Why healthcare workers are sick of TB

New Manual Quantitative Polymerase Chain Reaction Assay Validated on Tongue Swabs Collected and Processed in Uganda Shows Sensitivity That Rivals Sputum-based Molecular Tuberculosis Diagnostics

BACKGROUND

Sputum-based testing is a barrier to increasing access to molecular diagnostics for tuberculosis (TB). Many people with TB are unable to produce sputum, and sputum processing increases assay complexity and cost. Tongue swabs are emerging as an alternative to sputum, but performance limits are uncertain.

METHODS

From June 2022 to July 2023, we enrolled 397 consecutive adults with cough >2 weeks at 2 health centers in Kampala, Uganda. We collected demographic and clinical information, sputum for TB testing (Xpert MTB/RIF Ultra and 2 liquid cultures), and tongue swabs for same-day quantitative polymerase chain reaction (qPCR) testing. We evaluated tongue swab qPCR diagnostic accuracy versus sputum TB test results, quantified TB targets per swab, assessed the impact of serial swabbing, and compared 2 swab types (Copan FLOQSWAB and Steripack spun polyester).

RESULTS

Among 397 participants, 43.1% were female, median age was 33 years, 23.5% were diagnosed with human immunodeficiency virus, and 32.0% had confirmed TB. Sputum Xpert Ultra and tongue swab qPCR results were concordant for 98.2% (95% confidence interval [CI]: 96.2-99.1) of participants. Tongue swab qPCR sensitivity was 92.6% (95% CI: 86.5 to 96.0) and specificity was 99.1% (95% CI: 96.9 to 99.8) versus microbiological reference standard. A single tongue swab recovered a 7-log range of TB copies, with a decreasing recovery trend among 4 serial swabs. Swab types performed equivalently.

CONCLUSIONS

Tongue swabs are a promising alternative to sputum for molecular diagnosis of TB, with sensitivity approaching sputum-based molecular tests. Our results provide valuable insights for developing successful tongue swab-based TB diagnostics.

Exploring the Role of Healthcare Personnel in Designing Tuberculosis Infection Prevention and Control Measures in Healthcare Settings: A Scoping Review

Background: Healthcare personnel (HCP) in high TB-burdened countries continue to be at high risk of occupational TB due to inadequate implementation of Tuberculosis Infection Prevention and Control (TB-IPC) measures and a lack of understanding of the context and relevance to local settings. Such transmission in the healthcare workplace has prompted the development and dissemination of numerous guidelines for strengthening TB-IPC for use in settings globally. However, a lack of involvement of healthcare personnel in the conceptualisation and development of guidelines and programmes seeking to improve TB-IPC in high-burden countries generally has been observed. Objectives: The aim of this review was to explore the inclusion of HCP in decision-making when designing the TB-IPC guidelines, in healthcare settings. Methods: A scoping review methodology was selected for this study to gain insight into the relevant research evidence, identifying and mapping key elements in the TB-IPC measures in relation to HCP as implementors. Results: Studies in this review refer to factors related to HCP's knowledge of TB-IPC, perception regarding occupational risks and behaviours, their role against a background of structural resource constraints, and guidelines' adherence. They report several challenges in TB-IPC implementation and adherence, particularly eliciting recommendations from HCP for improved TB-IPC practices. Conclusions: This review highlights a lack of participation in decision-making by the implementers of the policies and guidelines, yet adherence to TB-IPC measures is anticipated. Future research needs to focus more on consultations with users to understand the preferences from both within individual healthcare facilities and the communities. There is an urgent need for research on the participation of the implementers in the decision-making when developing TB-IPC policies and guidelines.

Deep Learning-based Diagnosis of Pulmonary Tuberculosis on Chest X-ray in the Emergency Department: A Retrospective Study

Prompt and correct detection of pulmonary tuberculosis (PTB) is critical in preventing its spread. We aimed to develop a deep learning-based algorithm for detecting PTB on chest X-ray (CXRs) in the emergency department. This retrospective study included 3498 CXRs acquired from the National Taiwan University Hospital (NTUH). The images were chronologically split into a training dataset, NTUH-1519 (images acquired during the years 2015 to 2019; n = 2144), and a testing dataset, NTUH-20 (images acquired during the year 2020; n = 1354). Public databases, including the NIH ChestX-ray14 dataset (model training; 112,120 images), Montgomery County (model testing; 138 images), and Shenzhen (model testing; 662 images), were also used in model development. EfficientNetV2 was the basic architecture of the algorithm. Images from ChestX-ray14 were employed for pseudo-labelling to perform semi-supervised learning. The algorithm demonstrated excellent performance in detecting PTB (area under the receiver operating characteristic curve [AUC] 0.878, 95% confidence interval [CI] 0.854-0.900) in NTUH-20. The algorithm showed significantly better performance in posterior-anterior (PA) CXR (AUC 0.940, 95% CI 0.912-0.965, p-value < 0.001) compared with anterior-posterior (AUC 0.782, 95% CI 0.644-0.897) or portable anterior-posterior (AUC 0.869, 95% CI 0.814-0.918) CXR. The algorithm accurately detected cases of bacteriologically confirmed PTB (AUC 0.854, 95% CI 0.823-0.883). Finally, the algorithm tested favourably in Montgomery County (AUC 0.838, 95% CI 0.765-0.904) and Shenzhen (AUC 0.806, 95% CI 0.771-0.839). A deep learning-based algorithm could detect PTB on CXR with excellent performance, which may help shorten the interval between detection and airborne isolation for patients with PTB.

New manual qPCR assay validated on tongue swabs collected and processed in Uganda shows sensitivity that rivals sputum-based molecular TB diagnostics

Background

Reliance on sputum-based testing is a key barrier to increasing access to molecular diagnostics for tuberculosis (TB). Many people with TB are unable to produce and sputum processing increases the complexity and cost of molecular assays. Tongue swabs are emerging as an alternative to sputum, but performance limits are uncertain.

Methods

From June 2022 to July 2023, we enrolled 397 consecutive adults with cough >2 weeks at two health centers in Kampala, Uganda. We collected routine demographic and clinical information, sputum for routine TB testing (one Xpert MTB/RIF Ultra® and two liquid cultures), and up to four tongue swabs for same-day qPCR. We evaluated tongue swab qPCR diagnostic accuracy in reference to sputum TB test results, quantified TB targets per swab, assessed the impact of serial swabbing, and compared two swab types (Copan FLOQSWAB® and Steripack® spun polyester swabs).

Results

Among 397 participants, 43.1% were female, median age was 33 years, 23.5% were living with HIV (PLHIV) and 32.3% had confirmed TB. Sputum Xpert Ultra and tongue swab qPCR results were concordant for 98.2% [96.2-99.1] of participants. Tongue swab qPCR sensitivity was 91.0% [84.6-94.9] and specificity 98.9% [96.2-99.8] vs. microbiological reference standard (MRS). A single tongue swab recovered a seven-log range of TB copies, with a decreasing recovery trend among four serial swabs. We found no difference between swab types.

Conclusions

Tongue swabs show promise as an alternative to sputum for TB diagnosis, with sensitivity approaching sputum-based molecular tests. Our results provide valuable insights for developing successful tongue swab-based TB diagnostics.

Prevalence and incidence of tuberculosis in health workers: A systematic review of the literature

OBJECTIVE

To identify the prevalence and incidence of tuberculosis in health workers.

METHOD

Systematic literature review, according to the protocol of the Joanna Briggs Institute and report following PRISMA guidelines. Primary studies containing data on the incidence or prevalence of active or latent tuberculosis infection in health workers were considered.

