ICT Newsletter 4th Edition JULY 2019-1

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We the Editorial team of e-newsletter on ICT and IFCAI with the support of everyone present the current news letter Volume 1 | Issue 4 | July 2019 Circulation: Quarterly | All-India | e-Copy format CHIEF EDITOR Dr. Ranga Reddy EDITOR Dr. T V Rao EDITOR & CONCEPT Dr. Dhruv Mamtora TEAM MEMBER Sister Solbymol SPECIAL EDITION ON SPECIAL EDITION ON MYCOBACTERIOLOGY WE CONSIDER MOST IMPORTANT WORLD IN OUR LIVES IS WE WE ALL MADE IT WISHING MORE COOPERATION FROM YOU TO REACH GREATER HEIGHTS TO SUPPORT EDUCATE MANY HEALTH CARE PROFESSIONALS DOCTORS NURSES AND THE SOCIETY EDITORIAL TEAM OF ICT, AUTHORS AND ALL THE MEMBERS OF ICT

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 1 Volume 1 | Issue 4 | July 2019 Circulation: Quarterly | All-India | e-Copy format CHIEF EDITOR Dr. Ranga Reddy EDITOR Dr. T V Rao EDITOR CONCEPT Dr. Dhruv Mamtora TEAM MEMBER Sister Solbymol SPECIAL EDITION ON MYCOBACTERIOLOGY new sletter INFECTION CONTROL TRENDS

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 2 Respected Infecton Preventonist Hope earlier three editons of ICT had been some help to your IPC practce. Editorial team and eminent authors have put in their best eforts to bring out yet another thematc editon informaton and practcal advice to deal with the ancient infectous disease TB. WHO has called member natons to aggressively implement “END TB” program with an objectve to end Global TB epidemic by 2030. Prime Minister Modi has gone one step ahead and pledged at “Global Stop TB Summit” to eradicate TB in India by 2025 TB is the top infectous killer worldwide TB is also the leading cause of deaths among people with HIV a major cause of antmicrobial resistance related death. The ancient disease has killed almost 200 crore people in last 200 years. The emergence of Drug Resistant TB is becoming a major threat to global health security causing major economic costs to individuals and natons. As per WHO: TB treatment saved 54 crores lives globally between 2000 and 2017. Globally the treatment success rate for people newly diagnosed with TB was 82 in 2016. But one major problem for India is poor reportng of both cases and their treatment. “Economist Intelligence” has estmated India is losing USD 73 billion 730 crores in PPP terms due to deaths and work absence from TB which will have sizeable impact on GDP . WHO GOI initatves and proclamatons are laudable. But to make them real several steps to be taken. Early diagnosis of tuberculosis Treatment of all people with tuberculosis Preventve treatment of persons at high risk and vaccinaton against tuberculosis Politcal commitment with adequate resources for tuberculosis care and preventon Engagement of communites civil society organizatons and public and private care providers quality and ratonal use of medicines and infecton control are success mantra for WHO End TB program. Ending the global TB epidemic is feasible with dramatc decline in TB deaths and cases and eliminaton of economic and social burden of TB. Failure to do so will carry serious individual and global public health consequences. We as Infecton Preventonists have major role to play in “END TB” strategy. Hope you will fnd this editon too valuable tool to deal with ever increasing infectous disease burden. With this issue we complete one Golden Year. We thank all stakeholders for their part in this stupendous success. Sincere appreciaton goes to Dr Dhruv who has taken huge burden on himself to bring all four editons in tme. To further improve the standards and stay current we shall make changes to our content delivery and design. Our editorial team also be reconfgured to get new perspectves. Your suggestons proposals and ideas are most welcome. Regards Editorial Team Infecton Control Trends E-Newsleter. FOREWORD

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 3 EDITORIAL TEAM Dr. T.V. Rao is a former Professor of Microbiology from the Andhra Medical College Visakhapatnam Andhra Pradesh India. His experiences in Zambia showed him how people lose their lives to infectons and how the lack of resources was a great challenge that practcally forced patents to be treated blindly. His associaton with scientfc microbiologists at ICMR NICED Calcuta taught him how all that we do is not necessarily right and why it is essental to involve oneself in diagnostc laboratory conditons and even bedside medicine. His observaton includes the seamless working of Darwin’s Theory in relaton to microbes and how they pose real challenges. He also believes it is tme to rethink one’s role as Medical and Clinical Microbiologists especially during a tme where it is necessary to understand that Antbiotcs are not magic bullets but sof weapons to destroy the progress of medicine. Dr. Rao has created content that helps many in developing countries with a global following of 5 million. Dr. Ranga Reddy Burri is Health policy enthusiast focused on public health awareness educaton and training. Dr. Reddy is Physician Public Health specialist Social Entrepreneur with interest in business vertcals of high social impact. He graduated from Minsk Government Medical Insttute Belarus with MD Physician degree subsequently he did his PG Diploma in management from Pondicherry University and Advanced Management from IESE Barcelona Spain with specializaton in Strategy Business Development. Dr. Reddy is the founder trustee of Infecton Control Academy of India IFCAI. The organizaton is a result of his leadership skills knowledge and experience gained from working in both domestc and internatonal MNCs. Yet the Academy’s most valuable strength lies in the strong sense of empathy for humans and their health imparted by Dr. Reddy and his colleague trustees. His current responsibility includes leading Sanmed Healthcare a startup with world class manufacturing capabilites in external preparatons. He supports several non-proft organizatons in the capacity of advisor including Neelam Rajasekhar Reddy Research Center for Social Progress e-learning center of Hyderabad Central University Indian Insttute of Public Health. His fair for entrepreneurship has led him to mentor through impartng knowledge to NGO’s startups micro-small enterprises. Dr. Dhruv Mamtora is a clinical microbiologist and infecton control ofcer at S. L. Raheja Hospital A Forts associate Mahim Mumbai since 2015. Before joining in private sector he has worked with government sector both in Maharashtra state as assistant professor at RCSM GMC Kolhapur and GMC Latur as assistant professor and AIIMS Jodhpur as senior resident. He has passed out MBBS from L. T. M. Medical College Sion Hospital and done MD in microbiology from Government medical college Miraj. He has done his healthcare administraton EPGDHA from TISS Mumbai. He is member of multple professional bodies like IAMM IATP IMA HIS-MF insttutonal society of clinical microbiologists SCM and ISID internatonal society of infectous diseases. He has number of publicatons in peer reviewed journals both natonal as well as internatonal he is also faculty and speaker for various natonal and internatonal conferences. He has also organized many training actvites and a natonal level conferences. He is also a media subject expert. He has also guided as well as multple projects related to healthcare which is in feld of infecton control and clinical microbiology. He has been awarded multple tmes in his organizaton and at natonal level. His topics of interest are implementng and improving quality in healthcare hospital and laboratory accreditaton clinical microbiology infecton control antmicrobial stewardship improving medical educaton to a minimum basic standard which is suitable for current healthcare scenario in country and on internatonal level. Sister Solbymol P S is a PICU Nurse with 19 years of experience. She has worked as In-charge PICU Rainbow Children’s Hospital Hyderabad and Vikrampuri senior staf at Ernakulam Medical Centre Kochi. She is now working as Coordinator Quality and Infecton Control Nurse at Kinder Women’s Hospital and Fertlity Centre Cherthala Alappuzha. Dr. Ranga Reddy President IFCAI and Chief Editor “Infecton Control Trends” Email: dr.rangareddyifcai.in Dr. Dhruv Mamtora Consultant Microbiologist and Infecton Control Ofcer Email: dhruv_mamtorayahoo.com Dr. T. V. Rao Former Professor of Microbiology Email: doctortvraogmail.com Solbymol P S GNM ICCP Email: solbypsgmail.com

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 4 INDEX Guest Editorial - Dr. Chugh “End TB Strategy” : Indian Perspectve 06 Guest Editorial - Dr. Ameeta Joshi Tuberculosis Laboratory in a Resource limited setng 08 Guest Editorial - Dr. Vijaya Lakshmi Nag Non Tuberculous Mycobacteria Ntm: Advances In Diagnosis 10 Guest Editorial - Dr. Rakesh P S TB Infecton Preventon and Control: 2019 Update 15 The Enigma Of Tuberculosis Contnues Story of Success Failures and Hope - Dr. T. V. Rao 17 Understanding Airborne Transmission From Infecton Preventonists’ View - Dr. Dhruv Mamtora 19 Role Of An Infecton Control Nurse In Tuberculosis - Dr. Ankit Gupta Ms Prerna Rani Mr. Prijil Innocent 21 The Need For Psychosocial Interventon In Care For Chronic Illness - Ms. Pragya Lodha 24 Iron Mycobacterium Tuberculosis – Is There A Hope - Dr. Sourav Mait 27 Extrapulmonary Tuberculosis - Diagnostc Challenges - Dr. Sukanya Rengaswamy 28 Paediatric Tb-Trying To Understand From Ic Perspectve - Dr. H Srinivasa 31 Recent Updates In The Management Of Drug Resistant Tuberculosis - Dr. Aruna Shanmuganathan 33

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 5 INDEX Comparison Of CD4 Counts In HIV-TB Co-Infecton Before And Afer Art - Dr Ravikant Dr Sunitha.B.R. Prof Dr. G. Vishwanath 35 Tuberculosis Preventon In Healthcare Setngs - Dr. Nazia Khan 39 Community Infecton Control in The Context of Injecton - Dr. Joven Jebio Ongole Dr. Sharon Fynn Dr. Gregory Jagwer 44 Infecton Preventon In Community Health Facilites In The Northwest And Southwest Regions - Amungwa Athanasius Nche 50 Antbiotc Cycling and Antbiotc Mixing: Is it Time for Requiem - Dr. Abhijit Chaudhury 56 Objectves Of E -Newsleter On Infecton Control Trends 59 Rules and Regulatons 60

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 6 Dr. Chugh Natonal Professor Emeritus of Natonal Academy of Medical Sciences India. Past Prof Medical College Rohtak The World Health Organizaton WHO has launched an ambitous program of “End TB” in collaboraton with various internatonal and natonal organizatons. The targets are: 1. An incidence rate of less than 10 cases per 100000 populatons per year. 2. Reduce TB deaths by 95. 3. To cut new cases of TB by 95 in 2015-35. To achieve this goal we need to know: Our present burden of disease and measures to be taken to achieve the goal. Present status of TB Burden Worldwide 9.6 million new TB cases and 1.5 million deaths were seen during 2014. About 3.3 new cases and 20 retreatment cases were MDR-TB. The treatment success rate of MDR cases is 50 and only 2.2 for XDR cases. The annual burden of TB in India is 2.2 million. However since 80 of cases are treated in private sector this estmate is under-reported. The actual number of cases is 2-3 tmes higher. The mathematcal modeling of transmission in India shows an annual incidence of smear positve cases 89.8 per 100000 populaton. Urban TB cases infect more due to high populaton density and rural cases remain infectous for a longer period due to inappropriate treatment and poor compliance. The Government of India in its Natonal Strategic Plan has set an ambitous goal to achieve this target by the year 2025 fve year ahead of global deadline. With the current rate of annual decline of TB cases it seems to be an “almost impossible” task to achieve the goal by 2025. If we wish to achieve it the decline rate should be more than 10-15 per year the present rate of decline being less than 2. There is a need to provide beter diagnostcs and treatment support improved TB surveillance and healthcare system nutriton higher fnancial allocaton and health educaton for airborne precautons. Early detecton and treatment of patents and their follow-up with full compliance is the frst step to it. Global Fund executve director on 18/02/2019 stated: “India’s goal of ending TB by 2025 will be a tough task”. GUEST EDITORIALS “END TB STRATEGY”: INDIAN PERSPECTIVE

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 7 Other Issues of Human Tuberculosis in India are: 1. Zoonotc tuberculosis in humans caused by bovine. Mycobacterium tuberculosis bMTB its epidemiology and appropriate treatment is imprecise and unresolved issue. The potental zoonosis reverse zoonosis and mixed infectons in India need further studies. 2. Latent TB in India is seen in 40 populaton and 50 of healthcare personnel. Around 10 of these individuals develop full-fedged TB at some tme of their life. There is no current policy of diagnosis and treatment of cases of latent TB in India. 3. The risk of tuberculosis in patents with cancer is signifcantly high in India and globally. 4. Molecular techniques show mycobacterial DNA and RNA in 48 of sarcoid biopsy tssues in India. 3 5. Burden of nosocomial tuberculosis in healthcare personnel in India is signifcant due to lack of efectve infecton control policies and their implementaton. 45 6. The global burden of pediatric TB is 1.3 million new cases with 0.5 million deaths every year. Microbio- logical confrmaton is absent in three-fourth of the cases due to paucibacillary disease and impropriate diagnostcs. 6 7. Non-tuberculosis mycobacterium NTM prevalence in a TB endemic country India is high but ofen ignored. 1 8. Mycobacterial disease both MTB and NTM in patents with rheumatoid arthrits is 4-fold higher. There is a need to monitor such patents. 7 9. Tuberculosis and chronic obstructve pulmonary disease COPD have a statstcally signifcant associaton. With poor air quality high COPD in a TB endemic country Inida there is a need for beter vigilance. India needs to take a mult-pronged approach to reach its goal of “End TB”. References 1. Chugh TD. Human tuberculosis in Inida: Some neglected issues. Curr Med Res Prac 2017 8:64-66 2. Singh N Madan k Aggarwal AN et al. Pleuropulmonary tuberculosis following chemotherapy for lung cancer at a tertary care centre in India Intl J Curr Microbial 2013 47: 177-180. 3. Gupta D Agarwal R Agarwal AN Jindal SK. Molecular evidence for the role of mycobacterium in sarcoidosis : a meta- analysis. Eur Resp J 2007 30: 508-16. 4. Chugh TD. Burden of nosocomial tuberculosis in healthcare workers in India. Curr Med Res Prac 2017 7: 18-19. 5. Basavaraj A Chandanwale A Patl A et al. Tuberculosis risk among medical trainers Pune India. Emerg Infect Dis 2016 22: 541-543. 6. Chugh TD. Diagnosis of paediatric tuberculosis. Curr Med Res Prac 2016 6: 107-108. 7. Liao TL Lin CH Shen GH et al. Risk of mycobacterial arthrits Taiwan 2001-2011. Emerg Infect Dis 2015 21 8: 1387-1395. 8. Lee CH Lee MC Shucc et al. Risk for pulmonary tuberculosis in patents with chronic pulmonary obstructve disease in Taiwan: a natonwide cohort study. BMC Infect Dis 2013 13: 194.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 8 Dr. Ameeta Joshi Prof Head Microbiology GGMC JJ Hospital Mumbai Superintendent Cama Albless Hospital Mumbai Introducton Tuberculosis TB contnues to be India’s severest health crisis inspite of TB control actvites for more than half a decade. The Natonal Strategic Plan NSP 2017-2025 talks about a vision of TB-Free India with zero deaths disease and poverty due to tuberculosis and a goal to achieve a rapid decline in burden of TB morbidity and mortality while working towards eliminaton of TB in India by 2025. TB can be controlled in the modern era as long as TB is diagnosed early and treated properly and transmission thus interrupted. The challenge facing TB control in India remains delayed diagnosis and inadequate treatment partcularly among patents seeking care from private providers who alone are ill-equipped to sustain their patents on prolonged costly treatment. The requirements for moving towards TB eliminaton have been integrated into the four strategic pillars of “Detect – Treat – Prevent – Build” DTPB. For detecton we need diagnostc tests that are not only sensitve specifc but also algorithms so that every efort is made so as to not miss any case and for all these we need quality assured laboratories. Laboratory To achieve universal access to early accurate diagnosis of TB and enhance case fnding efciency identfcaton of presumptve TB cases at the frst point of care and linking them to the best available diagnostc tests is of paramount importance. For all these one needs a laboratory which is designed in such a way so that there is protecton of all personnel working inside the laboratory sample protecton as well as the surrounding environment is also protected. Whether to construct a biosafety level BSL 1 2 or 3 will depend on what are the tests that the lab is going to conduct but whatever the BSL of the laboratory good laboratory practces is mandatory. TUBERCULOSIS LABORATORY IN A RESOURCE LIMITED SETTING GUEST EDITORIALS

