Infectious Disease Outbreak Response Plan: MDR-TB

Infectious Disease Outbreak Response Plan: MDR-TB

Tuberculosis has continued to pose health danger globally over the years. The emergence of drug-resistant strains has made it difficult to deal with the disease. The disease has been of particular concern in South Africa where it has a major health issue [1]. Gandhi and colleague explain that the disease has increased 5-fold with the emergence of drug-resistant strain. The disease has continued to pose high mortality rate in the country and cause high cost. Klopper and colleagues explain that the health danger due to Multidrug-Resistant Mycobacterium Tuberculosis (MDR-TB) is escalated by the existence of diverse genetic composition of MDR-TB [2]. Moreover, MDR TB has been of concern due to increasing number of infection with the disease [3]. 1.8% new infections and 6.7% of previously treated infections had MDR-TB. Globally, the country is among the areas where MDR TB has high infections.

The increased prevalence of MDR-TB can be due to various factors in the South Africa. For instance, high rates of infection with Human Immunodeficiency Virus (HIV) has made treatment of TB difficult and consequently resulting in its advancement to MDR-TB [2]. Moreover, Klopper and colleagues argue that lack of effective treatment also contributes to the high rates of MDR-TB cases in South Africa. Marais and partners further explain that some of the drug-resistant strains are highly transmissible making the rate of infection even higher [3]. The high rate of TB infection in South Africa can also be accounted by the presence of settings that enhance high transmission rate such as mining areas [4]. Churchyard and Corbett further state that the disease has high latency rate, a stage at which transmission is possible. Consequently, lack of early detection results in the transmission of the disease to more individuals. The mode of transmission also facilitates its infection rate. Control of an outbreak requires effecting measures that based on three factors that are essential for the transmission of a communicable disease. These aspects include factors relating to the population, disease agent and the environment [21].

The case involves an individual infected with MDR-TB, who visits his parents in Brisbane. He does not take the necessary precautions resulting in the infection of several other individuals during his visit. Moreover, he is admitted to a hospital where he does not inform the authority that he is infected with MDR-TB possibly endangering those he interacts with in the hospital and other patients. This paper provides a response plan for this case. The paper considers short and long term responses to combat this outbreak. This response plan can also be used for any other case of MDR-TB or a similar outbreak. The following section considers various factors that ought to be considered and implemented to for effective response to MDR TB outbreak to be mitigated.

Phases of Responses

The response will constitute three phase. The first and the second phases comprise immediate initiatives for the control and regulation of MDR TB. The third phase comprise long-term initiatives for the control of MDR TB. The various phases are as discussed in the following sections.

First Phase

The first phase involves initial evaluation of MDR TB. Evaluation of the MDR TB involves specimen collection and identification of the drug resistance. These two sections are as discussed in the following sections

Specimen Collection, transfer and drug resistance screening

This strategy involves collecting of specimens from all the individuals suspected to have interacted with the patient in question.  This process involves taking adequate and good quality specimens from various individuals prospected to be exposed to the risk of infection due to interaction with the patient [5]. It involves collecting of sputum for three consecutive times at intervals of 8 or 24 hours [7]. Specimen collection is essential in the diagnosis of the disease to the patient and those exposed to the risk of infection through their interaction with him. Failure to collect or poor mode of collection may result in the failure of detection of the infection. Consequently, the patient would not be subjected to treatment programs to prevent further transmission.

In ensuring collection of proper specimen, several factors ought to be considered. For instance, it would be prudent for specimens to be collected with care and transported immediately to the laboratories or research centers. Moreover, storage conditions such as temperature and humidity should be maintained at conducive ranges that will prevent compromising specimens [8]. It is also necessary to ensure that laboratory technicians are trained on the proper process of ensuring that they collect sputum of good and high quality. Sufficient quality of sputa should also be collected from patients and others being screened for the disease.

After collection of specimen, they are required to be transported to the laboratory or research centers. According to Government, specimens collected ought to be transported within 72 hours in cold chains. Proper transport can be facilitated by identification of an appropriate and most effective courier service [8].

The DSO should be informed to collect specimens. DSO should then coordinate the transport means of the specimens to the District Surveillance Office. DSO should then contact and coordinate the transport of the specimen to the NSO. NSO may be required to source laboratory services out of the country.