RESULTS

2,310 potentially relevant studies were identified in ten databases, of which 24 were included. The prevalence of latent tuberculosis varied between 0.1% and 62.0%, and the annual incidence rate varied from 1.4% to 11.4%. A meta-analysis combining data from the studies identified the prevalence as 28% (95% CI 21-36). Occupational risk factors are related to direct contact with patients having active tuberculosis, and more years of professional experience.

CONCLUSIONS

Evidences show that tuberculosis is an important occupational problem in health care; however, there are still gaps in information about the epidemiology of tuberculosis in health workers, mainly related to the risk factors.

Longitudinal changes in COVID-19 concern and stress: Pandemic fatigue overrides individual differences in caution

Background:

Pandemic fatigue describes a phenomenon whereby individuals experience a decrease in COVID-19 concern over time, despite their risk for infection remaining stable, or even increasing. Individual differences in the experience of pandemic fatigue may have important implications for people’s adherence to public health recommendations.

Design and methods:

Using data collected from a large community cohort in McLennan County, TX, longitudinal changes in COVID-19-related concern, stress, and affect across three appointments separated by approximately 4 weeks (July–November 2020) were examined. About 495, 349, and 286 participants completed one, two, and three appointments, respectively. Changes to stress physiology and local travel over time were also analyzed.

Results:

Results of a latent class growth analysis revealed four distinct classes of individuals: (a) low concern, low stress, (b) moderate concern, moderate stress, (c) moderate concern, low stress, and (d) high concern, high stress. Despite differences between latent classes in initial levels of concern, stress, and negative affect, levels of each variable decreased over time for all groups. While this reduction of concern did not coincide with changes in local travel, it was reflected in heart rate and blood pressure.

Conclusions:

Together, these results suggest a general trend of pandemic fatigue in the sample, even for those with moderate-to-high levels of initial COVID-19 stress and concern. Such findings may provide insights into the expected challenges of promoting compliance with public health recommendations as the pandemic continues.

Tuberculosis attributed to transmission within healthcare facilities, Botswana—The Kopanyo Study

Objective:

Healthcare facilities are a well-known high-risk environment for transmission of M. tuberculosis, the etiologic agent of tuberculosis (TB) disease. However, the link between M. tuberculosis transmission in healthcare facilities and its role in the general TB epidemic is unknown. We estimated the proportion of overall TB transmission in the general population attributable to healthcare facilities.

Methods:

We combined data from a prospective, population-based molecular epidemiologic study with a universal electronic medical record (EMR) covering all healthcare facilities in Botswana to identify biologically plausible transmission events occurring at the healthcare facility. Patients with M. tuberculosis isolates of the same genotype visiting the same facility concurrently were considered an overlapping event. We then used TB diagnosis and treatment data to categorize overlapping events into biologically plausible definitions. We calculated the proportion of overall TB cases in the cohort that could be attributable to healthcare facilities.

Results:

In total, 1,881 participants had TB genotypic and EMR data suitable for analysis, resulting in 46,853 clinical encounters at 338 healthcare facilities. We identified 326 unique overlapping events involving 370 individual patients; 91 (5%) had biologic plausibility for transmission occurring at a healthcare facility. A sensitivity analysis estimated that 3%–8% of transmission may be attributable to healthcare facilities.

Conclusions:

Although effective interventions are critical in reducing individual risk for healthcare workers and patients at healthcare facilities, our findings suggest that development of targeted interventions aimed at community transmission may have a larger impact in reducing TB.

Predicting Airborne Infection Risk: Association Between Personal Ambient Carbon Dioxide Level Monitoring and Incidence of Tuberculosis Infection in South African Health Workers

BACKGROUND

High rates of tuberculosis (TB) transmission occur in hospitals in high-incidence countries, yet there is no validated way to evaluate the impact of hospital design and function on airborne infection risk. We hypothesized that personal ambient carbon dioxide (CO2) monitoring could serve as a surrogate measure of rebreathed air exposure associated with TB infection risk in health workers (HWs).

METHODS

We analyzed baseline and repeat (12-month) interferon-γ release assay (IGRA) results in 138 HWs in Cape Town, South Africa. A random subset of HWs with a baseline negative QuantiFERON Plus (QFT-Plus) underwent personal ambient CO2 monitoring.

RESULTS

Annual incidence of TB infection (IGRA conversion) was high (34%). Junior doctors were less likely to have a positive baseline IGRA than other HWs (OR, 0.26; P = .005) but had similar IGRA conversion risk. IGRA converters experienced higher median CO2 levels compared to IGRA nonconverters using quantitative QFT-Plus thresholds of ≥0.35 IU/mL (P < .02) or ≥1 IU/mL (P < .01). Median CO2 levels were predictive of IGRA conversion (odds ratio [OR], 2.04; P = .04, ≥1 IU/mL threshold). Ordinal logistic regression demonstrated that the odds of a higher repeat quantitative IGRA result increased by almost 2-fold (OR, 1.81; P = .01) per 100 ppm unit increase in median CO2 levels, suggesting a dose-dependent response.

CONCLUSIONS

HWs face high occupational TB risk. Increasing median CO2 levels (indicative of poor ventilation and/or high occupancy) were associated with higher likelihood of HW TB infection. Personal ambient CO2 monitoring may help target interventions to decrease TB transmission in healthcare facilities and help HWs self-monitor occupational risk, with implications for other airborne infections including coronavirus disease 2019.

Knowledge and Practice on Prevention and Control of Tuberculosis Among Nurses Working in a Regional Hospital, Nepal

Introduction

Tuberculosis (TB) is a highly prevalent communicable disease in Nepal. All health personnel who care for such patients are at high risk of developing tuberculosis. It is very necessary for all healthcare providers, especially nurses, who spend a lot of time with such patients, to have adequate knowledge and correct practice on the occupational safety measures to maintain health and prevent transmission of the disease. This study was carried out to assess the knowledge and practice of nurses in the prevention and control of TB infection.

Method

This study was a cross-sectional study conducted on nurses working in all wards and Outpatient Departments (OPDs) of Western Regional Hospital, Pokhara, Nepal. A complete enumeration of the respondents was performed, and data were collected consecutively, using a semi-structured self-administered questionnaire, from all nurses working in all the wards and OPDs of the hospital. The predictors of knowledge of TB infection prevention and control (TBIPC) were assessed using binary logistic regression.

Results

The study findings showed that a majority of nurses had an inadequate level of knowledge and poor practice of prevention and control of TB. Regarding practice, none of the nurses reported the use of an N95 mask or a respirator during care of the patients with TB and all the nurses reported that they used chemical disinfectant (virex) to clean the room and the surfaces. However, none of them reported the use of fumigation or ultraviolet irradiation for disinfection. Nurses who were 40 years and older (p = 0.001, adjusted odds ratio (AOR) = 5.965, CI = 2.083–17.457) and who were currently working in the wards with isolation rooms demonstrated higher odds for knowledge on TBIPC (p = 0.010, AOR = 2.686, CI = 1.264–5.710).

Conclusions

This study showed that a majority of nurses had an inadequate level of knowledge and implemented poor safety measures for the prevention and control of tuberculosis. This increases their risk of being infected with TB infection and cross-transmission. It is recommended that the hospital plan and conduct the necessary education/training for nurses to update their knowledge, develop the organizational structure and policies, and establish a system to support and monitor the practice of health workers on the prevention and control of TB, and maintain the health and safety of nurses caring for patients with TB.

