Agents
of
change:
The
role
of
healthcare
workers
in
the
prevention
of
nosocomial
and
occupational
tuberculosis
Ruvandhi
R.
Nathavitharana
1,2,
Patricia
Bond
1,
Angela
Dramowski
1,3,
Koot
Kotze
1,4,
Philip
Lederer
1,5,
Ingrid
Oxley
6,
Jurgens
A.
Peters
1,7,
Chanel
Rossouw
1,
Helene-Mari
van
der
Westhuizen
1,4,
Bart
Willems
1,8,
Tiong
Xun
Ting
1,9,
Arne
von
Delft
1,10,
Dalene
von
Delft
1,
Raquel
Duarte
11,12,
Edward
Nardell
13,
Alimuddin
Zumla
1,141.TBProof,CapeTown,SouthAfrica
2.BethIsraelDeaconessMedicalCenter,DivisionofInfectiousDiseases,Boston,MA
02215,USA
3.PaediatricInfectiousDiseases,StellenboschUniversity,DepartmentofPaediatrics
andChildHealth,CapeTown,SouthAfrica
4.EastLondonHospitalComplex,EastLondon,SouthAfrica
5.MassachusettsGeneralHospital,DivisionofInfectiousDiseases,,Boston,MA
02215,USA
6.NelsonMandelaMetropolitanUniversity,DieteticsDivision,,PortElizabeth,
SouthAfrica
7.LondonSchoolofHygieneandTropicalMedicine,FacultyofInfectiousand
TropicalDiseases,ClinicalResearchDepartment,London,UK
8.StellenboschUniversity,DivisionofCommunityHealth,FacultyofMedicineand
HealthSciences,,CapeTown,SouthAfrica
9.ClinicalResearchCenter,SarawakGeneralHospital,Kuching,Sarawak,Malaysia
10. SchoolofPublicHealthandFamilyMedicine,FacultyofHealthSciences,
UniversityofCapeTown,7925Observatory,SouthAfrica
11. InstituteofPublicHealth,PortoUniversity,EpiUnit,Portugal
12. CentroHospitalardeVilaNovadeGaia,VilaNovadeGaia,Portugal
13. BrighamandWomen'sHospital,DivisionofGlobalHealthandSocialMedicine,
02115Boston,MA,USA
14. UniversityCollegeLondon,andNIHRBiomedicalResearchCentre,University
CollegeLondonHospital,DivisionofInfectionandImmunity,London,UK
Correspondence:
RuvandhiR.Nathavitharana,BethIsraelDeaconessMedicalCenter,Harvard
MedicalSchool,DivisionofInfectiousDiseases,110,FrancisStreet,02215Boston,
MA,USA.
[email protected] Inthisissue
Editorial
WorldTuberculosisDay 2017:strengtheningthe fightagainsttuberculosis. I.Solovic(Slovakia)etal. Breakingthebarriers: Migrantsandtuberculosis. G.Sotgiu(Italy)etal. Tuberculosiseliminationand thechallengeoflatent tuberculosis.
A.Matteelli(Italy)etal. Thecursedduettoday: Tuberculosisand HIV-coinfection.
S.Tiberi(UK)etal. Thechallengeofthenew tuberculosisdrugs. S.Tiberi(UK)etal. Agentsofchange:Therole ofhealthcareworkersinthe preventionofnosocomial andoccupational tuberculosis. R.R.Nathavitharana(USA) etal.