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 9 If low risk actvites only microscopy and or GeneXpert tests are going to be ofered then BSL1 is sufcient wherein one has to have open bench operatons operable windows having insect screens standard lab practces. Biosafety Cabinets BSCs not required if GeneXpert machine is there then there should be a dedicated room for housing the GeneXpert machine this room will require air conditoning and a Uninterrupted Power Supply UPS for the machine. If the laboratory intends to perform medium risk actvites manipulate the sputum sample sputum concentraton or performing a Line Probe Assay LPA on sample then BSL-2 lab is required wherein all practces of BSL1 requirements along with limited access into laboratory BSC Class II A2 will be needed. In case the laboratory plans to do high risk actvites culture the TB organisms or manipulate/ perform tests on the cultures then all requirements of BSL1 BSL 2 plus lab design specifcally for biological containment that is BSL-3 will be needed along with special protectve clothing for staf and an autoclave. If one is planning on opening a TB laboratory professional help of architects who understand containment biosafety concepts fnancers to estmate capital and life cycle costs have to be used. There are vendors who give total turnkey infrastructural design as well as civil structure only equipment only consumables only solutons. In the public sector the microbiologists is totally involved right from the planning to the implementaton and maintenance phase which might not be the case in case of the private sector. While planning one need to estmate capital and life cycle costs for the laboratory operatng facility whereby the capital cost will include design constructon commissioning and equipment cost and the life cycle cost will include utlity expense for ventlaton and electric power flter testng / replacement inspectons insurance etc. HVAC heatng ventlaton Air Conditoning AHU Air Handling Unit Refrigerated Centrifuge and BSCs are main equipment where special focus needs to be given especially when one is planning to set up a culture facility. Locaton of the HVAC needs to be as close to the BSL3 with minimum bends in the ducts in order to cut down on the cost. It is preferable to ensure that all electrical light fxtures switch/sockets controls sensors etc. are fushed with the surface sealed with silicon sealant chemical resistant and able to withstand fumigaton with disinfectant chemicals. All Equipments favorably to have their own online UPS Uninterrupted Power Supply and batery backup of requisite hours based on the running tme of the machine e.g. for a refrigerated centrifuge batery backup of half an hour as the run tme of centrifugaton is 20 minutes Before the vendor hands over the TB facility ensure that he has supplied the validaton document detailed procedure for validaton parameters for validaton along with validaton schemes for architectural layout plans specialized systems like HVAC system air fltraton system pressure control system etc services utlity like power supply and distributon system water supply and distributon system etc The aim of the TB lab is not only to ofer quality assured TB diagnostc tests but ensure the safety of the laboratory workers the safety of the environment this will help in achieving the goal of achieving universal access to quality TB diagnosis including drug resistant TB in the Country.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 10 Dr. Vijaya Lakshmi Nag Prof. Head Department of Microbiology All India Insttute of Medical Sciences Jodhpur Rajasthan-India Non-tuberculous mycobacteria NTM defned as any mycobacterial pathogen other than Mycobacterium tuberculosis Mtb or M. Leprae. More than 170 diferent species known to cause disease ranging from skin ulceraton to severe pulmonary and disseminated disease. Some species like M. avium complex MAC M. abscessus implicated worldwide others like M. malmoense are regionally signifcant. According to the growth rate NTM classifed in to rapid and slow growing mycobacteria. These bacteria are widely isolated from environmental sources including drinking and natural water as well as soil and dust. The steady increase of NTM infectons is likely due to greater exposure to large-volume aerosols a modernizaton of plumbing away from antbacterial copper pipes and lower hot water temperatures which may promote environmental colonizaton and NTM persistence. The spectrum of disease caused by NTM include tuberculosis TB like pulmonary and extrapulmonary disease cervical lymphadenits in young children and visceral and disseminated disease. Pulmonary NTM infectons are most commonly due to MAC M. kansasii and M. abscessus which cause ofen unappreciated worldwide burden of illness. MAC species are abundant across the Americas Australia Europe and regions of Asia compared to other species causing pulmonary disease. Other frequently cultured NTM include M. kansasii and M. abscessus whereas less frequent infectons can occur with M. xenopi M. fortuitum and M. chelonae species. Indirect transmission of the bacteria partcularly occur in immunosuppressed individuals. The aerosolized NTM can also survive on fomites providing another mechanism for spread partcularly for susceptble cystc fbrosis CF patents. The ubiquitous presence of NTM in the environment makes them ideal candidates for opportunistc infectons and therefore warrants specifc and detailed diagnostcs and further evaluaton for interventon against disease. NTM may cause disease similar to Mtb however they generally do not respond to classic TB drug regimens and therefore a misdiagnosis of Mtb can lead to poor treatment partcularly in resource-poor setngs lacking diagnostc infrastructure. The treatment for NTM infecton in chronic cases requires lengthy complex and sometmes poorly tolerated drug regimens over many months to years and following treatment patents can experience relapse from incomplete treatment or reinfecton. The recent rise in interest in diseases caused by NTM atributed to increasing associaton of NTM with acquired NON TUBERCULOUS MYCOBACTERIA NTM: AD - VANCES IN DIAGNOSIS GUEST EDITORIALS

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 11 immunodefciency disease AIDS as well as increasing isolaton in non-AIDS populaton. This increase in the detecton rate is a result of improved awareness and laboratory methodology which require accurate identfcaton of NTM species from clinical specimens. Mycobacterial species difer in virulence and may present characteristc antmicrobial paterns hence correct species identfcaton is important as it may also aid in treatment decision. Diagnosis: The clinical evaluaton of a patent suspected of nontuberculous mycobacterial NTM infecton is required before processing of the sample. Important specimens are Sputum Broncho alveolar lavage BAL body fuids aspirates ascitc tap pleural tap synovial fuid drains pus discharge gastric aspirates and cerebrospinal fuid CSF and early morning whole urine sample for three consecutve days collected in a sterile containers. The NTM clinical disease in human are due to environmental mycobacteria therefore a single positve culture from nonsterile sources including the respiratory or digestve tract does not necessarily indicate infecton or disease and makes treatment decisions less straightorward. Ofen 2 positve microbiological cultures are needed to diferentate NTM disease versus colonizaton however these criteria have not been validated with respect to progression to disease. The clinical radiographic and microbiologic criteria are equally important in exclusion of other infectous diseases like TB nocardiosis fungal infecton and noninfectous diseases eg. Sarcoidosis to make a diagnosis of NTM disease. Microscopy: The smear can be stained with Ziehl-Neelsen ZN and modifed Kinyoun staining. The preferred staining procedure is fuorochrome microscopy studies reported that ZN and auramine staining are more sensitve than Kinyoun staining. While in histopathological examinatons the sensitvity of fuorescence microscopy and ZN staining is low due to negatve infuence by formalin fxaton. Furthermore smear sensitvity is lower in extra-pulmonary TB patents and persons infected with NTM as compared to M. tuberculosis cases. However it is very clear that ZN microscopy is an important method in detecton of mycobacteria but it alone is unable to help in identfcaton and must be associated with culture. Culture: Lowenstein-Jensen LJ is conventonal medium for the growth of Mycobacterium tuberculosis and inferior to Middlebrooks agar as an all-purpose medium for both M. tuberculosis and NTM. The liquid medium culture system BACTEC Becton-Dickenson Diagnostcs MB Redox Heipha Diagnostka BacT/ALERT® MP bioMerieux France MGIT BD Diagnostcs and Sept-check BD Diagnostcs are commonly used. Most media require additves OADC enrichment mixture of Bovine albumin Dextrose Catalase and Oleic acid to increase the growth rate and PANTA antbiotc mixture of polymyxin B amphotericin B nalidixic acid trimethoprim and azlocillin are ofen added to inhibit the growth of contaminants. The conventonal solid method for the growth of mycobacteria is tme-consuming 6–8 weeks but considered “gold standard. Liquid-based culture has high sensitvity and the growth of M. tuberculosis detected within 1–2 weeks. However they always be used in combinaton with the conventonal LJ method for NTM culture. NTM speciaton by phenotypic method: The rate of growth pigmentaton of colonies and various biochemical reactons used for phenotypic identfcaton of NTM species. However these tests are tme consuming and tedious to perform. Immunochromatographic test Rapid assays include Immunochromatographic test standard deviaton SD MPT64 TB Ag Kit developed by SD Bioline South Korea which facilitates rapid detecton and diferentaton of MPT 64 antgen in M. tuberculosis isolates and NTM. MPT 64 TB Ag kit is highly sensitve and give speedy identfcaton of MTBC together with M. tuberculosis M. africanum M. bovis and substrains of M. bovis BCG. The sensitvity is 99 and 100 specifcity. The advantage of

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 12 MPT64 TB Ag test are very easy to perform from direct culture positve specimens does not require any extraordinary equipment and can easily distnguish between MTBC and NTM. Molecular identfcaton: The molecular identfcaton of diferent NTM species done by genomic DNA compari - son but this is labor intensive. The mycobacterial 16S rRNA gene is highly conserved more accurate than phenotypic methods for species identfcaton. If there are diferences in the sequence of 1 or greater generally defne a new species. Studies favoring molecular-based PCR methods are more sensitve sensitvity 84 as compared to phe - notypic culture based methods sensitvity up to78.0 and phenotypic are methods are more tme consuming. For these reasons 16S rRNA can be used as a standard reference when comparing detecton techniques. NTM identfcaton done to the species level by line-probe assays used to amplify drug-resistance -determining regions. The GenoType NTM-DR line-probe assay Hain Lifescience Nehren Germany is one such tool used for the identfcaton of clinical M. abscessus subspecies subsp. and drug resistance. Rapid species identfcaton can also be determined using commercial DNA probes MAC M. kansasii and M. gordonae while group- or complex-level identfcaton accomplished with high-performance liquid chromatography HPLC. For some NTM isolates especially rapidly growing mycobacteria RGM M. fortuitum M abscessus and M. chelonae extended antbiotc in vitro susceptbility testng DNA sequencing or polymerase chain reacton PCR restricton endonuclease assay PRA may be necessary. Another assay available for the detecton of Mycobacterium species from clinical samples is a PCR-reverse blot hybridizaton assay REBA Myco-ID assay YD Diagnostcs Yongin South Korea in which multple targeted oligonucleotde specifc probes Mycobacterium-species specifc are bound to a nitrocellulose membrane strip then hybridized with biotnylated PCR products and subsequently visualized by colorimetric hybridizaton signals. MALDI-TOF: Rodríguez-Sánchez and colleagues assessed 125 NTM isolates using matrix-assisted laser de- sorpton ionizaton-tme of fight MALDI-TOF mass spectrometry the GenoType common mycobacteria CM/ad- ditonal species AS assay and a 16S rRNA/hsp65 gene sequencing reference assay to determine the alignment of these diferent techniques. The MALDI-TOF assay was in agreement with the reference assay in 94.4 cases and the GenoType CM/AS assay was in agreement in 84 cases showing some limitatons in loss of sensitvity of the Geno - Type CM/AS assay. However the MALDI-TOF assay requires a mass spectrometer the GenoType CM/AS assay can be performed using either manual or automated processing making it more accessible in resource-limited setngs. QMAP assay: Another innovatve molecular assay the Quanta matrix multplexed assay platorm QMAP sys- tem recently described by Wang and colleagues allows clinicians to discriminate between mycobacterial species. This assay utlizes an automated magnetc-bead–based assay following similar PCR steps as used in the PCR-REBA assay except denatured biotnylated PCR products added to species-specifc oligonucleotde probes coupled to carboxylat - ed microdisks followed by the additon of streptavidin R-phycoerythrin conjugate and automated reading of fuores- cence intensity. This process has high specifcity and sensitvity and very less tme consuming 3 hrs. Experimental animal models for NTM: Preclinical animal models can be used to study the infuence of the factors which afect the NTM disease process. and evaluate novel therapeutc drugs and regimens for treatment of NTM infectons. Two major categories of NTM disease to consider for animal model development include pulmonary disease and extra pulmonary-disseminated disease typically presentng in immunocompromised. NTM are generally less virulent than Mtb and therefore the capacity to induce a sustained progressive infecton in a mouse strain is an important criterion and current hurdle for the development of an experimental mouse model. Studies have shown that most immunocompetent mouse strains serve as outstanding models for the more virulent MAC species demonstrate rapid clearance when infected with the less virulent M. abscessus isolate making model development and selecton challenging. Many diferent mouse strains have been used to screen diferent drug compounds against MAC including CLR RIF rifapentne RPT moxifoxacin MXF EMB and amikacin AMK. Animal models for slow-growing mycobacteria: The Beige mouse is used as a standard model for MAC disease. This mouse model was developed in the mid-1990s because of the increasing numbers of HIV-seropositve patents becoming coinfected with M. avium. Beige mice display

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 13 many immune defciencies similar to those occurring in AIDS patents as well as a susceptbility to infecton with NTM following either intravenous or aerosol infecton providing a unique opportunity for the study of MAC infectons in this model. The Beige mouse model is also use to screen the chemotherapeutc potental of promising compounds for the treatment of MAC disease. CLR and rifampicin for 6 weeks and then treatment is stopped. Twelve weeks following drug treatment mice are given immunosuppressants dexamethasone or sulfasalazine for 5 weeks to expose any remaining bacteria post-treatment. Bacterial burden is assessed in the organs at diferent tmes afer immunosuppression to measure reactvaton. This model could also be useful for determining the potental efcacy of combined drug and immunotherapy regimens by quantfying the numbers of bacilli remaining afer treatment. Animal models for Rapid growing mycobacteria RGM: The most clinically important RGM to cause human lung disease belongs to M. abscessus. M. abscessus subsp. abscessus and M. abscessus subsp. bolleti have a functonal erm41 gene therefore resistance to macrolides may be identfed. It has been challenging to develop an animal model for screening compounds against RGMs because of gaps in fully understanding their pathogenesis of infecton and relatve avirulence. A progressive aerosol infecton model has proven elusive since most mouse models with signifcant defcits in innate or acquired immunity are stll able to clear an infecton with a high level of RGM. This highlights the need for improved understanding of the NTM pathogenesis of infecton. The biggest challenge that remains to advance the knowledge in NTM pathogenesis and protecton is to fully understand the process of human NTM infectons environmental nosocomial and endogenous/exogenous reinfecton which can be used to help in development of animal models. 1. Falkinham JO 3rd. Epidemiology of infecton by nontuberculous mycobacteria. Clin Microbiol Rev. 199692:177–215. 2. Jeong SH Kim SY Huh HJ Ki CS Lee NY Kang CI et al. Mycobacteriological characteristcs and treatment outcomes in extrapulmonary Mycobacterium abscessus complex infectons. Int J Infect Dis. 201760:49–56. 3. Koh WJ Jeong BH Kim SY Jeon K Park KU Jhun BW et al. Mycobacterial characteristcs and treatment outcomes in Mycobacterium abscessus lung disease. Clin Infect Dis. 2017643:309–16. 4. Koh WJ Moon SM Kim SY Woo MA Kim S Jhun BW et al. Outcomes of Mycobacterium avium complex lung disease based on clinical phenotype. Eur Respir J. 2017503: 5. Diel R Nienhaus A Ringshausen FC Richter E Welte T Rabe KF et al. Microbiologic outcome of interventons against Mycobacterium avium Complex pulmonary disease: A systematc review. Chest. 20181534:888–921. 6. Nishiuchi Y Iwamoto T Maruyama F. Infecton sources of a common non-tuberculous mycobacterial pathogen Mycobacterium avium Complex. Front Med Lausanne. 20174:27 10.3389/fmed.2017.00027 7. Prevots DR Marras TK. Epidemiology of human pulmonary infecton with nontuberculous mycobacteria: a review. Clin Chest Med. 2015361:13–34. 8. Grifth DE Aksamit T Brown-Elliot BA Catanzaro A Daley C Gordin F et al. An ofcial ATS/IDSA statement: diagnosis treatment and preventon of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med. 20071754:367–416. 9. Ryu YJ Koh WJ Daley CL. Diagnosis and treatment of nontuberculous mycobacterial lung disease: Clinicians’ perspectves. Tuberc Respir Dis Seoul. 2016792:74–84. 10. Falkinham JO 3rd. Environmental sources of nontuberculous mycobacteria. Clin Chest Med. 2015361:35– 41. 11. Haworth CS Banks J Capstck T Fisher AJ Gorsuch T Laurenson IF et al. Britsh Thoracic Society guidelines for the management of non-tuberculous mycobacterial pulmonary disease NTM-PD. Thorax. 201772Suppl 2:ii1– ii64. 12. Koh WJ Chang B Ko Y Jeong BH Hong G Park HY et al. Clinical signifcance of a single isolaton of