Preparedness of tertiary care hospitals to implement the national TB infection prevention and control guidelines in Bangladesh: A qualitative exploration

In high tuberculosis (TB) burden countries, health settings, including non-designated TB hospitals, host many patients with pulmonary TB. Bangladesh's National TB Control Program aims to strengthen TB infection prevention and control (IPC) in health settings. However, there has been no published literature to date that assessed the preparedness of hospitals to comply with the recommendations. To address this gap, our study examined healthcare workers knowledge and attitudes towards TB IPC guidelines and their perceptions regarding the hospitals' preparedness in Bangladesh. Between January to December 2019, we conducted 16 key-informant interviews and four focus group discussions with healthcare workers from two public tertiary care hospitals. In addition, we undertook a review of 13 documents [i.e., hospital policy, annual report, staff list, published manuscript]. Our findings showed that healthcare workers acknowledged the TB risk and were willing to implement the TB IPC measures but identified key barriers impacting implementation. Gaps were identified in: policy (no TB policy or guidelines in the hospital), health systems (healthcare workers were unaware of the guidelines, lack of TB IPC program, training and education, absence of healthcare-associated TB infection surveillance, low priority of TB IPC, no TB IPC monitoring and feedback, high patient load and bed occupancy, and limited supply of IPC resources) and behavioural factors (risk perception, compliance, and self and social stigma). The additional service-level gap was the lack of electronic medical record systems. These findings highlighted that while there is a demand amongst healthcare workers to implement TB IPC measures, the public tertiary care hospitals have got key issues to address. Therefore, the National TB Control Program may consider these gaps, provide TB IPC guidelines to these hospitals, assist them in developing hospital-level IPC manual, provide training, and coordinate with the ministry of health to allocate separate budget, staffing, and IPC resources to implement the control measures successfully.

Examining pulmonary TB patient management and healthcare workers exposures in two public tertiary care hospitals, Bangladesh

Implementation of tuberculosis (TB) infection prevention and control (IPC) guidelines in public tertiary care general hospitals remain challenging due to limited evidence of pulmonary TB (PTB) patients' duration of hospital stay and management. To fill this evidence gap, this study examined adult PTB patient management, healthcare workers' (HCWs) exposures and IPC practices in two public tertiary care hospitals in Bangladesh.Between December 2017 and September 2019, a multidisciplinary team conducted structured observations, a hospital record review, and in-depth interviews with hospital staff from four adult medicine wards.Over 20 months, we identified 1,200 presumptive TB patients through the hospital record review, of whom 263 were confirmed PTB patients who stayed in the hospital, a median of 4.7 days without TB treatment and possibly contaminated the inpatients wards. Over 141 observation hours, we found a median of 3.35 occupants present per 10 m2 of floor space and recorded a total of 17,085 coughs and 316 sneezes: a median of 3.9 coughs or sneezes per 10 m2 per hour per ward. Only 8.4% of coughs and 21% of sneezes were covered by cloths, paper, tissues, or by hand. The HCWs reportedly could not isolate the TB patients due to limited resources and space and could not provide them with a mask. Further, patients and HCWs did not wear any respirators.The study identified that most TB patients stayed in the hospitals untreated for some duration of time. These PTB patients frequently coughed and sneezed without any facial protection that potentially contaminated the ward environment and put everyone, including the HCWs, at risk of TB infection. Interventions that target TB patients screening on admission, isolation of presumptive TB patients, respiratory hygiene, and HCWs' use of personal protective equipment need to be enhanced and evaluated for acceptability, practicality and scale-up.

Tuberculosis infection status and risk factors among health workers: an updated systematic review

Tuberculosis (TB) infection is a common occupational risk for health workers (HWs) and poses a threat to the patients under their care and to other HWs. Hence, the development of a prevention strategy is crucial. We conducted a study to understand the status and risk factors of TB infection among HWs. The existing literature was searched for all published reports from 1 August 2010 to 31 December 2018, related to TB among HWs according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The inclusion criteria were: (1) study participants working in a health care facility; (2) TB cases diagnosed by medical professionals; (3) original research articles; and (4) English reports in a peer-reviewed journal. We finally included 61 studies from 642 articles searched initially. The TB infection rate in HWs was higher than that of the general population. Based on 39 studies, the prevalence of TB in HWs (tuberculin skin test positive) was 29.94%. In contrast, the global burden of latent TB infection was 23.0% (95% uncertainty interval: 20.4%–26.4%) in 2014. The risk factors of TB among HWs were aging, long duration of employment, nursing professionals, lack of Bacillus Calmette-Guerin vaccination, and low body mass index. HWs have an increased risk for TB infection, which can cause secondary infections in patients or other HWs. An effective prevention strategy must be developed to enable early diagnosis and prompt treatment.

Occupational Risk of Airborne Mycobacterium tuberculosis Exposure: A Situational Analysis in a Three-Tier Public Healthcare System in South Africa

This study aimed to detect airborne Mycobacterium tuberculosis (MTB) at nine public health facilities in three provinces of South Africa and determine possible risk factors that may contribute to airborne transmission. Personal samples (n = 264) and stationary samples (n = 327) were collected from perceived high-risk areas in district, primary health clinics (PHCs) and TB facilities. Quantitative real-time (RT) polymerase chain reaction (PCR) was used for TB analysis. Walkabout observations and work practices through the infection prevention and control (IPC) questionnaire were documented. Statistical analysis was carried out using Stata version 15.2 software. Airborne MTB was detected in 2.2% of samples (13/572), and 97.8% were negative. District hospitals and Western Cape province had the most TB-positive samples and identified risk areas included medical wards, casualty, and TB wards. MTB-positive samples were not detected in PHCs and during the summer season. All facilities reported training healthcare workers (HCWs) on TB IPC. The risk factors for airborne MTB included province, type of facility, area or section, season, lack of UVGI, and ineffective ventilation. Environmental monitoring, PCR, IPC questionnaire, and walkabout observations can estimate the risk of TB transmission in various settings. These findings can be used to inform management and staff to improve the TB IPC programmes.

"If I've got latent TB, I would like to get rid of it": Derivation of the CARD (Constraints, Actions, Risks, and Desires) Framework informed by South African healthcare worker perspectives on latent tuberculosis treatment

BACKGROUND

Healthcare workers (HWs) have at least twice the risk of tuberculosis (TB) compared to the general population. There is growing emphasis on latent TB infection (LTBI) in high-risk populations. Yet we know little about HWs' perspectives of LTBI testing and treatment to inform implementation in high-incidence settings. We developed a qualitative networked approach to analyze HWs' perspectives on LTBI testing and treatment.

METHODS

We conducted 22 in-depth interviews with nurse and physician stakeholders, who had been recruited as part of a larger study evaluating TB transmission risk in HWs at Tygerberg Hospital, Cape Town, South Africa. We performed open coding to identify emergent themes and selective coding to identify relevant text citations. We used thematic analysis to inductively derive the CARD (Constraints, Actions, Risks, Desires) framework.

RESULTS

All HWs desired to avoid developing TB but few felt this was actionable. Despite LTBI knowledge gaps, safety and cost concerns, most HWs reported hypothetical willingness to take LTBI treatment. The CARD framework showed that desire and action related to LTBI testing and treatment was clearly framed by the interactions between constraints, administrative action, and risk. The surprise HWs described on receiving a negative LTBI (Quantiferon-Plus) result suggests LTBI testing may recalibrate HWs' perceptions regarding the futility of actions to reduce their TB risk.

CONCLUSIONS

LTBI testing and treatment are acceptable to HWs and could counteract the perceived inevitability of occupational TB infection that currently may limit risk reduction action. This should be coupled with administrative leadership and infrastructural support. The CARD analytic framework is a helpful tool for implementation scientists to understand current practices within complex health systems. Application of CARD could facilitate the development of contextually-relevant interventions to address important public health problems such as occupational TB.