Summary
Healthcareworkers(HCWs)playacentralroleinglobaltuberculosis(TB)eliminationeffortsbut theircontributionsareunderminedbyoccupationalTB.HCWshavehigherratesoflatentandactive TBthanthegeneralpopulationduetopersistentoccupationalTBexposure,particularlyinsettings wherethereisahighprevalenceofundiagnosedTBinhealthcarefacilitiesandTBinfectioncontrol (TB-IC)programmesareabsentorpoorlyimplemented.Occupationalhealthprogrammesinhigh TBburdensettingsareoftenweakornon-existentandthusdatathatrecordtheextentofthe increasedriskofoccupationalTBgloballyarescarce.HCWsrepresentalimitedresourceinhighTB burdensettingsandoccupationalTBcanleadtoworkforceattrition.Stigmaplaysaroleindelayed
Availableonline:28February2017
e53
www.sciencedirect.com
Introduction
Tuberculosis(TB)isnowtheleadingcauseofadultdeath glob-allyfromaninfectiousdisease,surpassingHIVandmalaria[1]. Moreover, TB is airborne, with the main risk activity being breathing.Althoughhealthcareworkers(HCWs)haveacentral role in global TB elimination efforts, their contributions are underminedbytheriskofoccupationalTB.The2016WHOGlobal TBReportestimatesthat,in2015,thenumberofTBcasesper 100,000HCWswasmorethandoublethenotificationrateinthe general adult population [1]. The risk of TB transmission in healthcare and other congregate settings is high [2,3] and nosocomialoutbreaks ofmultidrug-resistantTB(MDR-TB)and extensively drug-resistant TB (XDR-TB) are well documented [4,5].TBinfectioncontrol(TB-IC)isoneofthekeycomponents ofthesecondpillaroftheWHOEndTBstrategy[6].However, limitedattentionandresourcesareappliedtoTB-ICatboththe facilityandnationallevel,resultinginongoingnosocomialTB transmission[2,7].Thisreviewwilldiscusssomeofthemajor challengesandpotentialsolutionstoimproveTB-ICeffortswith afocusontheroleofHCWs,althoughitisimportantto empha-sizethattherisksofnosocomialTBtransmissionalsoapplyto patients.Westartbydescribingthreecasesthatdemonstrate thecurrentrealityofoccupationalTBacrossHCWgroupsinhigh TBburdencountries(HBCs).
Case1– Russia
Amedicalstudentrememberedfindingitdifficulttobreathethe first timeshewore asurgicalmask inthe operating theatre. Outsidethetheatre,thedoctorswhotaughtherdidnotwear respiratorsandso shelearnt notto dosoeither. Therisksof occupationalTBwereneverdiscussed,althoughshewasaware thatamedicalstudentandalecturerhadpreviouslyfallenill frommultidrug-resistant(MDR)TB.Sherememberedtheshock shefeltwhenshereceivedherMDR-TBdiagnosisasaninternin herhometowninMalaysia,aftercompletingmedicalschoolin Russia. She felt particularly lonely and struggledto come to termswithherdiagnosis.InRussiaandotherEasternEuropean countries, HCWs have been demonstratedto be upto three timesmore likelyto developTB (includingMDR-TB) thanthe
generalpopulation,withtheriskdemonstratedtobeupto30– 90timeshigherforcliniciansemployedinTB-specificfacilities [8].
Case2–SouthAfrica
A nurse worked in a privately owned dialysis unit. She had trainedandworkedinbothpublicandprivatesectorhealthcare facilitiesinSouthAfricathroughouthercareerbutalthoughshe hadcaredforcountlesspatientswithTB,sheneverthoughtthat sheherselfwouldbeatsuchhighrisk.Lookingback,shenoted thattheventilationinthedialysisunitwaspoorwithnoopen windowsandTBtestingorexistingdiagnosesforpatientswere neverdiscussed.However,whenshe developed MDR-TB,she wasmadetofeellikeshehaddonesomethingwrongandwas very much affected by the stigma of TB. Although she is extremelygratefultohavesurvivedoccupationalMDR-TB,she developedhearinglossduetoaminoglycosidetherapyandhas been left with post-TB bronchiectasis,which causes frequent exacerbationsandimpairedlung function.Toher knowledge, infectioncontrolpracticesinthedialysisunithavenotchanged. Arecentsystematicreviewdemonstratedhigh ratesoflatent and activeTB in South African HCWsalthough availabledata werelimited[9].
Case3– India
InNovember 2015,aseniorlaboratory technicianatamajor hospitalinMumbaibecamethefourthHCWtodiefromMDR-TB thatyear.HavingdiabetesputhimatahigherriskofacquiringTB andhavingaworseoutcomefromTBbutitisunlikelythathe hadever receivedtesting ortreatment for latent TB.Despite havingnodirectcontactwithpatients,laboratorystaffhavean increased risk of developing TB due to exposure to sputum specimens if correct biosafety procedures including wearing personal protective equipment (PPE) are not strictly imple-mented.Deathshavealsobeennotedinothernon-clinicalstaff includingwardattendantsandcleaningstaff.Despitethe adop-tionofnational airborneinfection controlguidelines inIndia, site visits have demonstrated that TB-IC is frequently poorly developedandimplemented[10].