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 14 pathogenic nontuberculous mycobacteria from sputum specimens. Diagn Microbiol Infect Dis. 2013752:225–6. 13. Martniano SL Sontag MK Daley CL Nick JA Sagel SD. Clinical signifcance of a frst positve nontuberculous mycobacteria culture in cystc fbrosis. Ann Am Thorac Soc. 2014111:36–44. 14. Wright PW Wallace RJ Jr. Wright NW Brown BA Grifth DE. Sensitvity of fuorochrome microscopy for detecton of Mycobacterium tuberculosis versus nontuberculous mycobacteria. J Clin Microbiol. 1998364:1046–9. 15. Kehrmann J Kurt N Rueger K Bange FC Buer J. Genotype NTM-DR for identfying Mycobacterium abscessus subspecies and determining molecular resistance. J Clin Microbiol. 2016546:1653–5. 16. Wang HY Kim H Kim S Bang H Kim DK Lee H. Evaluaton of PCR-reverse blot hybridizaton assay for the diferentaton and identfcaton of Mycobacterium species in liquid cultures. J Appl Microbiol. 20151181:142–51. 17. Springer B Stockman L Teschner K Roberts GD Botger EC. Two-laboratory collaboratve study on identfcaton of mycobacteria: molecular versus phenotypic methods. J Clin Microbiol. 1996342:296–303. 18. Tortoli E. Impact of genotypic studies on mycobacterial taxonomy: the new mycobacteria of the 1990s. Clin Microbiol Rev. 2003162:319–54. 19. Deggim-Messmer V Bloemberg GV Riter C Voit A Homke R Keller PM et al. Diagnostc molecular mycobacteriology in regions with low tuberculosis endemicity: Combining real-tme PCR assays for detecton of multple mycobacterial pathogens with line probe assays for identfcaton of resistance mutatons. EBioMedicine. 20169:228–37. 20. Rodriguez-Sanchez B Ruiz-Serrano MJ Marin M Lopez Roa P Rodriguez-Creixems M Bouza E. Evaluaton of matrix-assisted laser desorpton ionizaton-tme of fight mass spectrometry for identfcaton of nontuberculous mycobacteria from clinical isolates. J Clin Microbiol. 2015538:2737–40. 21. Wang HY Uh Y Kim S Lee H. Performance of the Quantamatrix multplexed assay platorm system for the diferentaton and identfcaton of Mycobacterium species. J Med Microbiol. 2017666:777–87. 22. Jagielski T Minias A van Ingen J Rastogi N Brzostek A Zaczek A et al. Methodological and clinical aspects of the molecular epidemiology of Mycobacterium tuberculosis and other mycobacteria. Clin Microbiol Rev. 2016292:239–90. 23. Huh HJ Kim SY Jhun BW Shin SJ Koh WJ. Recent advances in molecular diagnostcs and understanding mechanisms of drug resistance in nontuberculous mycobacterial diseases. Infect Genet Evol. 2018. October 11 24. Wassilew N Hofmann H Andrejak C Lange C. Pulmonary disease caused by non-tuberculous mycobacteria. Respiraton. 2016915:386–402. 25. Bryant JM Grogono DM Greaves D Foweraker J Roddick I Inns T et al. Whole-genome sequencing to identfy transmission of Mycobacterium abscessus between patents with cystc fbrosis: a retrospectve cohort study. Lancet. 20133819877:1551–60. 26. Obregon-Henao A Arnet KA Henao-Tamayo M Massoudi L Creissen E Andries K et al. Susceptbility of Mycobacterium abscessus to antmycobacterial drugs in preclinical models. Antmicrob Agents Chemother. 20155911:6904–12. 27. Gangadharam PR. Beige mouse model for Mycobacterium avium complex disease. Antmicrob Agents Chemother. 1995398:1647–54. 28. Bermudez LE Inderlied CB Young LS. Mycobacterium avium complex in AIDS. Curr Clin Top Infect Dis. 199212:257–81. 29. Shiloh MU Nathan CF. Reactve nitrogen intermediates and the pathogenesis of Salmonella and mycobacteria. Curr Opin Microbiol. 200031:35–42. 30. Andrejak C Almeida DV Tyagi S Converse PJ Ammerman NC Grosset JH. Characterizaton of mouse models of Mycobacterium avium complex infecton and evaluaton of drug combinatons. Antmicrob Agents Chemother. 2015594:2129–35.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 15 Dr. Rakesh PS Medical Consultant TB Eliminaton WHO-RNTCP Technical Assistance Project Kerala With a burden of disease that accounts for more than 10 million new cases per year tuberculosis TB contnues to be a major global health threat 1. Although the global number of TB deaths fell by 42 between 2000 and 2017 and the annual decline in the global TB incidence rate is currently 1.5 1 much acton is needed to accelerate progress towards achieving global milestones to end TB 2. Interruptng the cycle of M. tuberculosis transmission is crucial to achieving global targets to end the TB epidemic. Thus there is a need to implement interventons to rapidly identfy source cases and impede person-to-person transmission by reducing the concentraton of infectous partcles in the air and the exposure tme of susceptble individuals. These principles form the basis for efectve infecton preventon and control IPC. Also it has to be kept in mind that 9299 TB cases among health workers were reported in 60 countries alone with the notfcaton rate for health care associated transmission of Mycobacterium tuberculosis being twice as high as the rate in the general adult populaton. The threats posed by epidemics pandemics and AMR have become increasingly evident as ongoing universal challenges and they are now recognized as a top priority for acton on the global health agenda. Efectve IPC is the cornerstone of such acton. The Internatonal health regulatons positon efectve IPC as a key strategy for dealing with public health threats of internatonal concern 2. United Natons Sustainable Development Goals SDGs highlighted the importance of IPC to safe efectve high-quality health service delivery and universal health coverage. WHO has released the TB Infecton Preventon and Control 2019 Update which is evidence-informed recommendatons outlining a public health approach to prevent M. tuberculosis transmission within the clinical and programmatc management of TB and to support countries in their eforts to strengthen or build reliable resilient and efectve IPC programmes to reach the targets of the “End TB Strategy”. The summary of recommendatons for TB IPC based on 2019 updates is as follows: Recommendaton 1: Triage of people with TB signs and symptoms or with TB disease is recommended to reduce M. tuberculosis transmission to health workers including community health workers persons atending health care facilites or other persons in setngs with a high risk of transmission. Conditonal recommendaton based on very low certainty in the estmates of efects TB INFECTION PREVENTION AND CONTROL: 2019 UPDATE GUEST EDITORIALS

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 16 Recommendaton 2: Respiratory separaton / isolaton of people with presumed or demonstrated infectous TB is recommended to reduce M. tuberculosis transmission to health workers or other persons atending health care facilites. Conditonal recommendaton based on very low certainty in the estmates of efects Recommendaton 3: Prompt initaton of efectve TB treatment of people with TB disease is recommended to reduce M. tuberculosis transmission to health workers persons atending health care facilites or other persons in setngs with a high risk of transmission. Strong recommendaton based on very low certainty in the estmates of efects Recommendaton 4: Respiratory hygiene including cough etquete in people with presumed or confrmed TB is recommended to reduce M. tuberculosis transmission to health workers persons atending health care facilites or other persons in setngs with a high risk of transmission. Strong recommendaton based on low certainty in the estmates of efects Recommendaton 5: Upper-room germicidal ultraviolet GUV systems are recommended to reduce M. tuberculosis transmission to health workers persons atending health care facilites or other persons in setngs with a high risk of transmission. Conditonal recommendaton based on moderate certainty in the estmates of efects Recommendaton 6: Ventlaton systems including natural mixed-mode mechanical ventlaton and recirculated air through high-efciency partculate air HEPA flters are recommended to reduce M. tuberculosis transmission to health workers persons atending health care facilites or other persons in setngs with a high risk of transmission. Conditonal recommendaton based on very low certainty in the estmates of efects. Overall the preference for ventlaton systems in resource-limited setngs based on available evidence of efectveness and assumptons about fnancial constraints was in order of decreasing preference: i natural ventlaton ii mixed-mode ventlaton iii mechanical ventlaton and iv recirculated air with HEPA fltraton. This order of preference may not be applicable in setngs where resources are sufcient to procure and sustain more sophistcated systems or where climatc conditons impede the use of natural or hybrid mixed-mode ventlaton systems. While robust or highly specialized systems can reduce the concentraton of infectous droplet nuclei in the air and thus prevent transmission such systems may cause a false sense of reassurance given the challenges in installaton and maintenance and the likelihood of human error in their implementaton. In additon in resource-limited setngs highly specialized systems e.g. mechanical ventlaton systems and recirculated air through HEPA flters would have a negatve impact on equity and access because they may not be adopted natonwide being too expensive to install and maintain properly. Recommendaton 7: Partculate respirators within the framework of a respiratory protecton programme are recommended to reduce M. tuberculosis transmission to health workers persons atending health care facilites or other persons in setngs with a high risk of transmission. Conditonal recommendaton based on very low certainty in the estmates of efects The interventons described under each recommendaton are not intended as stand-alone interventons rather they are to be implemented as a full IPC package. References 1. Global tuberculosis report 2018 WHO/ CDS/TB/2018.20. Geneva: World Health Organizaton 2. Internatonal health regulatons 2005 third editon. Geneva: World Health Organizaton 2016 3. WHO guidelines on tuberculosis infecton preventon and control 2019 update Geneva: World Health Organizaton 2019

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 17 Dr. T. V. Rao Former Professor of Microbiology Email: doctortvraogmail.com Tuberculosis contnues to be one of the most ancient diseases in human history. Skeletons of Egyptan mummies show clear evidence of the disease datng back 6000 years although some scientsts believe it is much older than that. Genetc analysis of Mycobacterium seems to suggest that modern strains of M. tuberculosis originated from a common ancestor in Africa about 15000 to 20000 years ago. ROBERT KOCH - STORY OF GREATEST INVENTION AND FAILURE TOO - In 1883 Robert Koch discovered that the cause was from a bacterium called Mycobacterium tuberculosis. A litle while afer he claimed to have discovered the cure. Afer announcement of treatment for Tuberculosis with tuberculin therapy the scientfc societes and people excited and over 2000 people congregated to Germany for treatment. Everyone thought that the new treatment would cure the patents but it actually did the opposite More and more people died at faster rates than TB patents without treatment. Although Koch tried to save thousands of peoples lives but failed however he was identfed with the inventon of the Bacteria as he discovered the cause of tuberculosis which was a major turning point in the annals of Medicine. A panoramic view of Kochs life reveals an array of unprecedented achievements intermixed with a few notable failures. Kochs principal failures – his belief in the therapeutc potental of tuberculin his error regarding bovine tuberculosis and his acerbic treatment of opponents – do litle to mar the legacy of a dedicated physician In 1905 Koch won the Nobel Prize in Physiology and Medicine for his work with tuberculosis. TUBERCULOSIS STILL HAPHAZARDLY TREATED Tuberculosis contnues to be haphazardly treated as many people who have become infected with tuberculosis don’t even realize that they have an actve infecton. One should be aware of someone infected with TB–whether they know it or not–can spread the illness to between 10 and 15 people without even knowing it this is where in WHO Public health organizatons and Governmental agencies stepped in to make the screening program for detecton of Acid Fast Bacilli in the sputum to contain the spread and open cases of tuberculosis. The programs of screening remained a success tll last few years as most of the treatments in tuberculosis contnues to be the decision of the Clinicians in startng drug regimes however when we are working with poor infrastructure and patent cannot aford many new generatons of tests it is ideal to do at least a sputum Microbiology with Z.N Methods. The emergence of Multdrug-Resistant Tuberculosis gives ways to fnd newer methods as just fnding Acid-fast bacilli sputum do not mean the routnely used drugs cure and is a concern whether we are looking at a dead bacilli or a Atypical Mycobacterium or even as MDR - TB and zeal to fnd the ways given the way for Molecular and new innovatons to diagnose and cure the patents with MDR tuberculosis. THE ENIGMA OF TUBERCULOSIS CONTINUES STORY OF SUCCESS FAILURES AND HOPE

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 18 CHOOSING THE RIGHT TEST TO DIAGNOSE TUBERCULOSIS - Factors in selectng which test to use include the reason for testng test availability and costng. many of the developing countries we lack facilites and many tmes patents are treated on assumpton and not on scientfc basis. SEARCH FOR BETTER DIAGNOSTIC TESTS - yet there are no specifc and sensitve tests to suit the clinical situaton and Mycobacterium contnues to be the most complex and above all many tmes if once we are infected it lives in us and wait for an opportunity to fare up which created a buzz with greater focus on HIV/AIDS patents as it will get reactvated with progress of HIV infecton turning to be AIDS. NEW CHALLENGES WITH MDR -TB An urgent and a persistent problem is the rise of TB that does not respond to the two most powerful antbiotcs for combatng the disease. Here treatment success is much lower and more atenton needs to be given to improving diagnostcs and getng people through efectve treatment which can be prolonged and arduous as well as fnding new medicines. HOW TO ACHIEVE OUR GOALS the collaboraton of all the health system departments in the management of TB is signifcant since the patent may seek health care either from private medical practce or natonal care and the main goals are the early diagnosis and start of treatment. Furthermore most of the clinical problems that may arise are addressed by ISTC and these guidelines should always be taken into consideraton at least untl future research provides more promising diagnostc and therapeutc modalites for disease control. DETECTION OF DRUG RESISTANCE A PRIORITY - CDC advises all patents the inital M. tuberculosis isolate should be tested for drug resistance. It is crucial to identfy drug resistance as early as possible to ensure efectve treatment. Drug susceptbility paterns should be repeated for patents who do not respond adequately to treatment or who have positve culture results despite 3 months of therapy. Susceptbility results from laboratories should be promptly reported to the primary health care provider and the state or local TB control program Improvements stll to come TUBERCULOSIS IN PEDIATRIC AGE GROUP AND EXTRAPULONARY TUBERCULOSIS -“Huge improvements in the diagnosis of tuberculosis infecton and disease are on the horizon However because most techniques are studied only in adults before they become available and TB is fundamentally diferent in children and extra pulmonary involvement although it is likely that all tests will have to be considered according to how cases present clinically and epidemiologically. THE SAGA OF TUBERCULOSIS CONTINUES - HOWEVER THE SEARCH ON FOR BETTER SOLUTIONS References 1 Problems in diagnosis and treatment of tuberculosis infecton Tsara E Serasli and P Christaki Hippokrata. 2009 Jan-Mar 131: 20–22. 2 Diagnosis of Tuberculosis Disease When Should You Suspect Tuberculosis TB CDC 3 Tuberculosis is curable. So why are so many people stll dying from the disease By Editorial Board September 18 2018 The Washington post.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 19 Dr. Dhruv Mamtora Consultant Microbiologist infecton control ofcer S. L. Raheja Hospital A forts associate Mahim Mumbai. Co-editor and designer “Infecton control trends” Email: dhruv_mamtorayahoo.com Airborne infecton control is given low priority in resource limited setngs especially in country like India. However there are many models which have come up in designing and planning a healthcare facility which addresses issue of airborne transmission of infecton. Some of these are adopted in development of treatment facility of tuberculosis and designing laboratories to undertake tuberculosis culture and sensitvity work. In the artcle I am going to review various systems of ventlaton which are available and scientfc principles which are related to engineering but are yet to be adopted by medical industry for beter airborne isolaton facility constructon. Infecton control involves multple aspects. First is preventon of aerosolisaton of partculate material. Second is mechanism whereby a partcle which has already escaped in air is killed before inhalaton by susceptble host and thirdly isolatng patent harboring tuberculosis in special ward which is negatve pressure isolaton facility so that transmission can be prevented or minimized. For the implementaton of same control falls in three categories frst is administratve control followed by personal protecton and lastly environmental and engineering controls. Administratve controls ensure that measures are taken appropriately to prevent transmission to susceptble patents. These include appropriate seatng arrangements triage communicaton and patent educaton. However it is administraton who also ensures that other steps which are personal protectve equipment and environmental and engineering controls are in place in any given organizaton at all tmes. Next is role of appropriate personal protectve equipment which includes use of respirator N95 Masks and appropriate procedures which are followed which minimizes risk of aerosolizaton like closed sucton methods use of biosafety cabinets for processing of samples use of water resistant apron and face shield when such procedures are taken and ensuring that appropriate quality tests e.g. ft test for respirators are performed and regular training is given to staf for using same. Third and last important part is environmental and engineering controls. Engineering and environmental control ensures that transmission do not happen from one patent to another. Basically ensuring appropriate ventlaton and exhaust controls. However at same tme engineering and environmental controls are major expenditure exercise for setng up appropriate isolaton facilites for hospital set ups. The designing include clarity on various aspects which include type of ventlaton systems airfow distributon structure air exchange rate temperature and humidity both of ambient air as well as climatc conditons of establishment of facility engineering maneuvers like fltraton of air HEPA flter installaton UV light and architectural and constructon team support for designing above mentoned all elements. Airborne pathogens can be bacterial viral or fungal spores which are suspended partcles either solid of liquid in air. Some of parasitc eggs can also be suspended in air. Viruses are smallest of partcles which are in nanometer sizes bacteria are in micrometer size and fungal spores are largest which are larger than bacteria 1-30 microns. UNDERSTANDING AIRBORNE TRANSMISSION FROM INFECTION PREVENTIONISTS’ VIEW

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 20 Human actvites which support spread of airborne pathogens include respiratory talking coughing sneezing breathing showering fushing tap water use sewage aerosolizaton from toilets leakage in pipe and plumbing systems etc. other specifc hospital actvites which can generate aerosols are bed making washing of medical equipments wet mopping and walking on carpets which can re-suspend partcles as aerosols. Hospital procedures like intubaton suctoning cardiopulmonary resuscitaton bronchoscopy autopsy surgery cauterizaton centrifugaton etc. can also form aerosols. Presently there is no precise list which can pin point exactly cause efect relatonship between ventlaton systems and hospital procedures. However this area can be of interest for future research. Basic and fundamental idea should be ventlaton system should be appropriate for the scope of services ofered by healthcare organizaton. Also the systems must be equipped to remove airborne contaminaton through efectve ventlaton system which has multple checks of flter and UV etc. ventlaton systems and ducts are regularly inspected and flters are tmely replaced so that the optmum functoning can be assured. Some cleaning measures are in place and parameters like airfow velocity air changes flter efcacy and functonality temperature. Pressure and humidity are monitored at regular intervals. Also pressure gauges are installed at entrance of all isolaton rooms and tubes should not be blocked or worn out and must actually measure pressure diferentals. Preventon of airborne transmission in hospitals and healthcare organizaton is a complex subject and it revolves around multple key performance areas. Cross contaminaton by airborne infecton can be signifcantly reduced in well designed and ventlated operatng rooms however the same can be complex subject when it comes to designing wards. Since wards have complex interplay of multple factors which are contact airborne and hand related contaminaton and cross contaminaton in mult bed general wards. Reduced infecton by airborne transmission needs robust systems which start right at point of installaton of ventlaton system and architectural design of building. It is also important that the systems which are functoning are maintained optmally to prevent cross contaminaton and reduce incidence of air borne infectons in a given healthcare facility. Maintenance of systems to their maximum desired efciency is challenge of this era and also major expenditure for tropical countries like India where the summer temperature are high and some of metro cites are coastal where humidity is exceeding more than 60 percent most of tme in a year e.g. Mumbai Chennai Kolkata etc. Very litle work has been done in this area of hospital startng from a scratch from designing aspect. Because many of organizatons are built on old infrastructure which is so vast that to make changes is major capital expenditure so also maintaining and sustaining new systems is further challenge. There are new challenges especially for developing countries like India where populaton explosion and overcrowding is major challenge to old existng infrastructure especially in general hospitals or any other places like bus depot railway staton or airports which are ran by governmental organizatons so also maintenance for optmum functonality in existng ventlaton systems which are in place ever since installaton and are looked afer or maintained only afer major breakdowns or major disasters. There is need for development of common consensus and it is an area of research so also validaton of existng system to its functonality is also challenging as there are no laid standards except some given by natonal and internatonal agencies. Since the area deals with multple complexites which want joint atenton for medical and adjoining felds of engineering maintenance and mechanics part of ventlaton there is huge unmet need especially at a juncture where we stand looking forward to eradicate biggest and chronic disease of tuberculosis which is rampant in our community and has gained new sensaton afer evolving as MDR XDR and XXDR forms. To conclude the so called modern medicine is yet to become modernized as far as airborne diseases and preventon of airborne diseases is concerned but baby steps are taken especially afer knowledge of diseases like swine fu bird fu MDR form of tuberculosis and SARS. There is much more to learn and execute especially in feld of designing planning and maintaining facilites where mass public gatherings and especially in hospitals where respiratory diseases are treated. hospitals where respiratory diseases are treated.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 21 Dr. Ankit Gupta Ms. Prerna Rani Mr. Prijil Innocent Department Of Infecton Control Max Superspeciality Hospital Vaishali Ghaziabad Utar Pradesh Since incepton tuberculosis has plagued the mankind and intrigued the researchers. The notorious Mycobacterium tuberculosis has witnessed revolutonary changes from inclusion of newer bacteria in Mycobacterium tuberculosis complex to development of newer diagnostc modalites culture based to NAAT based and overwhelming drug resistance to many antmicrobials. The bacteria contnue to evolve further with very few new antbiotc compounds for rescue i.e. bedaquiline delaminid. Being a highly communicable disease the preventon is the key to contain the spread in community. The infecton control measures in a hospital are crucial to the management of tuberculosis. This exercise is carried out with extreme diligence by infecton control nurses. With metculous planning they are entrusted with a responsibility to help in patent management by preventng the spread. With our experience the strategy can be aptly called as NIYANTRAN which may be considered as an abbreviaton for various processes. NOTIFICATION • Notfcaton of a case of tuberculosis is mandatory so that the patent can be ofered assistance for diagnosis and treatment. • The infecton control nurses serve as a bridge between clinical laboratories and departments which need to be notfed with a case of tuberculosis. ISOLATION • Isolaton for the control of infecton is used to prevent infected patents from infectng others source isolaton and/or prevent susceptble patents from being infected protectve isolaton. YEARLY HEALTHCHECK UP The infecton control nurse in collaboraton with other departments can coordinate and oversee an annual healthcheck up for all healthcare workers. AUDIT ROLE OF AN INFECTION CONTROL NURSE IN TUBERCULOSIS

