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Abstract

Tuberculosis (TB) is the leading cause of infectious disease mortality worldwide, accounting for more than 1.5 million deaths in 2014, and is the leading cause of death among persons living with human immunodeficiency virus (HIV) infection (1). Nigeria has the fourth highest annual number of TB cases among countries, with an estimated incidence of 322 per 100,000 population (1), and the second highest prevalence of HIV infection, with 3.4 million infected persons (2). In 2014, 100,000 incident TB cases and 78,000 TB deaths occurred among persons living with HIV infection in Nigeria (1). Nosocomial transmission is a significant source of TB infection in resource-limited settings (3), and persons with HIV infection and health care workers are at increased risk for TB infection because of their routine exposure to patients with TB in health care facilities (3-5). A lack of TB infection control in health care settings has resulted in outbreaks of TB and drug-resistant TB among patients and health care workers, leading to excess morbidity and mortality. In March 2015, in collaboration with the Nigeria Ministry of Health (MoH), CDC implemented a pilot initiative, aimed at increasing health care worker knowledge about TB infection control, assessing infection control measures in health facilities, and developing plans to address identified gaps. The approach resulted in substantial improvements in TB infection control practices at seven selected facilities, and scale-up of these measures across other facilities might lead to a reduction in TB transmission in Nigeria and globally.
Morbidity and Mortality Weekly Report
MMWR / March 18, 2016 / Vol. 65 / No. 10 263
US Department of Health and Human Services/Centers for Disease Control and Prevention
Tuberculosis (TB) is the leading cause of infectious disease
mortality worldwide, accounting for more than 1.5 million
deaths in 2014, and is the leading cause of death among
persons living with human immunodeficiency virus (HIV)
infection (1). Nigeria has the fourth highest annual number
of TB cases among countries, with an estimated incidence
of 322 per 100,000 population (1), and the second highest
prevalence of HIV infection, with 3.4 million infected persons
(2). In 2014, 100,000 incident TB cases and 78,000 TB deaths
occurred among persons living with HIV infection in Nigeria
(1). Nosocomial transmission is a significant source of TB
infection in resource-limited settings (3), and persons with
HIV infection and health care workers are at increased risk
for TB infection because of their routine exposure to patients
with TB in health care facilities (35). A lack of TB infection
control in health care settings has resulted in outbreaks of TB
and drug-resistant TB among patients and health care workers,
leading to excess morbidity and mortality. In March 2015, in
collaboration with the Nigeria Ministry of Health (MoH),
CDC implemented a pilot initiative, aimed at increasing health
care worker knowledge about TB infection control, assessing
infection control measures in health facilities, and developing
plans to address identified gaps. The approach resulted in
substantial improvements in TB infection control practices at
seven selected facilities, and scale-up of these measures across
other facilities might lead to a reduction in TB transmission
in Nigeria and globally.
To address the risk for TB transmission to uninfected
persons, the World Health Organization (WHO) recom-
mends implementation and scale-up of TB infection control
measures, including managerial (leadership and commitment
for establishing and implementing infection control policies
at the health facility), administrative (prompt identification
and separation of persons with presumptive TB, with timely
diagnosis and treatment of TB patients), and environmental
(optimization of building design and patient flow to reduce
the concentration of TB droplet nuclei in the air and control
directional flow of potentially infectious aerosols) measures
and personal protective equipment (PPE) use, implemented
in conjunction with other infection control measures, to
reduce the risk for TB transmission in health care facilities
(6). Preventing nosocomial TB transmission, aimed at reduc-
ing the impact of TB on persons living with HIV, is also a
priority for the U.S. President’s Emergency Plan for AIDS
Relief (PEPFAR) (7). However, infection control measures
to prevent TB transmission in health care facilities have not
been adequately implemented, especially in settings with high
incidence of TB and limited resources (8,9).
A four-phase TB infection control initiative, Building and
Strengthening Infection Control Strategies (TB BASICS), was
developed by CDC to assess and improve health care facility
infection control practices in countries with high numbers of
TB cases, using a continuous quality improvement approach.