diagnosis,poortreatmentoutcomesandimpairedwell-beinginHCWswhodevelopTB.Ensuring theprioritizationandimplementationofTB-ICinterventionsandoccupationalhealthprogrammes, whichincluderobustmonitoringandevaluation,iscriticaltoreducenosocomialTBtransmissionto patientsandHCWs.TheprovisionofpreventivetherapyforHCWswithlatentTBinfection(LTBI)can alsopreventprogressiontoactiveTB.Unlikeotherpatientgroups,HCWsareinauniquepositionto serveasagentsof changetoraiseawareness,advocatefor necessaryresourceallocationand implement TB-IC interventions, with appropriatesupport from dedicated TB-IC officers at the facilityandnationalTBprogrammelevel.Studentsandcommunityhealthworkers(CHWs)mustbe engagedandinvolvedin theseefforts. NosocomialTBtransmissionisanurgentpublichealth problem andadopting rights-basedapproachescan behelpful.However, theseeffortscannot succeedwithoutincreasedpoliticalwill,supportivelegalframeworksandfinancialinvestmentsto supportHCWsineffortstodecreaseTBtransmission.
Challenges
Theepidemiologyof TBinHCWs
HCWsgloballyareatincreasedriskforTBinfectionanddisease, althoughratesofoccupationallyacquiredTBarehighestin low-andmiddle-incomecountries(LMICs)[2,11].Inthesesettings, drug-resistant TB(DR-TB) also affectsHCWs ata greater fre-quencythanthecommunitiestheyserve[12,13].Theincreased riskofTBaffectsallhealthcarepersonnelincludingcommunity healthworkers(CHWs),clinicalsupportstaff,laboratoryworkers andhealth sciencestudents[14,15]. Clinicalstaff(nursesand doctors)appeartobeathighestrisk[16,17].Howeverthereisa dearthofdataregardingothergroupssuchasancillarysupport andadministrative staff who may workin clinical areas and CHWs,althoughatleastsomestudieshavedemonstratedthat thesegroupsarealsoatconsiderablerisk[9,18–20].Although HCWsinLMICsmayalsobeathighriskofTBexposureintheir communities,studiesthathavecontrolledforlivingconditions confirmadditionalriskofTBdiseaseattributabletoworkplaceTB exposure[21].Thedocumented3to6-foldincreasedriskofTBis due to persistentoccupational TB exposurein the setting of absentorpoorlyimplementedTB-ICprogrammes[2,11]anda high prevalence of undiagnosed TB in healthcare facilities [22,23].Ironically,accuratedataonTBexposureandinfection riskinHCWsismostlimitedfromsettingswithhighestTBburden [9,24].PossiblefactorsexplainingthepaucityofoccupationalTB dataincludethelackofnationalHCWTBsurveillance,weakor non-existent occupational health programmes, reluctance amongHCWsto discloseaTBdiagnosisowingtostigma and thechallengeofdiagnosingLTBIinTBendemicsettings[25].In somecountries, the close association of TB and HIV disease aggravatesstigmasurroundingaTBdiagnosis,resultingin diag-nostic and treatment delays among HCWs [25]. The risk of occupationallyacquired TBandtheadverseconsequencesfor infectedHCWscontributetoattritionofHCWsinregionsalready challengedbysevereshortagesinhumanresourcesforhealth [26,27].
TBinfectioncontrolgaps
Poorlyventilatedandovercrowdedindoorcongregatesettings wheretherearepeoplewithinfectiousbutunsuspectedTB,such ashealthcarefacilities,mayberesponsibleforahighproportion ofTBtransmissioninHBCs[3].Toaddresstheriskofnosocomial TB transmission, the World Health Organization (WHO) has proposed theadoption and rigorousimplementation ofTB-IC measures [28]. These guidelines divide TB-IC measures into differenttypes. ManagerialTB-ICmeasuresincludeleadership andcommitmenttoestablishandimplementinfectioncontrol policiesatthehealthfacilitylevel[29].Administrative control measuresincludethe promptidentificationandseparation of personswith probableTB,emphasizing timelydiagnosis and treatment ofactive TB[30]. Environmental measures include optimizedoperationalstructures,includingbuildingdesignand
patientflowtodecreasetheconcentrationofairborneTBdroplet nucleiandtocontrolthedirectionalflowofpotentiallyinfectious aerosols[31].PersonalprotectiveTB-ICmeasuresfocusonthe provisionof correctlyfittedrespirators[31]. However,evenif respiratorsareavailable,respiratorfittestingisoftennot per-formedandthuswearing respiratorsincorrectlyoffersafalse sense of security [32]. Additionally, respiratory protection is typicallyonlywornininstanceswherepatientsarebeing eval-uatedfor knownor suspected TB andthereforecannotoffer protectionfromtransmissionduetounsuspectedTB[31]. Despitethese clearrecommendations forTB-IC, studies have consistentlydemonstratedtheabsenceofTB-ICprogrammesin health-carefacilitiesinHBCs[2,33].Thelackofimplementation andscaleupofthesepreventativemeasures,withanemphasis onrapidlydiagnosingandtreatingunsuspectedTB,areprimarily responsiblefornosocomialTBtransmission[10,34,35].InHBCs suchasSouthAfrica,poorbuildingdesign,overcrowding,lackof knowledgeand trainingregardingfacility-based ICplans and guidelines,andpoormanagerialinvolvementinthedesignand implementationoflocalTB-ICpolicyhavebeennotedasbarriers totheimplementationofsuchmeasures[36,37].Itshouldbe mentionedthatTB-ICisalsooftenneglectedinlowandmedium incidencecountries.Astandardizedsurveytoolusedtoevaluate drug-resistantTB management in several Europeancountries identified the lack of a comprehensive TB-IC plan in all the referencecentres surveyed [38]. Administrativeand environ-mental controls in particular were often lacking. Alarmingly despite the availability of PPEs (i.e. respirators for staff and surgicalmasksforpatients),respiratorfittestingwasalsonot availableatanyofthesereferencecentres[32].
