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TB infection control for operating rooms in developing countries

By Alberto Mendoza | 30 Aug, 2017

Dear IC community members,
In Lima Peru, we need to increase our capacity to operate MDR/XDR TB patients. So my hospital, Villa El Salvador at South of Lima is modifying one of the regular operating room and several hospitalization rooms.
We need specifications for TB IC in operating rooms, do you know any?
Do the exhaust air need to be filtered by HEPA filter before to outreach to the environmental or not, (we are not going to re-inject this air into the rooms),
Is UVGI in ducts an option? (we want to avoid use HEPA filters due to cost and problems in re-changes).
Thanks for your assistance,

Alberto Mendoza MD MSc
Chief of ID Service
Hospital de Emergencias Villa El Salvador
Lima, Peru



Edward Nardell, MD Moderator Replied at 3:05 PM, 30 Aug 2017

This is a growing problem not only in Peru, but in Ethiopia and other
countries. There are conflicting needs.

ORs are traditionally positive pressure to keep airborne contaminants out,
but isolation rooms are negative pressure to keep contaminants in. The OR
cannot be both and maintenance of either is challenging in high burden
settings. Use of very sophisticated anterooms can allow the OR to be
negative and not receive air from outside, but these are difficult to
maintain. We have been advising a hospital on Lima on innovative
approaches to this special problem. Personally, I would recommend an
airflow neutral operating room, that is, well ventilated, but airflow
direction neither designed to be in or out, together with a well-designed
upper room germicidal UV system both inside the room and in all adjacent
rooms, including a MDR-dedicated recovery room. Upper room UV is highly
effective (if well designed and maintained), easier to maintain than
differential pressure ventilation systems, and protects staff and other
patients in the recovery room. These patients are infectious before
surgery, during surgery, and post surgery if there is residual disease.

I know of no official recommendations for MDR-TB ORs, but we need them,
with the above as one option. Whether or not to filter or irradiate
exhaust air, assuming an exhaust system, depends on where the air is
exhausted to - is there a risk of exhaust exposing others in the area
before dilution. It makes little sense to filter the air from an OR and
not filter the air from the recovery room - or from the pre-op room where
patients are coughing. The risk in the OR is real, but not necessarily that
much higher than other areas where these patients reside, receive
bronchoscopy, etc. If surgery is successful, infectiousness should be less
post-op, but precautions still warranted. UV in ducts is an option but
needs to be sized according to airflow to allow enough exposure time. Most
importantly, UV in ducts is unlikely to be maintained because it is out of
sight. In-duct (and upper room) UV needs to be cleaned periodically and the
lamps replaced according to measured output or a fixed schedule, with
appropriate precautions to prevent UV eye injury.

Alberto Mendoza Replied at 5:04 PM, 30 Aug 2017

Thanks, professor Nardell, for your fast and useful answer.
Please, some additional questions:
We are pursuing the idea to get an anteroom with positive pressure. Why is this anteroom sophisticated and difficult to maintain?
Will this anteroom and a negative pressure at OR with 12 air changes per hour avoid the UV lights in OR and adjacent rooms?
Our concern to use UV is the difficulty to get good providers in developing countries. Do you know any in Peru or we have to import the lamps, do you recommend any good company for it?
Do you recommend to use HEPA filter in ducts instead of UV, when the exhaust air is risky for others?

Thanks so much.

Alberto Mendoza MD MSc
Hospital de Emergencias Villa El Salvador
Lima, Peru

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