After collection of specimen, it is essentials to screen them to identify the type of drug resistance. Moreover, it is essential for investigation of possible transmission of drug resistant tuberculosis [33]. Screening can be achieved by performing tuberculin skin tests. It can also be done through symptom checks. Screening plays an essential role in the administration of preventive therapy to infected individuals to help curb the disease from developing into active form.

Second Phase

The second phase of the outbreak control plan involves treatment and other related approaches that would help to identify and locate possible infected individuals. This section covers treatment. Treatment often involves offering education to the patient and relatives. Moreover, this section incorporates the approach of contact tracing that is essential in identifying possible infected individuals who may require undergoing through the treatment process.

Treatment

Individuals diagnosed with MDR-TB should be treated to avoid further adverse effects on them and others [28]. Treatment of MDR-TB patients involves a three-phase process. The first phase .involves a pretreatment screening and initial evaluation. This phase is essential in the identification of patients who belong to groups faced with the greatest risk such as of poor outcomes of the treatment and adverse effects [10]. Implementation of this step requires evaluation of the medical history of patients involved. Moreover, it can be attained through their physical examination. Initial examination and screening of patients is essential for ensuring that patients exposed to greatest risks are monitored closely to avoid any adverse effect and ensure continued progress in their recovery. This phase accounts for the identification of individuals living with HIV, who are at a greater risk.

The second phase involves preparation of patients for treatment and education on the disease [10, 24]. This phase involves providing the necessary information to patients and their families or guardians [26]. Information disseminated involves such as that on the duration of treatment, drugs used, support required and possible side effects of the treatment. This phase is essential as it helps patients to attain better adherence and in mobilizing any support required in the course of the treatment regime.  Maintenance of an effective plan for the provision of education should be maintained [10]. Patient education can be done during their visits during checkups or through the provision of prints such as pamphlets with critical information [24]. For instance, the patient and his relatives should be educated regarding the disease. The information should also include the need for the patients to observe medical directive offered. Such information will help prevent further spreading of the disease due to failure to observe medical directives as was the case with the male patient.

The last phase involves establishment and maintenance a process of flow of the patient into the treatment regime. Treatment regime should be initiated to individuals infected or ill with MDR-TB. Afterward, it is essential to perform a drug susceptibility testing on the patients [10]. The flow of patients is critical in ensuring a progressive recovery of the patient and in avoiding any complication associated with the disease. This phase can be implemented by informing health system about where and how treatment is offered to patients. Laboratories should also ensure timely return of results on any testing performed on the patients.

The flow of patients involves the establishment of monitoring of the registry of all cases of MDR-TB infections. Moreover, an establishment of protocols is necessary to determine admission or outpatient treatment. Patients should also be guided on where and when to attend for regular follow-ups. The three phases are critical in diagnosis and promotion of effective treatment regime for MDR-TB patients. Moreover, it would allow close monitoring of cases that are subject to greater risks such as in the case of individuals infected with HIV and other special medical cases.

Contact Tracing

This approach is also called partner notification [14]. Armbruster and Brandeau explain that this approach is essential in the control of TB as well as other infectious diseases. Eames and Keeling add that the method should be followed by treatment and/ isolation [15]. Contact tracing is essential in preventing curbing rate of spread of the disease [18]. This method requires an understanding of the transmission pathways, the timespan between contact and detection and the extent of disease on the MDR TB patient [30]. MDR TB is an airborne disease and can also be transmitted by contact with body fluids of an infected patient. Consequently, there is need for establishing all the interactions the patient had with other people by enquiring areas he visited such as homes, the bus used to travel and people he .contacted.

According to the Department of Health of South Africa, contact tracing is essential in identifying individuals exposed to an infection [18].  Potential contacts involve such as symptom screening, investigation, assessment of risk factors and the environment. Symptom screening involves screening potential contacts for MDR-TB symptoms [30]. The investigation involves the collection of sputum in cases when potential contacts are coughing for testing by an expert. Assessment of risk factor involves the determination of any condition that endangers infected potential contact. Environmental assessment involves the determination of methods that can be implemented to curb spreading through the environment.

Third Phase

The third phase of the outbreak control involves all long-term initiatives for MDR outbreak control. These initiatives are concerned with the monitoring of the disease to prevent it from being passed to the next generation. Moreover, long-term initiatives help in curbing any possible occurrence of another outbreak. The following initiatives would be essential for long-term control of MDR TB outbreak.

