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TB Notes 4, 2003


Infection Control Efforts in Orel, Russian Federation

Against the backdrop of a major TB epidemic, the risk of TB among health care workers in Russia exceeds the risk in the general population more than 20-fold. Further, Russia has among the highest levels of multidrug-resistant TB (MDRTB) in the world. Patients who have MDRTB can remain infectious for prolonged periods because drugs are less effective in rendering these patients noninfectious. Thus, health care facilities should be particularly alert to the need for preventing transmission of M. Tuberculosis in settings in which MDRTB patients reside or receive care. The occurrence of TB, including MDR TB, among health care personnel and prison guards in Orel heightens anxiety about institutional transmission. In response, CDC, the US Agency for International Development (USAID), the World Health Organization (WHO), and Russian partners are implementing a program to combat drug-resistant TB, which includes infection control measures to protect health care personnel, patients, prison personnel, and other prisoners from nosocomial TB transmission.

To initiate this infection-control effort, Dr. Paul Jensen (then with CDC’s National Institute for Occupational Safety and Health [NIOSH], currently with NCHSTP/DTBE), Dr. Peter Cegielski (DTBE), and Dr. Ernie Moyer (NIOSH) presented an infection control training course to civilian and prison staff on October 17, 2001, in Orel. After the training course, infection control assessments of the Orel Dispensary and of a pre-trial detention center were conducted. The infection control assessments involved “following” the patients and specimens throughout the facility and observing administrative controls, environmental controls, and respiratory protection efforts along the way. Recommendations were presented to Dr. Boris Yakovlevich Kazionny, Chief TB Physician. Dr. Kazionny immediately implemented many administrative controls (separating smear-positive from smear-negative patients, minimizing worker exposures where possible, scheduling procedures for smear-positive patients after those for smear-negative patients, and continued case identification among workers). In addition, a respiratory protection program (use of respirators) was initiated, and workers in high-risk environments are wearing locally available FFP2 respirators certified by the European Committee for Standardization (CEN, Comité Européen de Normalisation). CEN-certified respirators undergo a total inward leakage test on a human subjects test panel to measure respirator fit characteristics as part of the certification criteria. NIOSH-certified N-95 filtering facepiece respirators are not required to meet any fit test criterion. The two models of CEN-certified respirators fit better than two models of NIOSH-certified N-95 filtering facepiece respirators used in Orel.

Mr. Gustavo Aquino, a CDC public health advisor assigned to Russia, developed a grant application to implement infection controls, which was funded by USAID to assist in the implementation of environmental controls and respirators in both the civilian and the prison sectors. To date, most of our efforts have been focused on the Orel Central Tuberculosis Dispensary; however, outreach to the prison sector has begun.

Workers at the Orel Dispensary and at the local pre-trial detention center have been fit tested for respirators. At each facility, staff members were given qualitative fit-test kits (Bitrex™) and a lead professional was trained to conduct routine respirator fit testing. The lead fit-test professional for each facility has continued to fit-test workers and distribute respirators as needed. One question often asked of us was, “How long can we use a respirator?” During return trips, we attempted to collect data to answer this question. Workers were fit-tested again with their old respirator and fit-tested with a new one. Nearly 80% of the workers passed on the retest of the old respirator, even after 3 months of intermittent usage. The old respirators were then tested by NIOSH to evaluate their filter efficiency. With the exception of one respirator, all would have passed the NIOSH certification test for filter penetration. The one that failed did so only by a few 100ths of a percent (note, five percent penetration is allowed in NIOSH certification). The biggest weakness in the respirators used (3M 9320 and 3M 9322) appeared to be the thin rubber bands used for head straps. The straps tend to stretch permanently after one use. Workers tied knots and did other innovative things to keep a tight seal between the respirator and face. Our recommendation is generally to follow manufacturer and NIOSH recommendations for respirator reusage. NIOSH states that the service time (i.e., reuse) is “limited by considerations of hygiene, damage, and breathing resistance.” Absent that, each worker can develop his or her own change-out schedule based on the physical and hygienic condition of the respirator, the fit of the respirator (which can be verified by on-site staff), and his or her comfort level in reusing respirators. Unfortunately, resource-limited countries do not have the luxury of unlimited supplies of respirators and rely on their reuse. Another frequently asked question has been, “How can we disinfect these respirators prior to reuse?” CDC/NIOSH has initiated a research effort to answer this important question.

Three environmental controls were recommended. Shielded, upper-room ultraviolet germicidal irradiation (UVGI) was recommended in certain areas (unshielded UVGI is commonly used when no workers or patients are present). Russian regulations specifically state that unshielded UVGI can only be used for specific amounts of time and only when the rooms are unoccupied. The regulations do not mention using shielded UVGI with people present and operating 24 hours a day, 7 days a week. Though this technology is used in the United States and many other countries, there is a reluctance in Russia to use such technology (more on UVGI will be presented in a future issue of TB Notes). An additional control is the use of ventilated booths or rooms for sputum induction or collection. A design was presented to local manufacturers, and after completion of the process of tender, a local company was awarded a contract to construct 25 sputum booths. The booths will be distributed throughout the region (both civilian and prison sectors). Finally, ventilation of the infectious patient areas and procedure rooms was recommended. Preliminary plans and estimates have been collected, and negotiations with the local administration for additional funding are ongoing. We hope to start the ventilation project by spring 2004.

The Russion Federation is an enjoyable region in which to work because the hospital administrators and staff, prison system administrators and staff, local governmental administrators, USAID staff, and WHO staff are dedicated to the prevention of the spread of TB within their respective facilities. Because of the raised awareness of TB and the methodical implementation of selected infection-control interventions, Orel TB Dispensary will be a model infection control center for the rest of the Russian Federation.

—Reported by Paul Jensen, PhD, PE, CIH
Div of TB Elimination


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

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