THE VULNERABI LI TY OF NURSI NG W ORKERS TO TUBERCULOSI S I N A TEACHI NG HOSPI TAL
1Juliana Ner y de Souza2 Mar ia Rit a Ber t olozzi3
Souza JN, Ber t olozzi MR. The vulner abilit y of nur sing w or ker s t o t uber culosis in a t eaching hospit al. Rev Lat
ino-am Enfer m agem 2 0 0 7 m ar ço- abr il; 1 5 ( 2 ) : 2 5 9 - 6 6 .
This st udy aim ed t o ident ify aspect s t hat pot ent ially incr ease t he v ulner abilit y of nur sing w or k er s t o
t uberculosis, t hrough t he verificat ion of personal life, work and disease knowledge indexes. The sam ple is com posed
of 81 nursing workers involved wit h assist ance in t he night and day shift s at USP Teaching Hospit al, who answered
a quest ionnair e about life and w or k habit s. The sam ple aggr egat ed t he index es t hat incr ease v ulner abilit y t o
t u ber cu losis: lon g pr ofession al ex per ien ce in h ospit als an d w or k load lon ger t h an 1 2 h ou r s. Dat a sh ow t h at
nursing auxiliaries and workers from t he night shift in general have a higher num ber of vulnerabilit y indexes.
DESCRI PTORS: t uber culosis; v ulner abilit y ; nur sing; educat ion, nur sing
LA VULNERABI LI DAD A LA TUBERCULOSI S EN TRABAJADORES
DE ENFERMERÍ A DENTRO DE UN HOSPI TAL UNI VERSI TARI O
En est e est udio se buscó ident ificar aspect os que pueden pot enciar la vulner abilidad de los t r abaj ador es
de enfer m er ía fr ent e a la t uber culosis, ut ilizando la v er ificación de indicador es de v ida per sonal, t r abaj o y los
r el aci o n ad o s al co n o ci m i en t o d e l a en f er m ed ad . La m u est r a est u v o co n f o r m ad a p o r 8 1 t r ab aj ad o r es d e
enfer m er ía inv olucr ados con la asist encia en los t ur nos diur no y noct ur no del Hospit al Univ er sit ar io de la USP,
los cuales r espondier on a un cuest ionar io sobr e los hábit os de v ida y de t r abaj o. A t r av és de la m uest r a fue
p osib le m ost r ar in d icad or es sob r e la v u ln er ab ilid ad a la t u b er cu losis: u n a lar g a ex p er ien cia p r of esion al en
hospit al y j or nada con m ás de 12 hor as diar ias. Los dat os m ost r ar on que, auxiliar es de enfer m er ía y t r abaj ador es
del t ur no noct ur no pr esent an m ay or núm er o de indicador es de v ulner abilidad. Gr an par t e de los t r abaj ador es
m o st r ar o n co n o ci m i en t o eq u i v o cad o so b r e l a en f er m ed ad , a p esar d e b r i n d ar at en ci ó n a p aci en t es co n
t uber culosis. Los r esult ados evidenciar on la necesidad de difundir el conocim ient o apr opiado sobr e la t uber culosis,
y a que est os t r abaj ador es const it uy en agent es par a su cont r ol.
DESCRI PTORES: t u ber cu losis; v u ln er abilidad; en f er m er ía; edu cación en en f er m er ía
A VULNERABI LI DADE À TUBERCULOSE EM TRABALHADORES
DE ENFERMAGEM EM UM HOSPI TAL UNI VERSI TÁRI O
Est e est udo buscou ident ificar aspect os que podem pot encializar a v ulner abilidade dos t r abalhador es
de enfer m agem r elacionada à t uber culose, por m eio da v er ificação de indicador es de v ida pessoal, t r abalho e
r elat iv as ao con h ecim en t o da en f er m idade. A am ost r a com pôs 8 1 t r abalh ador es de en f er m agem en v olv idos
com a assist ên cia n os t u r n os d iu r n o e n ot u r n o d o Hosp it al Un iv er sit ár io d a USP, q u e r esp on d er am a u m
quest ionár io sobr e hábit os de v ida e t r abalho. A am ost r a int egr ou indicador es que induzem à v ulner abilidade
à t uber culose: per íodo longo de ex per iência pr ofissional em hospit al e j or nada m aior que 12 hor as diár ias. Os
dados evidenciar am que auxiliar es de enfer m agem apr esent am m aior núm er o de indicador es de vulner abilidade,
a ssi m co m o o s t r a b a l h a d o r e s d o n o t u r n o e m g e r a l . Pa r ce l a e x p r e ssi v a d o s t r a b a l h a d o r e s a p r e se n t o u
conhecim ent o equiv ocado sobr e a enfer m idade, apesar de pr est ar em assist ência a pacient es com t uber culose.
Os r esult ados ev idenciam a necessidade de se difundir conhecim ent o apr opr iado sobr e a enfer m idade, j á que
esses t r abalhador es const it uem agent es no cont r ole da t uber culose.
DESCRI TORES: t u ber cu lose, v u ln er abilidade, en f er m agem , edu cação em en f er m agem
1 St udy funded by FAPESP; 2 RN Teaching Hospit al, e- m ail: j uli3@bol.com .br ; 3 RN, PhD Pr ofessor Univer sit y of São Paulo College of Nur sing, e- m ail:
m rbert ol@usp.br
I NTRODUCTI ON
K
n ow n as a “ social ev il” at t h e en d of t h e 1 9 t h c e n t u r y, t u b e r c u l o s i s s t i l l h a u n t s d i f f e r e n tco u n t r i e s a l l o v e r t h e w o r l d , m a k i n g v i ct i m s a n d
causing m any deat hs. Appr oxim at ely one t hir d of t he
w o r l d p o p u l at i o n i s i n f ect ed w i t h t h e t u b er cu l o si s
bacillus and, every year, 54 m illion people get infect ed,
6.8 m illion develop t he disease and 3 m illion die( 1). I n
Br azil, it is est im at ed t hat bet w een 35 and 45 m illion
of t he t ot al populat ion ar e infect ed by M. t uber culosis,
w it h about 1 0 0 t housand new cases and bet w een 4
and 5 t housand deat hs ever y year( 1). Alm ost one fift h
of t he cases occur in São Paulo St at e, w her e 18,975
cases w er e not ified in 1998( 1).
