The Triple Burden of Tuberculosis, Human Immunodeficiency Virus and Silicosis among Artisanal and Small-Scale Miners in Zimbabwe

Feasibility of respirable crystalline silica exposure reduction in small-scale tanzanite mining in Tanzania

INTRODUCTION

Respirable crystalline silica (RCS) exposures in tanzanite gem mining have been linked to tuberculosis and silicosis among miners. We conducted a plot study to assess RCS exposures and to introduce safer mining practices in one small-scale underground tanzanite mine.

MATERIALS AND METHODS

Personal and area air samples for RCS were collected during tanzanite mining operations before and after improved work practices employed to reduce exposures and analyzed using X-ray diffraction. Area samples were collected at the rest area, located approximately 300 m underground and 100 m from other work activities. Improved practices included the use of wet drilling methods and drilling with new bits.

RESULTS

A total of 33 personal and 4 area air samples were collected. Pre-intervention, mean exposures for all operations, drilling operations, non-drilling activities, and area samples were 122 mg/m3, 247 mg/m3, 34.3 mg/m3, and 1.95 mg/m3, respectively which exceeded the U.S. OSHA Permissible Exposure Limit (PEL) by 2,440 times for all operations, by 4,946 times for drilling operations, by 686 times for non-drilling activities and 39 times for area samples collected at an underground rest area. The post-intervention results showed a 99% reduction of RCS exposures for wet drilling operations, 98.5% reduction for non-drilling activities, and 36% reduction for area samples. Despite improvements, post-intervention RCS exposures during drilling had a mean of 2.08 mg/m3 or more than 41 times the OSHA PEL.

CONCLUSIONS

We successfully piloted a program to work with small-scale tanzanite miners to reduce RCS exposures and raise awareness about the occupational health risks of RCS, though additional measures are recommended to further reduce RCS exposures. Similar programs should be taken to scale throughout underground mining sites in Tanzania and other countries.

Pneumoconiosis among artisanal miners in Chunya district, Mbeya, Tanzania

This case series sheds light on the pulmonary diseases afflicting artisanal gold miners in Chunya district, Mbeya, Tanzania. We present 3 cases from a group of 21 miners. The patients, ranging in age and mining exposure, exhibited symptoms of severe pulmonary conditions, including pneumoconiosis, pulmonary hypertension and Cor pulmonale, attributed to prolonged exposure to dust and inadequate protective measures in mining environments. These cases underscore the urgent need for enhanced occupational health standards and preventive strategies in artisanal mining communities.

Public health assessment of Kenyan ASGM communities using multi-element biomonitoring, dietary and environmental evaluation

The Kakamega gold belt's natural geological enrichment and artisanal and small-scale gold mining (ASGM) have resulted in food and environmental pollution, human exposure, and subsequent risks to health. This study aimed to characterise exposure pathways and risks among ASGM communities. Human hair, nails, urine, water, and staple food crops were collected and analysed from 144 ASGM miners and 25 people from the ASGM associated communities. Exposure to PHEs was predominantly via drinking water from mine shafts, springs and shallow-wells (for As>Pb>Cr>Al), with up to 366 µg L-1 arsenic measured in shaft waters consumed by miners. Additional exposure was via consumption of locally grown crops (for As>Ni>Pb>Cr>Cd>Hg>Al) besides inhalation of Hg vapour and dust, and direct dermal contact with Hg. Urinary elemental concentrations for both ASGM workers and wider ASGM communities were in nearly all cases above bioequivalents and reference upper thresholds for As, Cr, Hg, Ni, Pb and Sb, with median concentrations of 12.3, 0.4, 1.6, 5.1, 0.7 and 0.15 µg L-1, respectively. Urinary As concentrations showed a strong positive correlation (0.958) with As in drinking water. This study highlighted the importance of a multidisciplinary approach in integrating environmental, dietary, and public health investigations to better characterise the hazards and risks associated with ASGM and better understand the trade-offs associated with ASGM activities relating to public health and environmental sustainability. Further research is crucial, and study results have been shared with Public Health and Environmental authorities to inform mitigation efforts.

Health Screening Strategies for Artisanal and Small-Scale Miners for Tuberculosis, Human Immunodeficiency Virus and Silicosis: A Case of the USAID-Supported Kunda Nqob'iTB Project in Zimbabwe