Tuberculosis: An Overview of the Immunogenic Response, Disease Progression, and Medicinal Chemistry Efforts in the Last Decade toward the Development of Potential Drugs for Extensively Drug-Resistant Tuberculosis Strains

Tuberculosis (TB) is a slow growing, potentially debilitating disease that has plagued humanity for centuries and has claimed numerous lives across the globe. Concerted efforts by researchers have culminated in the development of various strategies to combat this malady. This review aims to raise awareness of the rapidly increasing incidences of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis, highlighting the significant modifications that were introduced in the TB treatment regimen over the past decade. A description of the role of pathogen-host immune mechanisms together with strategies for prevention of the disease is discussed. The struggle to develop novel drug therapies has continued in an effort to reduce the treatment duration, improve patient compliance and outcomes, and circumvent TB resistance mechanisms. Herein, we give an overview of the extensive medicinal chemistry efforts made during the past decade toward the discovery of new chemotypes, which are potentially active against TB-resistant strains.

'It has become everybody's business and nobody's business': Policy actor perspectives on the implementation of TB infection prevention and control (IPC) policies in South African public sector primary care health facilities

South Africa is increasingly offering screening, diagnosis and treatment of tuberculosis (TB), and especially drug-resistant TB, at the primary care level. Nosocomial transmission of TB within primary health facilities is a growing concern in South Africa, and globally. We explore here how TB infection prevention and control (IPC) policies, historically focused on hospitals, are being implemented within primary care facilities. We spoke to 15 policy actors using in-depth interviews about barriers to effective TB-IPC and opportunities for improving implementation. We identified four drivers of poor policy implementation: fragmentation of institutional responsibility and accountability for TB-IPC; struggles by TB-IPC advocates to frame TB-IPC as an urgent and addressable policy problem; barriers to policy innovation from both a lack of evidence as well as a policy environment dependent on 'new' evidence to justify new policy; and the impact of professional medical cultures on the accurate recognition of and response to TB risks. Participants also identified examples of TB-IPC innovation and described conditions necessary for these successes. TB-IPC is a long-standing, complex health systems challenge. As important as downstream practices like mask-wearing and ventilation are, sustained, effective TB-IPC ultimately requires that we better address the upstream barriers to TB-IPC policy formulation and implementation.

A Continental Survey on the Impact of COVID-19 on Neurosurgical Training in Africa

Background

Containment measures for COVID-19 have affected surgical training globally. We sought to assess how neurosurgical training has been affected across Africa in April 2020.

Methods

A cross-sectional survey was distributed to African Neurosurgical trainees seeking to review demographics and effects of COVID on training.

Results

A total of 123 neurosurgery trainees responded from 23 African countries and a further 6 were abroad. A total of 91.80% were men, and 96.70% were training in public institutions. Only 41% had received training in COVID-19 with 61.79% worried that they would contract COVID-19 while performing their clinical duties. There was a marked reduction in clinical activities including a median reduction of elective surgery (−80%), clinics (−83%), and emergency surgery (−38.50%). A total of 23.58% of residents did not receive a formal salary, with 50% on less than $1000 USD gross per month.

Conclusions

This is the first continental survey of neurosurgery trainees in Africa. COVID-19 has significantly affected clinical and learning opportunities. There are concerns of the long-term effects on their training activities for an uncertain period of time during this pandemic. Although there has been a global increase in e-learning, there is need to evaluate if this is accessible to all trainees.

Work-Related Tuberculosis among Health Workers Employed in a Tertiary Hospital in Northeastern Thailand: A Report of Nine Cases

Between October 2016 and September 2018, fifteen health workers were diagnosed with tuberculosis (TB) at a tertiary hospital in northeastern Thailand. However, the cases could not be diagnosed as occupational TB according to international standards because of hospital limitations. The use of occupational epidemiological information provides a more effective work-related TB diagnosis. This study aims to provide a report of work-related TB using individual case investigation methods. We collected secondary data from the Occupational Health and Safety Office of the hospital in question, including baseline characteristics for the health workers, occupational history, source of TB infection and occupational exposure, and working environmental measurements. We found that nine of the fifteen cases were diagnosable as work-related TB due to two important factors: daily prolonged exposure time to an infected TB patient, and aerosol-generating procedures without adequate respiratory protection. The other six cases were not diagnosable as work-related TB because of inadequate evidence of activities related to the TB infection. The diagnosis of work-related TB thus requires occupational epidemiological information in order to complete the differentiation process.

The Effectiveness of Individual and Environmental Infection Control Measures in Reducing the Transmission of Mycobacterium tuberculosis: A Systematic Review

Background

Transmission of Mycobacterium tuberculosis in healthcare settings is a preventable driver of the global tuberculosis epidemic. We aimed to assess the evidence for infection control interventions, including cough etiquette, engineering and personal respiratory protection measures, to prevent transmission of M. tuberculosis in healthcare settings.

Methods

Three independent systematic reviews were performed using 6 databases and clinical trials websites. Randomized trials, cohort studies, before-after studies, and case-control studies were included. Searches were performed for controlled studies evaluating respiratory hygiene, engineering, and personal respiratory protection measures. Outcome measures included the incidence of tuberculosis infection and disease. Studies involving transmission to either humans or animals were included.

Results

Evaluation of respiratory hygiene and cough etiquette interventions identified 4 human studies, with 22 855 participants, and 1 guinea pig study. Studies in humans evaluated the effects of multiple concurrent interventions. Patient use of surgical masks reduced infection by 14.8%, and tuberculosis disease was reduced by between 0.5% and 28.9%. Engineering and environmental interventions were evaluated in 10 studies of humans, including 31 776 human participants, and 2 guinea pig studies. Mechanical ventilation was associated with between 2.9% and 14% less infection. Nine studies of personal respiratory protection were included, including 33 913 participants. Infection was reduced by between 0% and 14.8% in studies where particulate respirators were used. The quality of included studies was assessed as low.

Conclusions

Respiratory hygiene, engineering, and environmental infection controls and personal respiratory protection interventions were associated with reduced transmission of M. tuberculosis and reduced tuberculosis disease in healthcare settings.

Current Guidelines for Protecting Health Workers from Occupational Tuberculosis Are Necessary, but Not Sufficient: Towards a Comprehensive Occupational Health Approach

Health workers globally are at elevated occupational risk of tuberculosis infection and disease. While a raft of guidelines have been published over the past 25 years on infection prevention and control (IPC) in healthcare, studies in different settings continue to show inadequate implementation and persistence of risk. The aim of this commentary is to argue, based on the literature and our own research, that a comprehensive occupational health approach is an essential complement to IPC guidelines. Such an approach includes a health system framework focusing on upstream or mediating components, such as a statutory regulation, leadership, an information system, and staff trained in protective disciplines. Within the classical prevention framework, primary prevention needs to be complemented by occupational health services (secondary prevention) and worker's compensation (tertiary prevention). A worker-centric approach recognises the ethical implications of screening health workers, as well as the stigma perceived by those diagnosed with tuberculosis. It also provides for the voiced experience of health workers and their participation in decision-making. We argue that such a comprehensive approach will contribute to both the prevention of occupational tuberculosis and to the ability of a health system to withstand other crises of infectious hazards to its workforce.

Molecular epidemiology of drug resistant Mycobacterium tuberculosis in Africa: a systematic review

Background

The burden of drug resistant tuberculosis in Africa is largely driven by the emergence and spread of multidrug resistant (MDR) and extensively drug resistant (XDR) Mycobacterium tuberculosis strains. MDR-TB is defined as resistance to isoniazid and rifampicin, while XDR-TB is defined as MDR-TB with added resistance to any of the second line injectable drugs and any fluoroquinolone.