The im port ant incidence of t uberculosis in our
m idst , ev en m or e t han a cent ur y aft er t he discov er y
of t he et iologic agent , dem onst r at es t he lim it at ion of
t h e b iolog ical m ed ical m od el’s p r op osal, b ecau se it
d oes n ot ad op t st r at eg ies t h at at t em p t t o act u ally
d et er m in e t h e d isease. A st u d y car r ied ou t in t h e
r egion of But ant ã, São Paulo Cit y, in 1997, det ect ed
t h a t so ci a l i n se r t i o n ca n co n st i t u t e a n i m p o r t a n t
rest rict ive elem ent of ill people’s accessibilit y t o healt h
services as, in general, for t hose people w ho are closer
t o social ex clu sion , h ealt h car e becom es secon dar y
t o t he need t o sur vive( 2).
I n v i e w o f t h e d i se a se ’ s e m i n e n t l y so ci a l
nat ure, init iat ives t o cont rol it need t o focus on specific
act ions, but also incorporat e t he change in populat ions’
living condit ions. Hence, it is im port ant t o underst and
t he disease as a process developed in individuals w ho
ar e par t of a cer t ain for m of social or ganizat ion and,
as such, are subj ect t o dist inct risks and pot ent ialit ies,
depending on t he specific gr oups t hey belong t o. That
i s , i n t h e e n d , t h e d i s e a s e i s d u e t o d i f f e r e n t
socioeconom ic gr oups’ peculiar pr oduct ion and social
r epr oduct ion condit ions. This leads t o t he pr oduct ion
of dist inct pot ent ialit ies t o st r engt hen or ex haust t he
h u m an b od y. Th i s r el at i on b et w een b en ef i ci al an d
d est r u ct i v e f o r ces i s ex p r essed i n d i st i n ct h eal t h
-disease m an if est at ion s( 3 ).
Th u s , d a i l y w o r k a n d k n o w l e d g e c a n b e
f u n d am en t al in t er m s of p eop le’s v u ln er ab ilit y. Th e
t e r m v u l n e r a b i l i t y( 4 ) r e f e r s t o p e o p l e ’ s ch a n ce o f
ex posur e t o a disease, as a pr oduct of a set of not
only individual, but also collect ive, cont ext ual aspect s,
w hich ent ail great er or lesser suscept ibilit y t o infect ion
a n d i l l n ess a n d , i n sep a r a b l y, t o g r ea t er o r l esser
av ailabilit y of all k inds of r esour ces t o pr ot ect t hese
people against diseases. That is, v ulner abilit y is not
rest rict ed t o individual det erm inat ion, but includes t he
in div idu al- collect iv e. I t is also em ph asized t h at t h is
con cep t t ak es t h e f or m of i n d i v i d u al v u l n er ab i l i t y,
social v u ln er ab ilit y an d p r og r am m at ic v u ln er ab ilit y.
Th e f i r st r e f e r s t o t h e d e g r e e a n d q u a l i t y o f t h e
in f or m at ion in div idu als h av e at t h eir disposal abou t
h ealt h p r ob lem s, it s elab or at ion an d ap p licat ion in
pr act ice. Social v u ln er abilit y assesses t h e obt ain in g
o f i n f o r m a t i o n , a cce ss t o co m m u n i ca t i o n m e d i a ,
availabilit y of cognit ive and m at erial resources, pow er
t o part icipat e in polit ical decisions and inst it ut ions, t hat
is, it is r elat ed t o ser v ice st r u ct u r in g in t h e p olicy
spher e. Pr ogram m at ic vulnerabilit y, on t he ot her hand,
is t he assessm ent of pr ogr am s t o r espond t o disease
cont rol, besides t he degree and qualit y of inst it ut ions’
c o m m i t m e n t , o f r e s o u r c e s , o f m a n a g e m e n t a n d
pr ogr am m onit or ing at differ ent car e levels, t hat is, it
is r elat ed t o t he w ay ser v ice or ganizat ion and healt h
car e r espond t o collect iv e needs.
I n v i ew o f t h i s v u l n er ab i l i t y m o d el( 4 ), t h i s
st udy aim ed t o ident ify pot ent ial vulnerabilit y indicat ors
o f t u b e r c u l o s i s i n n u r s i n g w o r k e r s , w h i c h c a n
cont r ibut e t o it s pr event ion and cont r ol. The st udy is
b a se d o n t h e o b se r v a t i o n t h a t h e a l t h w o r k e r s i n
hospit als present a specific risk of get t ing t uberculosis,
m ainly t he m ult iresist ant form s, w hich has been w idely
docum ent ed in lit er at ur e( 5).
OBJECTI VES
To ch ar act er ize t h e gen er al liv in g an d w or k
condit ions of nur sing pr ofessionals w ho w or k day and
night shift s and t o ident ify var iables t hat can evidence
pot ent ial v ulner abilit y t o t uber culosis.