Artisanal and small-scale mining is characterized by excessive exposure to physical, chemical, ergonomic, psychosocial and biological hazards. There is a high burden of tuberculosis (TB), human immunodeficiency virus (HIV) infections and silicosis among artisanal and small-scale miners (ASMs). The aim of this project report is to describe lessons learned from strategies implemented to reach ASMs with screening services for TB, HIV and silicosis in Zimbabwe through the Kunda-Nqob'i TB (KNTB) project supported by the United States Agency for International Development (USAID). The intervention package for screening ASMs for TB, HIV and silicosis included service provision through two occupational health clinics at two provincial hospitals and a mobile workplace-based screening (WBS) facility at the mining sites. From 1 October 2020 to 30 September 2023, 10,668 ASMs were screened, with a high number of cases of silicosis (21%) and TB (7.4%). There was a high burden of HIV (30%) in ASMs attending the occupational health clinics. The two occupational health clinics screened 3453 ASMs, while the mobile WBS activities screened 7215 ASMs during the period. A total of 370 healthcare workers (doctors/clinical officers, nurses, environmental health technicians and district tuberculosis and Leprosy control officers) were trained on TB and the fundamental diagnostic principles of silicosis. The KNTB project has been successful in reaching out to many ASMs operating in remote and hard-to-reach mining areas. The KNTB project has brought to light the positive health-seeking behavior of ASMs operating in remote areas. The project has brought to the fore the effectiveness of multi-stakeholder engagement and collaboration in reaching out to ASMs in remote areas with health screening services. There is a high burden of TB, HIV and silicosis in ASMs. Screening for TB, HIV and silicosis using workplace-based screening and occupational health clinics is an effective strategy and should be rolled out to all areas with high artisanal and small-scale mining activity.

Silico-tuberculosis amidst COVID-19 pandemic: global scenario and Indian perspective

Inhalation of crystalline silica-rich dust particles can result in the deadly occupational lung disorder called silicosis. The risk of contracting tuberculosis (TB) and the potential for lung cancer increase due to silicosis. This review article aims to bring to light the state of silicosis and TB scenario in the world and India for evaluating hurdles in the present and future to achieve the elimination road map and assess these conditions in the backdrop of the COVID-19 pandemic. A patient with silicosis has a 2.8-2.9 times higher risk of developing pulmonary TB and 3.7 times that of extrapulmonary TB. Incidences of missed cases when TB was misdiagnosed with silicosis due to indifferent clinical manifestations of the two in the initial stages are not uncommon. The duration of silica exposure and silicosis severity are directly related to the propensity to develop TB. As per a study, an average gap of 7.6 years has been noticed in a South African population for silico-tuberculosis to develop post-silicosis. In a study done on mine workers at Jodhpur, Rajasthan, it was seen that there is no definitive relation between patients with silicosis and the possibility of having COVID-19. There is a significant need to integrate the Silicosis control program with the TB elimination program for the government. A few steps can include assessing the workplaces, periodic monitoring of the workers' health, active case surveillance, identification of hotspots, and introducing reforms to curb the spread of dust and particulate matter from industrialised areas be taken in this regard.

Knowledge, Attitudes, and Practices of Artisanal and Small-Scale Miners regarding Tuberculosis, Human Immunodeficiency Virus, and Silicosis in Zimbabwe

In Zimbabwe, artisanal and small-scale miners (ASMs) have a high prevalence of tuberculosis (TB), human immunodeficiency virus (HIV), and silicosis. Previous studies on ASMs utilised programme data, and it was not possible to understand reasons for the high prevalence of these comorbidities. We conducted a cross-sectional study to investigate the knowledge, attitudes, and practices of ASMs regarding TB, HIV, and silicosis. We enrolled a convenience sample of 652 ASMs. Their mean (standard deviation) age was 34.2 (10.8) years. There were 602 (92%) men and over 75% had attained secondary education. A total of 504 (80%) of the ASMs knew that TB is a curable disease, and 564 (87%) knew that they were at higher risk of TB than the general population. However, they were less likely to know that HIV increases the risk of TB disease, 340 (52%), with only 226 (35%) who perceived the risk of TB infection to be high among ASMs. Only 564 (59%) were aware that silica dust causes permanent and incurable lung diseases. Six hundred and twenty (97%) showed a positive attitude towards healthcare when they were sick, and 97% were willing to use special respirators to prevent dust inhalation. On practices, only 159 (30%) reported consistent use of either cloth or respirators to prevent dust inhalation. Three hundred and five (49%) ASMs reported consistent use of condoms outside their homes and 323 (50%) reported use of water to suppress dust. Only 480 (75%) of ASMs sought healthcare services when sick. ASMs cited challenges of accessing healthcare services due to lack of money to pay for healthcare (50%), long distances to clinics (17%), and the shortage of medicines at clinics (11%). Effective control of TB, silicosis, and HIV among ASMs requires addressing the identified knowledge gaps and barriers that are faced by ASMs in accessing personal protective equipment and healthcare services. This will require multisector collaboration and the involvement of ASMs in co-designing a package of healthcare services that are tailored for them.

Tuberculosis cohort analysis in Zimbabwe: The need to strengthen patient follow-up throughout the tuberculosis care cascade

INTRODUCTION

Globally people with tuberculosis (TB) continue to be missed each year. They are either not diagnosed or not reported which indicates possible leakages in the TB care cascade. Zimbabwe is not spared with over 12000 missed cases in 2020. A preliminary review of TB treatment outcomes indicated patient leakages throughout the presumptive cascade and undesirable treatment outcomes in selected cities. Chegutu District had pre-diagnosis and pretreatment losses to follow-up while Mutare City among others had 22.0% of outcomes not evaluated in the second quarter of 2021, and death rates as high as 14% were recorded in Gweru District. The problem persists despite training on data analysis and use. The TB cohorts were analysed to determine the performance of the care cascade and the spatial distribution of treatment outcomes in Zimbabwe.