The initiative includes 1) TB infection control training of
health care workers, 2) baseline health facility assessments and
development of intervention plans, 3) implementation, and
4) monitoring and evaluation through engagement of local
health officials and health care workers to encourage commit-
ment to the initiative. The pilot project was conducted in seven
health care facilities in Ebonyi, Enugu, and Imo states that are
supported by a PEPFAR implementing partner in southeastern
Nigeria. These facilities provide services to 1.48 million persons
and, during the past year, treated 1,600 TB patients.
A 3-day training workshop based on the WHO policy on
TB infection control in health care facilities, congregate set-
tings, and households (6) and delivered by MoH and CDC
was conducted for 50 health care workers, including physi-
cians, nurses, residents from the Nigeria Field Epidemiology
and Laboratory Training Program (NFELTP), TB and HIV
program coordinators, and TB/HIV program officers from the
MoH. A precourse assessment identified environmental and
administrative measures for infection control as the main gaps
in participant knowledge. Training materials, videos, and job
aids* were provided to all participants to facilitate their train-
ing of other staff members in their respective health facilities.
Teams conducted baseline assessments of TB infection control
practices at each of the seven facilities using a standardized facil-
ity assessment tool that included staff interviews, observation of
* http://www.cdc.gov/globalaids/Resources/pmtct-care/tuberculosis-infection-
control.html.
The seven teams included state, regional, and federal MoH officials, NFELTP
residents, PEPFAR implementing partners, WHO staff members, and CDC
staff members and were led by health care providers from the pilot health facilities.
Building and Strengthening Infection Control Strategies to Prevent
Tuberculosis — Nigeria, 2015
E. Kainne Dokubo, MD1; Bethrand Odume, MBBS2; Virginia Lipke1; Custodio Muianga, PhD3; Eugene Onu, MBBS4; Ayodotun Olutola, MBBS4;
Lucy Ukachukwu4; Patricia Igweike4; Nneka Chukwura, PhD5; Emperor Ubochioma, MBBS5; Everistus Aniaku, MBBS6; Chinyere Ezeudu, MBBS6;
Joseph Agboeze, MBBS6; Gabriel Iroh, MBBS6; Elvina Orji, MBBS6; Okezue Godwin, MBBS6; Hasiya Bello Raji7; S.A. Aboje, MBBS8;
Chijioke Osakwe, MBBS9; Henry Debem, MSc2; Mustapha Bello, MBBS2; Dennis Onotu, MBBS2; Susan Maloney, MD1
Morbidity and Mortality Weekly Report
264 MMWR / March 18, 2016 / Vol. 65 / No. 10 US Department of Health and Human Services/Centers for Disease Control and Prevention
routine practices, and review of available policies and procedures
on infection control. After completion of the baseline assessments
and identification of programmatic areas for strengthening, each
team developed a facility-specific intervention plan with a timeline
for implementation. Implementation of TB infection control
measures at each facility was reassessed at 2, 4, and 6 months after
the baseline assessment. Monitoring of 14 managerial measures,
13 administrative measures, seven environmental measures, and
three PPE measures was conducted by NFELTP residents, and
the final evaluations were performed by the teams that conducted
the baseline assessments. Data were displayed in a color-coded
dashboard (http://stacks.cdc.gov/view/cdc/38109) that indicated
elements that were not implemented (and for which there was
no implementation plan) in red, elements that were planned but
not yet implemented in yellow, elements that were not applicable
or assessed in blue, and elements that were fully implemented in
green. Site-specific feedback and a copy of the dashboard were
provided to the facilities immediately after the baseline assessment
was completed and at each of the bimonthly evaluations so that
staff members could visually track their own progress.
Baseline Assessment of TB Infection Control
Measures
At baseline, managerial measures were lacking in almost all
facilities. Only one site had national infection control policy
and guidelines or facility-specific plans available. There were
no infection control committees or designated practitioners, no
routine risk assessments or daily monitoring of infection control
activities, no ongoing or planned operational research to improve
infection control practices, and no occupational health programs.
