AZT – now we take triple therapy, so risk very
low.
How do most health workers get HIV?
Like anyone else – through sex!
• It is estimated that Health workers have 10x
the risk of getting TB compared to the general
population.

• Which one are we more at risk for (drug

sensitive TB or drug resistant TB)?

• Is your chance of getting DR TB bigger if

exposed than getting drug sensitive TB?
• It is estimated that Health workers have 10x the
risk of getting TB compared to the general
population.
• Which one are we more at risk for (drug sensitive
TB or drug resistant TB)?
• There is much more drug sensitive TB around, so
bigger chance of getting it.
• Is your chance of getting DR TB bigger if exposed
than that of getting drug sensitive TB?
• Same organism, just different resistance pattern
to antibiotics, so same risk if exposed.
 History of TB
• A hundred years ago, 20% of the population in
some parts of Europe died of TB, including well
known figures like the composer Chopin.

• What is the natural history of TB without

medication?
• What is the natural history of TB without
medication?

• 25% will cure even without medication

• 25% will die
• 50% will develop chronic lung disease and die
later
 DRTB
• Drug resistant TB is simply TB that needs to be
treated with different drugs, for longer.
• It has been shown in Peru to be curable, but
need scale up of the TB program, and patient
support. Can do home based care as part of
TB program.
• We need to take precautions for transmission
for all TB, not only when we suspect DRTB.
 DRTB Definitions
• MDR: resistant to Rifampicin and INH
• Mono resistance: resistant to only Rif or INH
• Poly resistance: resistance to other 1st line
drugs (not Rif/INH)
• XDR: resistant to Rif and INH and an injectable
and a quinolone
 Epidemiology
• World wide the countries with the biggest
burden of DRTB are China, India and the Russian
Federation (62% of cases world wide in 2004)
• Because such a high TB burden in Africa, even
though lower MDR incidence per population,
Africa has the same burden as Russia!
• Around 425 000 cases annually - not lucrative to
develop new drugs for a disease that only affects
half a million people a year…
Distribution of MDR in previously
treated TB cases (WHO 2006)
What is the MDR prevalence in SA?
• For first time TB?

• For retreatment TB cases?

 Prevalence in SA
First treatment Re-treatment
SA 2001 1.6% MDR 6.6% MDR
Khayelitsha 2009 5.2% Rif resistant 11.1% Rif resistant
Mozambique 3.5% MDR 11.2% MDR
Swaziland 7.7% MDR 33.4% MDR

• Of MDR patients in SA, around 5-8% are XDR

• Around 9000 new cases of MDR in SA in 2009
(Western Cape >2000)
• Around 600 new cases of XDR in SA in 2009
 What is TB infection control?
• TB infection control is prevention of
transmission
• TB is an airborne infectious disease
• How can we prevent TB transmission?
 Hierarchy of infection control
measures
• Administrative controls to reduce risk of
exposure, infection, and disease through policy
and work practice

• Environmental controls to reduce concentration

of infectious bacteria in the air

• Respiratory protection to protect personnel who

must work in environments with droplets (large
and small) (at the bottom of the hierarchy)
 1. Administrative controls
• Prevention of droplet nuclei containing
M.tuberculosis from being generated
• Prevention of TB exposure to staff and patients
• Implementation of rapid and recommended
diagnostic investigation and appropriate
treatment for patients and staff suspected or
known to have TB
Diagnose more TB cases and
start them on effective treatment!
 Administrative controls include…
• Assigning responsibility for TB infection control
• Prompt detection and timely diagnosis
• Conducting a TB risk assessment of the setting
• Developing and instituting a written TB IC plan
• Adjusting patient flow and waiting areas in facilities
(minimising overcrowding, and time spent in facilities)
• Provision of face masks or tissues for cough hygiene
• Training and educating HCW and patients
• Screening and evaluating HCWs who are at risk for TB or who
might be exposed to TB
 Sputum collection – ideally outside!
To consider:
•Infection risk
•Privacy
•Convenience
•Supervised sputum
 2. Environmental control
• Naturally ventilated rooms mostly adequate,
air conditioned areas often inadequate
• Need at least 12 air changes per hour to
decrease concentration of bacilli in air (WHO)
• Keep the windows open campaign!
• Can use ultraviolet light to kill bacilli
 Environmental control if patient
treated at home
• Separate room, keep kids away, masks,
educate patient and family
• Biggest risk of transmission is before diagnosis
and treatment!
 3. Personal Protective Equipment
• Respirators for staff
(e.g. N95 respirator)
• Tiny pores which
block droplet nuclei
and an airtight seal
around the edge
 Personal Protective Equipment
• Face masks for
patients
• Large pores and
lacks airtight seals
around the edges;
but prevent
aerosolization
Apart from masks, how can we
decrease our risk of getting TB?
 Apart from masks, how can we
decrease our risk of getting TB?
• Look after our own immunity – enough sleep,
exercise, not smoking
• A study of the common cold showed that
people who sleep less than 8 hours per night
are more at risk than those who sleep more…
• If a health worker is HIV+, to use INH
prophylaxis and start HAART at CD4=350
 Occupational Health Policy
• Annually:
– HIV testing and counseling strongly recommended

• Any active health worker with cough > 2

weeks:
– Sputum smear microscopy, sputum culture and
sensitivities
– CXR not always indicated
Where can students go for TB
investigation?
 Where can students go for TB
investigation?
• Student Health
• Staff health

• First test is sputum – can have a normal CXR

and have active TB
• Because of exposure, request culture and
sensitivities
 Take home messages
• DRTB is a treatable disease
• Early diagnosis and treatment important
• Universal TB infection control measures needed –
highest risk is undiagnosed patients!
• Health workers should be tested if they have TB
symptoms, and sensitivities requested