Practical and affordable measures for the protection of health care workers from tuberculosis in low-income countries

Abstract

With the global upsurge in tuberculosis (TB), fueled by the human immunodeficiency virus (HIV) pandemic, and the increase in multidrug-resistant TB, the condition has become a serious occupational hazard for health care workers worldwide. Much of the current understanding about nosocomial TB transmission stems from the USA; however, little is known about the risk of such transmission in low-income countries. The focus of this review is on sub-Saharan Africa, since this is the region with the highest TB incidence, the highest HIV incidence, the worst epidemic of HIV-related TB, and where the risk to health care workers is probably greatest. Measures used in industralized countries to control nosocomial TB transmission (ventilation systems, isolation rooms, personal protective equipment) are beyond the resources of low-income countries. Protecting health care workers in these settings involves practical measures relating to diagnosis and treatment of infectious cases; appropriate environmental control; and relevant personal protection and surveillance of health care workers. Research needs to be carried out to examine the feasibility and cost-effectiveness of measures such as voluntary HIV-testing of health care workers (to enable known HIV-positive health care workers to avoid high-risk settings) and isoniazid preventive therapy for workers in high-risk settings. More resources are also needed to ensure full implementation of currently recommended measures to decrease the risk of nosocomial and laboratory-acquired TB.

PIP: This review considers the occupational hazard to health care workers posed by the global increase in tuberculosis (TB), especially in multidrug-resistant TB. The review opens by focusing on the following aspects of TB in industrialized countries: the risk of TB among health care workers, reasons for the increase in nosocomial TB, which health care workers are most at risk, and effective interventions to reduce nosocomial TB transmission. Next, the review turns to developing countries, using Africa South of the Sahara as an example and considering the impact of AIDS and TB and the risk of nosocomial transmission to health workers. The review then notes that the measures used to control nosocomial TB in developed countries are not generally affordable in developing countries and discusses the following 1993 guidelines offered by the World Health Organization to address this problem as well as practical measures introduced in some African hospitals that 1) improve the diagnosis and treatment of TB patients, 2) involve appropriate environmental control, and 3) institutionalize the means of personally protecting health care workers. It is concluded that operations research is needed to test and evaluate inexpensive, sustainable, and cost-effective control measures in low-resource settings and that health care workers are a vital resource and must be protected against this occupational risk.