All facilities had systems in place for reporting all new TB diagno-
ses, and all patients with diagnosed TB disease were referred for
treatment. In accordance with the national TB treatment policy,
directly observed therapy was provided for TB patients; however,
staff members did not know how to properly educate patients
and their visitors or provide them with information on infection
prevention. Administrative measures also were generally not in
place. Only three facilities had posters describing proper cough
etiquette, and most did not have tissue or hygiene supplies for
coughing patients, staff members designated to identify cough-
ing patients and separate them from other patients to reduce
possible exposure to TB, or systems in place for patients with
presumptive TB to be prioritized for clinical evaluation. None
of the facilities provided routine TB evaluation, HIV testing or
secure documentation of health information for their staffs, and
most did not have WHO-recommended isoniazid preventive
therapy available for staff members with HIV infection.§
Collection of sputum in a designated location away from other
patients and timely processing of sputum samples were in place in
five of the seven facilities. Although all of the facilities had outdoor
patient waiting areas with good ventilation, other environmental
measures were poorly implemented. None of the facilities rou-
tinely checked airflow in examination rooms and waiting areas
to ensure adequate air exchange; signage reinforcing the opening
of doors and windows for cross-ventilation was not displayed,
and the facilities did not have extractor fans to facilitate removal
of infectious aerosols or use ultraviolet germicidal irradiation of
TB droplet nuclei. PPE was not consistently used in any of the
facilities. Coughing patients were not provided masks to cover the
nose and mouth. Staff members had not undergone respirator fit
testing and did not routinely wear respirators when interacting
with patients with presumptive or diagnosed TB disease.
Implementation of TB Infection Control
Improvements
Interventions to improve infection control practices were
carried out at each site to promote and enable facility-driven
program changes. No-cost interventions were immediately
put in place, and providers who had attended the training
used workshop materials to train other staff members at their
facilities. Posters and pamphlets with information on cough
etiquette, hygiene, and handwashing were provided to each
facility for display in patient waiting areas. Purchase of supplies
and minor renovations, including the construction of designated
sputum collection booths in remote areas of the facilities, were
undertaken. Facilities developed plans to monitor average patient
wait times and ensure that presumptive TB patients received
expedited care to reduce the amount of time they spent around
other patients and health care workers. Occupational health
programs were established at each facility, including routine TB
evaluations for health care workers, which led to the diagnosis
of TB in three staff members at two of the pilot facilities.
As measured by the dashboard, progress from predominantly
red indicators at baseline (indicating nonimplementation
of recommended measures), to almost all green indicators
(indicating full implementation) at the 6-month evaluation
reflected improvements made by the seven pilot facilities. At
baseline, only two of the 14 managerial measures were imple-
mented at all seven facilities. At the 6-month evaluation, 13
of the 14 managerial indicators had been implemented at all
of the facilities. Of the 13 administrative measures, the num-
ber implemented increased from zero at baseline to 10 at the
6-month evaluation. Of the seven environmental measures, the
number implemented increased from one to four, and of the
three PPE measures, the number implemented increased from
zero to three. As of February 2016, NFELTP residents, health
care providers, and health officials from the initial training
§ http://www.who.int/hiv/strategy2016-2021/Draft_global_health_sector_
strategy_hiv_01Dec2015.pdf?ua=1&ua=1.
Morbidity and Mortality Weekly Report
MMWR / March 18, 2016 / Vol. 65 / No. 10 265
US Department of Health and Human Services/Centers for Disease Control and Prevention
workshop had trained approximately 200 health care workers,
using materials and videos developed by CDC. The experiences
of participants in the project helped to inform revisions being
made to the TB infection control section of the Nigeria MoH
guidelines for TB/HIV collaborative activities.
Discussion
TB prevention is a key element in the strategy to end the global
TB epidemic (10) and an important component of prevention is
TB infection control. In Nigeria, as in many countries with high
numbers of cases and limited resources, implementation of TB
infection control measures has been inadequate (8). An initia-
tive aimed at increasing health care worker knowledge about TB
infection control and implementing measures to reduce nosoco-
mial transmission in Nigeria resulted in substantial improvement
in managerial, administrative, environmental, and personal
protective measures and in demonstrable country and facility
commitment to the initiative during a 6-month implementation
period. Managerial and administrative measures mainly involved
implementation of existing policies and change in practices and
were rapidly put into place. Environmental improvements and
PPE use were instituted at minimal cost.