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 22 NEGATIVE PRESSURE AND TRANSMISSION BASED PRECAUTIONS A. This process contains two ters of precautons: 1. Standard precautons 2. Transmission Based Precautons B. What are STANDARD PRECAUTIONS STANDARD PRECAUTIONS applicable to blood all body fuids secretons and excretons except sweat regardless of whether or not they contain visible blood non-intact skin mucous membrane C. What are the various modes of transmission TRANSMISSION BASED PRECAUTIONS Airborne precautons include • Isolaton of the patent in a private room with monitored negatve air pressure. • The door to the room must remain closed. • Always wear appropriate respiratory protecton - Use of N-95 mask for certain cases like H1N1. • Use required PPE. • Proper disposal of Bio medical waste. • Strict compliance to hand hygiene. • Limit the movement and transport of the patent from the room. • Terminal disinfecton afer discharge / transfer out. Droplet precautons • Keep the patent in a private room. • The door must remain closed. • Mask must be worn when entering the room and examining or transportng a patent. • Use required PPE. • Proper disposal of Bio medical waste. • Strict compliance to hand hygiene. • Limit the movement and transport of the patent from the room. • Terminal disinfecton afer discharge / transfer out. Contact precautons include • The door must remain closed. • Use required PPE such as clean gown glove etc.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 23 • Proper disposal of Bio medical waste. • Strict compliance to hand hygiene. • Limit the movement and transport of the patent from the room. • Limit the movement of visitors • Terminal disinfecton afer discharge / transfer out TRAINING • Regular sessions are taken by infecton control nurse to sensitze nursing and other health care workers regarding preventon. RESISTANCE MDR XDR AND TOTAL DRUG RESISTANCE and RNTCP • The infecton control nurses need to train healthcare workers about the threat of drug resistance. • The family members also need to educated about precautons to be observed at home and availability of various resources under RNTCP program. AUDIT AND SURVEILLANCE No infecton control actvity is complete without a comprehensive audit surveillance and feedback mechanism. N-95 RESPIRATOR MASK practces for health care workers AND USE OF RESPIRATOR/Surgical Mask – For patents while transportng for procedures to prevent spread of infecton.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 24 Ms. Pragya Lodha Clinical Psychologist Research Assistant Health can be holistcally determined by a bio-psycho-social model however ofen the medical model of illnesses overweighs in understanding managing and treatng illnesses. This is especially so for chronic illnesses as the inevitable frst line of treatment is that of pharmacological management. What this artcle tries to highlight is the complementary need for psychosocial interventons for long term management of the illnesses and beter quality of life for the patent. It is essental to understand that there are various pathways implicated in the development of chronic illnesses. The basic sciences focus on psycho-neuroendocrinology psycho-neuroimmunology psycho-physiology and psycho-somatc correlatons- which is an explanaton of physical and mental health afect each other and can aggravate the either conditons in terms of chronicity or symptom presentaton. Treatment of patents with chronic diseases will be one of the main challenges of medicine in the future because they are very ofen infuenced by psychosomatc or biopsychic factors. Though pharmacological management of chronic illnesses is an indispensable approach to treatment it must be remembered that medicine is not only a diagnostc discipline but it also involves other health care workers in acton as part of the ‘health care system’. A commonly noted phenomenon is also that patents inficted with chronic illnesses cancer renal problems diabetes chronic pain coronary heart disease bronchial asthma rheumatoid arthrits infammatory bowel disease essental hypertension atopic dermatts surgical issues and other illnesses can develop psychological and emotonal issues. Psychosocial interventons are strategies of care that generally fall under the mental health care dimension since it looks at psychological and emotonal well-being primarily. By defniton there is no one standard defniton for psychosocial care as the nature of care varies with what the problem is what is the nature and extent of care needed who provides the care and the overall context along with the illness. Psychosocial care in the health care setng is the provision of psychological and emotonal support and practcal advocacy as it relates to patents adaptng to their medical conditon accessing and adhering to medical treatment and developing coping skills to incorporate their illness successfully into their lives. The focus of psychosocial interventon is to assess and manage aspects such as psychological symptoms personality traits attudes toward disease and life risk behaviour and social isolaton. As biological targets the change of autonomic imbalance and of the efects of the psycho-endocrinological or psycho-immunological stress responses is also that is managed under psychosocial care. Psychosocial care is an aspect of treatment that works best along with clinical management of the illness. Straightorwardly the psychosocial interventon is inclusive of counselling the patent educatng them about the illness understanding the personal factors of the patent that may be exacerbatng the illness and involving the patent and family members in beter quality care at home along with managing illness in the long term. Psychosocial interventon addresses the following: • Adaptaton to Change THE NEED FOR PSYCHOSOCIAL INTERVENTION IN CARE FOR CHRONIC ILLNESS

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 25 • Grief and Loss • Coping Skills • Pain Management • Communicaton Skills • Stress Management • Problem Solving • Assertveness Training • Spirituality • Rehabilitaton • Post recovery care • Behavioural interventon lifestyle changes Through educaton developing of coping skills and supportve interventon patents are capable to efectvely handle the stressors of life. Professionals practcing psychosocial care are specifcally trained to help patents adjust to illness diagnose and treat behavioural and emotonal disorders including anxiety and depression work with patents on behaviour modifcatons to adapt to difcult situatons and respond to crisis situatons. It is ofen believed that symptoms of an illness reduce with clinical management and the need for psychosocial interventons is ofen not felt. Patent care has been built based on an understanding that many factors impact patents’ functoning which are importantly relatve to the illness. Patents need to be assessed fully for these factors and relevant interventons need to be implemented for beter management. What is quintessental to note is that the impact of illness varies from one person to another and consequently the treatment approach will also vary as the set of challenges faced by every patent are diferent. An individualized approach must be taken in order to eradicate the barriers and treat the patent holistcally. The importance of psychosocial interventon in chronic illnesses: 1. Addressing the patent and taking an interest to understand the patent’s personal variables increases trust and beter understanding between the doctor/therapist-patent relatonship which is a very essental factor in patent-recovery 2. Culturally India has a paternalistc doctor/therapist-patent relatonship where the doctor/therapist is almost equivalent to god a relatonship where doctor/therapist understand patent’s cultural variables can promote great amount of trust in the patent

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 26 3. Sometmes having the belief that one trusts to get well is essental as optmism is linked with physical and mental well-being which may lead to sooner and beter recovery 4. Psychosocial care has proven efcacy in alleviatng distress in patents medically treated for cancer cardiovascular diseases HIV/AIDS. 5. Psychosocial interventon can sometmes prevent chronic illnesses like HIV 6. Psychosocial care also improves compliance to medicaton and adherence to treatment as educaton and counselling are components of the care that allow for beter patent understanding. 7. Family involvement is an essental part of illness management and sometmes identfcaton of symptoms beforehand in order to prevent relapse as far as possible and early management of illness relapse. 8. Patent and family educaton about the illness is important for them to recognise early signs and symptoms to avoid delay in treatment and also learning management at home as and when required. 9. Counselling allows for the patent to share his / her psychological and emotonal baggage and get rid of it in order to improve quality of life and beter self-care. 10. Psychosocial interventons enhance the outcomes of clinical care. Along with medicaton addressing the personal variables in a patent helps reduce the need for medicaton for every symptom management which can be taken care of psychosocially and at an interpersonal level reassures the patent as a busy clinician may not always have the tme to spend with the patent whereas the psychosocial care provider fulfls that the queries of the illness get resolved by the psychosocial carer. Where to fnd psychosocial care Psychosocial support can include mental health counselling educaton spiritual support group support and many other such services. These services are usually provided by mental health professionals such as psychologists social workers counsellors specialized nurses clergy pastoral counsellors and others. Specifcally in India one can reach out to a psychotherapist counselling psychologist or clinical psychologist and / or a social worker who does counselling. Some hospitals also have psychiatric nurses who are capable of handling the care. These professionals can be sought either on a private clinic basis or at a hospital that has a psychiatry OPD. One may also fnd to join support groups that also foster psychosocial care. Conclusion Research evidence tells us that reasons for relapse of illness and re-hospitalisaton include psychosocial issues such as anxiety lack of emotonal and psychological support from family friends and caregivers and a lack of communicaton and coordinaton of care for patents. Perhaps because there are no published guidelines for incorporatng psychosocial care into usual clinical practce it stll is largely absent from routne patent care. The approach appreciates that all people must be treated in the context of their personal lives beliefs and backgrounds. It is this unique context that patents bring to their disease and its management. Health care providers must understand that identfying the conditon or illness and recommending a treatment is only part of efectve care. If illness is addressed without addressing its complex human host barriers to treatment will prevent best outcomes even if best medical therapies are ofered. References 1. Deter HC. Psychosocial interventons for patents with chronic disease. BioPsychoSocial medicine 201261 2. doi:10.1186/1751-0759-6-2 2. Congressional Research Service. Medicare hospital readmissions: issues policy optons and PPACA September 2010. 3. Wagner EH Austn BT Davis C et al. Improving chronic illness care: translatng evidence into acton. Health Af Millwood 200120:64–78. 4. Kemp K Grifths J Lovell K. Understanding the health and social care needs of people living with IBD: a meta-synthesis of the evidence. World J Gastroenterol 201218:6240–6249.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 27 Dr. Sourav Mait Chief Consultant Clinical Microbiologist In-Charge Department of Infecton Preventon Control Insttute of Neurosciences Kolkata Email: smait76gmail.com Electron transport is an essental biologic process required by almost all aerobic bacteria which is dependent upon availability of optmum amount of iron. Mycobacterium tuberculosis requires iron but in mammalian host nutritonal immunity limits the amount of free iron. In additon free iron is really scarce at physiological pH as it exists in the form of insoluble iron oxides. It requires 10 −7 M iron for growth whereas solubility of iron is only 1.4 × 10 −9 M at neutral pH. Hence for survival M. tuberculosis needs to rob of iron from transferrin in plasma and from lactoferrin in extracellular fuids and leukocytes. It has distnct mechanism of producton of siderophore for chelatng the metal iron from protein-bound as well as from the insoluble iron. Mycobacterial cell envelope contains lipid-rich organizaton which causes difculty in iron acquisiton. To overcome it produces 2 types of siderophores – hydrophobic mycobactns and hydrophilic carboxymycobactns. Gram-negatve bacteria use TonB –dependent receptor-mediated internalizaton of iron. Most likely mycobacteria incorporate iron by interplay of ferricarboxymycobactns at outside and cytoplasmic membrane-bound mycobactns. HupB might be having an important role in mediaton. Exochelins are not known to be produced by Mycobacterium tuberculosis. Since iron is an essental nutrient for survival of Mycobacterium tuberculosis could it have some implicaton in treatment Studies show for nosocomial mult-drug resistant strains of Staphylococcus aureus and Acinetobacter baumannii siderophore-mediated iron uptake has important implicatons. Host response includes hyperproducton of lipocalin-2 which binds to siderophore and prevents reuptake of siderophores inside bacterial cell. On the other hand synthetc siderophore analogues can be used as “Trojan horse” to deliver partcular antbiotcs like magic bullets. Researchers have shown that a bisubstrate inhibitor of the adenylaton enzyme MbtA which is responsible for the second step of mycobactn biosynthesis exhibited potent anttubercular actvity. Drug discovery focused its eforts on the inhibiton of MbtI also which is another enzyme involved in the mycobactn biosynthesis. Among other compounds MmpL3 inhibitors also demonstrated in vitro and in vivo anttubercular actvity. These are stll in experimental stages but they might answer the burning queston of MDR-TB and XDR-TB. Let’s hope for the future IRON MYCOBACTERIUM TUBERCULOSIS – IS THERE A HOPE

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 28 Dr. Sukanya Rengaswamy MD PGDID CIC Bangalore In the last few decades though there has been a remarkable progress in the diagnosis of pulmonary TB Extra pulmonary TB EPTB poses several clinical diagnostc and management challenges which stll need to be addressed. The common EPTB sites are TB Lymphadenopathy Pleural TB Abdominal TB Genitourinary TB and Infertlity setngs IVF and CNS TB. Diagnosis of EPTB is challenging due to several factors such as paucibacillary samples variable clinical presentatons need for invasive procedures to obtain appropriate samples and lack of laboratory facilites to process such samples in resource limited setngs where many such cases present. These can be further classifed as Pre analytcal and Analytcal challenges. Common challenges in the pre analytcal phase are Paucibacillary nature of samples/specimens Non uniform distributon of microorganisms in samples Inaccessible sites for routne sampling feasibility and acceptability of invasive methods for sampling. Analytcal phase issues are further classifed as: I. Methodological issues: A. Direct methods: a. Tissue aspirate Microscopy and staining - ZN requires more than 106 bacilli per gram of tssue to be positve which is a challenge in paucibacillary cases of EPTB. The sensitvity of sputum culture varies by site of EPTB: 28-50 for abdominal TB 10-11 for tuberculosis pericardits 24-29 for tuberculous meningits and 5-14 for tuberculous lymphadenits. Repeat tests improve diagnostc performance. In patents with urinary tract TB three to six frst-void morning urine specimens can improve the likelihood of a positve acid-fast bacilli AFB culture result with approximately 80-90 only 30-40 of single specimens are positve.Repeated lumbar punctures and cerebrospinal fuid CSF examinaton also increase diagnostc yield. b. Culture is regarded as the “Gold standard” in the diagnosis of EPTB but however the decontaminaton techniques of the EP samples are harmful to Mycobacteria thereby bringing down the sensitvity. c. Molecular methods - Gene expert is the only recommended Molecular assay for EPTB. However here again the sensitvity varies widely for diferent EP samples. CSF pleural peritoneal pericardial synovial and pleural samples show low sensitvites on Expert platorms. A recent meta-analysis reported that Xpert MTB/RIF has an overall sensitvity of 83.1 and a pooled specifcity of 98.7 for the diagnosis of EPTB .Others such as Real tme Nested PCRs. NAATs Nucleic Acid Amplifcaton Tests TMA Transcripton Mediated Amplifcaton LCR Ligase Chain reacton LPA LINE Probe Assay and Phage Tek MB assays are stll to be evaluated for EPTB samples. Currently no recommendatons are made for use of PCR in the diagnosis of EPTB. This because of several demanding factors such as DNA concentraton size of target DNA and repettveness of the amplifed sequence choice of primers used and the expertse of personnel involved in conductng the assay. A Quality control study of seven laboratories worldwide showed a false positvity ranging from 0-77. EXTRAPULMONARY TUBERCULOSIS - DIAGNOSTIC CHALLENGES