Lackof robustoccupationalhealth systems
Accuratesurveillanceandreportingof TB diseasein HCWsin LMICsiscrucialtogainingabetterunderstandingofthe epide-miologyofTBinthishigh-riskpopulation[39].AlthoughWHO publishedrecommendationsontheirglobalstrategyof occupa-tional health for all in 1994 [40] andreleased their 10-year Global Planof Action for Workers' Healthin 2007[41], only 31 countries have ratified the Convention on Occupational HealthServices[42]andithasbeenestimatedthatonly5to 10%ofworkersindevelopingcountrieshaveaccesstoadequate occupational health services [43]. While the impact of the 2014Ebolaepidemiconthehealthworkforce drewattention tothelackofinfectioncontrolandoccupationalhealthservices inWestAfrica[44],despitehavingamortalityratecomparable toEbola andcausingillness in anestimated580,000 people annually,DR-TBhasnotgarneredthenecessarypoliticalwilland urgencytoprioritizethe institutionandmaintenanceof occu-pationalhealthservicesinTBendemiccountries.
Challengeswithtreatmentandreturningtowork TBtreatment,particularlyfordrug-resistantstrains,isdaunting. Outcomesfortreatmentofdrug-resistantTBinHCWsarepoor,
with high rates of treatment failure, mortality and therapy relatedmorbidity [12,13]. AlthoughHCWsknowtherationale fortreatmentandneedforadherence,manyhavecommented thattheyhadlittleunderstandingofthetruedemandsofTBand itstreatmentregimensandtheeffectthatthediseaseandthe antibioticshaveonthebodyuntiltheybecamepatients them-selves [45].Consultations areoften pressedfortime, leaving littleornotimeforcompassionateconversationsthatdelveinto thepatient'semotionalstateorabilitytocopewithtreatment [27].ForHCWssuchasCHWsorancillarystaff,aswellasforeign HCWs, there may also be language, cultural or educational barriers that affect crucial knowledgetransfer. Socialsupport networksmaybelimited.Sideeffectssuchasperipheral neu-ropathy, ototoxicityandvision lossmay becareer-ending for HCWs [27,45,46]. AlthoughHCWs may have betteraccess to healthcare facilities than otherpatients, theymay encounter greaterstigmaandbereluctanttoengageincare[47].Thisalso hasimplicationsfortheirabilitytoreturntowork.The psycho-logicalandfinancialcostsofnotbeing abletoreturntowork maybecripplingforHCWsandtheirfamilies.
PerguidelinesfromtheU.S.CentersforDiseaseControl,HCWs withTBshouldbeallowedtoreturntoworkwhenthey:
havehadthreenegativeAFBsputumsmearresultscollected
8–24hoursapart (atleastone ofwhich shouldbe anearly morningspecimen);
haverespondedtoanti-TBtreatmentthatshouldbeeffective
basedondrugsusceptibilitytestingresults[48].
TheassessmentofwhetheraHCWwithTBisnolonger infec-tiousandcanreturntoworkshouldbemadebyaphysicianwho hasexpertiseinthemanagementofTB.Notably,HCWsinHBCs areoftenreluctanttoreturntohealthcarefacilities,wherethey riskre-exposureandreinfection[27].