Health Care Preparedness

Health preparedness involves ensuring focused efforts to control and prevent any further occurrence of MDR-TB. Achieving health preparedness involves the establishment of various factors. For instance, Frieden and Khabbaz explain that health preparedness can be by such as identification and validation of new tools for the diagnosis, prevention and control of MDR-TB [16]. Moreover, facilitating the use of proven methods and up to date systems in the control and treatment of the disease and conditions of special interest associated with it such as HIV. Facilitating proper laboratory capacity would also be essential in curbing the outbreak [29].

Healthcare preparedness also involves provision of up to date information regarding MDR-TB to the staff.  Dissemination of information to the staff can be through provision of refresher training on awareness on MDR-TB. Moreover, training on identification of symptoms and treatment of MDR-TB is essential in preventing the occurrence of further drug resistant strains [12]. Establishment and maintenance of emergency contacts are also required in ensuring the effectiveness of healthcare preparedness.

Research and investigation of the outbreak

This is both an immediate and long-term response strategy [22, 23]. It involves investigation of the outbreak. This strategy aims at confirming and establishing the extent of the outbreak [21, 26]. It would also help in identifying the cause of the drug resistance and development of effective tools of curbing the spread of the disease [27].  It is concerned with epidemiological research associated with the outbreak such as determination of the resistance of MDR-TB. Moreover, it aims at developing an effective medication, vaccines and promote their supply and availability to counter the outbreak and prevent future occurrences [22, 27, 29].

Outbreak research also involves screening for drug resistance [25]. Screening for drug resistance in the MDR-TB patients would be essential in ensuring that the most effective treatment regime is used and in minimizing its transmission [29]. Moreover, resistance screening is essential in preventing future occurrence of drug resistance. Formation of an outbreak response committee that coordinate all research, and investigation-oriented activities effect this strategy [21].

Surveillance

Surveillance involves timely detection of outbreaks and recording any cases of MDR-TB [28]. Surveillance can be achieved in two ways. One involves reporting by medical staff as well as through use of field researchers [32]. In both cases an effective channel of reporting ought to be formulated for reporting to be done in an efficient way. Considering the circumstances of the case of MDR TB outbreak, it involves reporting the all case involved with MDR TB disease and assessing unusual patterns of the activity of the disease [11, 21]. An effective surveillance system on ways depends on an effective communication channel. It requires identification of infectious disease, in this case, MDR-TB, submission of the report to the regional and national centers.

Surveillance is concerned with keeping of data and ensuring control of MDR-TB cases [27]. Surveillance is essential in the identification of the number of MDR-TB infection cases [17]. Various mechanisms allow for achievement of surveillance.  For instance, an effective district surveillance system can be formulated such by the DSO. Moreover, clinicians and laboratory technicians can provide useful data in determining the dynamics of control of MDR-TB [21].

 

Enhancement of Laboratories for MDR-TB diagnosis

Laboratories play an essential role in patient care. Equipping laboratories with the correct and up to date techniques necessary for MDR-TB diagnosis is essential [29]. Such a motive will enable the provision of services that assure quality treatment. Drug-resistant strains of TB result due to ineffective or low-quality treatment of TB patients. Moreover, development of new laboratory techniques and strategies would be indispensable in ensuring quality and effective TB and its drug-resistant strains treatment to prevent future drug resistance [25, 31]. Consequently, ensuring quality assured services through equipping of laboratories will be critical in preventing future occurrence of MDR-TB. According to World Health Organization, it would be prudent to equip laboratories countrywide to enable them to perform Drug Resistant Testing  (DST) for TB patients [9]. Moreover, facilitating good communication between the laboratories is essential in MDR-TB prevention and control [31].

Other initiatives necessary for MDR TB control

Containment

Containment refers to measures that are implemented to prevent spreading of a communicable disease [21]. Beebe and Myers explain that after the occurrence of an outbreak, it is essential for control measures to shift from surveillance to containment [19]. There are various containment measures. These include isolation, quarantine, restrictions, vaccines and medicines [19, 20].

Isolation involves moving infected and ill patients to an area or facility separate from that of the population [19]. Isolation is essential to prevent further social contacts that result to spreading the disease between people. It also helps to protect the vulnerable non-infected individuals in a hospital. Identification of a facility or laboratory that will deal with MDR-TB infections and patients allow for isolation.  Such will help prevent further infection of the patient and his relatives and other individual infected individuals identified through contact tracing.