Commitment from MoH and the conscientiousness of
participating health care workers were critical to the success
of this project. The limited knowledge of health care providers
and minimal implementation of infection control measures at
baseline was challenging. However, country capacity was built
by engaging local stakeholders in all aspects of the project,
including training, facility assessment, intervention planning
and implementation, monitoring, and evaluation. In addition,
many of the implemented practices required minimal interven-
tion. Continuing education and training of health care workers,
as well as monitoring of infection control practices, will help
to ensure that the progress attained is sustained.
The findings in this report are subject to at least two limi-
tations. First, the pilot project was conducted in PEPFAR-
supported facilities in southeastern Nigeria and might not
be representative of other facilities or sites in other parts of
the country. Second, although the initial achievements have
been encouraging, the long-term impact and sustainability of
the TB infection control practices implemented have not yet
been assessed.
The incidental diagnoses of TB among health care workers
as a result of this project highlight the value of routine health
care worker screening and underscore the importance of TB
infection control in health care settings. The outcome of the
pilot project and recommendations have been shared with
the government of Nigeria and in-country TB stakeholders,
and will guide ongoing capacity-building efforts, scale-up of
infection control practices in other health facilities in Nigeria,
and long-term monitoring plans.
Preventing TB infection is key to reducing the number of
TB cases worldwide, but there are still critical infection control
gaps in health facilities, posing a continued risk to persons liv-
ing with HIV infection, health care workers, and uninfected
persons. Widespread implementation of infection control
measures, especially in settings with high numbers of cases,
should help prevent further TB transmission and ultimately
bring the global TB epidemic to an end.
Acknowledgments
Staff members and management of Federal Teaching Hospital
Abakaliki, General Hospital Ezamgbo, St. Patrick’s Hospital Abakaliki,
District Hospital Enugu Ezike, General Hospital Nsukka, General
Hospital Abo-Mbaise, General Hospital Awo-Omamma, Nigeria;
Nigeria Federal Ministry of Health; National TB and Leprosy Control
Program; National Agency for Control of AIDS; National AIDS and
STD Control Program; Ebonyi State Ministry of Health; Enugu
State Ministry of Health; Imo State Ministry of Health; Nigeria Field
Epidemiology and Laboratory Training Program; Centre for Clinical
Care and Clinical Research, Nigeria; CDC Nigeria leadership and staff
members; TB BASICS Team, CDC.
1Division of Global HIV and TB, Center for Global Health, CDC; 2CDC
Nigeria; 3Agency for Toxic Substances and Disease Registry; 4Centre for Clinical
Care and Clinical Research, Nigeria; 5National TB and Leprosy Control
Program, Nigeria; 6Nigeria Field Epidemiology and Laboratory Training
Program; 7National Agency for Control of AIDS, Nigeria; 8National AIDS
and STD Control Program, Nigeria; 9WHO, Nigeria.
Corresponding author: E. Kainne Dokubo, vic8@cdc.gov, 404-797-7459.
Summary
What is already known about this topic?
Tuberculosis (TB) is the leading cause of infectious disease
mortality globally. Nosocomial transmission is a significant source
of TB infection and of particular risk for health care workers and
persons living with human immunodeficiency virus infection. TB
infection control measures to reduce the transmission of TB in
health care facilities have not been well implemented in settings
with high numbers of cases and limited resources.
What is added by this report?
An intervention in Nigeria that focused on training health care
workers, identifying TB infection control gaps, and using
continuous quality improvement measures to monitor strate-
gies in health care facilities was effective in improving TB
infection control.
What are the implications for public health practice?
Increasing health care worker knowledge and implementation
of TB infection control measures in health facilities are key to
preventing the nosocomial spread of TB and reducing the
incidence of TB globally. Ongoing support will be required to
ensure that gains are maintained and that the infection control
program is sustainable.
Morbidity and Mortality Weekly Report
266 MMWR / March 18, 2016 / Vol. 65 / No. 10 US Department of Health and Human Services/Centers for Disease Control and Prevention
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... 59 93 94 97 Three studies (23.1%) adopted longer term evaluation cycles or mentoring for the implementation of TB-IPC interventions. 42 68 88 Data collection methods Three-quarters of the studies (n=58; 75.3%) used structured data collection tools including questionnaires, checklists, audit and assessment tools, and record extraction, which were also used for structured interviews and observations. 5 11 14-17 32- 35 37 38 40-47 49 50 52-56 59 62-70 72 75 77-79 82 84-95 97 100 102 Thirty studies (40.0%) adopted observations. ...
