Three studies conducted in South Africa provide useful information about the presence of screening of HCWs and infection control for tuberculosis in health care facilities. All of these studies were cross-sectional and were thus not evaluated for risk of bias. These cross-sectional studies were identified through the literature search identified in the aforementioned PRISMA table and were excluded in the systematic review because of study design25,29.
First, the study by Tudor et al. signifies the need for improved infection control in hospitals that manage patients with TB25. This study was conducted in three district general hospitals with specialized multidrug resistant TB (MDR-TB) wards in KwaZulu-Natal, South Africa25. Kwazulu-Natal is the second largest populous province in South Africa and 21.4 percent or 10.8 million of the nation’s people resided in this province in 201031. Researchers determined the hospitals with the help for the provincial department of health and interviewed an occupational health (OH) and infection control (IC) nurse from each hospital as well as a
structured questionnaire They also reviewed the charts of OH employee medical records from Jan 2006-Dec 201025.
The results of the study indicate that screening and infection control practices in the district hospitals was inadequate on many levels. Screening HCW for active TB was a particular concern. Screening was described as monitoring weight, symptoms, and chest X-ray. Although the nurses from all three hospitals reported compliance with annual screening for TB in HCWs, active screening for TB was inadequate, only 19 percent of HCWs in these three hospitals were screened in 201025. A majority of the cases of active TB were only discovered when
symptomatic HCWs sought care. Increasing proportion of HCWs who receive regular TB symptom screening may improve case findings in this population.
Other infection control measures that were lacking included the availability of personal protective equipment. Although all of the hospitals had written infection control guidelines and a standing active infection control committee only two of the three nurses interviewed reported that they perform regular infection control risk assessments in the hospital. All three of the hospitals reported lack of access and problems with quality of personal protective equipment for tuberculosis.
This study is descriptive of the three hospitals in the study but may provide a basis for determining TB infection control implementation in other South African hospitals. Selection bias is a limitation in this study given only two nurses from each hospital were interviewed and this study may not be generalizable to other areas in South Africa. However, this study highlights that lack of implementation of screening for active tuberculosis in HCWs as well as the limitations in infection control operationalization in South Africa that both contribute to the epidemic of tuberculosis.
The second cross-sectional study was conducted with HCWs and medical students in Johannesburg, South Africa and provides key information about the TB knowledge and risk perceptions of the participants28. The authors collected socio-demographic information and had the HCWs answer a questionnaire to determine LTBI knowledge, risk perception of active TB, and willingness to participate in routine LTBI screening. The researchers also performed HIV testing and tuberculosis screening using IGRA as well as TST tests on the participant.
The study found elevated baseline prevalence of HIV and LTBI reported among the HCWs. None of the medical students and 18.3% of the HCWs was HIV positive 28. Overall 44.7% of HCWs and medical students combined had a positive TST compared with 47.7% positive IGRA28. Interestingly, there was a statistical association between a high LTBI
was not statistically significant when adjusted for age, job category and knowledge score28. This study highlights that increasing training of HCWs about the LTBI and TB can help to prevent their risk for infection.
Many HCWs in South Africa are exposed to TB outside of the health care facility and the HCWs and medical students perceive a significant risk of developing TB. Up to 50% of HCWs in the study reported a non-occupational tuberculosis contact28. About 50% of HCWs and 16% of medical students perceived a high risk of developing TB however a disconnection between risk perception and taking measures to protect themselves from infection was apparent28. Despite this heightened risk perception most HCWs (76.6%) denied protective measures to prevent from acquiring TB28. This finding highlights the need for additional research into how to encourage HCWs to take protective measures. A great majority, 90% and greater, of the study participants reported willingness to participate in a LTBI screening program with TST or IGRA providing evidence that HCWs would be receptive of screening programs.
The lack of personal protection and infection control measures taken by HCWs despite perceived risk may be a result of the lack of infection control program in the health care
facilities. A cross-sectional study by Engelbrecht et al funded by CDC South Africa to assessed the presence of infection control program of clinics in three districts (Alfred Nzo, OR Tambo, and John Taolo Gaetsew) in South Africa29. One hundred and twenty seven clinics were included in the study and the researchers examined several elements of the South African TB program including: TB and infection control training facility-level managerial controls, administrative control, and personal risk-reduction29. These elements of tuberculosis control were assessed through interviews with nurses and through the use of observational tools. This study highlights many deficits in these IC measures. First, most nurses and staff were not trained in infection control. Second, managerial controls were lacking and none of the facilities had an infection
For administrative level controls, most clinics did not have signs and symptom screening tools for TB and only half of the facilities separated coughing patients from others; and few provided these patients with masks. Environmental and personal protective controls were also not up to par. Only 20 percent of the clinics had open window registers and there was a shortage of N95 masks as well as knowledge of the correct usage in most facilities29.
Encouraging findings from the study are that most nurses reported that coughing patients were screened for TB and patients that had a history of cough for >2 weeks were immediately
referred for a sputum test29. Early diagnosis and isolation is essential to control the spread of TB in health care facilities. Most of the health facilities also had TB screening program for staff were available and the national guidelines on infection control were available at most clinics29.