Guideline: Management of Drug-Resistant Tuberculosis » Health Care Workers and DR-TB
 

17. HEALTH CARE WORKERS AND DR-TB

 

17.1. Introduction

 

TB is an occupational disease and HCWs have the legal right for a safe working environment where adequate protection is provided against infection. The onus rests on the employer to provide a safe working environment or alternative employment for HCWs with HIV infection, or other medical conditions leading to compromise immunity, which are therefore at greater risk.

Section 14 of the Occupational Health and Safety Act outlines the general duties of employees, including:

  • The employees must take reasonable care when carrying out work and to co-operate with the employer in creating a safe and health-working environment.
  • The employees must comply with the procedures of the organisation in the interests of safety and health.
  • The employees must report unsafe conditions and incidents or injuries to own self or other employer in the same shift.
  • The employees may not interfere or misuse any equipment that may be provided by the employer to reduce a risk.

Section 8 of the OHSA outlines the general duties of employers, these include:

  • Providing and maintaining a safe and healthy working environment with equipment that is not hazardous to the employees or any other person.
  • Removing hazards where possible.
  • Reduce risk where possible.
  • Control the risks at a tolerable level when the risk is inherent to the business.
  • Monitor the controls to ensure efficacy.
  • Medical surveillance is recommended where certain hazardous exposures occur, notably noise above 85 decibels (dB), chemical and biological agent exposure.
  • Informing employees of the nature and severity of the risks to which they are exposed and the necessary safe working procedures, which include the use of, appropriate personal protective equipment (PPE).
  • Training of employees in safe working procedures and the correct use of PPE.
  • Enforcing compliance with the OHSA.

 

Hazardous Biological Agents Regulations

These regulations were passed in December 2001 and they legally entrench infection control. A hazardous biological agent (HBA) is defined as any micro-organism, cell culture, and human endo-parasite, genetically modified which may cause infection, allergy, toxicity, or create hazard to human health. These are classified into four groups as shown in the following table.

 
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The employer has a duty to classify any HBA not listed in the schedules in the most appropriate grouping.

Section 4 deals with dissemination of information and training and this ranges from understanding the risk of infection to personal protection and engineering controls, the necessity for personal air sampling, medical surveillance, good housekeeping, personal hygiene and safe working procedures.

Section 5 deals with the duties of persons exposed to a HBA focusing mainly on the prevention of uncontrolled release of an agent (in this case M. tuberculosis), adherence to instructions regarding environmental and health practices and the disposal of materials containing the agent (M. tuberculosis) including the decontamination and disinfection requirements.

Sections 6, 7, and 8 places the onus on the employer to ensure that risk assessments are conducted, exposure monitored on a regular basis and medical surveillance of the employees are provided. The medical records of employees and risk assessment must be safely kept for a period of 40 years (Section 9).

Sections 10 and 11 address the control measures for prevention of exposure and the use of personal protective equipment.

Section 15 deals with special measures for health facilities, to prevent spread of infection in instances where patients may present with unknown or undiagnosed infections by implementing regulated infection control measures.

Compensation for Occupational Injuries and Diseases Act, 130 of 1993

The Compensation for Occupational Injuries and Diseases Act provides for compensation of HCWs who contract DR-TB, where the employee has contracted the disease and that such a disease has arisen out of and in the course of his or her employment involving the handling of or exposure to patients with DR-TB. Employees are entitled to compensation if they are injured while working or contract any work-related disease. The types of compensation paid to workers for injuries or diseases are:

  • Medical aid
  • Temporary disablement
  • Permanent disablement
  • Fatalities

An employee or someone on his behalf has the responsibility to report a disease, in writing, to the employer as soon as possible after a doctor’s diagnosis. If they fail to do this within 12 months of diagnosis, he/she will lose any rights to benefits (Section 43).

Employers must complete and submit the Employer’s Report of an Occupational Disease (W.Cl.1) to the Compensation Commissioner within 7 days after an injury and within 14 days of being notified of the diagnosis of a disease. Subsequently, the following reports must be submitted:

  • First Medical Report for an Occupational Disease (W.Cl.22).
  • Claim for Compensation for an Occupational Disease (W.Cl.14).
  • Progress Medical Reports (W.Cl.22) until the worker’s illness is stable.
  • Final Medical Report of an Occupational Disease (W.Cl.26) once the worker is stable.

