平成20年度合同臨地訓練報告

61〈教育報告〉
平成20年度合同臨地訓練報告
第 2 チーム

Risk Assessment on TB Transmission in Health Center Settings of Marikina
and Paranaque Cities, Philippines
フィリピン国マリキナ市及びパラニャケ市の保健所における結核感染のリスク評価
Team No.2
Guohong CHEN, Asaua FA’
ASINO, Yoko FUJITA, Miwa HAYASHI, Qingzhong JIN,
Michael MSANGI, Junko SATO, Hiromi SUWA, Maricel TRONO, Phoutnalong VILAY
Keywords:

Risk assessment, Tuberculosis, Health centers, WHO Guidelines, Philippines

Supervisors:

Nobuyoshi WATAHIKI, Nobuyuki HYOI, Michiko BANDO, Tomofumi SONE

I . Introduction
1. Background

The risk of transmission of M. tuberculosis fromindividuals with TB to other patients and to health care
workers (HCWs) has been recognized for many years. Thisrisk is high in health facilities especially in many low- andmiddle-income countries (LMICs). In view of thesechallenges, the WHO developed Infection Control (IC)Guidelines, which have three levels of IC measures:
administrative, environmental, and personal respiratory
protection.1)
Being considered as one of the 22 countries with highburden of TB1) and the apparent economic status of thecountry, the Philippines is not spared by the challenge ofhigh risk of transmission of TB infection in general
population and more so in health facilities. Therefore, thisstudy was aimed at assessing the potential risk of TB
transmission, by finding out the status of administrative,
environmental and personal respiratory protection control
measures to prevent TB transmission in the health centers(HCs) of two selected cities in the Philippines, namely
Marikina and Paranaque.
2. Objectives

The general objective was to assess TB infection control
measures in health center settings based on WHO

Guidelines2). Three specific objectives to assess were: 1)
administrative TB infection control measures, 2)environmental TB infection control measures and 3)
personal respiratory protection measure in health centersettings. The conceptual framework as indicated in Figure 1
provided the roadmap for the study.

II. Methodology
1. Study design and subjects

A cross-sectional descriptive study was conducted, using
a checklist of TB Infection Control measures. The target
was all 33 HCs in Marikina and Paranaque, Philippines, but
eventually 32 out of 33 HCs took part in the study. The
respondents for the checklist were the heads of the 32 HCs.
2. Data collection

The Data collection tools consisted of checklist,
interview, and layout drawing. The checklist was used tocollect information from 32 out of 33 HCs One HC was leftout because its head could not fill the checklist. Four HCs
were visited from which three doctors, four nurses, four
midwives, and three medical technologists were interviewed
and the layouts of each HC were sketched. In this report, we
focused on the results from the checklist only due to limited
space. The nine administrative control measures were: 1)
Assessment of at-risk settings by three elements, 2) IC planby six elements, 3) HCW training by five elements, 4)

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9平成20年度合同臨地訓練報告

62

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Figure1. Conceptual framework

Early identification and diagnosis by one element, 5)
Patient education, 6) Sputum collection by two elements,
and 7) Triage and evaluation of suspect TB patients by four
elements. The other measures were; 8) Reducing exposurein the laboratory (which was not included in analysis of thisstudy, because of limited number of laboratories; that is one
in Marikina and only nine in Paranaque);and 9) Evaluating
infection control intervention by five elements. The twoenvironmental control measures assessed were: 1)
Ventilation and 2) Hygiene and Sanitation. The personal
respiratory protection measure has one component, whichis the use of N95 masks. This measure was also excluded
from the analysis of this study because in practice very few
number of HCs in the Philippines use it due to high cost
involved in its purchase.

3. Data management and analysis

The raw data from the checklists were coded and enteredinto a database. The data was analyzed descriptively using
Microsoft Excel.