DESI GN AND METHOD
The st udy w as car r ied out at t he Univ er sit y
Ho sp i t a l ( UH) o f t h e Un i v er si t y o f Sã o Pa u l o a n d
i n v o l v ed n u r si n g w o r k er s. I n 2 0 0 3 , t h e h o sp i t al ’ s
n u r sin g t eam con sist ed of 1 6 4 n u r ses, 1 1 1 n u r sin g
t echnicians and 358 nur sing aids, besides 12 nur sing
at t endant s w ho, due t o legal r est r ict ions t o ex er cise
t he nur sing pr ofession, only per for m ed adm inist r at ive
funct ions. The st udy only looked at w or ker s fr om t he
div ision s dir ect ly in v olv ed in n u r sin g car e or w it h a
t h e d ay an d n ig h t sh if t . Th u s, p ar t icip an t s cov er ed
nur sing aids ( NA) , nur sing t echnicians ( NT) and nur ses
( N N ) , d i s t r i b u t e d a c r o s s t h e Ro o m i n g - I n u n i t
( m at er n it y ) , Mat er ial Cen t er, Su r gical Clin ic, Medical
Clinic, Pediat ric unit , Adult and Child Em ergency Care
and Adult I nt ensive Ther apy unit , t ot aling 81 w or ker s.
The em pirical st udy variables were relat ed t o
t he w or ker s’ per sonal char act er ist ics; living and w or k
con dit ion s an d v u ln er abilit y t o t u ber cu losis, su ch as
k now ledge about t he disease, how it is t r ansm it t ed,
people w ho had or hav e t he disease, healt h ser v ices
offering diagnost ic t est s and care, access t o inform at ion
about t he disease, beliefs about it , earlier care delivery
t o t uberculosis carriers, as well as t echnical preparat ion
for car e deliv er y t o t hese car r ier s.
Dat a w er e collect ed , w it h t h e p ar t icip an t s’
in f or m ed con sen t , bet w een Sept em ber an d Oct ober
2003, t hr ough a quest ionnair e w it h closed quest ions
t hat w as subm it t ed t o a pr et est and appr oved by t he
Resear ch Et h ics Com m it t ees at t h e USP Un iv er sit y
Hospit al and t he USP School of Nur sing.
We c a r r i e d o u t a d e s c r i p t i v e s t u d y. Th e
c o l l e c t e d d a t a w e r e s y s t e m i z e d i n Ep i I n f o 6 . 0 4
soft w ar e, t o ext r act absolut e and r elat ive fr equencies.
RESULTS
Per sonal char act er ist ics of t he nur sing w or k er s
The st udy sam ple m ainly consist ed of fem ale
w or k er s bet w een 31 and 42 y ear s old ( 42% , n: 34) .
I n t er m s of educat ion, 27.2% had only finished basic
an d 3 4 . 6 % secon dar y edu cat ion .
As t o pr ofessional cat egor y, 48.1% ( 39) w er e
nur sing aids, 29.6% ( 24) nur ses and 16% ( 13) nur sing
t ech n i ci an s ( o t h er p r o f essi o n al s d i d n o t r esp o n d ) .
Accor d in g t o t h e st af f list at t h e h osp it al’s Nu r sin g
Depar t m en t , at t h e t im e of dat a collect ion , n u r sin g
aids cor r esponded t o 50.5% of t he Depar t m ent ’s t ot al
st af f, ag ain st 1 7 . 3 % t ech n ician s an d 2 4 % n u r ses.
Hence, t he st udy sam ple cor r esponded t o t he st r uct ur e
of t he nur sing w or k for ce in Br azil.
Wit h r espect t o t h e sh if t dist r ibu t ion of t h e
pr ofessionals w ho answ er ed t he quest ionnair e, 53.1%
( 4 3 ) w or k ed d u r in g t h e d ay an d t h e r em ain d er at
n ig h t . Th e d ay sh if t is su b d iv id ed in t w o six - h ou r
per iods ( m or ning and aft er noon) . The night shift , on
t h e ot h er h an d, cov er s 1 2 con secu t iv e w or k h ou r s,
follow ed by 36 hour s of r est . I t should be r em inded
t h a t n i g h t w o r k c a n b e c o n s i d e r e d a f a c t o r o f
d est r u ct i o n , o f v u l n er ab i l i t y, t o t h e ex t en t t h at i t
dem ands gr eat er m ent al effor t t o m aint ain t he sam e
per f or m an ce lev el as in act iv it ies per f or m ed du r in g
ot her shift s( 6).
W h a t t h e d u r a t i o n o f t h e i r p r o f e s s i o n a l
ex er cise is concer ned, m ost par t icipant s ( 8 0 . 3 % , n:
6 5 ) h a d b e e n w o r k i n g f o r m o r e t h a n 2 y e a r s. A
con sid er ab le n u m b er of w or k er s ( 2 1 % , n : 1 7 ) h ad
been act ive for m or e t han 10 year s, 6 of w hom w or ked
in gener al pat ient car e, w hich includes car e deliv er y
t o t u b er cu l o si s ca r r i er s. Th i s r ev ea l s y et a n o t h er
pot ent ial v ulner abilit y fact or.
Their liv ing condit ions
Abou t 4 4 . 4 % ( 3 6 ) sh ar ed r esp on sibilit y f or
t heir household w it h anot her per son, w hich seem s t o
be a posit ive aspect in t er m s of vulnerabilit y. How ever,
34.6% ( 28) of par t icipant s w ho did not live alone w er e
solely r esp on sib le f or h ou seh old ex p en ses, d u e t o
t h e i r p a r t n e r ’ s u n e m p l o y m e n t o r a n o t h e r n o n
-infor m ed r eason. Alt hough t his is not a m aj or it y, t hey
r epr esent an im por t ant par t of t he t ot al gr oup. This
aspect can r epr esent an im por t ant vulner abilit y aspect .
The int er view ees’ m ont hly fam ily incom e w as
quit e het erogeneous, w it h t he highest salaries am ong
n u r ses w or k in g n ig h t sh if t s an d t h e low est am on g
nur sing aids w or k ing day shift s. A m aj or it y ( 27. 1% )
r eceiv ed b et w een 6 an d 8 m in im u m w ag es, w h ich
e x ce e d s t h e Br a zi l i a n p o p u l a t i o n ’ s m e a n m o n t h l y
i n co m e o f a p p r o x i m a t e l y 1 . 3 m i n i m u m w a g e s( 7 ).