The Commissioner has the responsibility to acknowledge the receipt of the documentation, register the claims and make the decision to accept liability or not and employer and employee informed accordingly. The Commissioner may refuse to award the whole or a portion of compensation and may hold the employer responsible for medical costs in cases where wilful misconduct or neglect of either the HCW or the employer could be proven.

The COIDA, Schedule 3 lists TB as compensable only in the following work situations:

  • Crystalline silica (alpha quartz) as found in the mines.
  • M. tuberculosis or NTMs (Non-tuberculous, mycobacteria) transmitted to an employee during the performance of health care work from a patient suffering from active open tuberculosis.

 

17.2. Infection Prevention and Control

 

Nosocomial infections are mainly due to delayed diagnosis of TB and confirmation of DR-TB and delayed start of appropriate treatment, which contributes to prolonged infectiousness. Inadequate or delayed isolation of suspects and patients, poor ventilation, lack of respiratory protective equipment and inadequate sputum collection procedures can result in exposure of HCWs, other patients and visitors to infection.

Priorities of Infection Control (for in-patients and out-patients)

There are three levels of infection control measures:

  • Administrative (managerial): Aims to reduce health care worker and patient exposure.
  • Environmental: Aims to reduce the concentration of infectious particles.
  • Personal respiratory protection: Protects HCWs in areas where the concentration of infectious particles cannot be adequately reduced by administrative and environmental controls.

Administrative controls are the most important and together with environmental controls will reduce but not eliminate the risk. Therefore in some high risk areas personal respiratory protective equipment may be used by people entering the high risk areas.

 

17.2.1. Administrative Controls

The first and most important level of infection control is the use of administrative measures to prevent infectious particles from being generated, thereby reducing the exposure of HCWs to M. tuberculosis. Important administrative measures include:

  • Developing and implementing an effective infection control plan to ensure rapid identification, isolation, testing and treatment of DR-TB suspects and patients;
  • Implementing effective work practices;
  • Educating, training and counselling HCWs about TB; and
  • Screening HCWs for TB disease and infection.

17.2.2. Environmental Controls

Environmental controls are the second-line of defence for the prevention of nosocomial transmission of DR-TB. When employed in conjunction with administrative controls, environmental controls can be effectively used to reduce the concentration of infectious particles to which HCWs or patients are exposed. Environmental controls are therefore most important in areas where there may be exposure to highly concentrated infectious particles, such as wards containing XDR-TB patients, wards containing large numbers of infectious MDR-TB patients, sputum induction areas, bronchoscopy suites, laboratories performing culture and susceptibility testing, and autopsy rooms.

The best way of reducing high concentrations of infectious particles in the work environment is through the following principles:

Ventilation

Adequate ventilation may be achieved by:

  • Open windows that maximise natural ventilation and dilute the air (the simplest and least expensive technique).
  • Overhead fans, which may be used to further enhance natural ventilation in settings where windows can remain open.
  • Exhaust fans which control the direction of air flow to prevent contamination in the areas adjacent to the infectious source and open windows and overhead fans are insufficient.
  • Exhaust ventilation systems that provide at least six air changes per hour and prevent contaminated air from escaping into ‘clean’ parts of the facility. The most common way, in which such ventilation can be established is through the use of negative pressure ventilation, in which a room is kept at negative pressure relative to the surrounding area and air is drawn into the room from the corridor and exhausted directly outside.

Air Sanitisation

Air sanitisation is through air filtration or ultraviolet germicidal irradiation (UVGI). Use of UVGI to kill infectious organisms or air filtration methods to remove infectious particles may be an option in some facilities where additional measures need to be implemented to further minimise risk. However, there is little evidence if any to prove the effectiveness of these methods.