Stigmaandoccupational TB
Despite romanticizedperceptions regarding 'consumption' in Victoriantimes,thelanguagethathassubsequentlybeenused within theTBcommunityhas undoubtedlycontributed tothe stigma associated withthispreventable and curabledisease. Termssuchas'TBsuspect'and'default'havecriminal connota-tions[49]andtherehasbeenanincreasingemphasison avoid-ing the use of such stigmatizing terminology. Goffman's definitionofstigma[50]wasreworkedandappliedtoHIVby Alonzo and Reynolds [51] who described stigma as being a 'powerful discrediting and tainting social label that radically changesthewayindividualsviewthemselvesandareviewed as persons.' This definition also introduces the concepts of externalandinternalstigma.
ExternalstigmaisdirectedtowardsHCWsbyotherHCWs. Accord-ingtoCourtwrightetal.,thecommonestcauseofstigmaisthe perceivedriskoftransmission[52].HCWsdiagnosedwithTBare excludedoravoided,oftenlongaftertheinitialhigh-riskperiod for transmission. TB is also stigmatized because of its
connotations with malnutrition,poverty and HIV, which may prompt openspeculationintheworkplaceabouttheaffected healthcareworker'simmunestatus[53,54].
InternalstigmaisdirectedbyHCWstowardsthemselves. Feel-ings of isolation and shame associated with TB can lead to withdrawal from the community. One ofthe symbols of the contagiousnatureofTB,andhencealsothestigmaassociated with it, is the mask. Interestingly, although masksare worn routinelyinsomeclinicalenvironmentsliketheoperating the-atre and in certain countries when using public transport, patientswearingmaskstoreduceTBtransmissionreportfeeling stigmatized and HCWswearing respiratorsfor protection find that this creates abarrier between themand their patients [47,55].
ThereisaneedtorefineexistingTBstigmascalesdevelopedfor HCWsandmeasuretheimpactofvariousstrategiestoreduce stigma [56]. Possible interventions include bringing affected HCWstogethertosupporteachother[52]orlarge-scale com-munity-basedcampaignsliketheUnmaskStigmacampaignthat has taken placeon World TBday [57,58]. Addressing stigma couldhaveapositive impactondiagnosticdelays, treatment outcomes,psychologicalwell-beingandawarenessaboutthe prevalenceofoccupationalTB.
Solutions
TBinfectioncontrolsolutions
TheprimaryaimoftheWHOchecklistforperiodicevaluationof TB-ICinhealth-carefacilitiesistopreventthetransmissionofTB tobothpatientsandHCWs[59].Fromamanagement perspec-tive,aTB-ICplanthatincludesapersonresponsibleforTB-ICand anadequatebudgetforTB-ICactivitiessuchastrainingshould beavailableatallhealthfacilities.Inaddition,allstaffshould receiveTB-ICtrainingatleasteverytwoyearsasrecommended by the WHO[59]. Eachfacility should haveadministrative IC measuresinplace,suchasFAST(FindcasesActivelyusingcough screeningandrapidmoleculardiagnostics,Separatetemporarily andpromptlyTreateffectively)[30]andenvironmentalcontrol measuressuchasimprovingventilation,decreasing overcrowd-ing and the use of germicidal ultraviolet disinfection [3,31]. These measures should be considered at the outset during thehealthfacilityplanningprocessandICofficersshouldthus bepartofadvisorycommitteesto architectsdesigninghealth facilitiestogiveinputonTB-ICmeasures.Althoughitisessential thatHCWsaswellasancillarystaffworkinginpatient-careareas shouldhaveaccesstoN95respiratorsthatfitthemcorrectly,this shouldnotprecludeconcurrentimplementationof administra-tiveTB-ICcontrols[60].Staffshortagesandinadequatetraining at facilities where TB is treated should be addressed [37]. RegulartrainingonTB-ICalongwithmonitoringofHCWs'and institutionaladherencetothesemeasuresshouldoccur,sothat areas withpooradherencecanbeidentifiedandremediated. Implementing a comprehensive TB-IC package may seem
overwhelming.Prioritizingkeyinterventionswillbenecessary andsetting-specificcontext isimportant.For example, maxi-mizingnaturalventilationwillbefeasibleinhealthcarefacilities inwarmerclimatesbutincolderclimates,interventionssuchas germicidalultravioletairdisinfectionmayyieldgreaterbenefits [31].Establishing reportingsystemsthroughwhich HCWscan document TB-IC implementation issues that would require attentionat the facilityand subsequentlyfailing that, atthe NTPlevel,couldhelptobridgethegapbetweenTB-ICpolicyand practice.