Quarantine is a containment strategy that involves a period of decontamination. It is essential for allowing protecting individuals who have been infected but not yet ill with a disease. Quarantine is essential for allowing a period of decontamination of the infectious agent [19]. An effective implementation of the quarantine would involve use of a community arrest. Such is effective due to the vast social relations established by the patient and his friends.  Restrictions are effective in monitoring the social contact of patients as a way of preventing further spreading of the disease. Healthcare specialist can develop effective vaccines and medicines that will be used to curb the spreading of MDR-TB.

MDR-TB is an infectious disease. Therefore, it can be transmitted easily through social interactions either directly or indirectly or through airborne particles floating in the air [13]. Daily activities are hence essential in promoting transmission of MDR-TB [12]. Limiting social interactions with individuals suspected to have interacted with the patients. Such a method would be essential in preventing further transmissions of the disease as these individuals have not yet been treated.

Limiting of social interactions can be attained through diverse ways. For instance, preventing any social gathering can help in preventing further transmission of MDR-TB [12]. Moreover, educating the public through such as media ,would also be essential in sensitizing the public to avoid crowded and high risk areas such as mines.

Effective communication

Effective communication channel has to be established to achieve efficient and effective disease control methods [6]. Communication is both an immediate and long-term response. Successful management of an outbreak requires accurate and timely communication between the various stakeholders. Communication is essential in matters of surveillance, resource allocation and assistance requests and delivery. In the case of the MDR TB outbreak, communication it would be prudent to ensure effective dissemination of information regarding the disease to the relevant research bodies, public and other governments. Consequently, surveillance and prevention would be facilitated. Risk communication to the public helps them to avoid areas that may expose them to the danger of infection. For instance, communication played a critical role in the spreading of SARS. Therefore, delay in communication may be detrimental in the effectiveness of any efforts of reducing infection rate of MDR-TB.

Effective communication channels have been shown to be crucial in infectious disease management as it allows for achievement of unified command towards common goals [6]. Koenig and Schultz argue that the media plays a pivotal role in the communication. Establishment of information centers would be essential. The information center allows for the coordination of information for dissemination to the public as well as other stakeholders. Considering the case of the MDR TB outbreak, an effective communication channel allowed for a timely diagnosis of the patient with the disease. Moreover, means of communication should be extended to the District Surveillance Officer (DSO) and the National Surveillance Office (NSO) to ensure an efficient and effective flow of information. Communication is also essential in public education about MDR-TB [28].

National Funding

Progress in control and prevention of MDR-TB cases requiresforts are to be made in achieving control and prevent further occurrences of MDR TB cases, the national government has to provide the necessary resources to facilitate the control programs [9]. Lack of funds facilitates MDR-TB spreading [31]. For instance, if laboratories have to be equipped with up to date diagnostic tools, they must be having the necessary finances to achieve this. Moreover, there is need to promote research on the disease. Research on MDR-TB is essential in facilitating the development of new and rapid techniques for diagnosis. National funding would also be essential in ensuring that the correct protective personal equipment are available to the healthcare workers.

National funding can be achieved through the allocation of finances aimed at promoting research and preparedness in infectious diseases in the country. Finances would be used to fund researches aimed at improving treatment, developing more effective diagnostic techniques. National funding can be achieved .through budgeting for MDR-TB healthcare services and any associated medical intervention [9]. Moreover, the government can resort to funding by international resources and nongovernmental organizations.

Policy Formulation

The government and local governments should enact policies advocating for the prevention, detection and control of MDR-TB [16]. Formulation and implementation of policies that are sound and based on evidence are indispensable in curbing MDR-TB infection. Such policies are critical in ensuring that MDR-TB prevention measures are developed and delivered to relevant centers [31]. Moreover, sound policies will promote the elimination of disparities in the health sector considering preparedness and ability to diagnose and treat MDR-TB. Such policies are also pertinent in ensuring that the health status of those in groups with higher risks such as HIV infection. Health policies are also pertinent in ensuring that there is mobilization of partnership at both national and .global level.

The presence of scientific data is essential in the formulation of cost-effective and evidence-based policies on the prevention and control of MDR-TB [16]. For instance, policies regarding MDR TB spreading, such as quarantine, are essential in control of transmission. Policies are also pertinent as they influence implementation of MDR-TB preventive measures into healthcare centers.

 

 

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