Anot her im por t ant piece of infor m at ion is t hat m ost
w or ker s belonged t o sm all fam ilies of up t o 4 people
( 7 2 . 9 % ) .
What healt h access is concer ned, 67.9% ( 55)
m ent ioned using public healt h services. This w as m ost
fr equent ly indicat ed by nur sing aids.
Abou t 4 2 % ( 3 4 ) in for m ed t h at t h ey n eit h er
pr act iced any spor t s, dance or m usic, nor par t icipat ed
in any gr oup act ivit y r elat ed t o school, chur ch or w or k.
All par t icipant s m ent ioned t hey had t im e and access
t o leisur e.
Wit h r espect t o in f or m at ion access, a lar ge
m aj or it y ( 87.7% , n: 71) indicat ed t hat t hey w at ched
t elevision, and a m aj or it y pr efer r ed w at ching t he new s
( 4 5 . 7 % ) . No ex pr essiv e dif f er en ce w as obser v ed in
t er m s of w or k shift , as bot h day ( 48.6% , n: 18) and
night shift w or ker s ( 51.3% , n: 19) used t elevision t o
Readin g n ew spaper s w as an ot h er sou r ce of
infor m at ion for t he st udy sam ple. Only 13.6% indicat ed
n ot r ead in g n ew sp ap er s, 5 8 . 3 % ( 7 ) of w h om w er e
nur sing aids. I n t he gr oup w ho had t his habit , 32.5%
u sed n ew s sear ch plat for m s.
About 93.9% ( 76) infor m ed t hat t hey usually
r e a d b o o k s , w i t h l i t e r a t u r e a s t h e m a i n t h e m e
( 34.6% ) . All par t icipant s w ho indicat ed t hat t hey did
not have t his habit w or ked night shift s.
What int er net access is concer ned, 75.3% ( 61)
m en t i o n ed u si n g i t . Ob t ai n i n g n ew s i n g en er al o r
differ ent k inds of infor m at ion w as t he m ost fr equent
r eason . A slig h t d if f er en ce w as f ou n d b et w een t h e
sh i f t s, w i t h 7 9 % o f d ay an d 7 3 . 7 % o f n i g h t sh i f t
w or k er s fr equ en t ly accessin g t h e int er net .
As t o exposur e t o violence, 84% ( 68) denied
any involvem ent in t hese sit uat ions. Accor ding t o t hem ,
t h e g r e a t e st e x p o su r e o ccu r s o n t h e st r e e t s a n d
n eig h b or h ood ar ou n d t h e USP/ UH. Th ey m en t ion ed
t heft / pilfer ing ( 6. 2% ) , v er bal aggr ession ( 4. 9% ) and
t r affic accident s ( 2. 5% ) .
Wh en ask ed ab ou t d r u g s u se, 3 4 . 6 % ( 2 8 )
i n d i ca t ed t h ey h a d n ev er u sed a n y k i n d o f d r u g s
( a l c o h o l , t o b a c c o , m a r i h u a n a , c r a c k , c o c a i n e ,
inj ect able dr ugs, glue, t r anquilizer s and st im ulant s) .
Never t heless, alcohol and t obacco w er e t he m ost used
dr ugs, w it h t he lat t er occupy ing t he fir st place.
Their w or k condit ions
Mo st p a r t i ci p a n t s ( 9 1 . 4 % ) i n b o t h sh i f t s
m e n t i o n e d t h e y c h o s e t h e i r w o r k h o u r s a n d
con sid er ed t h em selv es sat isf ied . Ab ou t 6 9 . 1 % ( 5 6 )
indicat ed t hey w or k ed a fix ed shift and did not need
t o ch an ge t h eir w or k h ou r s. Th is w ou ld r epr esen t a
h ar m f u l an d ex h au st in g f act or w it h r esp ect t o t h e
healt h- disease pr ocess, as inconst ant w or k pr act ices
j e o p a r d i z e t h e m a i n t e n a n c e o f t h e h o m e o s t a t i c
balance est ablished by t he sleep- w ak e cy cle( 8). Only
17.3% ( 14) infor m ed t hat t hey also w or ked at anot her
h osp it al, w h ich ev id en ces t h e p ossib ilit y of g r eat er
e x p o su r e t o b i o l o g i ca l a n d m e n t a l e x h a u st i o n i n
com par ison w it h people w ho have one j ob only. Fr om
t h e t ot al g r ou p , 3 4 . 6 % ( 2 8 ) w or k ed m or e t h an 1 2
hour s per day.
Aspect s t hat can influence vulnerabilit y t o t uberculosis
Wit h r espect t o v ulner abilit y t o t uber culosis,
t h i s i n cl u d ed asp ect s r el at ed t o t h e p r o f essi o n al s’
k n o w l e d g e a b o u t t h e d i s e a s e , a s w e l l a s t h e i r
k now ledge access and fr equency of car e deliv er y t o
t u b e r c u l o s i s c a r r i e r s , b r o a d e n i n g t h e i n d i v i d u a l
v u ln er abilit y con cept( 4 ).