Laboratory studies show that M. tuberculosis is killed if the organisms are sufficiently exposed to UV light. For UVGI to be effective, contaminated air must come into contact with the light rays, which may be a major problem in areas where air circulation is poor, and its effectiveness may be limited in areas where the humidity is high or in dusty areas. A final major limitation to the use of UVGI is the inability to assess its effectiveness in the field, especially given the various types of available products, positions in rooms, and variability of room air mixing in various settings.

If UVGI is installed, a regular program of maintenance is essential.  Responsibility should be assigned to ensure that the lamps are dusted periodically and changed at regular intervals. Also, it is important to periodically assess airflow to ensure that airflow patterns maximise the killing of the mycobacteria by UVGI. The quality of UVGI lamps is very important. Usually a good lamp will last 5 000 to 10 000 hours (7 - 14 months), after that, the irradiance drops off rapidly. Irradiance should be measured regularly with a radiometer.  In addition, care must be taken to minimise risk to HCWs and patients who, if inadequately protected, may get skin and eye irritation due to exposure to UV light if not properly installed.

17.2.3. Personal Respiratory Protection Equipment

Because neither administrative nor engineering controls can provide complete protection, the third-line of defence against nosocomial DR-TB transmission is the use of personal protection. This can prevent the wearer from spreading or acquiring the infection, depending on the type of equipment. The only types available for DR-TB are masks and respirators.

Surgical masks

Surgical masks are meant to prevent the spread of micro-organisms from the person wearing the mask to others by trapping large wet particles near the source, which in this case is the mouth. They do not provide adequate protection to the wearer from inhaling infectious droplet nuclei in the air. Masks usually have limited filtration capacity and are loosely fitted over the mouth and nose, allowing free entrance of aerosolised mycobacteria.

Although not the highest priority intervention, disposable masks can be used to reduce aerosols generated from potentially infectious DR-TB patients. They should therefore be considered for use by suspected and confirmed DR-TB patients.

Respirators

Respirators are a type of mask that covers the mouth and nose; they contain special filter material and are designed to fit tightly to the face to prevent leakage between the face and the edge of the mask. Respirators are designed to filter very small particles, including airborne mycobacterium. An industrial mask with a 1µm particle size and a filter efficiency of more than 95% is recommended. Disposable particulate respirators are the simplest and recommended devices to be used.

For a respirator to be effective there must be a tight seal between the mask and the wearer’s face.  If the respirator does not fit correctly, infectious particles will likely follow the path of least resistance and any leak between the face and the mask is a potential entry point for infectious droplet nuclei. Each individual should therefore be “fit tested” to ensure that an appropriate model is used for each worker and minimise the risk of leakages.

Disposable respirators are relatively costly, but may be re-used if well maintained (i.e., proper handling when wearing and removing them, good storage). They should be discarded when they become soiled, wet, or appear to lose their structural integrity, such that a tight seal can no longer be maintained between the edge of the mask and the face.  The main factors responsible for their deterioration are humidity, dirt, and crushing. The durability of these devices varies among designs and products, and the extent of use. There is often a trade-off between durability and cost. If respirators are to be re-used, they should be stored in an open, clean, dry location. Plastic bags should never be used since they retain humidity.

In all facilities training on the correct use of the respirators including putting them on and removing them, there must be procedures for:

  • Selecting respirators for use in the facility.
  • Storing and re-use of the respirators.
  • Evaluating the effectiveness of the use of respirators.
  • Fit testing to ensure correct fit of respirator.

 

17.3. Specific Measures for Prevention of Nosocomial Infection

 

Specific measures for preventing the spread of nosocomial infection:

 

Assign  infection  control  officers  who  will be  responsible for developing, implementing, monitoring and evaluating infection control plans.

Establish a multidisciplinary infection control committee comprising of an infection control officer, microbiologist, medical practitioner/physician, pharmacist, housekeeping supervisor/ manager food service manager, laundry service manager, maintenance manager and hospital manager.

Conduct risk assessments to evaluate the risk for transmission in each area and occupational group within the facility. These must be repeated annually to evaluate the effectiveness of the infection control interventions. Classification of risk for a facility, specific area, occupational group should be based on the profile of TB in the community, the number of infectious TB patients admitted or seen the area or ward, the estimated number of infectious TB patients an occupational category is exposed to, results of PPD test conversions among HCW and possible person-to-person transmission of M. tuberculosis.