... 15 81 83 Studies also reported the availability of more specific regulations (n=13), 5 15 17 42 50 63 64 78 82 84 91 93 102 such as for masks, 5 17 102 visitors 64 82 and waiting time monitoring. 42 Occupational health regulations surfaced in a small number of studies (n=5), 5 17 78 79 83 94 with more specific attention to history 83 and scope 83 94 thereof. ...
... Numerous studies looked at whether TB-IPC practices were monitored and evaluated (n=17), 5 88 91 93 Studies that considered quality improvement processes were either intervention studies or specifically referred to improvements of clinic layout and ventilation (n=10). 42 93 102 Stakeholders involved in policy development processes were healthcare providers, IPC committee members and experts (n=7). 42 59 81 83 87 90 94 One study noted the influence of the involved stakeholders' degree of authority. ...
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... Furthermore, a study by Dokubo et al. (2016) recommended that hospital administrators should ensure that managerial, supervision and environmental controls are strengthened in order to promote effective personal safety practices by every staff [18]. Again, similar research suggested that the Ministry of Health should develop and implement policies aimed at prevention and control of occupational tuberculosis thereby, improving the lives of health workers and the general population however, very few health facilities have successfully implemented tuberculosis infection control procedures [7]. ...
... Furthermore, a study by Dokubo et al. (2016) recommended that hospital administrators should ensure that managerial, supervision and environmental controls are strengthened in order to promote effective personal safety practices by every staff [18]. Again, similar research suggested that the Ministry of Health should develop and implement policies aimed at prevention and control of occupational tuberculosis thereby, improving the lives of health workers and the general population however, very few health facilities have successfully implemented tuberculosis infection control procedures [7]. ...
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The hospital is a high risk environment for the transmission of infections to health care workers, visitors, patients and the surrounding community. Healthcare workers are exposed to a variety of hazards which predisposes these “indispensable carers” to various life threatening infections and diseases. This study is aimed at evaluating the occupational hygiene and infection control practices in Federal Medical Center (FMC) Owerri and FMC Yenayoa, both located within southern Nigeria. Descriptive cross sectional study using a structured questionnaire and walk-through safety checklist was employed. A total of 379 healthcare workers were selected through disproportionate stratified sampling from the two facilities. The questionnaires were self-administered and analyzed using SPSS Version 22.0. Frequencies, chi-square were computed and multivariable logistic regression analysis was used to identify the predisposing factors to which health workers are exposed; 60.7% of respondents were male, dominant age group; 30 – 39yrs, nurses represented a larger proportion (34.8%) of healthcare workers in this study; 51.7% and 48.3% of respondents in FMC Yenagoa and FMC Owerri respectively had a good knowledge of hazards and controls. There was a significant difference with chi-square as, 9.710 p-Value <0.008. Good level of attitude was 44.7% in Owerri and 21.2% in Yenagoa, chi-square 18.295 p-Value <0.001. Overall level of occupational hygiene and infection control practices was poor in both facilities. Health care workers had a very high level of exposure to ergonomic hazards (88.9%) and biological hazards 47.6% in Owerri and 55.3% in Yenagoa. Nurses were 5 times more at risk of ergonomic hazards (95%CI) – 5.96 (2.19–16.24) p-Value < 0.001, while Medical Laboratory scientists were 5 times more at risk of chemical hazards (OR = 5.98, 95CI: 3.05–11.69, p-Value <0.001). The checklist revealed that both facilities were of imminent high risk category. Health care workers at FMC Yenagoa had higher exposures to all five categories of hazards than FMC Owerri. Working in FMC Owerri predisposes workers to higher health hazards than in FMC Yenagoa. There was better administrative controls including trainings and immunizations in FMC Yenagoa than in FMC Owerri.