As t o t r ansm ission for m , 58% ( 47) consider ed
t hat t he probabilit y of cat ching t he t uberculosis bacillus
sim ply by t alking w as low . I n fact , besides inhalat ion
o f t h e b a c i l l u s , t h e d i s e a s e n e e d s a n i m p a i r e d
i m m u n o l o g i c a l s y s t e m t o d e v e l o p . Ab o u t 5 % o f
infect ed per sons can get ill, alt hough t he r easons for
t h is h av e n ot been f u lly clar if ied( 9 ). How ev er, som e
f a ct o r s h a v e a l r e a d y b e e n e st a b l i sh e d , t h e m o st
im por t an t of w h ich ar e, as m en t ion ed abov e, t h ose
d ir ect ly in t er f er in g in t h e h ost ’s im m u n it y, su ch as
m aln u t r it ion , alcoh ol ab u se, ad v an ced ag e, st r ess,
Aids, diabet es, gast r ect om ies, ch r on ic r en al f ailu r e,
silicosis, p ar acoccid ioid om y cosis, leu k oses, t u m or s,
use of im m unodepr essive m edicat ion, am ong ot her s( 9).
I t sh o u l d b e em p h asi zed t h at a m aj o r i t y o f t h ese
co n d i t i o n s r e su l t s f r o m ce r t a i n l i v i n g co n d i t i o n s.
Mo r eo v er, t h e b a ci l l u s l o a d , i t s v i r u l en ce a n d t h e
or ganism ’s hy per sensit iv it y st at e also int er fer e in t he
dev elopm ent of t he disease( 9).
Alt hough m ost par t icipant s cor r ect ly answ er ed
t he quest ion about t r ansm ission t hr ough conver sat ion
w it h p eop le in g en er al, it is r em ar k ab le t h at m an y
in t er v iew ees con sid er ed con t am in at ion eit h er v er y
pr obable ( 30. 9% , n= 25) or im possible ( 7. 4% , n= 6) ,
as t h ese ar e h ealt h pr of ession als. As t o t h ose w h o
m en t ion ed t h at t r an sm ission w as im p ossib le, 5 8 %
w er e n u r sin g aid s, 1 2 . 9 % n u r sin g t ech n ician s an d
2 5 . 8 % n u r s e s . Th i s i s a s o u r c e o f c o n c e r n , a s
p a r t i c i p a n t s w e r e h e a l t h p r o f e s s i o n a l s w h o ,
t h e o r e t i c a l l y, s h o u l d k n o w h o w t h e d i s e a s e i s
t r a n sm i t t e d , i n d e p e n d e n t l y o f w h a t p r o f e ssi o n a l
cat egor y t h ey belon g t o. Wh en com par in g t h e w or k
sh if t s, w e f ou n d t h at 4 2 . 1 % of t h e w or k er s gav e a
w r ong answ er t o t his quest ion.
W h e n a s k e d a b o u t t h e p o s s i b i l i t y o f
cont am inat ion w hen t alk ing t o a t uber culosis car r ier,
71.6% ( 58) answ er ed t his was ver y pr obable. How ever,
23.5% ( 19) consider ed low pr obabilit y, 52.6% ( 10) of
w hom sur pr isingly w er e nur ses, w hile 2. 5% believ ed
t his cont am inat ion w as im possible.
Mor eov er, w e ask ed abou t t h e possibilit y of
t ransm ission t hrough conversat ion w it h a t uberculosis
car r ier under t r eat m ent , w it h 65. 4% ( 53) answ er ing
t hat t he pr obabilit y w as low . Dur ing t r eat m ent , bacillus
p op u lat ion s an d t h e n u m b er of ex p elled b acilli ar e
p a t i e n t ca n st i l l e l i m i n a t e b a ci l l i( 9 ). I t sh o u l d b e
highlight ed t hat 13.6% ( 11) m ent ioned cont am inat ion
w as im possible, w hile 3.7% ( 3) could not answ er t he
q u e st i o n . Th i s a g a i n e v i d e n ce s t h e n e e d t o o f f e r
inform at ion t o t his group of w orker s, as disease cont r ol
a l s o d e p e n d s o n t h e m . M o r e o v e r, 1 4 . 8 % ( 1 2 )
in d icat ed t h at con t am in at ion w as v er y p r ob ab le. I t
should be em phasized t hat t her e is no r isk for cont act s
w h en t h e i n d ex ca se st a r t s t o u se ch em o t h er a p y
adequat ely for at least t w o w eek s( 9). The pr obabilit y
of cat ching a t uber culosis infect ion is r elat ed t o t he
den sit y of or gan ism s in t h e en v ir on m en t at a giv en
t im e, w hich m ay be r elat ed t o t he pat ient , t o dr ugs
u se an d t o t h e n at u r e it self of t h e en v ir on m en t . A
ser ies of f act or s ar e r elat ed t o t h e per son , su ch as
t he nat ur e of t he expulsive effor t w hen coughing, t he
b act er iolog ical st at e of t h e b r on ch ial secr et ion , t h e
ext ent of t he disease and t he pr esence of cavit y( 9). I t
is sur pr ising t hat m ost of t he above m ent ioned w or ker s
w er e nur ses ( 45.5% = 5) . Anot her not ew or t hy aspect
is t h e f act t h at ab ou t 2 3 . 2 % of d ay an d 3 4 . 2 % of
night w or k s answ er ed t his quest ion w r ongly.
On t h e o t h e r h a n d , a b o u t 8 7 . 7 % o f t h e
int er v iew ees consider ed t hat t he t r ansm ission of t he
b a ci l l u s t h r o u g h ca r r i e r s w h o w e r e n o t r e ce i v i n g
t r eat m ent w as highly pr obable. Again, it is r em ar kable
t hat 11.1% ( 9) m ent ioned low pr obabilit y, 55.6% ( 5)
of w hom w er e nur ses, w hile 1.2% ( 1) m anifest ed t his
w as im possible. This once again ex poses t he lack of
know ledge about t his issue. Of all nur ses, 20.8% ( 5)
believed t he probabilit y of t ransm ission w as low , w hile
about 13.9% and 10.5% of day and night shift w or ker s,
r espect iv ely, gav e a w r on g an sw er t o t h is qu est ion ,
in line w it h our findings for t he pr evious quest ion.