  • Develop an infection control plan based on the risk assessment. This should include the development and implementation of policies or protocols for early identification, diagnosis and treatment of patients who may have infectious TB.
  • Provide prompt triage for and appropriate management of patients who may have infectious TB in the outpatient department. Ensure that staff:

      o Vigorously identify patients with active TB disease.

      o Conduct symptomatic screening of symptomatic patients.

      o Develop and use symptomatic screening tool.

      o Maintain a separate waiting area for TB suspects.

      o Provide tissues to cover the mouth when coughing and sneezing.

      o Use surgical masks to prevent spread of infectious particles when coughing or sneezing into the immediate surrounding areas.

  • Promptly initiate and maintain TB isolation for persons who may have infectious TB and admitted in the wards.

      o Include indications for isolation in policies for initiating isolation.

      o Designate a person to decide on initiation and termination of isolation.

      o Implement isolation practices in the facility.

      o Monitor isolation practices.

      o Manage patients who do not adhere to isolation practises.

      o Development and adhere to criteria for discontinuing isolation.

  • Effectively plan for discharge, which should include a confirmed outpatient appointment with the provider who will ensure continuum of care until the patient is cured, placement into case management (DOT) or outreach programmes, ensure systems to supply drugs.
  • Plan, install and evaluate ventilation and other engineering controls to reduce the risk of exposure to M. tuberculosis.
  • Plan, implement, maintain and evaluate a respiratory protection programme.
  • Educate and train HCWs about TB, effective methods for preventing transmission of infection and the benefits of medical surveillance programmes.
  • Develop and implement a programme for periodic counselling and screening for HCWs for latent infection and active disease.
  • Ensure that all HCWs know the importance of compliance to infection control interventions to minimise risk of exposure to infectious agents.
  • Offer alternative employment to HCWs who have a health condition that compromises cell mediated immunity when placed in high risk areas.
  • Ensure that information provided by HCWs regarding their HIV status is treated confidentially.
  • Ensure prompt evaluation of nosocomial transmission, including PPD test conversions or active TB in HCWs, epidemiological association of cases among workers, patients, contacts of patients or HCWs who have TB but were not promptly identified and isolated. The aim of epidemiological investigation is to:
  • Determine the likelihood that the transmission of and infection with MDR-TB have occurred in the facility.
  • Determine the extent to which M. tuberculosis has been transmitted.
  • Identify people who have been exposed and infected, enabling them to start treatment early.
  • Identify factors that could have contributed to the transmission and infection and to implement appropriate interventions
  • Evaluate the effectiveness of any interventions that are implemented and to ensure that exposure to and transmission of M. tuberculosis has been terminated.
  • Report all people confirmed with DR-TB and ensure adequate discharge follow up and the continuum of care.

 

17.4. Conducting Risk Assessment

 

The risk of infection with TB depends on the severity of disease in the source case and on prolonged, intensive exposure to this case. It follows, therefore, that all HCWs are not at equal risk of acquiring infection, and that for many cadres of HCWs the risk is almost equal to that of the general community. The following categories of risk may be summarised as follows:

 

 

Risk category

 

Definition

 

High risk

 

HCWs in prolonged close contact with infectious (smear-positive) MDR- TB cases (e.g., nursing staff and other medical staff in MDR-TB hospitals and wards).

 

HCWs involved in aerosol-producing procedures, e.g. pulmonary physicians, respiratory technicians and other medical staff performing bronchoscopy, sputum induction, tracheal intubation, aerosolised pentamidine therapy and autopsy procedures.

 

HCWs who are immuno-compromised and who are involved in regular

MDR tuberculosis patient management.

 

Medium risk

 

HCWs in primary health care centres who are involved in sputum collection procedures from tuberculosis suspects.

 

HCWs in prolonged close contact with retreatment tuberculosis patients, especially if such patients have a history of more than one previous treatment episodes and a record of poor adherence.

 

Low risk

 

HCWs in primary health care centres involved in management of tuberculosis patients on therapy.

 

Health care facility support staff, such as porters, cleaners and administrative staff.