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 29 d. Antgen detecton tests: 1. Serological tests: can detect mycobacterial antgens in body fuids but require a minimum of 3-20ng/ml of antgen. The commonly detected antgens from EPTB specimens are BCG Lipoarabinomannan LAM Non protein cell wall antgen antgen 5 14kDa antgen A60 45/47kDa antgen cord factor trehalose-6 6_dimycolate. However none of these tests have shown a good sensitvity in paucibacillary EPTB which poses the main diagnostc challenge. 2. Antgen based immunostaining-IHC/ICC: Immunohistochemistry and immmunocytochemistry. Advantage over the ZN as it can detect degraded bacteria while ZN requires intact bacilli. These tests have high sensitvity 70- 100 and specifcity 65-100.Perform well in atypical histology and HIV co infected samples and can be used on for - malin fxed parafn embedded tssues aspirates and body fuids too. The main challenge here is invasive tssue sample collecton and good sample preparaton Due to the above challenges the sensitvity of detecton by direct methods is only 20-25 B. Indirect Methods are Histopathology and Cytology 1. Histopathology: The main issues are the confusing diferentals in histopathological fndings of granulomas and atypical histological features in concomitant immunosuppressive conditons like HIV. In TB endemic countries like India granulomas with or without caseaton having Langhans Giant cells are diagnosed and treated as TB. Challenges are the lack of biopsy facilites in peripheral health care and it’s invasive nature. Incision biopsy is also associated with sinus tract and fstula formatons and therefore biopsies are limited for patents with high clinical suspicion but negatve FNACs Fine Needle Aspiraton 2. Cytology: FNAC is usually the frst line diagnostc test for EPTB in an accessible mass. However here again challenge is to diferentate other granulomatous conditons on tubercular mycobacterial infectons and atypical cytological presentatons in Immunosuppressed conditons such as HIV. The defnite diagnosis of TB has to be done only with concomitant bacteriological examinaton which has a sensitvity of only 20-25. The selecton of the diagnostc procedures depends on the organ of involvement in EPTB. Various methods that include needle biopsy excision endoscopy laparoscopy and biopsies under guidance of ultrasound computed tomography CT or endoscopic ultrasound have been employed to ascertain the diagnosis. Excisional biopsy has the highest sensitvity whereas FNA is less invasive and may be useful. Laparoscopy with target peritoneal biopsy is the current investgaton of choice in the diagnosis of peritoneal TB. In Bone TB CT-guided needle biopsy is the recommended frst approach to obtain tssue for assessment. 3. Body fuid examinaton: 3a. Tuberculous pleurits is an exudate with lymphocytc predominance in about 90 of cases. However polymorphonuclear cells may predominate in patents with symptoms of 2-week duraton. CSF typically reveals a leucocytosis 10-1000×103 cells/ml mostly lymphocytes raised protein 0.5-3.0 g/L and CSF: plasma glucose 50. Pericardial fuid assessment typically demonstrates a bloody exudatve efusion that is ofen predominantly neutrophilic and not lymphocytc. 3b. ADA - Adenosine deaminase enzyme Useful in early TB detecton in endemic countries. High sensitvity in EPTB. Determinaton of ADA isoenzymes and rato of the iso enzymes in body fuids helps in diferentatng various causes especially in borderline ADA levels. ADA-2 is elevated in TB as against other causes such as malignancy. 3c. GLC - Tuberculostearic acid found in femtomoles can be detected using GLC on body fuids for EPTB diagnosis. Issues are false positves and demanding infrastructure. C. Serological tests: 1. Antbody tests for diagnosis of TB have been banned in India. 2. Cellular immunity based tests- 2a. Skin tests-Mantoux – it is based on delayed hypersensitvity response.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 30 Challenges are: • inconsistencies in performance and interpretaton of the test • inability to diferentate between past latent and actve infecton • inability to diferentate between MTB and NTM infectons • False negatves in Immunosuppressed conditons like HIV co infectons 2b.IGRAs Interferon gamma release assays - Negatve recommendatons from WHO to use these assays for the diagnosis of TB and latent TB in low and middle income countries. Very few studies are available on the use of IGRAs in EPTB diagnosis. II. Policy issues- Natonal TB Control programmes in endemic countries does not include actve diagnosis and reportng of EPTB cases. Also the diagnostc work up for EPTB requires good infrastructure and expert personnel for invasive procedures sampling and specialized assays with good sensitvites. These are a challenge in TB endemic countries which come under low and middle income category. III. Challenges in HIV co infectons with TB especially EPTB which is common- EPTB Presentaton in HIV is usually atypical and protean. A high degree of clinical expertse and experience is essental along with availability and accessibility of advanced tests at the primary and secondary levels healthcare systems for the early and accurate diagnosis of EPTB in HIV. The Future: The cornerstone of Global TB control is rapid and accurate diagnosis of all forms of TB. The diagnostc challenges in EPTB HIV and TB and MDR TB have led to WHO FIND Foundaton for Innovatve and New Diagnostcs and the GLI Global laboratory Initatve prioritzing quality diagnostcs which are rapid low cost and easy to interpret with minimum infrastructure. Decentralizing NAAT tests leads to cost savings for both patents and providers as there are fewer investgatons shorter length of hospital stay reduced use of antbiotcs and visit costs. New diagnostc algorithms for the diagnosis of EPTB using assays like Immunochemistry have been validated and these need to be used as a routne diagnostc test. The availability of new guidelines and tools for such tests such as QADAS Quality Assessment of Diagnostcs Accuracy Standards and STARD Standards for reportng of Diagnostcs Acuracy can facilitate implementaton of such algorithms. Conclusions: Extra pulmonary TB is a huge diagnostc challenge faced by low and middle income countries which are also TB endemic countries where advanced and sophistcated molecular tests and drug sensitvity tests are not available widely. However WHO has speeded up the intake of new diagnostc tests which are evidence based. The evidence is provided by diagnostc accuracy evaluatons where accuracy performance is used as surrogate marker for patent-important outcomes. More evidence however is required to evaluate the operatonal efcacy of these tests at the feld level. References: 1. Manju Purohit and Tehmina Mustafa Laboratory Diagnosis of Extrapulmonary Tuberculosis Journal of Clinical and Diagnostc Research 2015 Apr Vol-94:EE01-EE06 2. Ji Yeon LeeDiagnosis and Treatment of Extrapulmonary Tuberculosis Tuberc Respir Dis Seoul 2015 Apr 782: 47–55. Published online 2015 Apr 2. doi: 10.4046/trd.2015.78.2.47

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 31 Dr. H Srinivasa MD Microbiology AIIMS New Delhi Freelance Consultant Microbiologist Infecton Control Bangalore Email: dr.srinivasa.microgmail.com INTRODUCTION Pulmonary TB contnues to be most important chronic infectous communicable diseases contributng to many deaths. More important is that is its socioeconomic impact on family. Compounding on that the person with Pulmonary Tuberculosis can spread to family members by droplet method that persons with weak Immunity .Is this the reason that children with weak immunity are more susceptble Childhood TB can manifest in infancy or in later childhood adolescents. the source may be mother or a family member or in nurseries/preschools or much later in community It is important to realize that TB infecton is diferent from TB as disease. The former indicates only past exposure. Children with frst exposure results in primary infecton which normally resolves with or without antbiotcs for 1-2weeks in most cases. It is those who fail to contain mycobacteria develop post primary tuberculosis. The locaton of disease may not be lungs but more commonly lymphnodes pleura bones etc. thus Paediatric TB is Pulmonary or Extra pulmonary.Those with malnutriton primary TB itself will be severe resultng in miliary TB or TB meningits Diagnosis and epidemiology Of Paediatric TB Recogniton of Paed TB: its diagnosis to treat or not to treat is challenging. When to consider defnite when probable when unlikely good review artcles with IAP recommendatons are available. I am not sure as to whether one should treat hilar Lymphadenopathy in otherwise healthy child or wait and watch is beter. Lab assistance in Paediatric TB careful and correct sampling is important. Sputum is simply not possible Hence gastric lavage is important throat laryngeal swab also yield positves by ZN smear for AFB. Now says gene expert has revolutonized the diagnosis and also provide informaton whether the bacteria is MDR or not. RNTCP guidelines have included in additon to frst sample for smear detecton of DNA. In place of second sample only few cases of drug resistant TB require prolonged drug regimen. PAEDIATRIC TB-TRYING TO UNDERSTAND FROM IC PERSPECTIVE

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 32 In summary we need to closely look at Paediatric TB diagnosis how much is evidence based Whether there is missed diagnosis Or over diagnosis. What is the impact of BCG on evoluton of primary TB its severity if it occurs. Is TB meningits Miliary TB decreasing or stll persistng in certain geographical areas what is the profle of child afected with severe TB as well as family members A study done in India showed that Family members are stll the major source for Paed Tb in more than 50 of cases. Another Study revealed that extra pulmonary TB is overlooked and not diagnosed early in many cases Future Perspectves A close study audit is required to be done by all infecton control practtoners to learn more about the current situaton of Paediatric Tuberculosis. Further impact of treatment Is also equally important References 1. Paeduiatric Tuberculosis a decade long experience K madhava Kamath etal Indian J child health vol 5 issue 2 2018 2. Pediatric Tuberculosis in children in India : A prospectve study Sanjay K Jain Biomed research Internatonal volume 2013

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 33 Dr. Aruna Shanmuganathan MD DNB Professor Department of Respiratory Medicine Chetnad Hospital research Insttute kelambakkam Chennai - 603103 Worldwide tuberculosis TB is among the top ten causes of death the leading cause from a single infectous agent. It is indeed disheartening to know that 2/3rds of the global TB incidence is in 8 high burden countries with India 27 topping the list. The “End TB” Strategy an ambitous vision of the Sustainable Development Goals SDG of the WHO to end the global TB epidemic by 2030 has a tough task to achieve. Drug resistant TB especially Multdrug resistant TB MDR TB poses a great threat in achieving the global targets to end the TB epidemic. Around 558000 cases of Rifampicin resistant TB have been reported with 82 of them being MDR TB. Again 3 countries account for almost half the burden with India followed by China Russia having the largest numbers. In India the percentage of MDR TB in new and previously treated patents is 2.8 and 12 respectvely. The important reasons for MDR TB fuelling the TB epidemic are delay in early diagnosis initaton of treatment poor compliance associated with long treatment regimens higher drug toxicites and the associated co-morbidites like HIV DM malnutriton and alcoholism. Only 1 in 4 MDR TB patents are initated on treatment and treatment success is a dismal 55. Though MDR TB initally was largely a man made problem primary MDR TB due to transmission of drug resistant strains is now being increasingly diagnosed. Drug resistant TB includes RR TB resistance to only rifampicin MDR TB resistance to INH Rifampicin with/ without resistance to other frst line drugs Mono resistance especially to INH and XDR TB MDR TB with additonal resistance to fuoroquinolone and second line injectable. Guidelines for treatment of the same were initated in 2000 by the WHO. In 2006 the PMDT Programmatc Management of Drug resistant TB guidelines replacing the erstwhile DOTS plus services were introduced and regular updates in these guidelines have taken place tll 2017. Introducton and approval of newer drugs with the hope of shortening treatment regimens like Bedaquiline 2012 and Delaminid 2014 and reports of greater success with shorter treatment regimens from countries like Bangladesh Uzbekistan etc lead to suggestons for changes in potental areas in the current guidelines. Hence in 2018 the WHO convened a Guideline Development Group GDP to update its policy recommendatons on the treatment of MDR TB/RRTB. Fresh evidence reviews from recently completed Phase 3 trials of Bedaquiline Individual Patent Data Meta-analysis IPD- MA of patents treated with shorter MDR TB regimens of 9-12 months duratonin comparison to 24-27 months in RECENT UPDATES IN THE MANAGEMENT OF DRUG RESISTANT TUBERCULOSIS

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 34 conventonal MDR regimen and pharmacokinetc data of Bedaquiline and Delaminid in patents less than 18 yrs of age were analyzed. These new recommendatons are now available in the WHO consolidated guidelines on drug-resistant TB treatment 2019. They include signifcant changes as compared to the previous ones 2011-2017. Some of the important recommendatons are discussed here. • Injectable agents like Kanamycin Capreomycin and Amikacin are no longer the priority drugs for longer MDR regimens and thus fully oral regimens are preferred for most patents. • Regrouping of drugs used in the longer MDR regimens has been done 3 groups of drugs as compared to 4 previously. • Fluoroquinolones Levofoxacin Moxifoxacin Bedaquiline and Linezolid Group A drugs are strongly recommended for use in longer regimens. • Ideally all drugs from Group A and 1 or more from Group B are preferred. Group C drugs are listed in the order of preferental use and are to be used only in circumstances when drugs from the above groups cannot be used. • Strong recommendatons are for Bedaquiline use in longer MDR regimens in patents more than 18 yr and consideraton for use in children 6-17yr. Delaminid may also be included in longer regimens for MDR/RR TB for patents above 3 yrs. • Other changes in guidelines include Ethionamide / Prothionamide which were previously recommended are now to be considered only if drugs from groups A and B cannot be used. Clavulanic acid is not recommended for use any more. • Hence the total duraton of the longer individualized MDR regimens would be 18-20 months with at least 4 drugs for the frst 6 months and 3 thereafer based on individual patent beneft and tolerance. The treatment duraton afer culture conversion should be 15-17 months. The recommendatons apply to children adults and PLHIV. The standardized shorter MDR TB regimens of 9-12 months duraton are recommended for MDR TB patents who have not been previously treated or have no resistance to fuoroquinolones and second line injectables. Response to treatment according to the new guidelines would be by monthly culture which translates into more frequent monitoring. The areas where there are no changes as compared to previous guidelines are start of Ant-retroviral therapy with MDR TB treatment use of surgery and models of TB care. In summary the recent update on the management of drug resistant TB focuses on fully oral regimens avoiding injectables shorter treatment regimens and use of newer drugs like Bedaquiline Delaminid. Patent centric care and support with Universal access to rapid diagnosis and DST Drug Susceptbility Testng facilites early initaton of treatment with pre-treatment counseling monitoring response to treatment and actve drug safety are the chief pillars in the management of drug resistant TB. References 1. Global TB Report 2018 – WHO 2. WHO consolidated guidelines on drug resistant Tuberculosis treatment 2019

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 35 Author - Dr Ravikant Dr Sunitha.B.R. Prof Dr. G. Vishwanath Prof HOD Dept of Microbiology J.J.M. Medical College Davangere Karnataka. SUMMARY Background: Epidemic of tuberculosis and HIV is a signifcant problem in developed and developing countries. Tuberculosis is the most common human immunodefciency virus related opportunistc infecton in India. Aim: The aim of the present study was to record the CD4 counts in HIV – TB co infected patents before and afer 6 months of ART. Material and methods: A prospectve study was conducted among HIV-TB infected patents who were initated ART during August 2012-March 2013. 189 TB with HIV diagnosed patents data were taken from CG Hospital treated under NACO guidelines. Follow up of cases done afer six months of duraton with CD4 count. CD4 Count done by Flow Cytometry Method. Results: 189 HIV-TB infected cases enrolled for the study. Of which 7540 were fresh cases of co-infecton and were started on ART therapy. 11460 cases were co-infecton already on ART therapy of age group 14 to 50 years. A large number were diagnosed as having pulmonary tuberculosis. Other diagnosis were lymphnode biopsy- 5 ascites-15 pleural efusion-10 extra pulmonary-70 sputum-84 CSF-5 and total 169 patents were having CD4 count of 200 before ART afer ART CD4 count increased to 300. Conclusion: The manifestatons of HIV-TB coinfected patents are quite varied and showed diferent patern of CD4 count. HIV-TB coinfecton leads to difcultes in both diagnosis and treatment of TB. Early diagnosis of HIV TB coinfecton with initaton of early ART reduces the mortality and morbidity. Key words: Tuberculosis HIV co-infecton Introducton Tuberculosis is a common cause of morbidity and mortality in patents infected with HIV infecton and increases the risk of both primary and reactvaton of tuberculosis 12 . Most of the patents with co-infecton have advanced HIV disease as defned by low CD4 counts and high viral loads 123 . Tuberculosis is critcally dependent on the presence of CD4 counts 34 . There is consequently an increased risk of progression to AIDS and death 45 . The dual epidemic of HIV-TB is a signifcant problem in developed and developing countries. The incidence of HIV- TB coinfecton is about a hundred fold than that in general populaton 23 . It is estmated that 60-70 of HIV positve COMPARISON OF CD4 COUNTS IN HIV-TB CO-INFECTION BEFORE AND AFTER ART - ORIGINAL ARTICLE

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 36 persons will develop TB in their life tme 78 . Around 50 of patents are infected with Mycobacterium tuberculosis and spread of HIV infecton leading to increase in number of cases of TB 234 . Tuberculosis is the only major opportunistc infecton in HIV infected individuals spread through the air from a HIV positve person to a HIV negatve person 567 . HIV seropositve persons infected with tuberculosis is 30 tmes more likely to develop TB disease than someone who is TB infected but is HIV seronegatve. HIV –tb is more difcult to diagnose due to several reasons including negatve sputum smears atypical radiographic fndings higher prevalence of EPTB 4568 . Aim: aim of the present study was to record the CD4 counts in HIV – TB co infected patents before and afer 6 months of ART. Materials and Methods: A prospectve study was conducted among HIV-TB infected patents who were initated ART during August 2012-March 2013. 189 TB with HIV diagnosed patents data were taken from CG Hospital treated under NACO guidelines. Follow up of cases done afer six months of duraton with CD4 count. HIV infecton was diagnosed using rapid kit tests like COMBAIDS TRISPOT TRILINE. CD4 Count done by Flow Cytometry Method. Specimen collecton: With strict aseptc precautons 3ml of venous blood sample was collected by venepuncture using EDTA vacutainer and processed. Procedure: CD4 count by fow cytometry was performed according to the standard protocol supplied by the man- ufacturer. PARTEC IVD FLOW CYTOMETER machine by Partec Gmbh. Am Flugplatg 13. D-02828 Gorlitz. Germany. Following investgaton were done to diagnose to TB: 1. Ziehl-Neelsen staining of sputum for AFB from given samplewas performed as per RNTCP guidelines. 2. The diagnosis ETPB was based on features suggestve of TB with supportve evidence in the form of pleural ascitcfuid lymphnode biopsy and radiographic fndings. Results: 189 HIV-TB infected cases enrolled for the study. Of which 7540 were fresh cases of co-infecton and were started on ART therapy. 11460 cases were co-infecton already on ART therapy of age group 14 to 50

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 37 years. A large number were diagnosed as having pulmonary tuberculosis. Other diagnosis were lymphnode biopsy- 5 ascites-15 pleural efusion-10 extra pulmonary-70 sputum-84 CSF-5 and total 169 patents were having CD4 count of 200 before ART afer ART CD4 count increased to 300. A large number of patents were diagnosed as having PTB on the basis of sputum smear microscopy and X-ray fndings. Discussion: TB is the most common opportunistc infectons in HIV infected patents in developing countries. The screening for TB is recommended for all patents with HIV infectons to identfy patents with actve disease 1234 . Unlike other opportunistc infectons TB can occur at any stage of HIV disease and its manifestatons depend largely on degree of immunosuppression 456. When the CD4 count was 200cells/cumm the disease was more likely to be upper lobe open cavitory /infltratve disease as immunosuppression increased atypical pulmonary and EPTB became progressively more common 5678 . TB leads to an increase in HIV replicaton and accelerates progression of HIV infecton with high mortality. Early initaton of ART results in a reducton in mortality among patents with TB who do not receive ART those with very low number CD4 have a high short term risk of death 4589 . WHO recommends that ART to be started within the frst 8 weeks afer the initaton of ATT and that patents with CD4 count 50cells/cumm receive ART within frst two weeks 51011 .

