Community health care workers in South Africa are at increased risk for tuberculosis

The epidemiology of tuberculosis in health care workers in South Africa: a systematic review

“…Throughout the study period health care workers had significantly higher annual TB incidence rate ratios (IRR) for each year of the study compared to that of the general population in KwaZulu-Natal.Incidence of active TB in South Africa: 981/100 000 (2010)Western CapeAdams: Prevalence and determinants of TB infection in health care workers, unpublishedStudy date: 2009–20117 primary and secondary level health care facilities in the Western Cape provinceNumber of participants: 505Age: <30 years (25 %); 31–40 years (27 %); 41–50 years (27 %); >50 years (22 %)Sex: 74 % femaleHIV status: Primary level staff 19 % HIV+; Secondary level staff 2 % HIV+Method of diagnosing TB: TB infection: TST, QFT-GIT, TSPOT.TB. TB disease: TB symptom screen, Chest X-Ray and 2× sputum culture.Annual incidence of active TB disease900/100 000; 95 % CI: 0.2–2.6 (2009–2011)Prevalence of active TB disease1400/100 000 (2009–2011)Prevalence of latent TB infection84 % (TST; 2009–2011)Annual incidence of latent TB infection38 % of HCWs converted from TST negative to positive (2009–20110)Annual incidence rate in Cape Town 799/100 000 population and Western Cape 935/100 000 population (2008–2011)3/5 HCWs with active TB were HIV+9 % of HCWs reported being diagnosed with or on treatment for diabetesAnnual incidence of latent TB infectionQFT-GITconversion rate 22 %reversion rate 7 %T-SPOT.TBconversion rate 22 %reversion rate 16 %Ayuk et al [20]Study date: 2008–2011Tygerberg Academic Hospital, Western Cape provinceNumber of participants: 249Age: Mean = 43.8 (range: 23–60) yearsSex: 71.4 % femaleHIV status: 30 % HIV+; 63 % HIV-; 6 % unknownMethod of diagnosing TB: smear+; culture+, histology and symptomsMean annual incidence rate of active TB disease2008–2011: 397/100 000 population (95%CI: 307–505 per 100 000; all health care workers)Incidence rate of active TB diseaseHousekeeping staff: 1181/100 000Nurses: 324/100 000Doctors: 194/100 000Annual incidence rate in Cape Town 799/100 000 population and Western Cape 935/100 000 populationHousekeeping staff incidence rate of active TB disease approximately 3 times (95%CI: 2.7–3.3) that of the entire workforce, 3.6 times (95%CI: 3.2–4.1) that of nurses and 6.1 times (95%CI: 5.2–7.1) that of doctors.Kranzer et al [6]Study date: 2008/2009Mobile HIV testing unit (the TUTU tester) provided HIV testing, CD4 counts and TB screening to TB and antiretroviral adherence supporters employed by the TB/HIV Care Association in Cape Town on 8 days in 8 venues in the Western Cape provinceNumber of participants: 215 community health workers (CHW) were offered HIV and TB testingAge: Most common age group was 40–49 years old ( N  = 72, 33 %)Sex: All femaleHIV status: 42 CHW HIV+ (20 %)Method of diagnosing TB: Smear and culture testingPrevalence of active TB disease5 % (10/215; 2008–2009)Naidoo et al [24]Date of study not reportedWestern CapeNumber of participants: 100 randomly selected practicing dentists; 78 % response rate.Age: Mean = 40 yearsSex: 80 % maleHIV status: Not reportedMethod of diagnosing TB: Mantoux and multipuncture testsPrevalence of latent TB infection33 % (No dates provided)Mehtar et al [29]Study date: 2010Retrospective rev...…”

“…The included studies provide information on TB epidemiology in health care workers in primary, secondary and tertiary level health care facilities. One study was conducted from a mobile testing unit in a community-based, as opposed to facility-based, setting [6]. …”

“…However, HIV status of all participants was assessed.Cross sectional studyAyuk et al [20]UNCLEAR: Not all HCWs completed questionnaireIncidence and prevalence of TB disease: LOWRisk factors for TB: HIGH (HCWs completed questionnaires which are prone to information bias)UNCLEAR: Community vs. occupational exposure to TB; HIV status of all of the HCWs not knownClaassens et al [15]LOW: Although authors report that health care facilities were randomly selected there is no explanation of how the randomisation process was conducted.Incidence of TB disease: HIGH (In each health care facility a questionnaire was completed by the facility manager to indicate the number of HCWs who were registered in that facility and who had been on TB treatment from January 2006 to December 2008.UNCLEAR: Community vs. occupational exposure to TB; HIV status of all of the HCWs not knownDwadwa et al: Health worker access to HIV/TB prevention, treatment and care services in Africa: situational analysis and mapping of routine and current best practices, unpublishedUNCLEAR: Six of the facilities were randomly selected although there is no explanation of how this was conducted. Four of the facilities were specifically selected based on current best practice as recommended by the Department of Health and AIDS and TB Directorates.Number of TB cases: HIGH (Data obtained from questionnaires and interviewsUNCLEAR: Community vs. occupational exposure to TBKranzer et al [6]UNCLEAR: It is not clear how the community health workers (CHWs) were selected, if all of the CHW were selected to participate or if participation was voluntaryPrevalence of TB disease: LOW (standard TB diagnostic techniques used)UNCLEAR: HIV status of all of the HCWs not knownNaidoo et al [24]UNCLEAR: Although authors state that a randomly selected sample of dentists was approached to participate in the study, it is not clear how this randomisation process was conducted. Only 78 of the 100 dentists participatedPrevalence of LTBI: LOW (LTBI diagnosed with Mantoux tests)UNCLEAR: It is not clear where the dentists practiced or the demographics of their patients; Community vs occupational exposure to TB; HIV status of all of the HCWs not knownRetrospective cohort studyBalt et al [26]LOW: Detailed review of health staff records at the four dedicated TB centresIncidence of TB disease: LOWUNCLEAR: Community vs. occupational exposure to TBMalangu et al [5]LOW: A pre-designed data collection form was used to extract data from claims submitted to the Compensation Commissioner from January 2007 to December 2009Cases of TB disease: LOW (Data based on reported cases of TB.…”

“…The increased number of sick patients with HIV-related TB has increased health care workers’ exposure to occupationally acquired diseases such as TB. Additionally, 11–20 % of South African health care workers are themselves, HIV-positive [6–8]. These HIV-infected health care workers have an increased risk for acquiring TB as well as for progressing from latent TB to active clinical disease [6].…”

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

“…However there is a dearth of data regarding other groups such as ancillary support and administrative staff who may work in clinical areas and CHWs, although at least some studies have demonstrated that these groups are also at considerable risk. 9,18–20 Although HCWs in LMICs may also be at high risk of TB exposure in their communities, studies that have controlled for living conditions confirm additional risk of TB disease attributable to workplace TB exposure 21 . The documented 3 to 6-fold increased risk of TB is due to persistent occupational TB exposure in the setting of absent or poorly implemented TB infection control (TB-IC) programmes 2,11 and a high prevalence of undiagnosed TB in healthcare facilities 22,23 .…”