 

HCWs in general hospitals and community health centres.

 

17.5. Infection Control Plans

 

The development of the infection control plan is based on the results of the risk assessment. The plan should be specific for each area and occupational group in the facility. A facility may have a combination of low, intermediate, and high-risk areas or occupational groups at the same time.

Irrespective of the level of risk, the following principles must apply:

  • Provide on-going education and training on the transmission and pathogenesis of TB, the consequences of DR-TB, the infection control measures implemented in the facilities and importance of compliance to these.
  • Stress a continuous awareness of risk situations and avoidance thereof.
  • Promote HIV testing due to the increased risk of acquiring tuberculosis among HIV- positive people.
  • Offer alternative employment to staff who are immuno-compromised.
  • Implement universal infection control procedures (including safe waste disposal) in all health care facilities.
  • Strictly adhere to cough hygiene.
  • Collect sputum in an open area or cough booths where available.
  • Ensure that in-patients who are coughing are in a single ward with good outside ventilation. The door must remain shut and the windows open as far as possible if the ward is not under negative pressure.

17.5.1. Cough Hygiene

The prevention of DR-TB focuses on both the infectious patient (and infected material) and on the HCW at risk of getting infected.

All patients should be instructed to cover their mouths and noses with a handkerchief, surgical mask or a tissue when coughing and other forms of forced expiration. After use, these materials should be disposed of in small plastic or paper refuse bags, which should be regularly changed and discarded into larger refuse bags for incineration. Alternatively, 5% concentrations of an iodine-containing solution or a hypochlorite solution containing 10 000 ppm active chlorine should be used for disinfection and disposal.

HCWs should wear particulate respirators which are impermeable to droplet nuclei when nursing patients or collecting sputum.

17.5.2. Sputum Collection

Collection of sputum specimens should take place in the open air on the sunny side of the ward. A special veranda should be built for this purpose in the case of bad weather. The correct procedure for sputum collection must be implemented and patients must be observed during the collection. The HCW should:

  • Stand directly behind the patient so as to minimise droplet infection exposure.
  • Ensure that the patient holds the container as close as possible to the mouth.
  • Ask the patient to close the container immediately after expectoration.
  • Ensure that all sputum jars are labelled prior to collection taking place to minimise handling of specimens.
  • Wear gloves when handling specimens.
  • Wash hands with appropriate disinfectant if hands have contacted sputum without gloves.
  • Ensure that the lids of sputum containers are properly closed to avoid spillage.
  • Follow correct procedures if breakage or spillage occurs: gloves should be worn, spillage covered with paper towel and wiped up and area cleaned with warm water and detergent, area then should be wiped with hypo-chlorite solution.
  • Ensure that all specimens are placed in a plastic bag.

The HCW should also follow these protective measures:

  • Wear disposable apron, gloves  and  particulate filter respirators during  cough inducing procedures.
  • Follow correct hand washing before and after each patient contact.
  • Wash all instruments in the ward to remove respiratory secretions before being sent to CSSD.
  • Ensure that all resuscitation equipment is in order and no mouth-to-mouth resuscitation is conducted.
  • Supply each patient with a disposable sputum mug with a lid and sputum mugs must be replaced three times per day.

17.5.3. Isolation Practices

Isolation wards for the following categories of patients must be available in the MDR-TB hospitals to prevent cross infection with different or new strains of M. tuberculosis:

  • New patients admitted into a ward must be isolated from those who have been on treatment for more than two weeks.
  • MDR-TB patients must be isolated from XDR-TB patients.
  • Children should be kept separate from adults.
  • Very sick patients should be admitted in a ward separate from stable patients.

In hospital settings, isolation may be stopped after a patient has three negative sputum smear microscopy results taken on three separate occasions, and shows maintained clinical improvement, including resolution of cough. If sputum smears in MDR- and XDR-TB patients remain consistently positive but repeated sputum cultures are negative, consideration can also be given to removing them from isolation if they have also shown clinical improvement. Positive smear and negative culture may be due to dead bacilli visualised during microscopy.