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 38 Conclusion: The manifestaton of HIV-TB infected patents are quite varied and showed diferent patern of CD4 counts. High degree of suspicion of TB with acute clinical and laboratory fndings is the key for early diagnosis and management. Tuberculosis is the most frequent opportunistc infecton within the frst three months afer ART. Regular CD4 count monitoring of patents before ART initaton as well as earlier HAART initaton reduces death and also incidence of TB mortality. Initaton of ART at low CD4 counts early diagnosis and treatment of TB among HIV patents will have signifcant clinical and public health benefts. References: 1. Badri M wilson D Wood R .Efect of highly actve antretroviral therapy on incidence of tuberculosis in South Africa: a cohort study . Lancet 2002:3599323:2059-64. 2. Santro-Lopes G Felix de Pinho AM Harrison LH Schechtor M. Reduced risk of tuberculosis among Brazilian patents with advanced human immunodefciency virus infecton treated with highly actve antretroviral therapy. Clin Infect Dis 2002:34:543-46. 3. Nicholas S Sabapathy KVaraine F Rodriguez M P . Incidence of tuberculosis in HIV infected patents Before and Afer Startng Combined Antretroviral Therapy in 8 sub –Saharan African HIV Programs.J Acquir Immune Defc Syndr 2011:57:311-318. 4. Ong C KTan W CLeong K NMutalif A R.Tuberculosis-HIV Coinfecton: The Relatonship Between Manifestaton Of Tuberculosis And The Degree Of Immunosuppression CD4 Counts. IeJSME 2008:22:17-22. 5. Kwara A Flanigan T P Carter E J.Highly actve antretroviral therapyHAART in adults with tuberculosis: current status. Int J Tuberc Lung Dis 2005:93:248-257. 6. Sunkanuparph S Vibhgool A Mootsikapun P Chetchotsakd P Tansuphaswaswadikul S Bowonwatanuwong C. Opportunistc infectons afer the initaton of highly actve antretroviral therapy in advanced AIDS patents in an area with a high prevalence of tuberculosis.AIDS2003:1714:2129-31. 7. Anthony. s. Fauci H. Chifordlane Humanimmuno defciency virus disease AIDS Related Disorders In: Lango D. LLasper. D. Ljameson. J. LFAUCI. A. L Hauser. S. LLoscalzo. j Elsevier Harrisons Principles of Internal Medicine 17th ed vol 1London 2008 pg no1137-1203. 8. Lawn SDBekker LGMiller RF.Immune reconsttuton disease associated with mycobacterial infectons in HIV- infected individuals receiving antretrovirals. Lancet Infect Dis 2005: 56 :361-73. 9. Collee J G Fraser AG Marimon BP Simmons A. Mackie McCartney Practcal medical microbiology 14th ed Elsevier London. 2012 10. Anthony. s. Fauci H. Chifordlane Humanimmuno defciency virus disease AIDS Related Disorders In:Lango D. LLasper. D. Ljameson. J. LFAUCI. A. L Hauser. S. L Loscalzo. j Elsevier Harrisons Principles of Internal Medicine 17th ed vol 1London 2008 pg no1137-1203. 11. Ghate M Deshpande S Tripathy S Nene M Gedam P Godbole S et al. Incidence of common opportunistc infectons in HIV-infected individuals in Pune India: analysis by stages of immunosuppression represented by CD4 counts. Int J Infect Dis : 200913:e1-e8.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 39 Dr. Nazia Khanum M.D Microbiology MHA SMU Clinical Microbiologist Assistant consultant Infecton Control Infecton Preventon Control Department KSMC Riyadh Email: drnaz.khangmail.com In the recent past there were multple reports of patents and healthcare workers who acquired tuberculosis infecton in a healthcare setng one of the reasons being some specialtes are less likely to make an early diagnosis of TB leading to delays in airborne isolaton 1 . It is very likely that TB transmission in healthcare setngs frequently goes undetected therefore in 1994 CDC published extensive guidelines recommended to prevent healthcare-associated TB transmission as “TUBERCULOSIS CONTROL PLAN” which was revised in 2005 2 to “a multlevel interventon strategy” which include recommendatons for laboratories and additonal outpatent and nontraditonal healthcare setngs and in 2009 the WHO published similar recommendatons. These guidelines include expanded measures aimed at reducing incidence of TB and eliminatng TB transmission from undiagnosed patents to HCP . The efectveness of these protectve interventon strategies is dependent on HCP recognizing and isolatng patents with pulmonary TB. A deviaton from the CDC protocols due to the delay in identfying and diagnosing TB or placing patents with suspected TB under appropriate isolaton precautons places not only other patents but also HCP at high risk of developing actve TB. 4 and has been associated with an increased rate of TST conversion marker of TB infecton. As per these guidelines Control measures should be undertaken for patents who are likely to be contagious. Patents with pulmonary or laryngeal disease or suspected disease are considered contagious. Most patents with extrapulmonary TB are not contagious because the organism is not aerosolized Except during aerosol producing procedures like for example irrigatng cutaneous wounds caused by MTB or during the performance of autopsies on patents with extrapulmonary TB. The various control measures are administratve controls environmental control PPE and others. TUBERCULOSIS PREVENTION IN HEALTHCARE SETTINGS

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 40 CDC and WHO Recommendatons for Preventng TB Transmission in Healthcare Setngs CDC2 WHO3 Administratve controls • Assign responsibility for TB infecton control • Develop facility plan for TB control promote local coordinatng bodies for TB preventon/control • Conductng TB risk assessment • Optmize use of available spaces and consider renovaton or additonal constructon to optmize implementaton of controls • Disseminate writen TB infecton control plan to detect isolate airborne and treat suspected or confrmed TB cases • On-site surveillance of TB among HCP assess the facility • Timely availability testng and reportng of testng to infecton control and ordering provider • Advocacy communicaton and social mobilizaton for patents HCP and visitors • Efectve practces for management of suspected or confrmed TB cases • Evaluate and monitor TB control measures • Proper cleaning and disinfecton of contaminated equipment • Partcipate in research • Train HCP on TB preventon transmission and symptoms • Triage separaton of TB patents infecton control strategies cough etquete/ respiratory hygiene and decrease tme in healthcare facility Administratve controls • Screening and management program of HCP at risk for with or exposed to TB • Preventon of HIV for HCP ART for those who are positve and LTBI and TB treatment • Use epidemiology-based preventon principles such as using setng related infecton data • Rapid testng shorter turnaround tme of testng parallel rather than sequental investgaton of cases and use of algorithms • Use signs advising proper infecton control practces i.e. respiratory hygiene and cough etquete • Coordinate with local or state health department eforts to control TB Environmental controls/ personal protectve equipment • Develop and implement a respiratory protecton program • Use of respirators • Train HCP on respiratory protecton and patents on respiratory hygiene and cough etquete • Ventlator systems: ideally 12 air exchanges per hour • Use and availability of negatve-pressure rooms based on risk assessment ongoing monitoring of negatve- pressure ventlaton rooms • UV light irradiaton when appropriate/ ventlaton not available • UV light may be used in additon to appropriate ventlaton Additonal comments Infecton preventon interventons are based on pre- defned risk assessments which place setngs in one of three categories: low risk medium risk or ongoing trans- mission. Need for HCP PPD screening is defned based on these categories. Includes elements of TB preventon not only in the healthcare setng but also at the natonal and subnatonal levels.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 41 ADMINISTRATIVE CONTROLS: Administratve controls are the most important part of a TB control plan it consists of the policies and procedures used to identfy patents with potental TB as rapidly as possible so that they may be appropriately isolated and other controls initated. Administratve controls in outpatent areas: The emergency room and clinic areas should have plans for placing the suspected patent in a separate area from other patents and placing a surgical mask on him or her untl appropriate isolaton can be arranged. Administratve controls in Inpatent areas: Airborne Infecton Isolaton All Room Once the decision to place the patent in Airborne Infecton Isolaton All Room has been made patent and family educaton is important. The patent should understand why isolaton measures are required. Even if the patent is in an appropriate isolaton room he or she should be instructed to cover the mouth with a tssue when coughing to minimize the number of organisms released into the air. Release from Air borne Infecton Isolaton AII Room: Patents with suspected TB may be released from AII once TB has been adequately excluded as a possible diagnosis. The decision depends in part on the clinical suspicion for TB. If there is low clinical suspicion but stll enough to do an evaluaton the patent may be moved from All once three sputum samples are negatve for AFB on smear. If however there is a high clinical suspicion for TB the patent must remain in isolaton even if three sputum samples are AFB smear negatve. The patent may have All discontnued if an alternatve diagnosis is found and TB ruled out. Isolaton for hospitalized patents with pulmonary TB may be discontnued when the patent has been on the appropriate treatment for at least 2 weeks has had a good clinical response e.g. resoluton of fevers and cough and has had three consecutve negatve AFB smears. ENVIRONMENTAL CONTROLS5: Preventng the fow of infectous airborne partcles from the patents room by the use of negatve pressure ventlaton and reducing the concentraton of airborne partcles by means of frequent air exchanges are cornerstones of TB engineering control. All rooms for TB patents should be at negatve pressure relatve to the hallway so that air fows from the hall into the room . A minimum of 6 to 12 air exchanges an hour is recommended to reduce the concentraton of infectous airborne partcles The air from an All room should be directly vented outside in a locaton that prevents it from re-entering the facilitys ventlaton system. If recirculaton of the air is unavoidable then the air must be fltered through a high-efciency partculate air HEPA flter to remove droplet nuclei before the air re-enters the main ventlaton system.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 42 The door to the patents room should be kept closed at all tmes to maintain proper negatve pressure and airfow. The All room should have an automatc door closer installed and a permanent visual monitoring system to ensure that negatve pressure is maintained. The TB control plan should provide for daily monitoring for rooms used for AII in patents with known or suspected TB. Regular monthly inspecton and testng of all AII rooms to verify and document proper negatve pressure so the rooms are always ready to receive TB patents. The admissions ofce and infecton preventon should be notfed of rooms that fail testng so that they will not be used untl repairs are made. Changes in the facilitys ventlaton system should be made in consultaton with the infecton preventonist to ensure that the need for AII rooms is met. Ultraviolet germicidal irradiaton UVGI may be used as an adjunct to negatve-pressure ventlaton and high airfows. UVGI is bactericidal for MTB but proper placement is critcal for its efectveness. Concerns over the use of UV lights include the possibility for sunburn skin cancers and cataracts in HCP with frequent exposure to the lights. If UV lights are in place they must be monitored and maintained appropriately to ensure the safety of the patent and HCP . UV lightng alone is not acceptable to control airborne spread of MTB PERSONAL RESPIRATORY PROTECTION: Personal respiratory protecton consists of wearing a respirator or other protectve device to prevent the inhalaton of infectous droplet nuclei. Currently the U.S. Occupatonal Safety and Health Administraton OSHA have mandated that HCP who may be exposed to TB must wear respiratory protecton that meets at a minimum the N95 ratng. Fit testng should be performed to ensure a tght facial seal before entering the AII room. HCP should not remove the respiratory protecton untl they are outside of the AII room. HCP must be trained in proper use handling and storage of the respirator and ft tested to ensure that the respirator provides an adequate face seal so that inhaled air comes through the flter rather than around the sides. Annual ft testng is mandatory under OSHA regulatons 6 and recommended in current CDC guidelines for preventng transmission of TB. Annual ft testng can also serve as an efectve training tool when included in infecton preventon training for HCP . The healthcare facility should purchase several types and sizes of N95 respirators so that a seal can be achieved for a variety of face types. If an employee cannot be properly ft tested with an N95 respirator he or she may use alternatve respiratory protecton such as a powered air purifying respirator PAPR with an appropriate partculate flter. INTRAFACILITY MOVEMENT OF TUBERCULOSIS PATIENTS: Patent transport should be limited. If the patent must leave the room he or she should be instructed to wear a surgical mask. Surgical masks were designed to prevent the spread of partcles from the patent into the air. If the patent is contnuously wearing a surgical mask HCP in the area may not need to wear N95 respirators. However because the patents proper use of the mask cannot be guaranteed respirators should be considered for HCP in the procedure and test areas. Operatng room: Electve procedures on patents with known or suspected TB should be deferred untl the patent can be removed

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 43 from All either because TB was ruled out or because the patent has been treated and otherwise meets criteria established by the healthcare facility. If a procedure cannot be delayed an efort must be made to minimize the risk of transmission to HCP in the operatng room OR. a. The surgical procedure should be the last of the day b. Minimize the number of HCP in the area. If possible the c. Patent should be intubated in an All room and brought directly to the OR-not permited to linger in a preoperatve holding area. An antbacterial flter should be placed on the endotracheal tube or at the expiratory side of the ventlator circuit. d. OR personnel should wear N95 respirators. e. The patent should be taken to an All room before being extubated. f. If this is not possible the patent may recover in the OR. A portable HEPA flter may be used in the OR during intubaton and extubaton to supplement air cleaning but should not be used during surgery. So if the patent is intubated or extubated in the OR the doors may not be opened untl the amount of tme required to remove 99 percent of airborne contaminants is reached. PREVENTION AND CONTROL OF NONTUBERCULOUS MYCOBACTERIA INFECTIONS 7 Surveillance plays an important role in early recogniton and identfcaton of outbreaks and pseudo outbreaks caused by NTM. Because NTM infectons may be difcult to diagnose the recovery of a single NTM isolate from a surgical patent dialysis patent or sterile site should prompt further investgaton to ensure that additonal cases have not gone unrecognized. Because NTM are not typically spread person-to-person there is no need to follow anything other than Standard Precautons. References: 1. Harris TG Sullivan Meissner J Proops D. Delay in diagnosis leading to nosocomial transmission of tuberculosis at a New York City health care facility. Am J Infect Control2013 Feb412:155-160. 2. Jensen PA Lambert LA lademarco MF et al. Guidelines for preventng the transmission of Mycobacterium tuberculosis in health-care setngs 2005. MMWR Recomm Rep2005 Dec 3054RR-17:1-141. 3. Sehulster LM Chinn RY Arduino MJ et al. Guidelines for environmental infecton control in healthcare facil ites: recommendatons of CDC and the Healthcare Infecton Control Practces Advisory Commitee HICPAC. CDC website. 2003 : htp://www.cdc.govlhicpaclpdfquidelinesleic in hcf 03.pdf. 4. Grifth DE Hardeman JL Zhang Y et al. Tuberculosis outbreak among healthcare workers in a community hospital. Am J Respir Grit Care Med1995 Aug1522:808-811. 5. Sehulster L Chinn RY CDC et al. Guidelines for environmental infecton control in health-care facilites. Recommendatons of CDC and the Healthcare Infecton Control Practces Advisory Commitee HICPAC. MMWR Recomm Rep2003 Jun 652RR-10:1-42 6. U.S. Department of Labor Occupatonal Health and Safety Administraton OSHA. OSHA website. Standard 29 CFR 1910.134f2 Standard Interpretaton: Tuberculosis and Respiratory Protecton Enforcement. Available at: htp://www.osha.govlplsloshaweblowadisp.show document p tableINTERPRETATIONSp id26013. 7. Jose A Cadena MD Chapter-9Tuberculosis and Other Mycobacteria I Healthcare-Associated Pathogens and Diseases APIC Text 4th editon. Washington DC 20005 2014

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 44 Dr. Joven Jebio Ongole Sharon Fynn Dr. Gregory Jagwer Specialist Family Physician Department of Family Medicine University of Pretoria. TB Manager Department of Health eThekwini District. Chief of Party USAID TB SA Project Confict of interest: None Abstract: Introducton: In July 2018 South Africa introduced the injecton free bedaquiline based treatment regimen to replace the kanamycin-based regimen for drug-resistant DR TB. With support from the USAID Tb South Africa Project eThekwini district with the highest burden of DRTB in South Africa rapidly decentralised DR-TB care from an inital three centralised admission TB Hospitals to 18 peripheral district community health centres and clinics to improve access while focusing on ambulatory care as opposed to insttutonalized hospital based care. The ambulatory model of care meant patents where managed within their households and thus communites while on treatment. An efectve infecton control in the household and community was implemented to prevent and control infectons among families and close contacts. Afer six months 98 of the patents remained in ambulatory care and no transmission recorded among close contacts This publicaton shares interventons used and early outcomes from this interventon. Method: A DR-TB care package was developed and adapted to each of the identfed decentralised facilites and implemented in three layers. This include an orientaton package for facility leadership to ensure appropriate governance leadership and management for DRTB care at facility level DRTB care package for DRTB providers and facility teams DRTB teams and a DRTB service package for the community functonally linked to the facility interventons. Training systems mentorship and support supervision were the main interventons implemented. Results: Between Oct 2018 – Mar 2019 16 of the 18 decentralised sites in eThekwini District adapted the DRTB care package and consttuted their DRTB teams. Within the six months a total of 142 patents were initated on treatment of which 139 98 remained in ambulatory care by the end of March 2019. Three patents with advance disease died in the frst month of enrolment. Of the 142 index patents 211 contacts of were screened 44 at home COMMUNITY INFECTION CONTROL IN THE CONTEXT OF INJECTION- FREE REGIMEN AND DECENTRALISED AMBULATORY CARE: SIX MONTH FOLLOW OF DR-TB CASES IN DECENTRALISED FACILITIES ETHEKWINI DISTRICT SOUTH AFRICA.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 45 56 at the facilites 85 of the patents culture converted in the frst month 3 contacts were diagnosed with TB 2 drug sensitve 01 drug resistant. No transmission occurred in contacts afer enrolment into DRTB care. Conclusion: The possibility of transmission of infecton to DRTB contacts exist among patents placed in ambulatory care. However among the patents that were provided with the DRTB care package in eThekwini District there was no transmission associated with the index patents. It is thus recommended that infecton control interventons that starts from facility is extended to the communites using systematc and applied interventons specifc to the communites and facilites be scaled as cost efectve and efcient interventon for DRTB in high burden locatons. Community Infecton Control in The Context of Injecton-Free Regimen and Decentralised Ambu- latory Care: Six Month Follow of DR-TB Cases in Decentralised Facilites eThekwini District South Africa. Background: South Africa is one of the countries with the highest TB caseload in the world. According to WHO 2018 report the country notfed 227224 cases of drug sensitve TB and 7700 of drug resistant TB in 2017.227 224 The country piloted a decentralised MDR-TB care programme in 2008 in Kwa Zulu Natal and Western Cape the two provinces with the highest incidence of TB disease. The successes and lessons learnt in these piloted programmes as well as internatonal experience informed the natonal policy framework on “Decentralised” and “Deinsttutonalised” management of Mult-Drug Resistant Tuberculosis MDR-TB services launched in 2011. Since then South Africa has had a remarkable progress in operatonalising the natonal policy framework of the decentralised MDR-TB services with over 651 MDR-TB treatment initaton sites 1 decentralized to date and the the number of patents treated for MDR-TB increased from 5313 in 2010 to 11119 in 2016. The Treatment Success Rate improved from just below 40 to 54 2014 cohort 2. The implementaton of the decentralisaton programme is province specifc however aligned to the natonal policy framework on decentralised and deinsttutonalised management of MDRTB1. Further South Africa introduced the “injecton free” bedaquiline based DR-TB treatment regimen that replaced the kanamycin-based regimen in July 2018. Shortly afer this policy change eThekwini district with the highest burden of TB embarked on an aggressive expansion of DRTB care to improve both geographic and technical access and availability at local health facilites. This was done in line with SA policy on decentralisaton and insttutonalisaton of DRTB in the country. The district rapidly scaled DRTB care from the inital three sites one centralised centre of excellence and two decentralised with admission facilites to 16 facilites without admission facilites. This publicaton shares the approach used to strengthen infecton control in the facility homes and community in the context of ambulatory care. The goal was to prevent infecton among close contacts through the provision of DRTB package of care home visits and partnership with local community-based organisatons and families. Methods: The DR-TB care was introduced in decentralised facilites and implemented in three layers. Orientaton package for facility management DRTB care package for DRTB providers DRTB teams and DRTB service package for the community. Training mentorship and support supervision were the interventons implemented. Approach: To provide community infecton control four facility customised interventons were implemente 1. The DRTB care package: The operatonal package defnes the roles of site providers and teams as a whole based on the conventonal health and community systems strengthening approach including strengthened governance management leadership and coordinaton of DRTB care. The DRTB teams are provided with skills and