... The result presented in Table 2 shows the sample population of 8124 (55% male and 45% female) TB cases were placed on revealed that generally across the duration, male patients had the highest prevalence, unlike the female patients. In this study, 52040 presumptive cases were identified from the year 2014-2019, with a progressive increase from the year 2015 this agrees with Anih et al., [1] and Dokubo et al., [3] who suggest that Nigeria has the fourth highest annual number of TB cases among countries. Subbaraman et al., (2019) reported that most presumptive pulmonary TB patients fail reach a health facility and access TB tests or individuals TB might be diagnosed empirically, This gap may reveal patient losses from use of suboptimal diagnostic tests.Most individuals who have negative sputum smears have conditions other than TB this agrees with the low number of 12% ...
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Tuberculosis (TB) remains a major global public health problem, as it is an infectious disease and a leading cause of death globally. The issue of missing TB cases has attracted so much attention globally; the same is the case in Enugu state as the primary drivers of TB transmission vary considerably from Local government to another. Community sensitization led to increasing in presumptive tested for TB (from 10230 in 2014 to 13260 in 2018). To ascertain Tuberculosis prevalence in Enugu state using5-year data. This current retrospective study was conducted on patients' record who reported at the TB directly observed treatment short course (DOTS) clinic from 2014 to 2018 in Enugu state. The study population consists of all documented data found in the TB Presumptive CASE STUDY ARTICLE Page491 CASE STUDY and Treatment registers within the study duration. Data collected were subjected to statistical analysis, using One-way ANOVA and descriptive statistics. A total of 51,292 presumptive were tested for TB within the year under review, out of which 6371 were diagnosed bacteriologically to have TB, hence, a prevalence of 12%. Bacteriologically diagnosed cases of 98% (6250) were linked to treatment within the year 2014-2018. Statistical analysis revealed that generally across the period, male patients had a higher prevalence than the female patients. The treatment success rate (TSR) has gradually increased from 2014 to 2018 as TSR for 2014 was 79%, 2015 was 80%, 2016 was 81%, while 2017 and 2018 had 80% respectively. The number of presumptive cases increases yearly as a result of intervention going on in the state. A need for stakeholders to intensify the campaign in rural and urban areas to enhance community awareness will go a long way in reducing the burden of TB.
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A total of 663 human immunodeficiency virus (HIV) care and treatment sites in nine tuberculosis (TB) affected African countries, serving over 900 000 persons living with HIV. To determine the implementation of infection control (IC) measures and whether program and facility characteristics were associated with implementation of these measures. A survey was conducted to assess the presence of a TB IC plan, triage practices for TB suspects, location of sputum collection and availability of particulate respirators. The association of facility characteristics with IC measures was examined using bivariate and multivariate methods. Forty-seven per cent (range across countries [RAC] 2-77%) of sites had written TB IC plans; 60% (RAC 5-93%) practiced triage; of those with access to microscopy, 83% (RAC 59-91%) performed sputum collection outdoors and 13% (RAC 0-36%) in ventilated indoor rooms; 16% (RAC 1-87%) had particulate respirators available. Sites providing anti-tuberculosis treatment were more likely to have written IC plans (54% vs. 12%, P < 0.0001) and particulate respirators (18% vs. 8%, P = 0.0126), and to perform TB triage (65% vs. 40%, P = 0.0001) than those without anti-tuberculosis treatment services. To protect HIV-infected patients and health care workers, there is an urgent need to scale up IC practices at HIV care and treatment sites, particularly at sites without anti-tuberculosis treatment services.
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The importance of infection control (IC) in health care settings with tuberculosis (TB) patients has been highlighted by recent health care-associated outbreaks in South Africa. To conduct operational evaluations of IC in drug-resistant TB settings at a national level. A cross-sectional descriptive study was conducted from June to September 2009 in all multidrug-resistant (MDR-TB) and extensively drug-resistant TB (XDR-TB) facilities in South Africa. Structured interviews with key informants were completed, along with observation of IC practices. Health care workers (HCWs) were asked to complete an anonymous knowledge, attitudes and practices (KAP) questionnaire. Multilevel modeling was used to take into consideration the relationship between center and HCW level variables. Twenty-four M(X)DR-TB facilities (100%) were enrolled. Facility infrastructure and staff adherence to IC recommendations were highly varied between facilities. Key informant interviews were incongruent with direct observation of practices in all settings. A total of 499 HCWs were enrolled in the KAP evaluation. Higher level of clinical training was associated with greater IC knowledge (P < 0.001), more appropriate attitudes (P < 0.001) and less time spent with coughing patients (P < 0.001). IC practices were poor across all disciplines. These findings demonstrate a clear need to improve and standardize IC infrastructure in drug-resistant TB settings in South Africa.