The highest burden of drug resistant TB is seen in countries further experiencing an HIV epidemic. The molecular mechanisms of drug resistance as well as the evolution of drug resistant TB strains have been widely studied using various genotyping tools. The study aimed to analyse the drug resistant lineages in circulation and transmission dynamics of these lineages in Africa by describing outbreaks, nosocomial transmission and migration. Viewed as a whole, this can give a better insight into the transmission dynamics of drug resistant TB in Africa.

Methods

A systematic review was performed on peer reviewed original research extracted from PubMed reporting on the lineages associated with drug resistant TB from African countries, and their association with outbreaks, nosocomial transmission and migration. The search terms “Tuberculosis AND drug resistance AND Africa AND (spoligotyping OR molecular epidemiology OR IS6110 OR MIRU OR DNA fingerprinting OR RFLP OR VNTR OR WGS)” were used to identify relevant articles reporting the molecular epidemiology of drug resistant TB in Africa.

Results

Diverse genotypes are associated with drug resistant TB in Africa, with variations in strain predominance within the continent. Lineage 4 predominates across Africa demonstrating the ability of “modern strains” to adapt and spread easily. Most studies under review reported primary drug resistance as the predominant type of transmission. Drug resistant TB strains are associated with community and nosocomial outbreaks involving MDR- and XDR-TB strains. The under-use of molecular epidemiological tools is of concern, resulting in gaps in knowledge of the transmission dynamics of drug resistant TB on the continent.

Conclusions

Genetic diversity of M. tuberculosis strains has been demonstrated across Africa implying that diverse genotypes are driving the epidemiology of drug resistant TB across the continent.

Perceived Health System Barriers to Tuberculosis Control Among Health Workers in South Africa

Background

The healthcare workforce in high tuberculosis burden countries such as South Africa is at elevated risk of tuberculosis infection and disease with adverse consequences for their well-being and productivity. Despite the availability of international guidelines on protection of health workers from tuberculosis, research globally has focused on proximal deficiencies in practice rather than on health system barriers.

Objective

This study sought to elicit perceptions of informed persons within the health system regarding health system barriers to protecting health workers from tuberculosis.

Methods

Semi-structured interviews were conducted with 18 informants active in spheres related to workplace tuberculosis prevention and management in South Africa. Interviews were audio recorded and transcribed verbatim, validated and analysed to derive emergent themes. Responses were analysed using the World Health Organization building blocks as core elements of a health system bearing on protection of its health workforce.

Findings

The following health system barriers were identified by informants: leadership and governance were "top-down" and fragmented; lack of funding was a major barrier; there were insufficient numbers of staff trained in infection prevention and control and occupational health; occupational health services were not comprehensively available and the ability to sustain protective technologies was questioned. A cross-cutting barrier was lack of priority afforded to workforce occupational health associated with lack of accurate information on cases of TB among health workers.

Conclusions

We conclude that deficiencies in implementation of recommended infection control and tuberculosis management practices are unlikely to be corrected until health system barriers are addressed. More committed leadership from senior health system management and greater funding are needed. The process could be assisted by the development of indicators to characterise such barriers and monitor progress.

Unpacking the dynamics of double stigma: how the HIV-TB co-epidemic alters TB stigma and its management among healthcare workers

BACKGROUND

HIV and tuberculosis (TB) are intricably interlinked in South Africa. The social aspects of this co-epidemic remain relatively unexplored. More specifically, no research has quantitatively explored the double stigma associated with HIV and TB in this context, and more specifically the impact of the co-epidemic on [1] the stigmatisation of TB and [2] the TB stigma mangement strategy of covering (i.e. the use of TB as a cover for having HIV). The current study aims to address this research gap by disentangling the complex mechanisms related to HIV-TB stigma.

METHODS

Using Structural Equation Modelling (SEM), data of 882 health care workers (HCWs) in the Free State province, South Africa, are analysed to investigate the link between the stigmatization of HIV and TB and the stigma management by those affected. The current study focuses on health care workers (HCWs), as both TB and HIV have a severe impact on this professional group.

RESULTS

The results demonstrate that the perceived link between the epidemics is significantly associated with double HIV-TB stigmatization. Furthermore, the link between the illnesses and the double stigma are driving the stigmatization of TB. Finally, the link between HIV and TB as well as the stigmatization of both diseases by colleagues are associated with an increased use of covering as a stigma management strategy.

CONCLUSIONS

This is the first quantitative study disentagling the mediating role of double stigma in the context of the co-epidemic as well as the impact of the co-epidemic on the social connotations of TB. The results stress the need for an integrated approach in the fight against HIV and TB recognizing the intertwined nature of the co-epidemic, not only in medical-clinical terms, but also in its social consequences.

TRIAL REGISTRATION

South African National Clinical Trials Register, registration ID: DOH-27-1115-5204. Prospectively registered on 26 August 2015.

Risk factors of delayed isolation of patients with pulmonary tuberculosis

OBJECTIVES

The aim was to examine the rate of delayed or no isolation of hospitalized patients with pulmonary tuberculosis (TB) and the causes for isolation failure.

METHODS

This retrospective study included patients with pulmonary TB at a university-affiliated hospital in South Korea between January 2015 and June 2018 after excluding those with a stay ≤2 days and those who only visited the emergency department. Patients who were not isolated for ≥3 days were classified as the delayed or no isolation group. We compared the clinical findings and diagnostic test results, between patients managed with delayed or no isolation (D-isolation) and timely isolation (T-isolation).

RESULTS

Of 486 patients with pulmonary TB, 222 patients were included. In 106 cases (47.7%), isolation was delayed or not applied, while in 116 cases, isolation was applied in a timely manner. Typical findings of TB were seen on the chest X-rays of 87 (75.0%) patients in the T-isolation group versus 25 (23.6%) patients in the D-isolation group (p < 0.001). Other factors significantly associated with delayed or no isolation on univariate analyses were older age, admission route (emergency room vs. other), admitting department, negative acid-fast bacilli (AFB) stain, and negative MTB PCR. On multivariate analysis, admission through an outpatient clinic, admission to a department other than infectious diseases or pulmonology, an atypical chest X-ray finding and negative sputum AFB stains were risk factors for isolation failure.

DISCUSSION

Delayed or no isolation of patients with pulmonary TB was attributed mainly to atypical radiological findings and negative findings of direct TB diagnostic tests.

Waiting to inhale: factors associated with healthcare workers' fears of occupationally-acquired tuberculosis (TB)

Background

Fear of TB infection is rooted in historical and social memories of the disease, marked by stigma, segregation and exclusion. Healthcare workers (HCWs) face these same fears today, and even seek to hide their TB status when infected. This study sought to investigate factors associated with HCWs fears of acquiring TB while at work, including selected biographic characteristics, TB knowledge, infection control and perceptions that their colleagues stigmatise co-workers with TB/ presumed to have TB.

Methods

In the Free State Province, South Africa, a representative sample of 882 HCWs from eight hospitals completed self-administered questionnaires on issues related to fear of occupationally acquired TB, infection control, TB knowledge and workplace TB stigma. The data were analysed using descriptive statistics as well as binomial logistic regression.

Results

Most of the HCWs (67.2%) were concerned about contracting TB at work. Support staff were less likely to worry about acquiring TB than clinical staff (OR = 0.657, P = 0.041). Respondents who indicated that there were inadequate numbers of disposable respirators at work, were 1.6 times more likely to be afraid of contracting TB at work (P = 0.040). With every unit increase on the TB stigma scale, respondents were 1.1 times more likely to fear acquiring TB at work (P = 0.000).