As t o t he possibilit y of cont am inat ion t hr ough
t he use of per sonal obj ect s ( cups, plat es, cut ler y et c.)
u sed b y sick p er son s, 4 9 . 4 % ( 4 0 ) m en t ion ed h ig h
pr obabilit y an d 2 5 . 9 % ( 2 1 ) low pr obabilit y, again st
22.2% ( 18) for im possibilit y. When analyzed in t er m s
o f p r o f e ssi o n a l ca t e g o r y, i t w a s e v i d e n ce d t h a t ,
alt hough a lar ge m aj or it y of inadequat e answ er s cam e
fr om w or ker s w it h low er educat ion levels, w e obser ved
t hat t he r em ainder, w hose educat ion lev el in t heor y
sh ou ld su ppor t adequ at e k n ow ledge, also pr esen t ed
h i g h p e r ce n t a g e s o f w r o n g a n sw e r s. Th e h i g h e st
f r e q u e n c y o f w r o n g a n s w e r s w a s f o u n d a m o n g
w or k er s at t he Room ing- I n unit ( m at er nit y ) , follow ed
b y Mat er ial Cen t er an d I CU w or k er s. Th ese r esu lt s
evidence t hat nursing professionals st ill share t he old
belief t h at t u ber cu losis con t am in at ion can occu r by
u s i n g t h e p a t i e n t ’ s p e r s o n a l o b j e c t s . N o w , t h i s
t r a n sm i ssi o n f o r m i s r e d u ce d , a s p e o p l e n e e d t o
i n h a l e t h e b a c i l l i s u s p e n d e d i n t h e a i r t o g e t
cont am inat ed. Bacilli deposit s can be found on obj ect s.
This m ak es ingest ion m or e pr obable t han inhalat ion,
m aking it im possible for t hem t o r each t he lungs, get
in st alled an d r epr odu ce. Wh en pat ien t s t alk , cou gh
or sneeze, t hey elim inat e par t icles of differ ent sizes,
w hich can cont ain t he bacillus. How ever, only bacilli
suspended in t he air r each t he alv eoli and st ar t t he
pr im ar y lesion( 9 ), w h ile t h e lar gest par t icles t en d t o
be deposit ed on t he floor and m ixed w it h dust , w hile
t h e sm allest f loat in t h e air( 9 ). Th e at om izat ion of
secr et i o n s t o co n st i t u t e co n t am i n at i n g p ar t i cl es i s
r e l a t e d w i t h t h e s p u t u m ’ s p h y s i c a l - c h e m i c a l
char act er ist ics and t he vigor of t he cough. Thus, t hick
an d adh er en t spu t u m pr odu ces a lesser qu an t it y of
infect ing par t icles, as opposed t o m or e liquid t y pes.
Only 1% of t he bacilli in suspended dr oplet s sur v iv e
f o r a co u p l e o f h o u r s, p r o v i d e d t h a t t h e y a r e i n
unvent ilat ed locat ions t hat ar e not exposed t o sunlight ,
w hich is fat al for t he bacillus. Hence, t he m ain ent r y
door is t hr ough t he pulm onar y alv eolus.
Mor eov er, w it h r esp ect t o t r an sm ission , w e
f o u n d t h a t t h e n u r s i n g w o r k e r s c o n s i d e r e d
co n t am i n at i o n w as p r o b ab l e w h en sl eep i n g i n t h e
sam e r oom ( 9 5 . 1 % ) an d liv in g in t h e sam e h ou se
( 88.9% ) as t he pat ient s. I t is a fact t hat t he pr obabilit y
o f i n f ect i o n i s h i g h er am o n g co n t act s i n si d e t h an
out side t he hom e. There exist s a direct and st at ist ically
si g n i f i can t r el at i o n b et w een p r o x i m i t y ( sam e b ed ,
sam e r oom , sam e h ou se) an d r elat ion sh ip ( m ot h er,
fat her, siblings and ot her r elat ives) on t he one hand
an d in fect ion an d t h e disease am on g com m u n ican t s
o n t h e o t h e r( 9 ). Ot h e r i m p o r t a n t f a ct o r s a r e t h e
v e n t i l a t i o n c o n d i t i o n s i n t h e e n v i r o n m e n t t h e
t r a n s m i s s i o n i s e s t a b l i s h e d i n . Ve n t i l a t e d
e n v i r o n m e n t s i n w h i ch a i r i s co n st a n t l y r e p l a ce d
pr ov ide m or e safet y in cont am inat ion pr ev ent ion( 9).
Al m o st h a l f o f t h e sa m p l e ( 4 6 . 9 % ) k n e w
som eon e w h o h ad or w as h av in g t u b er cu losis, an d
9 0 . 1 % ( 7 3 ) h a d a l r e a d y d e l i v e r e d c a r e t o a
t uber culosis pat ient . About 27.2% ( 47) m ent ioned car e
deliv er y t o t u ber cu losis car r ier s at least on ce ev er y
si x m o n t h s a n d 2 2 % a t l ea st o n ce p er m o n t h . A
consider able num ber of pr ofessionals m ent ioned car e
d el i v er y t o t h ese p at i en t s at l east o n ce p er w eek
( 6.2% ) . About 43.2% indicat ed t hey did not have t his
ex p er ien ce in d aily w or k . Lit er at u r e r ep or t s h ig h er
p r of ession als w h o ar e d ir ect ly in v olv ed in car e( 1 0 ),
w h i c h i s w h y t h i s c a n c o n s t i t u t e a t u b e r c u l o s i s
v ulner abilit y indicat or in t he st udy sam ple. I n t er m s
of pr ofessional cat egor y, nur ses r ev ealed t o be m or e
fr equent ly inv olv ed in car e for t uber culosis pat ient s.
Th e l a r g e s t n u m b e r o f w o r k e r s w i t h p r e v i o u s
t u b er cu losis car e d eliv er y ex p er ien ce w as f ou n d at
t he I CU and Medical Clinic.