Developingandstrengthening occupationalhealth systems
Occupationalhealthprogrammes shouldbeprioritized, main-tainedandrigorouslyevaluated,withanemphasisonelectronic datacollectiontofacilitateoperationalmonitoringand evalua-tion [61]. We advocate that occupation should be added to facility TBpatient registers andrecordedby national TB pro-grammessothattheepidemiologyofoccupationalTBcanbe betterunderstoodandenabletheprioritizationoftarget inter-ventions[39].RegularoccupationalscreeningforTBshouldbe availableateachhealthfacility.Thisinvolvesovercoming chal-lengessuchasshortagesoftuberculin forskin testingorthe costsofinterferongammareleaseassaytesting,bothofwhich are used for the diagnosis of latent TB. Occupational health programmesinTBendemicsettingsshouldalsoofferHIVtesting and linkage to care, which should at minimum include the provisionof isoniazid preventivetherapy (IPT) for HCWswith HIV.ThefeasibilityofrelocatingHCWslivingwithHIVtoalower riskclinicalarea[28]iscontentioussincethemajorityofclinical areas in HBCs pose a TB transmission risk due to the high prevalenceofundiagnosedTB.
HCWs(regardlessofHIVstatus)inmanylowprevalencesettings haveaccesstotreatmentforLTBI,aninterventionprovenover decadestobeeffective[62–64].HCWsinhigh-burdensettings should therefore also have an opportunity to prevent their progressionfrominfectiontodiseasethroughtheprovisionof LTBI therapy, since the risk of progression is higher in high transmissionsettings.ThelackofLTBItreatment forhigh-risk groupssuchasHCWSrepresentsnotonlyanimportantgapinTB control efforts but also one that is within the power of the currenthealthcaresystem itselftoremediate.Access torapid moleculardiagnostictestssuchasXpertMTB/RIFforactiveTB diagnosis[65]mustbeensuredsothathealthcareprofessionals canbepromptlytestediftheyexperienceanysymptomsofTB andstarteffectivetherapybasedondrugsusceptibilitytesting [28].Confidentialityshouldbeensuredasfaraspossiblewith regard to the outcome of tests, to overcome this barrier to gettingtested [61], although it isimportant thatthis should not preclude contact screening. Building robust occupational health systems will be an important component for overall TBeliminationefforts[42].
HowcanHCWsbe agentsof change?
HCWsshould advocate for the adoption of policies aimed at documenting,preventingandaddressingnosocomialTB trans-mission. HCWsare in a unique situation, compared to other populationswhoareparticularlyvulnerabletoTB,astheymay beabletohavegreaterinputintodevelopingandimplementing such policies to protect not only themselves but also their patients[39]. Althoughhealthadvocacyhasnotalwaysbeen anexplicitlyexpectedroleforHCWstofulfill,andwhilemany HCWsmay view theirarea of expertiseand responsibility as clinical,theimportanceofadvocacywasstressedina commis-siononglobalhealthprofessionaleducationpublishedinThe Lancetin2010[66]andaspartoftheCanMEDSframeworkfor physiciancompetency[67].
OneapproachdesignedtoengageHCWstobecomeagentsof change has focused on sharing relatable stories of HCWs affected by tuberculosis to destigmatize occupationalTB and dispelthe notionthat HCWsare "TBProof'', highlightingthe sharedriskinhealthcarefacilities[45].HCWscanalsoadvocate fortestingandtreatmentforLTBI,whichhasbeenaneglected issuein HBCsbutisnowthesubjectofgreaterattention.The HCWsdescribedinCases1and2werebothsuccessfullytreated forMDR-TBandarenowstaunchadvocatesforHCWworkplace safetyfocusedonTBpreventionanddestigmatizationandare workingwithotheragents ofchangeto raiseawarenessand mobilisethewiderHCWcommunity.
Theimportance ofeducatingandengaging healthcarestudents
Studentstrainingtobecomehealthprofessionalsareexposedto the same occupationalhazards as theirprofessional counter-partsandresultantlyhaveahighriskofoccupationalTB[68]. Althoughstudentsinendemic settingsmay reportperceiving themselvestobeathigherriskofTBandaremorelikelytohave receivedTB-ICtrainingthanotherHCWs[69],theyarenotmore likelytoprovidecorrectexamplesofTB-ICmeasuresortouse PPEasrecommended[70,71].Additionally,itisconcerningto notethathealthcarestudentshaveindicatedthattheyperceive theirprofessionalmentorstobesimilarlyawareoftherisksof occupationaltuberculosis,butreportthattheydonottakethe necessary precautions [47,69]. Many professional behaviours aremodeledonthoseofmentors[72],andeffortsneedtobe madetoensurethatsafepracticesareemphasizedinorderto form afoundation for futurepractices.Engagingfuture HCWs duringthisearlystageoftheirtrainingbyfocusingsome inter-ventioneffortsonlargehospitalsthatserveasteachingsitescan help to facilitate HCWs becoming and remaining agents of change(figure1).