III. Results
1. Overall assessment of administrative and environmental
control measures

This assessment was based on the availability of ten TB
infection control measures in the HCs (eight administrative
and two environmental measures). Table 1 below shows thenumber of HCs which did not implement certain TB
infection control measures as specified. Out of the ten
control measures three were implemented by all of the 32
HCs. Out of the remaining seven measures, five control
measures, which are: IC plan (28.1%), sputum collection

Table 1. Number of HCs not implementing related TB infection control measures

Number of HCs not implementing each measure
TB infection control measures
Assessment of at-risk settings for TB infection
IC plan
HCW training
Early identification and diagnosis
Patient education
Sputum collection
Triage and evaluation of suspect TB patients in health settings
Evaluating infection control interventions
Ventilation
Hygiene and sanitation

Marikina (17)n%Paranaque (15)
n
%

N

%

0
8
1
0
0
4
0
3
3
5

0
1
0
1
0
2
0
2
3
0

0
9
1
1
0
6
0
5
6
5

0
28.1
3.1
3.1
0
18.8
0
15.6
18.8
15.6

0
47.1
5.9
0
0
23.5
0
17.6
17.6
29.4

8 1

9

0
6.7
0
6.7
0
13.3
0
13.3
20.0
0

Total (32)

平成20年度合同臨地訓練報告(18.8%), evaluating infection control interventions (15.6%),
ventilation (18.8%), and hygiene and sanitation (15.6%)
were the least used since they were not implemented by ahigher proportion of the HCs. It is considered that the fewer
the measures implemented, the higher the risk of TB
transmission become.
In assessing the level of risk based on lack ofimplementation of the above components, Table 2 below
shows that 31.3% (10/32) of HCs in Marikina andParanaque implemented all the ten components forcontrolling TB infection, and therefore regarded as of thelowest risk for TB transmission. In addition, 50.0% (16/32)
implemented nine components, 12.5% (4/32) implemented
eight components. However, 3.1% (1/32) implemented six
components and another 3.1% (1/32) implemented fivecomponents. These two HCs were regarded as being at a
relatively higher risk for TB transmission.

63

Identification of risk areas, 2) Assessment of TB infection
amongst HCWs, 3) Assessment of TB training needs for
HCWs, 4) Recommendations of area-specific IC, 5)
Timeline for TB IC, and 6) Budget for IC. HCs in bothcities implemented either some or all of IC plan elements asshown in Table 3. Among 32 HCs, 12.5 % (4/32)
implemented all six elements while 9.4% (3/32) HCs
implemented none of the elements and 18.7% (6/32)
implemented only one element (these two account for the
28.1% for IC plan component in Table 1).
2.2 Sputum collection: There were two precautionary

measures being assessed: sputum collection at proper place,and sputum collection using correct method.
Implementation of these two measures in order to avoid TB
transmission during sputum collection has to be carried out
simultaneously. As shown in Table 4, 6.3 % (2/32) of theHCs reported not to practice both precautionary measures(one from each city), and 12.5% (4/32) practiced only oneof the two measures. This in total accounted for 18.8% of
the HCs not implementing the precautionary measures as
required.

2. Administrative infection control measures

Based on the major findings, the three least implemented
administrative control measures to prevent TB transmission
in health center settings were: IC plan, sputum collection,and evaluation of infection control intervention.

2.3 Evaluation of infection control interventions: The study
2.1 IC Plan: The IC Plan comprises of six elements whichassessed implementation of five elements: 1) Time intervalfrom admission to suspicion of TB, 2) Time interval fromsuspicion of TB to ordering sputum for Acid Fast Bacilli

when properly followed, the infection control programme
can be effectively implemented. These elements were: 1)

Table 2. Distribution of scores on TB infection control components among 32 HCs

Distribution of scores

Marikina

Paranaque

Total

%

0 (lowest risk)
12
4
5 (highest risk)

3
9
3
1
1

7
7
1
0
0

10
16
4
1
1

31.3
50.0
12.5
3.1
3.1

Total

17

15

32

100

Note: 0: all 10 components implemented; 1: 9 components implemented; 2: 8 components implemented; 4: 6 components implemented and5: 5 components implemented
Table 3. Fulfillment of numbers of IC plan elements implemented by HCs in both cities

Fulfillment of IC
plan elements

Marikina

Paranaque

Total

%

0/6
1/6
2/6
3/6
4/6
5/6
6/6

3
5
2
3
0
1
3

0
1
2
5
4
2
1

3
6
4
8
4
3
4

9.4
18.7
12.5
25.0
12.5
9.4
12.5

Total

17

15

32

100

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平成20年度合同臨地訓練報告

64smears, 3) Time interval from ordering to the collection of
sputum, 4) Time interval from the examination of the smear
to the reporting of results, and 5) Time interval from thereturn of laboratory results to the initiation of treatment. As
shown in Table 5 below, 68.8% (22/32) of the HCs
conducted evaluation of infection control interventions for
all five elements. However, 15.6% (5/32) of the HCs did
not have any of the five elements in place for evaluating TB
infection control interventions; three of these were from
Marikina and two from Paranaque. Moreover, thiscomponent is one of five which were not implemented by alarger proportion of HCs.

