Tuberculosis infection is widespread among healthcare workers in South African hospitals, clinics and laboratories. This message was repeatedly brought home at the country's first ever TB Conference held in Durban earlier this month.
In South Africa TB has reached epidemic proportions – last year 337 641 people were reported to be living with the disease, and this figure is expected to rise to over 500 000 in 2008. According to the World Health Organization (WHO), South Africa is ranked as the country with the fourth highest TB burden in the world, and Statistics South Africa has calculated that TB is the leading cause of natural death in the country.
Caregivers at risk
Now evidence is emerging that TB - including the vicious drug-resistant strains – is not only rife among hundreds of thousands of poor South Africans, but is hitting the caregivers assigned to helping them.
Our minister of health, Dr Manto Tshabalala-Msimang rightfully admitted that "TB is a disease of poverty", with those living in crowded, low-income settings bearing the brunt of the country's TB epidemic. For this reason, most TB sufferers cannot afford private health care, and consequently flock to the country's over-burdened public healthcare facilities. In these low-resource settings, patients sometimes wait for hours on end to receive treatment, all the while exposing other patients and healthcare staff to the disease.
(TB is spread mainly through the air. When infectious people cough, sneeze, talk, laugh or spit, droplets containing the bacteria are sprayed into the air. Others inhale these bacteria and also become infected.)
A 2006 study by the Centre for Occupational and Environmental Health at the Nelson R Mandela School of Medicine in KwaZulu-Natal found the incidence of TB-infection among healthcare workers in eight public sector hospitals to be alarmingly high. Infection occurred in 1 133/100 000 population healthcare workers, compared to 998/100 000 population in the general public.
The study also showed that the risk of developing TB among healthcare workers is much higher among paramedical staff (including laboratory technicians, radiographers and physiotherapists) and nurses, who are the first point of contact and continuously with patients.
In addition, TB-infection was highest amongst healthcare workers between the ages of 25 and 29 years.
HIV-positive employees at health care facilities are at an even greater risk of acquiring TB, as a compromised immune system makes one vulnerable to active TB–infection.
"There is growing evidence of [TB] infection in healthcare workers," said Mr Mark Heywood of the Aids Law Project at the recent TB Conference. "There are reports of high levels of MDR- and XDR-infection among nurses and doctors."
Although very little official data exists on what the actual incidence of TB-infection among healthcare workers is, studies have shown that healthcare workers in the developing world are at a greater risk of infection than the general population.
"Those at risk include not only healthcare providers, but also any staff [at these facilities]… including porters, cleaners, educators and councillors," reads the Department of Health's (DoH) National Infection Prevention and Control Policy.
There are obvious dangers associated with TB-infection among healthcare workers – the primary concern is for the health of the person.
A secondary concern is the fact that healthcare staff spend a lot of time around people who are already sick. And having a compromised immune systems makes one more susceptible to acquiring TB-infection when exposed to the germ.
The high incidence of HIV-infection in South Africa adds a dangerous element to this equation. The risk of developing active TB is increased tenfold by HIV, according to the WHO.
And, with hoards of HIV-positive patients flocking to public healthcare facilities for treatment, exposure to a TB-infected staff member could put each of these patients at an alarmingly high risk of becoming co-infected with both of these deadly diseases.
Infection control measures
The best way to manage TB-infection among healthcare workers is to develop and implement strict infection control measures at public healthcare facilities.
"A recent study showed that a relatively low number of South African health facilities pass international infection control norms and standards," the Treatment Action Campaign (TAC) stated in their Guidelines to the Prevention, Early Diagnosis, Treatment and Cure of Tuberculosis document.
The DoH has developed an infection control policy, but "the proper implementation of this policy needs to occur in all health facilities and must be monitored.
"This policy, which is based on the WHO's infection control policy, needs to be adapted to the South African specific context, and specific plans also need to be developed for congregated settings such as prisons, mines, schools and detention centres," said the TAC.
According to the National Infection Control Policy there are two main ways in which even settings with limited resources can reduce the chances that TB will spread, these include (i) work practice and administrative control measures, and (ii) environmental control measures.
Work practice and administrative control measures require that each healthcare facility have an infection prevention control plan where suspected TB patients are identified early (prolonged cough), separated from crowded areas, and taught respiratory etiquette (covering their nose and mouth when coughing, or wearing a face mask).
Another work practice that has shown to greatly reduce the risk of TB-infection is to train all staff on TB and the TB infection prevention and control plan.
The TAC agrees on this point: "Healthcare workers… should be educated on infection control policies, on the occupational risk of TB and how to protect themselves from exposure. In addition, all people who are working in these settings, including administrative staff, security guards and cleaning staff should be educated on infection control measures."
In the National Infection Control Policy the DoH states that "although many environmental control measures require resources not available in resource-limited settings, some can be implemented, and staff can be trained in their purpose, capabilities, proper operation, and maintenance."
Although ventilation, filtration and ultraviolet germicidal irradiation is mentioned as environmental control measures in the infection control policy, only in rare cases are mechanical environmental modifications in place to control infection, and most facilities have to rely on natural ventilation (opening windows and doors).
However, during a recent TB Clinical Forum at the Tygerberg Hospital in Cape Town, clinical staff pointed out the flaws in this method. They complained that during winter months, with temperatures dropping below 10 degrees Celsius, the clinics' windows and doors have to be closed in order to create a feasible work environment, and to protect already sick patients from the harsh elements. Thus ruling out natural ventilation as a measure to control TB infection.
The DoH admits that "the risk to staff will never be zero," and encourages staff to have themselves tested for TB at the first sign of possible infection.
- (Wilma Stassen, Health24, July 2008)
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