Humanrightsandtherole ofthelaw
Legalandregulatoryframeworkshavearoletoplayin decreas-ing TB transmission [73]. There have been scant efforts in highlightingtheroleandimportanceofhumanrightsinglobal
TBcontrolefforts.Thisreflectstheabsenceorpoor implemen-tationofTB-specificlegislation,whichcanarticulatetherightsof peoplewithTB,the riskofTBinnosocomialsettingsandthe harms of stigma anddiscrimination,in TBendemic countries [74].
WithregardstoTB-IC,theglobalhealthcommunitylacksasound understanding of the law's effect on population health. Althoughtheexistenceoflawsandregulationsdoesnotensure thattheywillbeimplemented,theyprovideastructural frame-worktoguideTB-ICefforts.Consequently,abetter understand-ingoftheexistinglawsthataddressTB-ICisaprerequisiteto assessingtheirimplementationandtheireffectonpractice.A reviewoflawsandregulationsdescribedandanalysed legisla-tiveapproachestoTB-ICpracticesinBotswana,SouthAfricaand Zambia,focusing onselected elementsof WHO'sTB-IC policy [75].Inallthreecountries,TBcasereportingisrequired,asisTB surveillanceamongHCWs.Eachcountry'slegalandregulatory frameworkalsoaddressestheneedtorespectindividuals'rights andprivacywhilesafeguardingpublichealth.Althoughthese lawsandregulationsshouldcreateastrongfoundationforTB-IC, poorTB-ICimplementation[2]andscantdataonoccupationalTB
from LMICs such as these [9] suggests otherwise. Future researchshouldassesstheimplementation andpublichealth impactoflawsandregulationsregardingTB-IC.
LawssuchastheOccupationalHealthandSafetyAct(OHSA)in SouthAfrica[76]classifyTBasanoccupationaldisease,which meansthatHCWswhodevelopTBshouldreceivecompensation, includingoccupationalsickleave,medicalexpenses,permanent disabilitypaymentsandpaymentstosurvivingfamilymembers. Unfortunately students, CHWsand volunteers with the same exposures typicallydo not receivethe same legal protection despite suffering the same devastating consequences [45]. Legal frameworksmustbestrengthenedto ensurethatTB-IC measures areimplemented,monitoredandevaluatedas rec-ommendedandtoprovidecareandcompensationtoallHCWs includingtraineesandvolunteerswhoareaffectedby occupa-tionalTB.Thisisanethicalimperativeforpolicymakers[77]. Ongoingscientificchallenges
Itisestimatedthat1.7billionpeoplegloballyareinfectedwith TB [78]. Certain risk factors that increase the likelihood of developingactiveTBhavebeenidentifiedsuchasHIV,diabetes
Figure1
TBProofawarenessandadvocacysession,FacultyofMedicineandHealthSciences,StellenboschUniversity,CapeTown,SouthAfrica
andtobacco use. However, in otherpopulations that include HCWs, who are more likely to have LTBI than the general population[24],itisnotpossibletopredictwhowilldevelop activeTB.IPToralternativeLTBItreatmentregimenshavebeen recommendedinhighandlow-incidencesettingsforgroupsat highriskofTBreactivation,suchaspeoplelivingwithHIVand contactsofpatientswithpulmonaryTB[79].However,thereis currentlynoguidance forHIV-uninfectedHCWs(orother HIV-uninfectedindividuals)inHBCswhoareatfrequentriskof re-exposureandre-infection[80].Thisisthesubjectofdebatebut basedonevidencethattreatmentofLTBIdecreasestheriskof futurereactivationtoTBdisease[62–64]resultinginthisbeinga policyrecommendationfor low-incidencecountries[81], pre-ventive therapy should be recommended and available for HCWsaswellasothersinHBCswithTBinfectiondespitetheir re-exposureandre-infection risk. Dueto the increasing inci-dence ofMDR- andXDR-TB, thereareincreasing numbers of people (includingHCWs) with latent DR-TB,butthereareno guidelines regarding preventive therapy for DR-TB exposure. AlthoughHCWsinHBCswilltypicallyhavereceivedthe Myco-bacteriumbovisBacilleCalmette-Guérin(BCG)vaccineaspartof
the childhood immunization series, the effectiveness of this vaccineisprimarilytoreducetheriskofTBmeningitisininfants. DatasuggeststhatBCGalsoreducestheriskofinfection[82],but BCGimmunitysubsequentlywanesovertime,suchthat vacci-nationdoesnotpreventadultsfromdevelopingTB[83].Dueto thecomplex biologyofMycobacterium tuberculosis,multiple vaccinestrategiesarebeingpursuedto:
preventTBinfectionafterinitialexposure;
prevent the development of TB disease in those who are
infectedbutasymptomatic;
topreventrecurrentdiseaseinthosewhohavedevelopedand
beentreatedforTBdisease[84].
