Health care workers have a risky job when it comes to treating tuberculosis. They can become ill themselves and suffer stigma and job loss. In countries where resources are scarce, this is a strain on the health care system as it loses valuable staff and expertise. There are already difficulties recruiting and retaining health care workers in many countries, this issue just adds to that. How many health care workers (HCW) are infected with TB and what could be done to protect them and reduce stigma about the disease? Action is needed at all levels.
How bad is the problem?
I went to look on Global Health database to see, and the extent of infection has been the subject of a recent systematic review. The researchers measured latent TB in HCW . This is the first stage of TB where infection has occurred but the HCW isn’t ill and isn’t spreading disease. These cases should be treated before they become active.
The systematic review measured TB in HCW in seven ‘high burden countries” (1) and found the prevalence of latent TB was lowest in Brazil (37%) and highest in South Africa (64%). The pooled prevalence from all the countries was 26% in medical and nursing students while the prevalence among all types of health care workers was 57%. It partly reflects the high burdens of TB in these countries anyway. Global estimates suggest HCW have 3-4 times higher levels of infection (2, 3). The impact of a diagnosis on HCW can be huge, there is often denial that they are vulnerable (4).
What can be done to reduce TB in HCW?
There are the obvious things of making sure that there is protection for workers and that they know how to use it. Less obvious actions include reducing barriers to getting diagnosed and treated, including addressing stigma, i.e. being discriminated against, socially isolated, punished, because of your disease.
Dealing with stigma
TB patients suffer stigma, and it is often based on ignorance about how the illness spreads. This letter about stigma in India shows how bad stigma can be. It can wreck lives. There’s an ironic comment in this blog- TB is curable but what about the stigma? which brings home how difficult it can be for someone with TB. The myths about TB include that it is caught from sharing meals, cutlery, travelling in public transport, that treatment is dangerous.
From a disease control point of view, stigma prevents people being tested for TB and from coming forward for treatment when they have it. Both of which allow the disease to spread.
What surprised me was that HCW stigmatise each other as well as patients. Stigma can take many forms in the workplace it includes policies that identify people with TB and examples that are given are: mandatory testing; difficulties taking time off to go to clinics; discrimination when it comes to promotion; and job loss. Fear of stigma stops HCW using occupational clinics and makes them underreport exposures and can affect whether they complete the course of pills (which takes some months).
In a study designed to reduce stigma and get HCW to use occupational clinics more, researchers identified concerns among HCW about confidentiality, alongside concerns about getting time off to go to clinics, having to pay for treatment and treatment availability. HCW suggested more education about TB and support from higher levels in the organisation about stigma, would also help them. (5) The paper pointed out that intervention is needed at all levels.
In 2010 WHO and ILO recommended (7) that HCW and their representatives are included in developing policy and that health care workers and their families be prioritised for treatment so HCW are not lost from the workforce. These could help combat stigma too they say.
References sourced from Global Health database (links for CAB direct customers):
1/ Prevalence of latent tuberculosis among health care workers in high burden countries: a systematic review and meta-analysis.: Nasreen, S.; Shokoohi, M.; Malvankar-Mehta, M. S.. PLoS ONE 2016 Vol.11 No.10 pp.e0164034 ref.49 https://www.cabdirect.org/cabdirect/abstract/20173002134
2/ Protecting our front-liners: occupational tuberculosis prevention through infection control strategies. Verkuijl, S.; Middelkoop, K. Clinical Infectious Diseases 2016 Vol.62 No.Suppl. 3 pp.S231-S237 ref.36
3/ Tuberculosis among health care workers. Baussano, I.; Nunn, P.; Williams, B.; Pivetta, E.; Bugiani, M.; Scano, F. ,Emerging Infectious Diseases 2011 Vol.17 No.3 pp.488-494 ref.27
4/ Why healthcare workers are sick of TB. : Delft, A. von; Dramowski, A.; Khosa, C.; Kotze, K.; Lederer, P.; Mosidi, T.; Peters, J. A.; Smith, J.; Westhuizen, H. M. van der; Delft, D. von; Willems, B.; Bates, M.; Craig, G.; Maeurer, M.; Marais, B. J.; Mwaba, P.; Nunes, E. A.; Nyirenda, T.; Oliver, M.; Zumla, A. : International Journal of Infectious Diseases 2015 Vol.32 pp.147-151 ref.39
5/ Workplace interventions to reduce HIV and TB stigma among health care workers - where do we go from here? Author(s) : Siegel, J.; Yassi, A.; Rau, A.; Buxton, J. A.; Wouters, E.; Engelbrecht, M. C.; Uebel, K. E.; Nophale, L. E. Global Public Health 2015 Vol.10 No.8 pp.995-1007 ref.many
6/ Joint WHO/ILO policy guidelines on improving health worker access to prevention, treatment and care services for HIV and TB.WHO, 2010 pp.xii + 123 pp. ref.many .ISBN 9789241500692