Infection control and tuberculosis in health care workers: an assessment of 28 hospitals in South Africa

SETTING

Twenty-eight public hospitals in the Free State Province, South Africa.

OBJECTIVE

To examine the association between tuberculosis (TB) infection control (IC) scores in Free State hospitals and the incidence of TB disease among health care workers (HCWs) in 2012.

DESIGN

A cross-sectional survey and mixed-methods analysis of TB IC policies, practices and infrastructure using a comprehensive, 83-item IC audit and observation tool.

RESULTS

As the total IC score increased, the probability of TB in an HCW at that hospital decreased. When adjusted for other covariates in multivariate analysis, if the total score of a hospital increased by one unit, the odds of an HCW having TB decreased by 4.9% (95%CI 0.9-8.8). Significant associations were also seen for the personal protective equipment (PPE) score, where odds decreased by 11.5% (95%CI 1.8-20.1) for each unit increase in score. Administrative score, environmental score and miscellaneous score were not statistically significant in the multivariate model.

CONCLUSIONS

These findings reaffirm that overall IC and PPE are essential to protect HCWs from acquiring TB. More attention to TB IC is required to protect the health care workforce and to stop the South African TB epidemic.

Unsuccessful TB treatment outcomes with a focus on HIV co-infected cases: a cross-sectional retrospective record review in a high-burdened province of South Africa

BACKGROUND

South Africa did not meet the MDG targets to reduce TB prevalence and mortality by 50% by 2015, and the TB cure rate remains below the WHO target of 85%. TB incidence in the country is largely fuelled by the HIV epidemic, and co-infected patients are more likely to have unsuccessful TB treatment outcomes. This paper analyses the demographic and clinical characteristics of new TB patients with unsuccessful treatment outcomes, as well as factors associated with unsuccessful treatment outcomes for HIV co-infected patients.

METHODS

A cross-sectional retrospective record review of routinely collected data for new TB cases registered in the Free State provincial electronic TB database between 2009 and 2012. The outcome variable, unsuccessful treatment, was defined as cases ≥15 years that 'died', 'failed' or 'defaulted' as the recorded treatment outcome. The data were subjected to descriptive and logistic regression analyses.

RESULTS

From 2009 to 2012 there were 66,940 new TB cases among persons ≥15 years (with a recorded TB treatment outcome), of these 61% were co-infected with HIV. Unsuccessful TB treatment outcomes were recorded for 24.5% of co-infected cases and 15.3% of HIV-negative cases. In 2009, co-infected cases were 2.35 times more at risk for an unsuccessful TB treatment outcome (OR: 2.35; CI: 2.06-2.69); this figure decreased to 1.8 times by 2012 (OR: 1.80; CI: 1.63-1.99). Among the co-infected cases, main risk factors for unsuccessful treatment outcomes were: ≥ 65 years (AOR: 1.71; CI: 1.25-2.35); receiving treatment in healthcare facilities in District D (AOR: 1.15; CI 1.05-1.28); and taking CPT (and not ART) (AOR: 1.28; CI: 1.05-1.57). Females (AOR: 0.93; CI: 0.88-0.99) and cases with a CD4 count >350 (AOR: 0.40; CI: 0.36-0.44) were less likely to have an unsuccessful treatment outcome.

CONCLUSIONS

The importance of TB-HIV/AIDS treatment integration is evident as co-infected patients on both ART and CPT, and those who have a higher CD4 count are less likely to have an unsuccessful TB treatment outcome. Furthermore, co-infected patients who require more programmatic attention are older people and males.

The implementation of the Choice on Termination of Pregnancy Act: some empirical findings

The Choice on Termination of Pregnancy Act of 1996 substantially liberalised abortion law. Whilst a substantial number of terminations of pregnancies (TOPs) have already been performed in terms of the new Act, it has also surfaced that an array of factors of various kinds may impede its further implementation and operation. A study was undertaken to determine the nature and extent of any such impediments to the implementation of the Choice on Termination of Pregnancy Act. More specifically a survey was conducted amongst a sample of 75 women who had undergone a TOP since the implementation of the Act; health professionals and social workers who provide TOP services (n = 16); and health professionals and social workers who are in a position to refer women to TOP facilities (n = 63). Overall, the clients were well treated at the TOP facilities, and were satisfied with the service given to them. However, post-counselling and to a lesser extent pre-counselling, is lacking. Counselling is important as a considerable proportion of the clients suffered from emotional feelings usually associated with depression and/or self-reproach before and after the termination procedure. Furthermore these clients did not usually discuss their termination with family members. TOP service providers were dissatisfied with the TOP facilities, especially the insufficient number of consultation and counselling rooms. Health care workers in a position to refer clients to TOP facilities were not always willing to do so, thereby obstructing the referral system. In the main, it is recommended that the entire TOP procedure should be done at clinics/hospitals so that clients will not have to do inductions at home, more trained staff should be available, facilities should be adequate and accessible, and there should be psychological support for staff.