METHODS

Using data from district health information software version 2.3 (DHIS2.3), a secondary data analysis of 2020 drug-sensitive (DS) TB treatment cohorts was conducted. We calculated the percentage of pre-diagnosis, and pre-treatment loss to follow-up (LTFU). For TB treatment outcomes, 'cured' and 'treatment completed' were categorized as treatment success, while 'death', 'loss to follow-up (LTFU), and 'not evaluated' were categorized as undesirable outcomes. Univariate analysis of the data was conducted where frequencies were calculated, and data was presented in graphs for the cascade, treatment success, and undesirable outcomes while tables were created for the description of study participants and data quality. QGIS was used to generate maps showing undesirable treatment outcomes.

RESULTS

An analysis of national data found 107583 people were presumed to have TB based on symptomatic screening and or x-ray and 21.4% were LTFU before the specimen was investigated. Of the 84534 that got tested, 10.0% did not receive their results. The treatment initiation rate was 99.1%. Analysis of treatment outcomes done at the provincial level showed that Matabeleland South Province had the lowest treatment success rate of 77.3% and high death rates were recorded in Matabeleland South (30.0%), Masvingo (27.3%), and Matabeleland North (26.1%) provinces. Overall, there were high percentages of not-evaluated treatment outcomes.

CONCLUSION

Pre-diagnosis LTFU was high, and high death and loss to follow-up rates were prevalent in provinces with artisanal and small-scale mining (ASM) activities. Unevaluated treatment outcomes were also prevalent and data quality remains a challenge within the national TB control program. We recommended strengthening patient follow-up at all levels within the TB care cascade, strengthening capacity-building for data analysis and use, further analysis to determine factors associated with undesirable outcomes and a study on why LTFU remains high.

Exploring medical terminology inexpediencies: Tripledemic vs. triple epidemic

Accurate and consistent medical terminology has a fundamental value in medicine. It enables medical students to understand the meaning of each term, medical physicians to communicate with each other, and it also enables science to adopt a logical language of high-level understanding and scientific regularity. Medical terminology inexpediencies caused by the adoption of etymologically illogical or linguistically false terms lead to misunderstanding and confusion among clinicians. The medical terms epidemic and pandemic are as old as Hippocrates and Sophocles, respectively. The present article evaluates the new medical terms tripledemic and triple epidemic, which were introduced during the recent COVID-19 pandemic.

Factors associated with the unsuccessful TB treatment outcomes in the northern regions of Namibia: a mixed methods study

BACKGROUND

Tuberculosis (TB) is among the leading causes of death globally. The disease has a huge burden in Namibia, with a case notification rate of at least 442 per 100,000. To date, Namibia is among the countries with the highest global TB burden, despite all efforts to reduce it. This study aimed to determine the factors associated with the unsuccessful treatment outcomes of the Directly Observed Therapy Short course (DOTS) programme in the Kunene and Oshana regions.

METHODS

The study utilised a mixed-methods explanatory-sequential design to collect data from all TB patient records and healthcare workers who work directly with the DOTS strategy for TB patients. The relationship between independent and dependent variables was analysed using multiple logistic regression analysis, while interviews were analysed using inductive thematic analysis.

RESULTS

The overall treatment success rates of the Kunene and Oshana regions throughout the review period were 50.6% and 49.4%, respectively. The logistic regression analyses showed that in the Kunene region, the type of DOT used (Community-based DOTS) (aOR = 0.356, 95% CI: 0.835-2.768, p = 0.006) was statistically significant with the unsuccessful treatment outcomes. While in the Oshana region, age groups 21-30 years old (aOR = 1.643, 95% CI = 1.005-2.686, p = 0.048), 31-40 years old (aOR = 1.725, 95% CI = 11.026-2.9, p = 0.040), 41-50 years old (aOR = 2.003, 95% CI = 1.155-3.476, p = 0.013) and 51-60 years old (aOR = 2.106, 95% CI = 1.228-3.612, p = 0.007) had statistically significant associations with the poor TB-TO. Inductive thematic analysis revealed that patients in the Kunene region were challenging to reach owing to their nomadic lifestyle and the vastness of the area, adversely affecting their ability to observe TB therapy directly. In the Oshana region, it was found that stigma and poor TB awareness among adult patients, as well as mixing anti-TB medication with alcohol and tobacco products among adult patients, was a prevalent issue affecting TB therapy.

CONCLUSION

The study recommends that regional health directorates embark on rigorous community health education about TB treatment and risk factors and establish a robust patient observation and monitoring system to enhance inclusive access to all health services and ensure treatment adherence.