Promoting health equity by addressing the needs of health workers
A collaborative, international research program

In resource-limited settings, healthcare workers are at increased risk of contracting tuberculosis (TB). The bacteria that cause TB float in the air for long periods of time, so healthcare workers are supposed to wear protective facial equipment (respirators) when they care for a patient suspected of having TB. The South African-Canadian team led by Drs. Annalee Yassi, Elizabeth Bryce, Muzimkhuhu Zungu and colleagues based at the National Institute of Occupational Health (NIOH), University of Free State, University of Cape Town and health department, have been conducting research into the magnitude of the problem and ways to address it.

One project, for example, was carried out in a clinic for new and existing medical outpatients of a regional public hospital in South Africa that treats an average of 170 patients a day. Throughout the study, which was led by Tanusha Singh and NIOH colleagues  in the summer of 2013, participating staff (medical doctors, nurses, and phlebotomists) were requested to maintain a diary during their regular working hours at the clinic to document both their perceived risk of TB exposure and their compliance with the use of personal protective equipment. Air samples, which were collected from personal air samplers and from several areas of the clinic (both patient and administrative) over a 4-day period, were subsequently sent for polymerase chain reaction (PCR) analysis.

There were 49 air samples taken in total, and the bacteria were detected in 11 of them (22.4%). Five of the personal samplers from 10 physicians (50%) and three of those from the 13 nurses (23%) were positive. Most of the healthcare workers (87.5%) with the positive air sample results were not wearing a respirator while in contact with coughing patients.

The air sampling demonstrated the risk of TB exposure. The study also highlighted the importance of engineering controls, particularly in terms of assessing ventilation and airflow in clinic settings, as well as establishing a clear understanding of the areas in the facility where there could be admixing of air (i.e., where contaminated air could travel to otherwise uncontaminated areas) so that appropriate measures could be taken. Overall, the findings provide an impetus for strengthening infection prevention and control measures for TB among healthcare workers and patients alike. A program has now been launched in this hospital to decrease the risk of TB. Lessons learned from the design, implementation and evaluation of the program will no doubt be scaled up across the country.

Meanwhile, a randomized controlled trial conducted by an overlapping sub-team funded by this programmatic grant in 28 hospitals in the Free State Province also highlighted the importance of having user-friendly data systems in order to strengthen the provision and monitoring of HIV and TB prevention and treatment. In addition, the project highlighted the importance of healthcare systems providing confidential, no cost, no wait time screening for TB for staff. New insights into the value of North-South-South partnerships to address such issues were also contributed. The team is now further testing innovative approaches to preventing TB transmission in healthcare, extending to Zimbabwe and Mozambique in addition to elsewhere in South Africa.