Tuberculosis and Healthcare Workers in Underresourced Settings

In October 2015, the World Health Organization (WHO) reported that tuberculosis now ranks alongside human immunodeficiency virus (HIV) as the leading cause of death worldwide, with >1.5 million deaths and 9.6 million new active cases in 2014. The majority of these tuberculosis cases occur in the 22 high-burden countries, where the healthcare systems are often fragile and underresourced. It comes as no surprise that healthcare workers (HCWs) are disproportionately affected by contagious conditions such as Ebola virus disease, influenza virus, and tuberculosis. The emergence of multidrug-resistant (MDR) tuberculosis, which now accounts for 3.3% of new tuberculosis cases and 20% of repeat tuberculosis cases, and extremely drug-resistant tuberculosis, which accounts for 10% of MDR tuberculosis, also increases the risk to HCWs, especially in areas of high HIV seroprevalence. In this supplement, many of the risks, issues, and possible solutions to the ongoing problem of transmission of tuberculosis to the healthcare workforce are addressed. Verkuijl et al [1] discuss the main pillars of the approach to tuberculosis infection control: managerial and administrative, environmental, and utilization of personal protective equipment (PPE). They present data that in underresourced settings, the initial step of a managerial plan, including policy setting, facility assessment, and annual planning, is only rarely implemented [2]. Likewise, administrative work practices such as triage, redeployment of HIV-infected staff to lower-risk settings, and practice guidelines for diagnoses, are equally rarely followed [3]. In surveys in sub-Saharan Africa, environmental controls that extend beyond using open ventilation, such as the implementation of ultraviolet germicidal irradiation, are generally not even acknowledged or known, much less practiced. Verkuijl et al further contend that there is an overemphasis on the role of PPE, despite the fact that it is intermittently used, not appropriately fit-tested, and frequently too expensive to be readily available. Encouragingly, they describe a test case program in Eastern Cape Province, South Africa, where all the pillars are implemented with little monetary infusion, but to a greater extent due to the will of management and staff. Van Cutsem et al [4] point out the inadequacy of the worldwide DOTS (directly observed treatment, short-course) program to address the issue of MDR tuberculosis, with <20% of the 450 000 annual cases receiving treatment [5].They highlight the fallacy that in high-burden countries, tuberculosis is contained and only occurs in tuberculosis clinics and wards. They point out studies in which HCWs in other areas are as vulnerable to tuberculosis risk as those who are confined to work in tuberculosis areas [6, 7]. The potential broadened use of a specific tool for infection control, the FAST approach (Find cases Actively, Separate safely, and Treat effectively) is emphasized, although difficult when <10% of the Mycobacterium tuberculosis isolates from hospitalized patients undergo drug sensitivity testing. The rapid rise in MDR tuberculosis [8], and the fact that MDR and XDR tuberculosis are rarely identified and thus appropriately treated, only compound the problem. One solution is decentralized care with universal precautions, rather than targeted ones, in high-incidence settings. They point out that the cost of MDR tuberculosis, at US$8300 per case in South Africa, or single case of XDR tuberculosis, which in the United States approaches US$500 000 per person [9], and which is massively impacting multiple countries’ healthcare budgets, justifies the cost of implementing such measures. As with the findings of other authors in this series, an overemphasis on PPE has led to complacency in addressing the issue more systematically. One issue with many of the needed policies and procedures is the stigma associated with either tuberculosis, HIV, or both in the healthcare setting. Most everyone may agree on the need to address the issue, but woefully little work has been done to develop appropriate tools to measure stigma in order to study the impact of any given intervention. Wouters and colleagues begin to address this gap by examining stigma in the hospital setting that is both internalized and externalized [10]. The 7 quantitative Correspondence: T. G. Evans, Aeras, 1405 Research Blvd, Rockville, MD 02421 (tevans@ aeras.org). Clinical Infectious Diseases 2016;62(S3):S229–30 © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com. DOI: 10.1093/cid/ciw015