Conclusions

Being a professional clinical HCW, not having adequate disposable respirators available and seeing/perceiving co-workers stigmatise colleagues with (presumptive) TB were all significantly associated with the fear of occupationally-acquired TB. It is recommended that campaigns to destigmatise TB, as well as appropriate TB infection control education and measures, are necessary to alleviate HCWs fears of acquiring the disease in the workplace. Ultimately this should create a health-enabling working environment, where HCWs are not afraid to function and are free to seek treatment and support when necessary.

Health care workers' recommendations for strengthening tuberculosis infection control in the Dominican Republic

OBJECTIVE

To describe health care workers' practical recommendations for strengthening adherence to Mycobacterium tuberculosis infection control practices in their health institutions and elsewhere across the Dominican Republic.

METHODS

In this qualitative study, 10 focus groups, with a total of 40 clinicians (24 physicians, 16 nurses), were conducted in 2016 at two tertiary-level institutions in the Dominican Republic. Grounded theory guided the analysis to expand on health care workers' recommendations for empowering clinicians to adhere to M. tuberculosis infection control practices. To ensure reliability and validity, the authors analyzed data and incorporated both peer debriefing with qualitative experts and participant feedback or validation on the final themes.

RESULTS

Six emerging themes were described: 1) education and training; 2) administrative policy; 3) infrastructure policy; 4) economic allocations; 5) research; and 6) public health policy.

CONCLUSIONS

Future efforts may combine the health care workers' recommendations with evidence-based strategies in M. tuberculosis infection control in low-resource settings. This could pave the way for interventions that empower health care workers in their application of M. tuberculosis infection control measures in clinical practice.

Tuberculosis Elimination in the Asia-Pacific Region and the WHO Ethics Guidance

The World Health Organization has produced ethical guidance on implementation of the End TB strategy, which must be considered in local context. The Asia-Pacific Region has important distinctive characteristics relevant to tuberculosis, and engagement with the ethical implications raised is essential. This paper highlights key ethical considerations for the tuberculosis elimination agenda in the Asia-Pacific Regions and suggests that further programmatic work is required to ensure such challenges are addressed in clinical and public health programs.

Prevalence and risk factors of tuberculosis in developing countries through health care workers

In the last two decades, tuberculosis (TB) have threatened the public across the globe and continuing new TB cases and their transmission pooled with the global emergence of drug-resistant strains present an enduring occupational risk for health care workers (HCWs). Since last decade, government and funding agencies has given a significant amount of funds to tackle the problem of TB infection among medical staff or HCW in hospitals of developing countries, but the effects of these efforts have not yet been reported. Working environments are the major risk factors for TB infections among the HCW in hospital settings. Twenty-two high burden countries endorsed to the preponderance of worldwide tuberculosis cases in 2015. Urgent preventive strategies and mediations are needed to ensure the safety and sustained availability of these exquisite healthcare resources. This timeline review will provide the theoretical basis of high TB burden among the HCW which can be used for further improvement in strategies for the prevention of TB infections in hospital settings and provide a reliable basis for improving the personal health of HCW or medical staff.

Tuberculosis infection control practices in a high-burden metro in South Africa: A perpetual bane for efficient primary health care service delivery

Background

Tuberculosis (TB) prevention, including infection control, is a key element in the strategy to end the global TB epidemic. While effective infection control requires all health system components to function well, this is an area that has not received sufficient attention in South Africa despite the availability of policy and guidelines.

Aim

To describe the state of implementation of TB infection control measures in a high-burden metro in South Africa.

Setting

The research was undertaken in a high TB- and HIV-burdened metropolitan area of South Africa. More specifically, the study sites were primary health care facilities (PHC), that among other services also diagnosed TB.

Methods

A cross-sectional survey, focusing on the World Health Organization levels of infection control, which included structured interviews with nurses providing TB diagnosis and treatment services as well as observations, at all 41 PHC facilities in a high TB-burdened and HIV-burdened metro of South Africa.

Results

Tuberculosis infection control was poorly implemented, with few facilities scoring 80% and above on compliance with infection control measures. Facility controls: 26 facilities (63.4%) had an infection control committee and 12 (29.3%) had a written infection control plan. Administrative controls: 26 facilities (63.4%) reported separating coughing and non-coughing patients, while observations revealed that only 11 facilities (26.8%) had separate waiting areas for (presumptive) TB patients. Environmental controls: most facilities used open windows for ventilation (n = 30; 73.2%); however, on the day of the visit, only 12 facilities (30.3%) had open windows in consulting rooms. Personal protective equipment: 9 facilities (22%) did not have any disposable respirators in stock and only 9 respondents (22%) had undergone fit testing. The most frequently reported barrier to implementing good TB infection control practices was lack of equipment (n = 22; 40%) such as masks and disposable respirators, as well as the structure or layout of the PHC facilities. The main recommendation to improve TB infection control was education for patients and health care workers (n = 18; 33.3%).

Conclusion

All levels of the health care system should be engaged to address TB prevention and infection control in PHC facilities. Improved infection control will address the nosocomial spread of TB in health facilities and keep health care workers and patients safe from infection.

Outbreak column 21: Tuberculosis (TB): Still a nosocomial threat

This outbreak column explores the epidemiology and infection prevention guidance on tuberculosis (TB) in the UK. The column finds that, at present, national guidance leaves UK hospitals ill-prepared to prevent nosocomial TB transmission. Reasons for this conclusion are as follows: (1) while TB is predominantly a disease that affects people with 'social ills', it has the potential to infect anyone who is sufficiently exposed; (2) nosocomial transmission is documented throughout history; (3) future nosocomial exposures may involve less treatable disease; and (4) current UK guidance is insufficient to prevent nosocomial transmission and is less than that advocated by the World Health Organization and the Centers for Disease Control and Prevention.

Occupational tuberculosis in South Africa: are health care workers adequately protected?

Setting: A provincial tertiary hospital in Gauteng province, South Africa, with a high burden of tuberculosis (TB) patients and high risk of TB exposure among health care workers (HCWs). Objective: To determine HCWs' adherence to recommended TB infection prevention and control practices, TB training and access to health services and HCW TB rates. Design: Interviews with 285 HCWs using a structured questionnaire as part of a large, international mixed-methods study. Results: Despite 10 HCWs (including seven support HCWs) acquiring clinical TB during their period of employment, 62.8% of interviewees were unaware of the hospital's TB management protocol. Receipt of training was low (34.5% of all HCWs and <5% of support HCWs trained on TB transmission; 27.5% of nurses trained on respirator use), as was use of respiratory protection (44.5% of HCWs trained on managing TB patients). Support HCWs were over 36 times more likely to use respiratory protection if trained; nurses who were trained were approximately 40 times more likely to use respirators if they were readily available. Conclusion: Improved coordination and uptake of TB infection prevention training is urgently needed, especially for non-clinical HCWs in settings of regular exposure to TB patients. Adequate supplies of appropriate respiratory protection must be made available.

Protecting Our Front-liners: Occupational Tuberculosis Prevention Through Infection Control Strategies

Healthcare workers (HCWs) in low- and middle-income countries with high tuberculosis prevalence are at increased risk of tuberculosis infection; however, tuberculosis infection control (TBIC) measures are often poorly implemented. The World Health Organization recommends 4 levels of TBIC: managerial (establishment and oversight of TBIC policies), administrative controls (reducing HCWs' exposure to tuberculosis), environmental controls (reducing the concentration of infectious respiratory aerosols in the air), and personal respiratory protection. This article will discuss each of these levels of TBIC, and review the available data on the implementation of each in sub-Saharan African countries. In addition, we review the attitudes and motivation of HCWs regarding TBIC measures, and the impact of stigma on infection control practices and implementation. After summarizing the challenges facing effective TBIC implementation, we will discuss possible solutions and recommendations. Last, we present a case study of how a clinic effectively addressed some of the challenges of TBIC implementation.

