结核病之感染管制政策优质PPT课件.ppt

按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,結核病之感染管制政策,如何避免結核病在醫院內散播,行政上之作為,醫療硬體環境之作為,執行醫療業務之作為（個人防護）,行政上的作為,Organizational Policies and Procedures,Examples,TST screening programs,（篩出感染者）,Symptom screening to detect patients who have TB disease,（篩出有病者,，例如咳嗽監測,）,Isolate patients with infectious TB disease from other patients,（隔離傳染性結核病患）,Conduct diagnostic evaluation of such patients,Treat patients who likely have TB disease,（治療）,TB suspects,contacts,risk groups,執行醫療業務及行政上之作為,完善的院內感染管制計畫,醫療主管支持院內感染管制計畫,醫療人員及病患之教育,各項結核病管控措施必須有良好的搭配,篩出感染者,:,Tuberculin skin test,Tuberculin preparation,Old tuberculin(OT),1908:Robert Koch produced in Germany filtered heat-sterilized TB bacilli,Purified protein derivative(PPD),1939:Florence Siebert in Philadelphia precipitate prepared from OT reference standard PPD-S(Sieberts Lot 49608)3 dosage strength:1 TU,5 TU,250 TU,Inject intradermally 0.1 ml,of 5TU PPD tuberculin,Produce wheal 6 mm to 10,mm in diameter,Represent DTH,Mantoux test,Reading of Mantoux test,Read reaction 48-72 hours,after injection,Measure only induration,Record reaction in mm,Distribution of PPD:Alaskans,Distribution of PPD:white Navy recruits,Distribution of PPD:New York,Classifying the tuberculin reaction,5 mm is classified as positive in,HIV-positive persons,Recent contacts of TB case,Persons with fibrotic changes on CXR consistent with old healed TB,Patients with organ transplants and other immunosuppressed patients,Classifying the tuberculin reaction,10,mm is classified as positive in,Recent arrivals from high-prevalence countries,Injection drug users,Residents and employees of high-risk settings,Mycobacteriology laboratory personnel,Persons with clinical conditions that place them at high risk,Children,15 mm is classified as positive in,Persons with no known risk factors for TB,Occupational exposure to TB,Cutoff value depend on,Risk factors for TB,Prevalence of TB in the facility,Factors that may affect the TST,False positive,Nontuberculous mycobacteriaBCG vaccination,False negative,AnergyRecent TB infectionVery young age(6 months old)Live-virus vaccination Overwhelming TB disease,Boosting,Some people with LTBI may have negative skin test reaction when tested years after infection,Initial skin test may stimulate(boost)ability to react to tuberculin,Positive reactions to subsequent tests may be misinterpreted as a new infection,Two-Step Testing,Use two-step testing for initial skin testing of adults who will be retested within 1-3 weeks,If first test(+),consider the person infected,If first test(-),give second test 1-3 weeks later,If second test(+),consider person infected,If second test(-),consider person uninfected,篩出有病者,:,咳嗽監測全院員工胸部,X,光檢查,醫院之咳嗽偵測機制,Cough officer,之設立由病房護理長擔任每日回報咳嗽已經五天的病患以警語提醒醫師要為病患作,CXR,、送痰檢、作結核病防護,(,五歲以下兒科病患除外,),全院員工每年胸部,X,光檢查,VS,高危險員工每年胸部,X,光檢查,Identify Suspected or Confirmed TB Cases,Know the current case definition and criteria for the classification of suspected and confirmed TB cases,Gather information to verify cases reported routinely to the TB program,Confirmed Case,Isolation of M.tb complex on culture,Demonstration of M.tb by nucleic acid amplification test,Demonstration of AFB when culture cannot be obtained,ie post mortem setting,Clinical Case,Positive tuberculin skin test,+,Signs or symptoms compatible with TB such as fever,night sweats,cough,weight loss,hemoptysis or an abnormal CXR,+,Improvement shown with treatment on anti-TB meds,+,Completed medical evaluation,TB Classification System,Class,Type,Description,0,No exposure to TB,Not infected,No history of exposure,negative reaction to tuberculin skin test,1,Exposure to TB,No evidence of infection,History of exposure,negative reaction to a tuberculin skin test given at least 10 weeks after exposure,2,TB infection,No TB disease,Positive reaction to the tuberculin skin test,negative smears and cultures(if done),no clinical or x-ray evidence of current TB disease,3,Current TB disease,Positive culture for,M.tuberculosis,(if done),or,A positive reaction to the tuberculin skin test and clinical or x-ray evidence of current TB disease.,4,Previous TB Disease(not current),Medical history of TB disease,or,Abnormal but stable x-ray findings for a person who has a positive reaction to the tuberculin skin test,negative smears and cultures(if done),and no clinical or x-ray evidence of current disease,5,TB suspected,Signs and symptoms of TB disease,but evaluation is not complete,隔離傳染性結核病患,:,誰有傳染性？