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 46 experience to conduct DRTB clinical audit on regular basis. The package provides for the educaton and empowerment of the index patent on DRTB ambulatory care HIV care if applicable infecton control and interacton with contacts. This package has ten components and targeted the facility management health care workers specifcally DRTB team and community health workers and the index patent. The interventon package provided facility managers with skills and knowledge of DRTB outline specifc roles in implementng DRTB and identfed resources required to support DRTB implementaton. It provided DRTB implementaton teams physicians nurses social workers dietcians physiotherapist pharmacist clinical associates data capturers and community health workers capacity to strengthen DRTB services systems orientated operatonal package to systematcally manage MDRTB patents utlise available resources and infrastructures develop site-specifc functonal and bi-directonal referral pathways that enabled a contnuum of response based on the DRTB care cascade from above site and into the community. The package also enabled informaton management through appropriate documentaton in the clinical records correct registraton and reportng and translatng manual records into an electronic Drug-resistant web-based register. 2. The Home Visit: Home visits provide a crucial step in controlling infecton control in the household and immediate neighbourhood. This actvity is coordinated by a TB focal nurse in the team and involves nurses social worker and community health workers. Six critcal actvites are implemented which includes infecton control in the household separaton of sleeping space for patent screening and monitoring of contacts for TB and HIV assessment of social and economic status and needs educaton and counselling of family and screening of neighbours. The assessment is conducted in the household and at least fve neighbouring houses to the north south west and east. This is done in accordance with the department of health guidelines on infecton control in the urban community setng and diferent team members play roles depending on the interventon. Figure 1: DRTB home visit service package

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 47 3. Partnership and strengthening of structures in the community: This interventon is used for tracing DRTB cases lost to follow-up contact tracing infecton control screening and monitoring contacts for HIV and TB family counselling and educaton and screening neighbours and ensuring separaton of sleeping spaces at home. In 12 facilites the DRTB teams included community health workers CHWs who worked within the community to ensure the contnuity of care. In two sites the community caregivers CCGs from community-based organisatons linked the facility services in the community they serviced. Both CHWs and CCGs have the same scope of work. Those recruited by Government and place at facilites are referred as CHWs and those based in the community organisatons are referred to as CCGs. Thus the approach remained similar whether the CHWs or CCGs were deployed to ensure contnuity of care in the communites. Coordinated by TB focal nurse the DR-TB cases for tracing and home visits are identfed by the facility and list given to the CCGs/CHWs during the weekly briefng and debriefng session. During these sessions the tasks were assigned and feedback is provided. Results: Sixteen of the planned 18 DRTB sites in eThewkini District were functonally decentralised between October – December 2018. Of the 16 facilites four were hospitals and 12 primary health care PHC centres. Cumulatvely by the end of March 2019 a total of 142 patents had been initated on treatment with a retenton rate of 98 2 died in the frst month one defaulted at 4 months. Despite four sites not having partcipated in the home visit 91 of the enrolled patents were visited at home and provided DRTB service package of care for a home visit. By March 2019 these new decentralised sites initated and monitored 142 patents with 98 of them placed on ambulatory care. The patents remained in their homes and communites throughout the treatment period. Community infecton control was the central in ambulatory care and was provided implemented from the facility through to community. Figure 2:cumulatve DRTB initatons in decentralised sites

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 48 The 6 months result is summarized in the table below. Table 2: fndings in DRTB patents initated at decentralised sites in 3-6 months Discussion: Decentralisaton in eThekwini District has increased access to care for MDR-TB patents and expanded MDRTB care into communites. DRTB care expanded to 16 of the 18 health facilites and improved access to DR-TB treatment care and support from the local facility by 89 and ambulatory care to 98 of patents. Unlike PHCs the hospitals do not have a direct link to the community and lack CHWs in their staf compliment to conduct the home visits. Thus the hospitals refer patents to the feeder clinics Community Health Centre and Clinics who in turn take responsibilites to conduct home visits. Access to DRTB service package of care to the family and community was important for infecton control interventons and retenton of patents into care. The risk of transmission of TB to contacts was very low and all three contacts one drug-resistant and two drug-sen- sitve TB who were infected occurred prior to treatment of index patents. The transmission therefore occurred prior to the initaton of treatment. The contacts were followed over 3-6 months and no further transmission have been registered. The absence of transmission in patents on treatment is explained by several factors. First all patents who were diagnosed were placed on treatment. Since the diagnosis is by Genexpert these patents were initated early on treatment and therefore provided early infecton control interventons. Secondly these patents received injecton free regimen of seven drugs which comprise four core drugs be- daquiline clofazimine levofoxaccin linezolid and three companion drugs high dose isoniazid ethambutol pyrazin- amide. All the core drugs in the regimen are bactericidal and sterilising and in additon bedaquiline actvely pene- trates lung cavites. Along with companion drugs the regimen kills and clears bacilli from the lungs in a few days and renders patents non-infectve despite coughing. The regimen suppressed cough in 84 of patents in the frst week and 85 of the DR-TB patents culture converted in the frst month. The early suppression of cough as well as the culture conversion played an important part in the curtailing transmission to contacts. Secondly implementng DRTB home visit service package provided the families with interventons like infecton control family educaton and counselling contact screening and separaton of sleeping space that reduced the risk through behavioural change and practces.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 49 Lastly the home environment provided an open space for the family to spend tme outside. The outside environment is supported by nature specifcally wind and sunlight to disperse and kill bacilli respectvely. The risk of transmission of TB is signifcantly reduced in a home setng and encourages ambulatory care. Conclusion: The results confrmed that the risk of transmission of infecton is low among DR-TB patents in ambulatory care. The implementaton of DRTB service package of care from the facility early diagnosis prompt initaton of treatment infecton control etc to DR-TB home visit service package in the house household and community are complementary in ensuring a reducton in the transmission of infecton. Therefore decentralised DRTB services should focus on ambulatory care but ensure infecton control through a specifc facility and home-based care package. The package provides holistc DRTB care by building the capacity of the community and health insttutons health care workers patents families and communites. Recommendaton: We recommend systematc implementaton of DRTB care package and DRTB home service care package interventons to achieve community infecton control in ambulatory care setngs. This approach strengthens both facility and community systems through a series of locally adapted interventons that control TB infecton and reduced transmission to contacts. References 1. Summary report on Decentralised and Deinsttutonalised Management of Mult-drug resistant Tuberculosis services in South Africa. June 2018. 2. Global tuberculosis report 2018. Annex 2 Country profles for 30 high TB burden countries. TB publicaton. World Health Organisaton. 3. Interim clinical guidance for the implementaton of injectable free regimens for rifampicin resistant tuberculosis in adults adolescents and children. Department of Health Republic of South Africa. Sep 2018.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 50 Amungwa Athanasius NchePhD Public Health Expert. Lectuer St.Jude University Insttute and Public Health Consultant to Cameroon Baptst Conventon. Certfed Infecton Preventon trainer Supervisor and Trainer Member of the Internatonal Sciety of Hypertension. Email: athanestherhawgmail.com Abstract Introducton Infecton preventon is a public problem that needs a health-oriented approach to scale down infecton in health facilites and in the communites. Also poor infecton preventce practces can increase the incidence and prevalence of infectous including co-infectons such as HIV and TB. Methodology This artcle is a by-product of the evaluaton of one of Cameroon Baptst Conventon’s projects. Using JHPIEGO’s 32 infecton preventon indicators we evaluated the infecton preventon statuses of 32 of its 127 facilites in rural and semi-urban areas in the Northwest and Southwest Regions of Cameroon. Findings 18N32 56.25 were in the Northwest and 143243.75 in the Southwest Regions. 26N-32 81.5 of the health facilites had and efectvely used very deed placenta disposal pits. Some culture-minded community members stll took placentas home for ritual burying for cutursal reasons. The remote areas of health facility-locaton faced enormous water problems so CBC invented an efectve pitcher from recycled plastc drug cups to circumvent 15N47 stll burned refuse openly a practce prohibited by WHO while 17N53 disposed of refuse correctly as per WHO guidelines. Staf lacked decontaminaton 49.5 Cleaning instruments67.5 High-level disinfecton69 and Housekeeping 77.5skills because we set the clinical acceptable level of performance at 80 to ensure quality care in CBChealth facilites and hospitals in seven of Cameroon Regions. Recommendatons for downscaling infecton 1. Training soluton of a fve-day infecton preventon course necessary to all staf in the feld including feld supervisors to scale up the quality of infecton preventon service provision. 2. Make an extra efort to reduce air polluton by practsing closed burning of refuse. 3. Clinical psychologists or cultural communicators should be charged to sensitze communites against the hazardous cultural ritual disposal of placentas at home withouth clinical supervision. INFECTION PREVENTION IN COMMUNITY HEALTH FACILITIES IN THE NORTHWEST AND SOUTHWEST REGIONS

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 51 4. The CBC should contnue to use and expand its best practce of designing hand washing devices from used plastc drug cups for use in remote health facilites with no tap water. Conclusion The worldwide concepts of infecton preventon should be applied by all health systems to scale down hospital-acquired infecton including the co-infectons of HIV and TBspreadable from community to community. To do this staf capacity building is necessary to handle infecton control issues both in the community and health facilites. This evaluaton of infecton preventon practces between two categories of infecton preventon providers in 32 health facilites has shown that supervisors of staf in the feld need to be monitored and evaluated to ensure quality infecton preventon services in health facilites and in the community. 1. Introducton Barbara A 2007 defnes infecton as an invasion of the body by disease pathogens that can be spread between humans and within communites. WHO’sdisease preventon guidelines indicate that handwashing the use of personal protecton equipmentPPE cleaning disinfecton disposing of solid and liquid waste and taking care of medical equipment protect the body against pathogenic invasion including HIV and TB. Based on these WHO guidelines and within the context of a project the writer in the capacity of a consultant worked with Cameroon Baptst Conventon to evaluate disease control statuses of some 32 remote health facilites and environments in Northwest and Southwest health districts. 2. Literature Review WHO2011 defnes disease preventon as using simple efectve and cost-efectve strategiesto break pathogenic invasion of the body causing diseasespreadable from person to person and community to community that health care providersshouldblock pathogens from invading the body when treatng broken skins or cuts and from such invasion to spread to other people and comunnites. WHO strongy advised the use of BBB burn bury and bin efcienty and correctly.Linda T Wendy C and Noel M.1992 and WHO 2011 conceived the following universal infecton preventon IP measures to be used worldwide. 1. Considereverybody you meet as infectous client personnel 2. Wash hands commonest IP measure worldwide. 3. Personal Protecton Equipment PPE such as gloves goggles face masks and aprons boots are madatory against splashes of secretons and excretons including TB cough secretons andglovingis considered as the commonest PPE measure. 4. Safe practces don’t reuse or recap needles don’t tatoo or scarify the bidy 5. Processing instruments decontaminate clean disinfect correctly. Linda et al 1992 seriously promoted the above WHO guidelines along seven principles: 1. Hand washing which removes at least 70 of pathogens from the hands 2. Proper gloving for all clinical risks 3. Limited pelvic examinatons because each pelvic examinaton carries a high risk of infecton to the woman being examined 4. Using auto-disable or disposable syringes and needles:Re-sterilizaton should be done with the utmost care only in resource poor communites