Exposed, but Not Protected: More Is Needed to Prevent Drug-Resistant Tuberculosis in Healthcare Workers and Students

"Occupational MDR-TB"  …  "XDR-TB"  …  "Treatment-induced hearing loss": 3 life-changing messages imparted over the phone. Three personal accounts are shared highlighting the false belief held by many healthcare workers (HCWs) and students in low-resource settings-that they are immune to tuberculosis despite high levels of occupational tuberculosis exposure. This misconception reflects a lack of awareness of tuberculosis transmission and disease risk, compounded by the absence of accurate occupational tuberculosis estimates. As the global problem of drug-resistant (DR) tuberculosis evolves, HCWs are increasingly infected and suffer considerable morbidity and mortality from occupational DR tuberculosis disease. Similarly, healthcare students are emerging as a vulnerable and unprotected group. There is an urgent need for improved detection, vaccines, preventive therapy, treatment, and support for affected HCWs and those they care for, as well as destigmatization of all forms of tuberculosis. Finally, efforts to protect HCWs and prevent DR tuberculosis transmission by universal implementation of tuberculosis infection control measures should be prioritized.

Adherence to precautions for preventing the transmission of microorganisms in primary health care: a qualitative study

Background

Health care associated infections (HAIs) are a source of concern worldwide. No health service in any country can be considered HAI risk-free. However, there is scarcity of data on the risks to which both patients and health workers are subject in non-hospital settings. The aim of this study was to identify issues that determine the adherence of professionals to precautions for preventing transmission of microorganisms in primary health care.

Method

This was a qualitative study, using focus groups of primary health care staff, in two Brazilian municipalities. The data were analysed using content analysis.

Results

Four focus groups were conducted with 20 professionals (11 community health workers, 5 nursing assistants and 4 nurses), and the analysed content was organized into four thematic categories. These categories are: low risk perception, weaknesses in knowledge, insufficient in-service training and infrastructure limitations.

Participants expressed their weaknesses in knowledge of standard and transmission based precautions, mainly for hand hygiene and tuberculosis. A lack of appropriate resources and standardization in sharps disposal management was also highlighted by the participants.

Conclusion

The study points out the need to provide in-service training for professionals on the transmission of microorganisms in primary health care to ensure adequate level of risk perception and knowledge. Further recommendations include investment to improve infrastructure to facilitate adherence to precautions and to minimize the risk of disease transmission for both patients and health care workers.

The neglected burden of tuberculosis disease among health workers: a decade-long cohort study in South Africa

Background

Health workers (HWs) in resource-limited settings are at high-risk of exposure to tuberculosis (TB) at work. The aim of this study was to estimate the rate of TB disease among HWs in the Free State Province of South Africa between 2002 and 2012 and to compare demographic and clinical characteristics between HWs and the general population with TB. This study also explores the effect of occupational variables on risk of TB among HWs.

Methods

Probabilistic record linkage was utilized to identify HWs who were also registered as TB patients. This historical prospective cohort study calculated incidence rate ratios (IRR) for TB disease among HWs in Free State from 2002 to 2012. Generalized linear mixed-effects regression was used to model the association between sex, race, facility type, occupation, duration of employment, and the rate of TB.

Results

There were 2677 cases of TB diagnosed among HWs from 2002 to 2012 and 1280 cases were expected. The overall TB incidence rate in HWs during the study period was 1496·32 per 100,000 compared to an incidence rate of 719·37 per 100,000 in the general population during the same time period. IRR ranged from 1·14 in 2012 to 3·12 in 2005. HWs who were male, black, coloured and employed less than 20 years had higher risk of TB. Facility type and occupation were not associated with increased risk of TB when adjusted for other covariates.

Conclusion

HWs in South Africa have higher rates of TB than the general population. Improved infection prevention and control measures are necessary in all high-burden TB healthcare settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2659-3) contains supplementary material, which is available to authorized users.

Feasibility of district wide screening of health care workers for tuberculosis in Zambia

Background

Many health care workers (HCWs) are at increased risk for tuberculosis (TB). The World Health Organization (WHO) recommends screening HCWs for TB in high burden settings but this is often not implemented in countries with a high TB incidence. We assessed the feasibility of TB screening among HCWs, including participation rate and yield, as part of a project introducing facility specific TB interventions.

Methods

This study had a cross-sectional design. HCWs (including paid staff and community volunteers) from 13 clinics and two hospitals in the Ndola district of Zambia participated. HCWs were screened by a designated person in their own facility. The agreed screening algorithm for HCWs included annual symptom screening, with sputum smear, culture (or Xpert) and chest x-ray offered to HCWs with at least one TB symptom, i.e. those with presumptive TB.

Results

A total of 1011 out of 1619 (62%) staff and 71 out of 138 (51%) community volunteers were screened within one year, total 1082/1757 (62%). Five percent (52/1082) of those screened were presumptive TB patients. Seventy-three percent (38/52) of presumptive TB patients received all diagnostic tests according to the agreed algorithm. Eighteen out of 1757 staff and volunteers combined were diagnosed with TB within a calendar year, showing a notified TB incidence of 1%. At least five of them were diagnosed during the screening appointment (0.5% of those screened). One of the 18 HCWs died of TB. Seventy-six percent (822/1082) of screened HCWs indicated that they already knew their HIV status. Screening was considered feasible if confidentiality can be guaranteed although challenges such as the time required for screening and sample transport were reported.

Conclusions

It is feasible to conduct and implement screening programs for TB among HCWs in hospitals and clinics, and the notified incidence and yield is high. Advocacy is needed to educate managers and HCWs on the importance of screening and the implementation of locally relevant screening algorithms. It is essential to ensure access to TB infection control, diagnostics, treatment and confidential registration for HCW.

Agents of change: The role of healthcare workers in the prevention of nosocomial and occupational tuberculosis

Healthcare workers (HCWs) play a central role in global tuberculosis (TB) elimination efforts but their contributions are undermined by occupational TB. HCWs have higher rates of latent and active TB than the general population due to persistent occupational TB exposure, particularly in settings where there is a high prevalence of undiagnosed TB in healthcare facilities and TB infection control (TB-IC) programmes are absent or poorly implemented. Occupational health programmes in high TB burden settings are often weak or non-existent and thus data that record the extent of the increased risk of occupational TB globally are scarce. HCWs represent a limited resource in high TB burden settings and occupational TB can lead to workforce attrition. Stigma plays a role in delayed diagnosis, poor treatment outcomes and impaired well-being in HCWs who develop TB. Ensuring the prioritization and implementation of TB-IC interventions and occupational health programmes, which include robust monitoring and evaluation, is critical to reduce nosocomial TB transmission to patients and HCWs. The provision of preventive therapy for HCWs with latent TB infection (LTBI) can also prevent progression to active TB. Unlike other patient groups, HCWs are in a unique position to serve as agents of change to raise awareness, advocate for necessary resource allocation and implement TB-IC interventions, with appropriate support from dedicated TB-IC officers at the facility and national TB programme level. Students and community health workers (CHWs) must be engaged and involved in these efforts. Nosocomial TB transmission is an urgent public health problem and adopting rights-based approaches can be helpful. However, these efforts cannot succeed without increased political will, supportive legal frameworks and financial investments to support HCWs in efforts to decrease TB transmission.