,How is tuberculosis transmitted,？,Respiratory maneuvers&elaboration of particles,Speaking:0-210 particles,Coughing:0-3,500 particles,Sneezing:4,500-1,000,000 particles,Duguid J.Edinburgh Med J 1945;52:385,Droplet-nucleus transmission,Sneezing droplet:10,m,m,Droplet nucleus:1-10,m,msettle at a rate of 0.2 mm/sec8,m,m size 10%reach alveoli2-3,m,m size 40%reach alveoli,Baltimore Veterans Administration Hospital Pilot Ward Experience,Riley R.and Wells W.1956-1961,Materials and Methods,第一階段：,在六間負壓,TB,病房的出風口外放置一動物養殖籠，裡面飼養,150-240,隻天竺鼠實驗用天竺鼠均先經,30,天檢疫且,TST(-),實驗後天竺鼠均接受系列之,TST,，,TST,若轉陽性則必須接受解剖,第二階段：,負壓房間的出風口外分成兩股，一股接受,UV,照射，另一股則無。感染的天竺鼠並依抗藥性模式而判定被何人傳染。,結 果,(,一,),天竺鼠平均感染時間為,10,日,TB,的感染劑量為,1 in 11,000-12,500 ft,3,of air,14/63,隻感染的天竺鼠是被一,TB laryngitis,的人所傳染，此人之住院日數只佔總人日數的,1%,130,住院病人中，其中,8,人傳給了,46%,的天竺鼠,未治療病患的傳染力是治療病患的,10-50,倍,非抗藥性結核的傳染力是抗藥性結核的,4-8,倍,結 果,(,二,),絕大多數新感染結核病的天竺鼠解剖時，肺部均只有一個,tubercle,，表示都只感染到一隻結核菌,也有些新感染結核病的天竺鼠解剖時，肺部並沒有任何發炎反應,經過,UV,處理的空氣不會感染任何天竺鼠,Epidemic in Arkansas industrial school,在阿肯色工業學校曾有二位學生有開放性肺結核，對其接觸者做調查發現與患者同一唱詩班的學員有最高的被傳染率,結論：,rapidly vibrating vocal cords,最容易產生,droplet nuclei,NEJM 1965;272:714-7,U.S.Navy,Richard E.Byrd,study,1966,年,9,月美國軍艦,Richard E.Byrd,號出現了第一例開放性肺結核案例，病患已咳了,6,個月，,CXR,開了一個,5,公分的洞,308,位船員接受了完整的流行病學調查,Arch Environ Health 1968;16:4-6,Arch Environ Health 1968;16:26-35,結 果,在,308,位船員中,45%(139,人,)TST,轉為陽性,2.2%(7,人,),胸部,X,光發現肺結核病變,Compartment 1(index case,所睡的地方,),全部,66,人，,6,人發病、,47,人陽轉共,80%(6+47/66),的人被傳染,Compartment 2(,與,C1,同一空調出口,),共,53%(43/81),陽轉，多睡在出風口附近,Transmission rate,according to index cases sputum smear status,Study Index case sputum status Sm+/Cu+Sm-/Cu+,England 1954 65%27%,Canada 1954 45%26%,Netherland 1967-9 5%5%,Am Rev Tuberc 1954;69:724-32,Am Rev Respir Dis 1964;90:707-20,Bull Int Un Ag Tuberc 1975;50:107-21,Defined as TST return to positive,Transmission rate,according to index cases sputum smear status&type of contact,Study Index case sputum status Sm+/Cu+Sm-/Cu+,Household 20.2%1.1%,Causal 3.7%0.2%,Am Rev Respir Dis 1964;90:707-20,Bull Int Un Ag Tuberc 1975;50:107-21,Defined as TST return to positive,Develop active TB according to index cases sputum smear status,Study Index case sputum status Sm+/Cu+Sm-/Cu+,Close,age 0-14 y 38%18%age 15-29 y 11%1%,Causal,age 0-14 y 24%18%age 15-29 y 6%3%,Am Rev Respir Dis 1964;90:707-20,Bull Int Un Ag Tuberc 1975;50:107-21,Transmission from nonpulmonary source,Cutaneous TB,Soft tissue TB,案 例,67,歲的男性,1985,年,1,月,8,日因,left hip pain,住院。,1,月,12,日接受外科手術，證實為,TB,並開始吃藥，但每天都必須以高壓沖洗傷口。,4/5,為病患開刀的人後來得到,TB,6/20,MICU,的,staff,後來得到,TB,28/33,病房的,staff,後來得到,TB,Infectiousness vs.Non-infectiousness of TB,Factors Associated with,Infectiousness,Factors Associated with Noninfectiousness,TB of the lungs or larynx,Most extrapulmonary TB,Cavity in the lung,No cavity in the lung,Cough or cough-inducing procedures,No cough or cough-inducing procedures,Patient not covering mouth when coughing,Patient covering mouth when coughing,Acid-fast bacilli on sputum smear,No acid-fast bacilli on sputum smear,Not receiving adequate treatment,Receiving adequate treatment(dose and time),肺結核病患何時具有傳染力,？,Persons with active TB disease of the lungs and throat are considered infectious if they:,Are coughing,Are undergoing cough-inducing or aerosol-generating procedures,Have sputum smears positive for acid-fast bacilli and are not receiving therapy,Have just started TB therapy,Have poor clinical response to therapy,肺結核的傳染力與何種因素有關,？