17.5.4. Medical Surveillance Programme

Medical surveillance programmes are in existence for all employees. The objectives of surveillance programmes are to:

  • Establish the baseline of TB infection status of the workers;
  • Identify those with latent TB infection and offer them preventive therapy to decrease their risk of developing active TB;
  • Identify workers with active TB disease and initiate TB treatment immediately;
  • Document conversion rates, those who are initially negative and then later become positive;
  • Investigate the possible source of infection for all converters;
  • Notify district and provincial health authorities; and
  • Monitor the effectiveness of the infection control program.

The elements of the medical surveillance programme include the following:

  • Pre-placement.
  • On-going surveillance.
  • Exit.
  • Post-employment.

Baseline Health Assessment of Employees

This includes medical history of the employee relating to past tuberculosis disease, BCG vaccination status, underlying medical conditions which may increase susceptibility of the employee to tuberculosis and previous contact with people/patients with confirmed tuberculosis.

Sputum microscopy and culture must be done for all symptomatic employees, including the following baseline tests:

  • Chest X-ray
  • Mantoux tuberculin skin test (TST)
  • Lung function tests
  • Glucose blood and urine levels
  • Hepatitis B

Provider-Initiated Counselling and Testing (PICT)

HCWs should be counselled about the risks of working with DR-TB patients, the necessary precautions that must be taken, and the substantially increased risks if they are, or become, HIV positive. Voluntary HIV counselling and testing should be offered on the basis that alternative working environments will be sought for those who are HIV positive and who wish to minimise their risk of infection with DR-TB. Any disclosure of HIV status should be voluntary, made to a designated health care provider, and held in the strictest confidence.

On-going Surveillance

Table XXXIII shows the recommended frequency of on-going medical surveillance based on the facility, and activity risks

 
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HCWs should declare information on their health status in the form of answers to specific questions relating to the early signs and symptoms of tuberculosis. These include cough for longer than three weeks, weight loss (i.e., unexplained loss of 10% or more of body weight), anorexia, night sweats and the frequent occurrence of colds or other respiratory infection episodes in recent weeks. When these are present the individual must be investigated for TB.

The following tests should be conducted routinely:

  • Full size chest x-ray examinations must be conducted for evidence of recent tuberculosis disease. Individuals exhibiting changes on serial examination should be evaluated for tuberculosis, both clinically and microbiologically.
  • Tuberculin skin test to detect converters. Individuals with TST reactions of <10mm should be re-tested. Strongly positive reactors with skin test diameters of >15 mm and recent skin converters should be evaluated clinically and microbiologically.

Post-exposure Monitoring

If any HCW has been exposed to an infectious DR-TB patient for more than two hours or to aerosolised infected material (e.g. in autopsy rooms), their monitoring files should be consulted and their chest x-ray and TST records reviewed. The HCW should also be carefully monitored clinically. Eight weeks after the exposure episode, a chest x-ray examination should be performed, together with a TST in cases where the previous reaction diameter was <10 mm.

Record Keeping

Each worker should have a confidential disease-monitoring file in which screening procedures for tuberculosis, the minimum physical examination and tests to be conducted, as well as other health-related data, including records of results of tests conducted and updates of any changes in the health status of the worker are recorded.

Other essential information that should be recorded includes:

  • Name, job title, position, placement in facility, shift and hours worked.
  • Date of employment in the health facility.
  • Results of baseline assessment.
  • Results of regular ongoing assessment.
  • Record of reported TB exposure.
  • Results of post-exposure screening.
  • Management plans for treatment and follow-up of workers with confirmed disease
  • Management and follow-up of workers on preventive therapy.
  • Counselling provided to the HCW.

As a general rule, HCWs who contract DR-TB through work should not be dismissed on the basis of incapacity at the expiry of their paid sick leave. A fair procedure should be followed, including an investigation into the nature and extent of the incapacity, the effects of treatment, and alternatives to dismissal. This would usually result in extended sick leave being granted. The provision of extended sick leave to an employee, at least on an unpaid basis or at less than full pay, in order to undergo treatment for MDR-TB would be regarded as fair. Fairness can only be tested in the circumstances of each particular case, and factors such as disability insurance and ill-health retirement benefits as alternatives would be relevant.