Hospitalized care for MDR-TB in Port Harcourt, Nigeria: a qualitative study

BACKGROUND

In Nigeria multidrug-resistant tuberculosis (MDR-TB) is prevalent in 2.9% of new TB cases and 14% of retreatment cases, and the country is one of 27 with high disease burden globally. Patients are admitted and confined to one of ten MDR-TB treatment facilities throughout the initial 8 months of treatment. The perspectives of MDR-TB patients shared on social media and in academic research and those of providers are limited to experiences of home-based care. In this study we explored the views of hospitalised MDR-TB patients and providers in one treatment facility in Nigeria, and describe how their experiences are linked to accessibility of care and support services, in line with international goals. We aimed to explore the physical, social and psychological needs of hospitalized MDR TB patients, examine providers' perceptions about the hospital based model and discuss the model's advantages and disadvantages from the patient and the provider perspective.

METHODS

We conducted two gender distinct focus group discussions and 11 in-depth interviews with recently discharged MDR-TB patients from one MDR-TB treatment facility in Nigeria. We triangulated this with the views of four providers who played key roles in the management of MDR-TB patients via key informant interviews. Transcribed data was thematically analysed, using an iterative process to constantly compare and contrast emerging themes across the data set for deeper understanding of the full range of participants' views.

RESULTS

The study findings demonstrate the psycho-social impacts of prolonged isolation and the coping mechanisms of patients in the facility. The dislocation of patients from their normal social networks and the detachment between providers and patients created the need for interdependence of patients for emotional and physical support. Providers' fears of infection contributed to stigma and hindered accessibility of care and support services.

CONCLUSION

The current trend towards discharging patients after culture conversion would reduce the psycho-social impacts of prolonged isolation and potentially reduce the risk of occupational TB from prolonged contact with MDR-TB patients. Building on shared experiences and interdependence of MDR-TB patients in our study, innovative patient-centred support systems would likely help to reduce stigma, promote access to care and support services, and potentially impact on the outcome of treatment.

Factors associated with good TB infection control practices among primary healthcare workers in the Free State Province, South Africa

Background

Despite the availability of TB infection control guidelines, and good levels of healthcare worker knowledge about infection control, often these measures are not well implemented. This study sought to determine the factors associated with healthcare workers’ good TB infection control practices in primary health care facilities in the Free State Province, South Africa.

Methods

A cross-sectional self-administered survey among nurses (n = 202) and facility-based community healthcare workers (n = 34) as well as facility observations were undertaken at all 41 primary health care facilities in a selected district of the Free State Province.

Results

The majority of respondents were female (n = 200; 87.7 %) and the average age was 44.19 years (standard deviation ±10.82). Good levels of knowledge were recorded, with 42.8 % (n = 101) having an average score (i.e. 65–79 %) and 31.8 % (n = 75) a good score (i.e. ≥ 80 %). Most respondents (n = 189; 80.4 %) had positive attitudes towards TB infection control practices (i.e. ≥ 80 %). While good TB infection control practices were reported by 72.9 % (n = 161) of the respondents (i.e. ≥75 %), observations revealed this to not necessarily be the case. For every unit increase in attitudes, good practices increased 1.090 times (CI:1.016–1.169). Respondents with high levels of knowledge (≥80 %) were 4.029 (CI: 1.550–10.469) times more likely to have good practices when compared to respondents with poor levels of knowledge (<65 %). The study did not find TB/HIV-related training to be a predictor of good practices.

Conclusions

Positive attitudes and good levels of knowledge regarding TB infection control were the main factors associated with good infection control practices. Although many respondents reported good infection control practices - which was somewhat countered by the observations - there are areas that require attention, particularly those related to administrative controls and the use of personal protective equipment.

[Multidrug resistant tuberculosis among health personnel in Côte d'Ivoire]

Multidrug resistance tuberculosis (MDR-TB) of health workers raises the question of hospital-borne transmission of infection.

OBSERVATIONS

We report 4 cases of MDR-TB confirmed at the health workers over a period of 8 years (January, 2005 to December 2012), in the 2 services of pulmonology from Abidjan to Côte d'Ivoire). It was about young grown-up patients (aged between 28 and 39 years), all HIV negatives, in a no-win situation of antituberculosis treatment (3 patients/4). The most concerned staffs were the male nurses (2/4). Two agents worked in general hospital and the only one in a pulmonology department at the time of the diagnosis. The tuberculosis was of lung seat with bilateral radiographic hurt (3/4) and multiples excavations (4/4). The case index, when it was identified (2/2), was a family case. Among 3 agents who benefited from a second line treatment, 1 died further to an extensive drug resistance and 2 are declared to be cured. The fourth died before the beginning of the treatment. These cases of cure were in touch with a premature care.

CONCLUSION

Multidrug resistant tuberculosis at the health workers could have a negative impact on the antituberculosis fight imposing rigorous measures of infection control and better implication of the occupational medicine.

Taking forward the World TB Day 2016 theme 'Unite to End Tuberculosis' for the WHO Africa Region

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Tuberculosis (TB) has remained a global emergency ever since it was declared as such by the World Health Organization (WHO) in 1993.

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Of the 9.6 million people who developed TB in 2014, 28% were in the WHO Africa Region, where the case rate was 281 per 100 000 population.

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An estimated 1.2 million (12%) TB cases were HIV-positive and the Africa Region accounted for 74% of these cases.

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The global spread of multidrug-resistant TB (MDR-TB) is now a major public health challenge.

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Scientific, political, and funder communities seriously need to ‘Unite to End TB’, the theme of the 2016 World TB Day.

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TB control programs in Africa can only succeed if mechanisms for close engagement of developing country scientists, healthcare workers, patient groups, governments, and policy-makers are ensured by funding and donor agencies.

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Several funder, political, and community initiatives provide hope for achieving the goals of the WHO post-2015 TB strategy.

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TB activities and funder investments in Africa need to be aligned in parallel with international efforts at improving social and living conditions and with the ‘one health’ initiative.

Tuberculosis (TB) remains a global emergency, with an estimated 9.6 million new TB cases worldwide reported in 2014. Twenty-eight percent of these cases were in the World Health Organization (WHO) Africa Region, where the annual case detection rate was 281 per 100 000 population—more than double the global average of 133 per 100 000. Of the 9.6 million people who developed TB, an estimated 1.2 million (12%) were HIV-positive, and the Africa Region accounted for 74% of these cases. Three million people with TB remain undiagnosed and untreated. Globally, an estimated 480 000 had multidrug-resistant TB (MDR-TB). Whilst of the African countries, only South Africa has reported a high prevalence of MDR-TB, it is likely that all of Sub-Saharan Africa has an unreported high load of drug-resistant TB. Tragically, in 2014, only 48% of individuals diagnosed with MDR-TB had successful treatment and an estimated 190 000 people died of MDR-TB. Of the global TB funding gap of US$ 0.8 billion, the largest funding gap was in the Africa Region, amounting to US$ 0.4 billion in 2015. The MDR-TB pandemic in particular now threatens to devastate entire regions and may fundamentally alter the life-expectancy and demographic profile of many countries in Sub-Saharan Africa. The theme designated for this year's World TB Day, March 24, 2016, is ‘Unite to End TB’. From the Africa Region, there is an urgent need to seriously address the political, economic, and social factors that influence host–Mycobacterium tuberculosis interactions and result in disease. Recent political and funder initiatives that provide renewed hope for the alleviation of Africa's TB and TB/HIV problems are discussed.