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To assess the annual risk for latent tuberculosis infection (LTBI) among health care workers (HCWs), the incidence rate ratio for tuberculosis (TB) among HCWs worldwide, and the population-attributable fraction of TB to exposure of HCWs in their work settings, we reviewed the literature. Stratified pooled estimates for the LTBI rate for countries with low (<50 cases/100,000 population), intermediate (50-100/100,000 population), and high (>100/100,000 population) TB incidence were 3.8% (95% confidence interval [CI] 3.0%-4.6%), 6.9% (95% CI 3.4%-10.3%), and 8.4% (95% CI 2.7%-14.0%), respectively. For TB, estimated incident rate ratios were 2.4 (95% CI 1.2-3.6), 2.4 (95% CI 1.0-3.8), and 3.7 (95% CI 2.9-4.5), respectively. Median estimated population-attributable fraction for TB was as high as 0.4%. HCWs are at higher than average risk for TB. Sound TB infection control measures should be implemented in all health care facilities with patients suspected of having infectious TB.
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The risk of transmission of Mycobacterium tuberculosis from patients to health-care workers (HCWs) is a neglected problem in many low- and middle-income countries (LMICs). Most health-care facilities in these countries lack resources to prevent nosocomial transmission of tuberculosis (TB). We conducted a systematic review to summarize the evidence on the incidence and prevalence of latent TB infection (LTBI) and disease among HCWs in LMICs, and to evaluate the impact of various preventive strategies that have been attempted. To identify relevant studies, we searched electronic databases and journals, and contacted experts in the field. We identified 42 articles, consisting of 51 studies, and extracted data on incidence, prevalence, and risk factors for LTBI and disease among HCWs. The prevalence of LTBI among HCWs was, on average, 54% (range 33% to 79%). Estimates of the annual risk of LTBI ranged from 0.5% to 14.3%, and the annual incidence of TB disease in HCWs ranged from 69 to 5,780 per 100,000. The attributable risk for TB disease in HCWs, compared to the risk in the general population, ranged from 25 to 5,361 per 100,000 per year. A higher risk of acquiring TB disease was associated with certain work locations (inpatient TB facility, laboratory, internal medicine, and emergency facilities) and occupational categories (radiology technicians, patient attendants, nurses, ward attendants, paramedics, and clinical officers). In summary, our review demonstrates that TB is a significant occupational problem among HCWs in LMICs. Available evidence reinforces the need to design and implement simple, effective, and affordable TB infection-control programs in health-care facilities in these countries.
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In sub-Saharan Africa, high rates of tuberculosis (TB) and human immunodeficiency virus (HIV) infection pose a serious threat for occupationally acquired TB among health care workers. To identify factors associated with TB disease among staff of an 1800-bed hospital in Kenya. We calculated TB incidence among staff and conducted a case-control study where cases (n = 65) were staff diagnosed with TB and controls (n = 316) were randomly selected staff without recent TB. The annual incidence of TB from 2001 to 2005 ranged from 645 to 1115 per 100000 population. Factors associated with TB disease were additional daily hours spent in rooms with patients (adjusted odds ratio [aOR] 1.3, 95%CI 1.2-1.5), working in areas where TB patients received care (aOR 2.1, 95%CI 1.1-4.2), HIV infection (aOR 29.1, 95%CI 5.1-167) and living in a slum (aOR 4.7, 95%CI 1.8-12.5) or hospital-provided low-income housing (aOR 2.6, 95%CI 1.2-5.6). Hospital exposures were associated with TB disease among staff at this hospital regardless of their job designation, even after controlling for living conditions, suggesting transmission from patients. Health care facilities should improve infection control practices, provide quality occupational health services and encourage staff testing for HIV infection to address the TB burden in hospital staff.
World Health Organization Global tuberculosis report 2015 Switzerland: World Health Organization
World Health Organization. Global tuberculosis report 2015. Geneva, Switzerland: World Health Organization; 2015. http://www.who.int/tb/ publications/global_report/en