Enclosed space with windows always closed, and 4)
Enclosed space with no windows at all (1&2 were regarded
as good, 3&4 were regarded as inadequate). As shown in
Table 6 below, 18.8% (6/32) of the HCs (three from eachcity) had inadequate ventilation in consultation rooms. In
addition, 6.3% (2/32) of the HCs had inadequate ventilationin waiting areas. Ventilation was one of the measures which
was not implemented by a higher proportion of HCs.
3.2 Hygiene and sanitation: Out of 32 HCs in the two cities,

30 implemented regular disinfection using disinfectants.
From Table 7, 10% (3/30) of the HCs carried out
disinfection less than once a week and this was attributed toirregular or interrupted supplies of disinfectants.

3. Environmental control measures

Environmental control measures encompass two mainelements namely: 1) Ventilation and 2) Hygiene andsanitation.

IV. Discussion
1. Overall assessment of administrative and environmental
control measures

3.1 Ventilation: Four elements for ventilation were assessed.

The aim of this study was to assess the risk of TB
transmission in HC settings of Marikina and Paranaque, by

These were: 1) Natural ventilation, 2) Exhaust fan, 3)

Table 4. Fulfillment of numbers of precautions taken during sputum collection

Fulfillment of
precautionary measures

Marikina

Paranaque

Total

%

0/2
1/2
2/2

1
3
13

1
1
13

2
4
26

6.3
12.5
81.2

Total

17

15

32

100

Table 5. Fulfillment of measures used in evaluating TB infection control interventions

Fulfillment of elements

Marikina

Paranaque

Total

%

0/5
3/5
4/5
5/5

3
1
1
12

2
2
1
10

5
3
2
22

15.6
9.4
6.2
68.8

Total

17

15

32

100

Table 6. Ventilation situation of three areas in 32 HCs

Ventilation situation
Sputum collection area
goodinadequate
Consultation room
good
inadequate
Waiting area
goodinadequate

Marikina (17)Paranaque (15)Total (32)

%

17
0

15
0

32
0

100
0

14
3

12
3

26
6

81.2
18.8

15
2

15
0

30
2

93.7
6.3

Note: good: natural ventilation, or exhaust fan, inadequate: enclosed space with windows always closed, or enclosed spacewith no windows at all

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65

Table 7. Distribution of frequency of disinfection performed in HCs

Frequency

Marikina

Paranaque

Total

%

≥ once per day
Once a week
< once a week

7
5
3

11
4
0

18
9
3

60.0
30.0
10.0

Total

15

15

30

100

Note: Two HCs from Marikina used methods which did not meet our criteria for disinfection so were
excluded.

looking at the TB infection control measures. This wasdone using a checklist based on the WHO Guidelines.
Three of the components, namely assessments of at risk
setting for TB infection, patients’education and triage andevaluation of suspect TB patients; were implemented by all
the HCs. This could be due to various reasons such as
routine HC practice, general IC practice, or otherwise being
regulated by National TB Programme (NTP) Guidelines.
For the remaining seven components, two of them, HCWs
training and Early identification and diagnosis of TB
patients closely followed behind the three above by having
a lower proportion of HCs not implementing them (Table
1).
The other five components were not implemented by ahigher proportion of HCs; hence, our report focuses onthem.
2. Administrative control measures
2.1 IC Plan: Having a comprehensive IC plan andoverseeing its proper implementation is important for TB
IC. Among the ten components assessed in the study,
28.1% (9/32) of the HCs did not implement an IC plan as
required. This represents a relatively higher proportion of
HCs from the two cities. This could be attributable to thefact that there was no specific TB Infection Control policy;
hence, not regulated through the NTP Guidelines. This
component needs major considerations by City Health
Offices and the Department of Health for routine andeffective implementation, especially through integration
into the NTP Guidelines.
2.2 Sputum collection: Sputum collection should always bedone outside and away from HCWs and other people. The
HCWs should stand behind the patient and away from thedirection of wind. This is important in preventing
transmission to the HCWs who must supervise the patientsduring collection so as to obtain a specimen of goodquality. It is only when both of the above precautions aredone simultaneously; TB transmission would be more
effectively prevented. From the study, 18.8%（6/32）of theHCs fulfilled one or none of the two precautionary
measures. It is important that emphasis is put on proper
implementation of these measures because they are safe,
simple and practical to apply.
2.3 Evaluation of infection control interventions: It is