,The infectiousness is directly related to the:,number of tubercle bacilli the TB patient releases into the air,clinical characteristics of the patient,s TB disease,patient,s response to therapy,Infectiousness declines rapidly after adequate treatment is started,Patients with TB disease are considered non-infectious if they meet all of the following criteria:,They are on adequate therapy for at least 2 weeks,They have had a significant positive clinical response to therapy,They have had 3 consecutive negative specimen smear results,何種肺結核病患不具傳染力,？,傳染性肺結核病患何種狀況下可判定不具傳染力？,Must meet all of the following criteria:,Receiving appropriate treatment,Dose and time,depending on regimen chosen,Sensitivity results show treatment is adequate,Shows improved symptoms and/or chest x-ray,Has three negative sputum smears,Collected on different days,年輕人肺結核的傳染力,Less likely than adults and adolescents to be infectious,Thought to have smaller bacterial load,Not effective coughers,Less likely to produce sputum or expel bacteria into the air,治療疑似,、確認之,結核病患,結核病的治療有那些新的訊息？,(1),治療成功與否的關鍵在醫師的處方，不能全把責任推給病人,病患的治療強調,DOTS,對於治療的模式出現了很多新的證據，對於評斷何種治療方法最有效？相當有幫助,藥物治療兩個月後痰培養的結果成為有效預測病患是否會再發的重要依據,結核病的治療有那些新的訊息？,(2),即使是藥物敏感性之結核病人，若有造成再發之因子存在，應接受,e,xtend treatment,正確定位抗結核新藥如,rifabutin,rifapentine,及,fluoroquinolones,的角色,對於正確給藥、合併用藥、副作用之處置、及藥物相互作用均有了較新的準則,結核病的治療有那些新的訊息？,(3),是否完治決定於是否在一定期間內服完所有的藥物,特殊治療狀況之準則制定,:,HIV/AIDS,Children,Extrapulmonary TB,Culture-negative TB,Pregnancy and breast feeding,Hepatic and renal disease,結核病感控之硬體設施,Reduce/dilute droplet nuclei containing,M.tuberculosis,in the air,Reconfigure waiting areas,exam rooms to maximize controlled natural ventilation,Propeller and exhaust fans,Engineering Controls,Examples,Ventilation,HEPA filters,Ultraviolet germicidal irradiation,結核病之個人防護,CDC,界定之結核病高危險傳染場所,Health care settings,Correctional institutions,Homeless shelters,Long-term care facilities for the elderly,Drug treatment centers,高傳染風險之行為,Characterized by potential to generate airborne secretions,Aerosolized medication treatment,Bronchoscopy,Sputum induction,Endotracheal intubation and suctioning,Autopsies,何時該做結核病個人防護？,When to Use:,In TB isolation rooms,In rooms where cough-inducing procedures are done,In ambulances and other vehicles transporting infectious TB patients,In homes of infectious TB patients,結核病個人防護設備之品管,Where respirators are required:-,Employers must provide and make sure employees use NIOSH-approved high-efficiency particulate respirators-Employers must have a respiratory protection program in accordance with OSHA requirements-Respirators must be“fit-tested”annually with employee-Respirators must be“fit-checked”by employee prior to each use,Locate and screen close contacts of active case(s),Close contacts include:,Spouse/significant others,Individuals sharing households,berthing compartments,and workspaces,Screen close contacts with TST immediately and in three months,Evaluate converters for active TB,接觸者調查與追蹤,人口密集機構之結核病感染管制政策,Includes facilities such as:,Nursing homes,correctional facilities,homeless shelters,and drug treatment centers,Goal,Detect TB disease early,Arrange for isolation of persons with TB disease,Treat persons suspected of TB disease,Identify unrecognized transmission,Identify potentially undetected cases,傳染性結核病患居家注意事項,Instruct symptomatic patients to cover mouth and nose when coughing/sneezing,Disposal of tissues,etc.,Isolation instructions,No visitors,work school,etc.,Wear mask when leaving home,Open windows and blinds for ventilation and sunlight,公衛單位在結核病院感上所扮演的角色,Work closely with health care facilities,Conduct contact investigations,Coordinate follow-up care,Assist other facilities in screening,surveillance,outbreak investigations,and other aspects of TB infection control,公衛訪視員在家訪時該注意的事項,Wear personal respirator when visiting the home of an infectious TB patient or when transporting an infectious TB patient in a vehicle,Collect sputum,if necessary,in a well-ventilated area,away from other household members,Participate in a TB screening program,懇 請 賜 教,