I n t he gr oup of int er v iew ees w ho m ent ioned
t h i s e x p e r i e n c e , 4 8 . 1 % ( 3 9 ) f o u n d t h e m s e l v e s
sufficient ly pr epar ed t o do t his. Those par t icipant s w ho
indicat ed t hey felt unpr epar ed because of insufficient
k now ledge appoint ed pr ev ent ion m odes as t he m ost
pr ecar ious aspect . Most of t hem w or ked at t he Pediat r ic
u n i t , w h er e an i m p or t an t n u m b er of p r of essi on al s
r e p o r t e d t h e y h a d d e l i v e r e d ca r e t o t u b e r cu l o si s
pat ient s befor e: 6 1 . 5 % .
Wh en ask ed ab ou t t h e at t it u d e t h ey w ou ld
assum e if a colleague/ friend/ relat ive had t uberculosis,
96.3% ( 78) m ent ioned t hey w ould not like t o change
j obs an d/ or places t h e pat ien t at t en ded. On ly 1 . 2 %
( 1 ) w ou ld lik e t h e pat ien t t o ch an ge places, 5 5 . 6 %
( 4 5 ) w o u l d n o t r e m a i n i n t h e p l a ce s t h e p a t i e n t
at t ended and 95.1% ( 77) w ould suppor t t he per son.
Ab ou t 7 6 . 5 % ( 6 2 ) in d icat ed t h at , at w or k ,
t hey could t alk openly, i. e. w it hout pr ej udice, about
t uber culosis and Aids, w hile 70.4% ( 57) r epor t ed t hey
could only t alk about t uber culosis som et im es. Am ong
t hose w ho m ent ioned t alk ing about t he subj ect w as
im possible, 75% ( 6) belonged t o t he night shift .
As t o t h e op p or t u n it y t o ob t ain an d sh ar e
k n ow ledge abou t t h e disease, 4 8 . 1 % ( 3 9 ) in dicat ed
t hey had never had t he oppor t unit y t o lear n anyt hing
a b o u t t u b e r c u l o s i s a t w o r k . Th i s i n f o r m a t i o n i s
ex t r em ely r elev ant and dir ect ly r elat es t o t he qualit y
of nur sing car e. How ev er, 19.8% m ent ioned t hat t he
oppor t unit ies t hey had had w er e excellent and allow ed
for at t it udinal changes t ow ar ds t he disease and w ays
of car e deliver y t o pat ient s. On t he ot her hand, m ost
i n t e r v i e w e e s ( 7 4 % = 6 0 ) r e p o r t e d t h e y h a d h a d
cont act w it h t he t hem e t uberculosis t hrough t elevision,
n e w sp a p e r s o r m a g a zi n e s, a l t h o u g h 2 2 . 2 % ( 1 8 )
co n si d er ed t h ey h ad m ad e i n su f f i ci en t u se o f t h i s
cont act , w it hout adding any new infor m at ion.
DI SCUSSI ON
Th e s a m p l e i n c l u d e s s o m e i n d i c a t o r s o f
pot en t ial v u ln er abilit y t o t u ber cu losis, su ch as lon g
professional experience at a hospit al unit and w orking
m or e t han 12 hour s per day ( including anot her j ob) .
Th e len gt h of t h e w or k per iod in t h e h ealt h ar ea is
im p or t an t , as it ev id en ces t h e t im e of ex p osu r e t o
disease- causing agent s, including t he one t hat causes
t uber culosis. I n a st udy of pr ofessionals w ho w or k ed
in t his ar ea, it w as obser ved t hat 40% of t uber culosis
cases occur r ed in t he fir st 2 year s aft er adm ission( 11).
Anot her r esear ch, at a r efer ence out pat ient clinic for
pulm onary diseases and t uberculosis of t he São Paulo
S t a t e H e a l t h S e c r e t a r y, d e m o n s t r a t e d t h a t
pr ofessionals w ho had w or ked longer at t he inst it ut ion
w er e all r eact iv e t o t h e t u ber cu lin t est f iv e y ear s( 9 )
aft er t heir adm ission.
Dat a evidenced t hat t he nur sing aids pr esent
a h igh er n u m ber of v u ln er abilit y in dicat or s, as w ell
as n igh t sh ift w or k er s in gen er al. Som e in for m at ion
w ould obviously have t o be explor ed in gr eat er dept h
i n o r d e r t o q u a l i f y m o r e a p p r o p r i a t e l y h o w w o r k
p r ocesses ar e car r ied ou t , in or d er t o g et a m or e
pr oper underst anding of issues direct ly associat ed w it h
st r en g t h en in g an d / or ex h au st ion , su ch as t h e w ay
t echnical and social r elat ions ar e pr ocesses at w or k ,
in clu d in g t h eir d iv ision , t h e com m an d lin e, b esid es
o t h e r s t h a t ca n i n t e r f e r e i n t h e d i se a se p r o ce ss.
A n o t h e r i m p o r t a n t a s p e c t r e f e r s t o t h e d i s t i n c t
pot en t ialit ies of st r en gt h en in g an d/ or ex h au st ion in
differ ent pr ofessional cat egor ies, as nur sing aids w ill
v er y possibly display a gr eat er chance of get t ing ill,
d u e t o t h e i r p e cu l i a r l i v i n g a n d w o r k co n d i t i o n s,
r esult ing fr om t heir ow n inser t ion as a social gr oup.