important to evaluate the implementation of the ICinterventions, to prevent transmission of TB within HC
settings. In order to achieve this, records such as timeinterval from suspicion of TB to ordering sputum, timeinterval from the examination of smear to the reporting of
the results and time interval from the return of laboratory
results to the initiation of treatment; need to be reviewed
regularly. These records are important to ensure timely
diagnosis and treatment of TB patients and avoid delays.
The longer the delay in diagnosis and treatment, the higher
the risk of TB transmission within the HC settings. Fromthe study, 15.6% (5/32) of the HCs did not keep any of therecords for evaluating IC interventions, which indicate theneed for these to be initiated and maintained as a routine
part of TB Infection Control in the HCs.
3. Environmental control measures

The environmental control measures include two aspects,
one is ventilation and the other is hygiene and sanitation.
3.1 Ventilation: Having natural or mechanical ventilation

contribute to prevention of TB transmission by minimizing
the concentration of TB infectious droplets in the air.
From the study, ventilation in some of the consultation
rooms and waiting areas were not in good condition.
Almost all HCs provided the air conditioners for the
consultation rooms, so the windows could not be opened. If
there were no exhaust fan in place, then it would be very
difficult to increase the ventilation of these rooms; therefore,
it is recommended that exhaust fans be installed in rooms
with air conditioners, and where windows cannot be opened.
3.2 Hygiene and sanitation: Even though most of the HCs

showed good practice in terms of frequency of cleaning
being done, three of the HCs did disinfection less than once

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66

a week, which was regarded as poor practice. This could bea result of irregular and interrupted supplies of disinfectant.
Therefore, a systematic support in terms of logistics andon-site supervision and monitoring are important toimprove on these situations.

2.

3.

4. Limitations

Listed here are the main limitations of this study as
follows:
1. We determined criteria of assessing risk in health centersbecause of no standard criteria in HC settings; and2. Checklist was to find out the control measures available
in HCs, but not how well, effective, or frequent that thesemeasures were being practiced.

V . Conclusion
On the basis of the results of this assessment it isconcluded that most of the HCs adopt the WHO Guidelines
on TB infection control measures to some extent but
generally need further improvement in specific areas. In
terms of administrative control measures, most of the HCs
complied with five out of the eight components. These are:a) relevant records of assessment of at-risk settings for TB
infection, b) patient education, c) triage and evaluation of
TB suspects, d) training contents and e) policies of early
detection and diagnosis. The three components with which
HCs showed major inadequacies were: a) Infection Control
plan, b) sputum collection precautions and c) routine
evaluation of infection control interventions. For
environmental control measures, some HCs did not comply
with both components which are: a) ventilation and b)
hygiene and sanitation.

VI. Recommendations
1.

In the HCs where existing control measures are
considered adequate, it is important that efforts are4.

taken to ensure sustainability.
As most HCs lack an IC plan, the incorporation ofsuch an IC plan into local NTP guidelines will
possibly help to ensure standardized implementation.
In the city level, it is suggested that NTP supervisionand monitoring to specifically include infection
control component so that relevant weaknesses such as
issues on practice can be effectively addressed.
Moreover, there is a need to strengthen advocacy
specifically at the local government level to address
constraints associated with logistics.
At the HC level, areas for further improvements
include, a) strengthening of supervision andmonitoring especially where sputum collection isconcerned, b) in-house environmental control
measures particularly of ventilation and disinfection
and c) implementing routine evaluation of infection
control interventions.

VII. Acknowledgements
We would like to extend our sincere appreciation to those
who supported this study: College of Public Health,
University of the Philippines, Manila; Dr. Nina Gloriani,
Prof. Jonathan Guevarra, Dr. Arlene Bertuso, Dr. Maria
Christina F. Batac, and staff members of CPH, Dr Albert
Herrera, Dr. Allan Fabella from the CHO of Marikina andDr. Olga Virtusio from the CHO of Paranaque.

VIII. References
1 ）Joshi R, Reingold AL, Menzies D, Pai M. Tuberculosis
among health-care workers in low- and middle-income
countries: a systematic review. PLoS Med 2006 Dec; 3(12):e494.
2 ）WHO. Guidelines for the prevention of tuberculosis in
health care facilities in resource-limited settings.
Geneva:WHO;1999.

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