Conclusions
TBeliminationeffortscannotsucceedwithoutincreased atten-tionandresourcesbeingchanneledtowardsTB-ICand occupa-tional health systems strengthening. Table I demonstrates suggested action points at the individual healthcare facility, NationalTBProgrammeandsupranationalWHOlevelthatare criticaltodecreasenosocomialTBtransmission,whichincludes occupationalTB. Afocus on monitoring and evaluatingTB-IC
TABLEI
Suggestedactionpoints
Levelofhealthsystem Suggestedactions
Localfacility EstablishaTB-ICplaninaccordancewithWHOchecklistguidelineswithregularmonitoringandevaluation(M&E) ProvidetrainingtoandsupportfordedicatedTB-ICofficers
DeveloppeereducationsessionsthatmaybestrengthenedbyadvocacyfromoccupationalTBsurvivors ImplementOccupationalHealthProgrammesthatincludetestingHCWsfordevelopmentoflatentTBinfectionand activeTBdiseaseandprovidingtreatmentforboth,alongwithlinkagetoHIVtestingandcare.Confidentialityshould beassuredwhereverpossiblebutnotprecludecontactevaluation
OccupationshouldberecordedonTBregistryforms
Identifyhigh-riskareasthatarepoorlyventilatedorovercrowdedformitigationbychangingpatientflowand/or implementingstrategiessuchasmechanicalventilationand/orgermicidalultravioletairdisinfection
Ensurethatfit-testedrespiratorsareavailableforallstaffworkinginclinicalareas,includingstudents NationalTBprogramme EnsurerobustM&EprogrammesforTB-ICandOccupationalHealthProgrammes
Includecommunityhealthworkers,at-risknon-clinicalhospitalstaffandstudentsintheseprogrammesandensurethat theyreceiveadequatetraining
InstituteandutilizesupportivelegalframeworkstoensurethatTB-ICimplementationoccursalongwithrequisiteM&E EnsureaccesstodiagnostictestingandtreatmentforlatentandactiveTB
WHO RecordannualnumbersofHCWsthatdevelopTBinfectionanddiseasebasedonfacilitycaserecordsthatshould includeoccupationasanindicator
ProvideguidanceregardinglegalframeworkstosupportTB-ICandoccupationalhealthprogrammes
ProvideguidanceregardingpreventivetherapyforHIV-uninfectedHCWs,includingthosewhomayhavebeenexposed toDR-TB
interventions is needed to ensure that meaningful improve-mentsarebeingmade.HCWsareuniquelyplacedasagentsof change to raise awareness and decrease stigma regarding occupationalTB,advocateforpoliciessupportedbylegislation andcriticallytoactbyimplementingthesolutionsdiscussedin thisreview.Thiscanleadtohealthcarefacilitiesbecomingsafer for both HCWsandthe patientstheyserveandenabling the deliveryofhighqualitycare,eveninunder-resourcedhighTB burden countries. Strong leadership coupled with sustained political commitment,supportive legislative frameworks and
adequatefinancialinvestmentwillbecriticaltoachievethese goals.
Fundingsources:RRNwassupportedbyagrantfromtheHarvardCenter
forAIDSResearch(NIAID2P30AI060354-11,http://cfar.globalhealth.
harvard.edu)andanImperialCollegeInstitutionalStrategicSupportFund
GlobalHealthFellowship.PLwassupportedbyanNIHT32award
(AI007061).ENwassupportedbyanNIHFogartyAward(D43TW009379).
Disclosureofinterest:theauthorsdeclarethattheyhavenocompeting interest.
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