A c c o r d i n g t o t h e o b t a i n e d r e s u l t s , w h a t
v u ln er abilit y t o t u ber cu losis is con cer n ed in r elat ion
wit h knowledge about t he disease, it could be observed
t hat , alt hough m ost par t icipant s pr esent ed a cer t ain
degree of knowledge, considering t hat t hey are healt h
professionals who should have proper t raining in order
t o work in t his area, everybody would be expect ed t o
be able t o answers basic quest ions about t he disease,
for car e deliv er y as w ell as for t he adequat e use of
p r e c a u t i o n f o r m s . We o b s e r v e d e r r o n e o u s a n d
m ist aken concept s in knowledge about t he disease and
it s t r ansm ission for m , depending on t he pr ofessional
cat eg or y an d t h e w or k u n it t h e p r of ession als w er e
act ive at , part icularly at t he Room ing- I n unit , Mat erial
Cen t r al an d I CU. Mor eov er, it is h igh ligh t ed t h at an
im por t ant par t of t he sam ple indicat ed t hat t hey did
n o t f e e l su f f i ci e n t l y p r e p a r e d t o d e l i v e r ca r e t o
t uber culosis pat ient s. This r ev eals t he need t o inv est
co n t i n u ed ed u cat i o n ser v i ces, l o o k i n g at t h e car e
appr oach w it h a focus on pr ofessional pr ot ect ion and
pr ev en t ion of cr oss- in f ect ion , as est ablish ed by t h e
Cent er s for Disease Cont r ol ( CDC) , w hose r esolut ion
r ecom m ends, for diseases w hose m icr oor ganism s ar e
t r ansm it t ed t hr ough aer osols, specific pr ecaut ions in
t er m s of h osp it alizat ion sit e, r esp ir at or y p r ot ect ion
( m asks filt ering part icles m easuring = 5ìm ) and pat ient
t r anspor t( 12).
We can conclude t hat a par t of t he w or k er s,
even if sm all, present s an im port ant vulnerabilit y level
t o t uberculosis, w hich reveals t he need for t he service
t o play t his r ole for t hese w or k er s, t r aining t hem in
t e r m s o f i n t e r v e n t i o n s t r a t e g i e s , i n c o r p o r a t i n g
p r ev en t i on an d car e act i on s an d m ak i n g av ai l ab l e
m at erial resources t o execut e t hem . The World Healt h
Or g an izat ion ( WHO) r ecom m en d s t h at in st it u t ion al
r espon sibles su ppor t t u ber cu losis con t r ol pr ogr am s,
appoint ing t hat at risk sit es, including t he nosocom ial
en v ir on m en t , b ot h in st it u t ion s an d h ealt h w or k er s
sh o u l d a ssu m e p a r t i cu l a r r esp o n si b i l i t y sh o u l d b e
assum ed t o im plem ent cont r ol m easur es( 13- 14). The fact
t h a t t h e d i s e a s e m a i n l y a f f e c t s p e o p l e i n t h e
eco n o m i cal l y p r o d u ct i v e ag e, b esi d es cau si n g t h e
u n av oid ab le su f f er in g of t h e d isease it self, r ed u ces
p r od u ct iv it y an d can en t ail t h e n eed t o t em p or ar y
r eplace t he w or k for ce, besides t he need t o t r ain new
w or k er s, w hich m eans an im por t ant indir ect cost . I n
t his r espect , t he WHO indicat es t hat , at global lev el,
t uber culosis decr eases pr oduct ivit y by about 12 billion
dollars every year and also result s in a pot ent ial fam ily
incom e r educt ion by about 20 t o 30%( 14).
Alt h ou g h w e f ou n d n o im p or t an t d if f er en ce
bet w een t he day and night shift s, w e suggest fur t her
r esear ch, using st at ist ically appr opr iat e m easur es, as
t his is a pow erful vulnerabilit y variable, as t his fact or
does not only change t he biological sy st em , but also
im pairs t he individual’s social dynam ics, as night shift
w or k er s ar e obliged t o use w hat should be t heir r est
hour s t o r espond t o daily event s: societ y and t he fam ily
st ill funct ions at a t radit ional dayt im e act ivit y rhyt hm( 8).
Th e n i g h t s h i f t l i m i t s o r m a k e s t h e w o r k e r ’ s
part icipat ion in associat ions, organizat ions, part ies and
u n ion s et c. im p ossib le. Mor eo v er, t h e r est p er iod s
m ade obligat or y by t he shift syst em gener ally do not
occu r at w eek en ds, w h ich su bst an t ially ch an ges t h e
u t i l i t y o f t h i s f r e e t i m e . Th i s cr e a t e s f e e l i n g s o f
d i s a d v a n t a g e a n d e v e n s o c i a l i s o l a t i o n i n m o s t
w or k er s( 6 ).
Alt hough som e pr ofessionals w or k night shift s
because t hey choose t o and adapt easily, in v iew of
t h e abov e, all ear lier descr ibed t r an sf or m at ion s can
be consider ed as dest r uct iv e fact or s ( count er - v alues)
i n t h e h e a l t h - d i se a se p r o ce ss si n ce t h i s sh i f t , i n
g en er a l , i s i m p o sed a n d a ccep t ed , g i v en ex i st i n g
difficult ies in t he j ob m ar k et .
We al so su g g est a r esear ch w i t h a l ar g er
p o p u l a t i o n sa m p l e , b e si d e s t h e a p p l i ca t i o n o f a
t uberculin t est t o det ect clust ers of professionals w ho,
aft er a per iod of t im e, can pr esen t PPD con v er sion ,
w it h a view t o t he im plem ent at ion of disease cont rol,
pr ot ect ion an d pr ev en t ion st an dar ds f or w or k er s at
t his inst it ut ion.
There is a need for increased awareness about
t he fact t hat t uber culosis can be pr oper ly cur ed and
t hat healt h workers can also be suscept ible. They should
b e st i m u l at ed t o seek em er g en cy car e i n case o f
com p at ib le sy m p t om s, w it h ou t f ear of an y k in d of
censorship, considering t he need for an act ive search
of cases, including in t he int ra- hospit al environm ent .
REFERENCES
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