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 52 5. Wiping working surfaces with 0.5 chlorine soluton is a WHO-proven standard to properly kill germs including HBV HIV and TB 6. Disposingsingle-use equipment and supplies properly and safely: Each health facility is requested to use sharps boxes and dispose them properly when they are three-quarters full and 7. Eliminatng wastes properly and safely in pits lidded plastc bins incinerators for burnable waste with supervision needed. JHPIEGO 1997 stated that10 surgical patents in developing countriesacquirepost operaton infecton and that 20 Africa woman undergoingCaesarean Secton acquired infecton. JHPIEGO 1997 stated that worldwide drugresistance seriously threatensthe ability to treat several common infectons including HIV and TB while JHPIEGO 2007 stated that HAIs are of public health concern and are promoted by urinary tract infecton bloodstream infecton surgical operaton ventlator-associated pneumonia multdrug-resistant infectons infectous diarrhoea and clostridium difcile infectons and went on to state that the cause of HAIs in resource-limited setngs stems from high patent -to - nurse rato bed space less than 1 metre apart inconsistent hand hygiene lack of infrastructurefor isolatng and cohortng patents with same infectous diseases inadequacy of trained infecton preventon providers increasing use of sophistcated difcult- to- use medical and health care equipment going for more invasive procedures improper handling of health care packs which may favour infecton spread substandard cleaning disinfecton and sterilizaton measures and overuse of broad-spectrum antbiotcs leading to antbiotc resistance. CDC 2018 added that 5 of hospitalized patents will acquire a preventable and controllable. Healthcare-associated infectonif the following measures are not efectvely and efciently applied: 1. Hand Hygiene 2. Environmental hygiene. Keeping clinically surfaces pathogen free to prevent infecton transmission 3. Proper screening and cohortng of patents sufering from the same disease 4. Proper immunizaton. 5. Regular Surveillance for IP program database maintenance 6. Proper and well-monitored antbiotherapy to avoid resistance 7. Proper care coordinatonto avoid surgical site infectons and to avoid missed opportunites of care 8. Evidence-based health care delivery use of scientfcally tested procedures 9. Appreciaton and rewards:motvaton of acceptable performances 10. Availability and good use of all-inclusivefacility-based Safety Programs. Sepideh B. N Benedeta A. Shamsuzzoha B. S. Benjamin E Didier P . 2011stated that Health-care-associated infecton HAI is a major public health concern for both patents and health-care professionalsin health care setngs clarifying that hospitalized patentsacquire 5 - 15hospital infecton and that this may climb to 50 in ICUs. The authors observed that despite some obstacles there are encouraging signs that some African countries including Algeria Uganda Ghana and Senegal have made some progress. It could be deduced from the above review that health care professionals and policy makers consider HAI a very serious problem needing simple and low-cost measures in Africa. Despite Africa’s fragmented politcal and fnancial situatons and that WHO and partners are supportng and encouraginghealth facilites to fght HAI the status quo stll prevails to a certain extent in resource-poor setngs.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 53 JHPIEGO 1999designed 32 disease preventon indicators. We decided to use these 32 indicators to evaluate disease preventon practces in 32 health facilites inthe health Northwest and Southwest Regions of Cameroon for facilitatve supervisors and village health workers. Methodology to carry out the study: 1We designed the study project approved by CBC Health Services Health Board that also provided the resources and logistcs 2 A project tmetableitnerary approved by the LCI/HIV AIDS Program Administrator and said tmetable sent to Key Interviewees per site 3At each site the team briefed chief of centre followed by a brief pre-interview meetngwith interviewees4At each site: Interviews document review of disease preventon and control were done 5 At end of each at each site interview was over the chief of Centre and his team were debriefed 6 Data/informatonentryand consolidatonwasongoing 8 Analysis interpretaton of the was done by the data analyst within the team and 7 A report was writen for disseminaton of the results of the study. Sampling Sampling Size 32 health facilites were selected out of 127 25 CBC health facilites 18 of them 56.25 were in the Northwest14 /32 43.75 were in the Southwest.The sampling was stratfed and purposive as suggested by CBC. Findings Most of the 3280 health facilites had very deep pitssee two pictures abovefor placenta disposal. Although this service was provided for allplacentas to be put in these pits some 15 culturally addicted mothers and entourage stll ritually buried placentas under plantain or banana plants which plant would later be divided toclose family members when it gets ready. They believe that the plants where the navel nuitong of the child was buried has cultural power that no mater where the child might later wander to that child must later return to it because his or her nuitong was buried there and so it is home to return.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 54 Running water was ofen a problem in the remote health facilites so the CBC workers efectvely used recycled plastc drug containers to design a pitcher that was hung up and that fowed without aid to anyone washing the hands. Necessity is the mother of inventon they say. It is a technique worth imitatng as it promotes envionmental health though making beter use of plastcs. Even though a majority of the health facilites had deep dirtpits to dispose of refuse wastes which they covered with a thin layer of the earth whenever the pit was three-quartersfull and which is a WHO guidelinea good number of health facilites 15/32: 47 stll did open burning of refuse see picture above which is prohibited by WHO guidelines. Table 1: Summary of Infecton Preventon skills of FSs and VHWs. Level of skill/100 Performance Gap between Score over 80 FSs VHWs ALP1 for all YES NO YES NO FSs and VHWs Hand washing 92.5 7.5 79 21 13.5 85.6 Gloving 100 0 96 4 4 98 Antseptcs and disinfectants 100 0 77 23 23 85.5 Use and disposal of sharps 93 7 76 24 17 84.5 Processing instruments 100 0 75 25 25 87.5 Decontaminaton 67 33 32 68 35 49.5 Cleaning instruments 67 33 68 32 1 67.5 High-level disinfecton 89 11 49 51 40 69 Housekeeping 78 22 76 34 2 77.5 Waste disposal 89 11 80 20 9 84.5 The above table shows that both facilitatve facilitators and village health workers scored below the acceptable level of performance in four important areas: Decontaminaton 49.5 Cleaning instruments 67.5 High-level disinfecton 69 and Housekeeping 77.5. However while the facilitatve supervisors had an Acceptable Level of Performance ALP of between 66-78 Village Health workers had ALPs ranging from 32 to 79 and had only 2 skills 80 or above. However both categories of infecton control workers performed poorly in the decontaminaton cleaning instruments high-level disinfecton and housekeeping needing training solutons for the upgrading of these skills. Two professional groups facilitatve supervisors FSs and village health workers VHWs were supervised and observed in infecton preventon skills. FSs performed more than VHWs because they are beter trained in supervision. Globally FSs scored 87.6 above the ALP while VHWs performed below the ALP indicatng an infecton gap to be addressed probably with a training soluton. However FSs scored below the ALP in decontaminaton housekeeping and cleaning while VHWs scored far below the ALP in hand washing using antseptcs and disinfectants using and disposing of sharp instruments processing instruments and other items decontaminaton cleaning of instrumentshigh-level disinfecton and housekeeping VHWs registeredthe weakest score in housekeeping which could be a signifcant factor in HAIs further strengthening the need for a training in infecton preventon.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 55 Recommendatons for downscaling infecton 1. Run a fve-day infecton preventon course for both Field Supervisors Community Health Workers and Village Health Workers with emphasis on the skills where the providers registered poor performance. 2. Supervisors should take an extra and reinforced infecton preventon course since they have to supervise the CHWs and village health workers as well. 3. Stress on the practce of housekeeping and waste disposal should be reinforced to ensure environmental hygiene. 4. Supervisors should make an efort to upscale waste disposal by burying according to the WHO guidelines. 5. Clinical psychologists or cultural communicators should talk families out of the practce of taking the placenta home to be buried under a plantain or banana as this tantamounts to excessive handling which may take HAI from the maternity to the home and to the community. 6. The CBC should contnue with the good practce of designing a hand washing device to wash hands in remote health facilites and lobby with the Government and other stakeholders to make pipe-borne water to places where they are absent. Conclusion Infecton preventon is a very important discipline in breaking infecton chains in health facilites or in the community. Training in infecton preventon to be able to handle infecton control issues both in the community and in the health facilites is crucial. Lack of awareness about how to keep infecton away has to be fought back with providing training solutons. This study of infecton preventon practces between two categories of infecton providers has reminded us that both those who supervise infecton preventon and control need to be always monitored and evaluated to ensure quality infecton preventon service provision. References Amungwa A.N 2014 Life Abundant PHC Project Evaluaton report CBC Health Services Kumbo Nso Cameroon. Barbara A. 2007 Emergency Medical Responder Mcgraw-Hill New York htps://www/jhpiego.org/what do we do/infecton-preventon-control. JHPIEGO Corporaton 1997 Infecton preventon Course Notebook for Trainers Baltmore USA Linda .T Wendy C. Noel McIntosh 1992 Infecton Preventon for Family planning Service Protocols: A Problem – Solving Reference manual Baltmore Linda .T Wendy C. Noel McIntosh 1992 Preventon des Infecton: Guide Pratque a l’intenton des programmes de Plannifcaton familiale: Manuel de Reference pour la Resoluton de Problemes Baltmore. MOPH 1993 Family planning Services Protocols Ministry of Public Health Directorate of Family Planning and Mental Health Yaounde Cameroon. WHO2011 Family Planning: Global Handbook for Providers Geneva Yatn M Abhinav G.Subhash T. Myatra S.N.Samaddar D.P . Vijaya P .K.B.Suresh. R. 2007.Guidelines for the preventon of hospital-acquired infectons.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 56 Dr. Abhijit Chaudhury MD DNB DABMM. Professor Microbiology Sri Venkateswara Insttute of Medical Sciences and Sri Padmavathi Medical College Women Tirupat AP . E mail: ach1964redifmail.com With the frst human use of penicillin in 1940s the war between the microbes and humans started and in a short span of less than a century it appears that the microbes are gaining the feld. The microbes with their intelligence of millions of years have thwarted the atacks of each and every antbiotc and have come out with strategies to combat any new antbiotc. Antbiotc resistance claims about 700000 live each year worldwide 1 and it is projected that if things remain unchanged the number of deaths will climb to 10 million by 2050 2. The intensive care units ICUs are hotbeds for nurturing and spread of antbiotc resistance with a vulnerable patent populaton being an easy target. For the same reason the ICUs also serve as the setngs for various interventon strategies to minimise antbiotc resistance development and serves the ideal niche to implement any antmicrobial stewardship programme. In 1985 Gerding and Larson 3 frst reported the usefulness of antbiotc cycling to bring down resistance among members of aminoglycoside group. This strategy utlises periodic substtuton of a new class of antbiotc for a drug of a diferent class but with similar type of spectrum for a specifed tme period with the ratonale that the substtuton will reduce level of resistance to the older class of antbiotc4. By cycling the acquired resistance will be lost in the diferent cycles because of the inability of these mechanisms to confer resistance to the antbacterial agent used in the new cycle together with the ftness cost which may be induced 5. Another strategy which has been used is antbiotc mixing where all available antbiotcs are used concurrently in diferent patents which will theoretcally provide heterogeneity in a constant manner 6. The strategy of antbiotc cycling was an atractve one which prompted the publicaton of a large number of reports claiming its success and usefulness in reducing resistance and increasing the efcacy of existng antbiotcs startng with the inital study by Gerding 37 and later by other workers8-10. The wheel started rolling the other way when Bergstrom et al in 2004 11 proposed a mathematcal model wherein they showed that antbiotc cycling is unlikely to be efectve and may even promote the emergence of resistance. The same fndings were arrived at by Beardmore et al 2017 when they stated that “neither cycling or mixing is a priori beter than the other in mitgatng selecton for antbiotc resistance” 12. These mathematcal models have been proved correct by various studies where contrary to the claims about the efectveness of cycling strategy in reducton of resistance a change for the worse has been noted. It has been noted that for most antbiotcs cycling with a 3-month or longer intervals can actually promote resistance in Gram-negatve bacilli to the scheduled drug and even lead to multple-drug resistance ANTIBIOTIC CYCLING AND ANTIBIOTIC MIXING: IS IT TIME FOR REQUIEM

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 57 or contribute to the development of outbreaks due to carbapenem-resistant A. baumannii or multple-drug resistant P . aeruginosa 13 In a report in 2005 it was noted that cycling of homogeneous antbiotc is unlikely to control the emergence of gram-negatve antmicrobial resistance in intensive care units 14. In another instance an outbreak of mult-drug resistant Pseudomonas aeruginosa followed cycle 2 cefepime coinciding with cycles 3 and 4 ciprofoxacin and piperacillin-tazobactam 15. Njssen et al observed that reductons in beta-lactam use were not associated with reduced cephalosporin resistant enterobacteriaceae CRE acquisiton and increased use of fuoroquinolones was associated with increased acquisiton of fuoroquinolone resistant CRE 16. The latest blow to the advocates of antbiotc cycling and mixing has been dealt by a European multcentre cluster-randomized crossover study 17. Over a three year study period from 2011-14 4069 patents were admited to the ICUs during the cycling periods and 4707 were admited during the mixing periods. As per the authors "In this cluster-randomised crossover study in eight ICUs 9-month periods of antbiotc cycling and mixing did not change the unit-wide prevalence of antbiotc-resistant gram-negatve bacteria". They further noted that "structured rotaton of antbiotc prescripton policies for possible gram-negatve bacteria cannot be considered as a measure to reduce antbiotc resistance in ICUs." Hence according to the authors the most efectve acton to minimize the impact of antbiotc resistance in ICUs is beter antbiotc management leading to diminished antbiotc consumpton and a subsequent reducton in the pressure exerted on microorganisms which include beter diagnostc tools resultng in more ratonal antbiotc use. Conclusion: As per the 2016 guidelines of Infectous Diseases society of America and Society for Healthcare Epidemiology “available data do not support the use of antbiotc cycling” as antbiotc stewardship strategy and that “further research is unlikely to change that conclusion” 18. References: 1. The Review on Antmicrobial Resistance chaired by Jim O’Neill. Antmicrobial Resistance: Tackling a crisis for the health and wealth of natons. Dec 2014. Available online: htp://www.jpiamr.eu/wp-content/uploads/2014/12/ AMR-Review-Paper-Tackling-a-crisis-for-the-health-and- wealth-of-natons_1-2.pdf 2. de Kraker ME Stewardson AJ Harbarth S. Will 10 million people die a year due to antmicrobial resistance by 2050 PLoS Med 201613:e1002184. 3. Gerding DN Larson TA . Aminoglycoside resistance in Gram-negatve bacilli during increased amikacin use. Comparison of experience in 14 United States hospitals with experience in the Minneapolis Veterans Administraton Medical Center. Am J Med. 1985 79: 1-7. 4. Brown EM Nathwani D. Antbiotc cycling or rotaton: a systematc review of the evidence of efcacy. J Antmicrob Chemother. 2005 55:6-9. 5. Ruiz J Pons MJ. In an inhospitable ICU not even antbiotc cycling or mixing are the solutons. Ann Infect 20182:2 6. Cobos-Trigueros N Solé M Castro P Torres JL Rinaudo M De Lazzari E et al. Evaluaton of a Mixing versus a Cycling Strategy of Antbiotc Use in Critcally-Ill Medical Patents: Impact on Acquisiton of Resistant Microorganisms and Clinical Outcomes. PLoS One. 2016 Mar 16113:e0150274 7. Gerding DN Larson TA Hughes RA Weiler M Shanholtzer C Peterson LR. Aminoglycoside resistance and aminoglycoside usage: ten years of experience in one hospital. Antmicrob Agents Chemother 199135: 1284–1290.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 58 8. Rahal JJ UrbanC HornD et al. Class restricton of cephalosporin use to control total cephalosporin resistance in nosocomial Klebsiella JAMA 1998 280 : 1233-7. 9. Gruson D Hilbert G Vargas F et al. N Strategy of antbiotc rotaton: long-term efect on incidence and susceptbilites of gram-negatve bacilli responsible for ventlator-associated pneumonia Crit Care Med 2003 vol. 31pg. 1908-14. 10. Teranishi H Koga Y Nishio H Kato W Ono H Kanno S et al. Clinical efcacy of cycling empirical antbiotc therapy for febrile neutropenia in pediatric cancer patents. J Infect Chemother. 2017 23:463-467. 11. Bergstrom CT Lo M Lipsitch M. Ecological theory suggests that antmicrobial cycling will not reduce antmicrobial resistance in hospitals. Proc Natl Acad Sci U S A. 2004101:13285-90. 12. Beardmore RE Peña-Miller R Gori F Iredell J. Antbiotc Cycling and Antbiotc Mixing: Which One Best Mitgates Antbiotc Resistance Mol Biol Evol. 2017 34:802-817. 13. Cobos-Trigueros N Solé M Castro P Torres JL Rinaudo M De Lazzari E et al. Evaluaton of a Mixing versus a Cycling Strategy of Antbiotc Use in Critcally-Ill Medical Patents: Impact on Acquisiton of Resistant Microorganisms and Clinical Outcomes. PLoS ONE 2016 113: e0150274. htps://doi.org/10.1371/journal.pone.0150274 14. van Loon HJ Vriens MR Fluit AC Troelstra A van der Werken C Verhoef J et al. Antbiotc rotaton and development of gram-negatve antbiotc resistance. Am J Respir Crit Care Med. 2005171:480-7. 15. Hedrick TL Schulman AS McElearney ST Smith RL Swenson BR Evans HL et al.. Outbreak of Resistant Pseudomonas aeruginosa Infectons during a Quarterly Cycling Antbiotc Regimen. Surg Infect Larchmt. 20089: 139– 52. 16. Nijssen S Fluit A Van De Vijver D Top J Willems R Bonten MJ. Efects of reducing beta-lactam antbiotc pressure on intestnal colonizaton of antbiotc-resistant gram-negatve bacteria. Intensive Care Med. 201036: 512– 519. 17. van Duijn PJ Verbrugghe W Jorens PG Spöhr F Schedler D Deja M et al . The efects of antbiotc cycling and mixing on antbiotc resistance in intensive care units: a cluster-randomised crossover trial. Lancet Infect Dis. 201818:401-9. 18. Barlam TF Cosgrove SE Abbo LM MacDougall C Schuetz AN Septmus EJet al. Implementng an Antbiotc Stewardship Program: Guidelines by the Infectous Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016 May 156210:e51-77.

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 59 Theme of October 2019 editon is dedicated to Medical Mycology. Artcles on current infectons of Natonal importance as Tuberculosis Dengue and any other emerging infectous diseases are welcome. Artcle on laboratory quality control quality assurance Antmicrobial stewardship therapeutc drug monitoring critcal care transplant care immunosuppressive therapy hand hygiene isolaton precautons disinfecton and sterilizaton housekeeping laundry and kitchen practces are also welcome. Artcle related to nursing best practces role model and healthcare associated costs are also desired. Or Any other topic of relevance can be published with consent of editorial team members. MEETING THE OBJECTIVES OF E-NEWSLETTER The fundamental rule for creatng an email newsleter is to make it interestng relevant and up-to-date informaton that is enjoyable to read and practce. Hope that it meets the expectatons of the knowledge seekers. Moto behind e-newsleter format was to be informed about things which are otherwise difcult to be able to fnd out about with general searches. People share the real tme experiences challenges and solutons through this accessible and free platorm. Stck to the Topic you have chosen and elaborate on the theme in mind for each so idea doesn’t get jumbled. Authorship is for clinical microbiologists consultants both medical surgical and dental felds teaching professionals infecton control and preventon experts clinical pharmacists hospital quality personnel administrator and also members of recognized professional bodies. The person has to be associated with medical feld in direct or indirect way. Internatonal authors are also welcome and resource poor setngs like African region and other Asia pacifc region low and middle income countries will be given special encouragement for authorship. 1. Allow for some fexibility in the length of the content. Afer all this is not a print publicaton that has to ft on a certain paper size 500 words mean can be 100 words + or 100 words less. 2. Today many are short of tme Devise creatve and informatve subject lines Ensure content is educatonal informatve and concise. Artcle to be writen with scientfc language and references are to be added in Vancouver style only. Menton all scientfc names in italics. Follow font size of 11 with tmes new roman style with 1.15 line spacing. Artcle submission to be done in MS word format only. We have not many editorial reviewers yet all the artcles to be submited with scientfc spirit to be checked for plagiarism spell check and grammatcal errors by the authors declaring the CONFLICT OF INTEREST IF ANY If any comparatve or invasive tests are done on humans or animal studies then the scientfc work must accompany the Ethical commitee approval/IRB insttutonal review board approval. Artcle can be accepted or rejected for lack of place or not suitng the purpose of the topic chosen and will retuned at the earliest and decision of editorial members is fnal in approving or rejectng the artcles for publicaton. Dr. Dhruv Mamtora | Dr. T. V. Rao MD | Dr. Ranga Reddy Burri OBJECTIVES OF E-NEWSLETTER ON INFECTION CONTROL TRENDS

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VOLUME 1 | ISSUE 4 | JULY 2019 INFECTION CONTROL TRENDS 60 The Rules And Regulatons For The Infecton Control Trends Newsleter Are As Follows:- • Artcle has to be writen with scientfc language and references are to be added in Vancouver style. Menton all scientfc names in italics. Follow font size of 11 with tmes new roman style with 1.15 line spacing. Artcle submission to be done in MS word format only. • The high quality images of authors are to be submited along with artcles separately. • Artcle must be submited by authors only. Artcles submited by students and secretaries of authors will not be entertained. • If the artcles are resent by editorial commitee for necessary correctons all necessary correctons shall be done and resubmited within 3 days afer receipt of email. The only reason being the context and concept in which the artcle is writen is with author hence editors can never judge or write in same manner. • Artcle should be sent one month in advance for themed newsleter. • We encourage reviewers for upcoming newsleter so you can submit your names along with CV to editorial team. • Any verbal communicaton with editorial team members should be done in working hours only between 9:00 AM and 5:30 PM. • The purpose of newsleter is to promote scientfc content and enhancing research and scientfc approach related to infecton control and related topic and not publicity for person or product or services. • We appreciate Feedback and suggestons which should be conveyed only through ofcial email. • Any queries related to newsleter will be addressed directly to editorial team members. RULES This Newsleter has been made possible with the Academic Grant from SANMED HEALTHCARE PVT LTD Email - infosanmed.in A WHO GMP ISO: 13485 ISO 9001 GLP accredited Company working towards actualizaton of MAKE IN INDIA and SWACHH BHARATH. Manufacturer Marketer Exporter of ‘Disinfectants and Antseptcs’. Web Development | Digital Marketng | Branding Solutons Reputaton Management | Email Marketng | Content Marketng Design And Content Layout www.medicomantra.com | Email: infomedicomantra.com

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