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Healthcare workers in South Africa are at a significantly increased risk of developing drug-resistant tuberculosis, or XDR-TB, in a trend which threatens to further exacerbate the already beleaguered healthcare systems in sub-Saharan countries, according to results of a new study.

Researchers say the results underscore the urgent need for stringent TB screening policies among healthcare workers in these areas.

Keertan Dheda (M.D., Ph.D., Associate Professor of Medicine at the University of Cape Town), and collaborators, Julie Jarand (M.D. from University of Calgary) and Max O'Donnell (M.D. from the Boston University), will present their findings at the 105th American Thoracic Society International Conference in San Diego.

XDR-TB is a potentially untreatable strain of tuberculosis that is resistant to all major primary and secondary anti-tuberculosis drugs. This retrospective study is the first to focus on healthcare workers who have contracted XDR-TB in a non-outbreak setting, said Dheda.

How the study was done
"The purpose of this study was to describe a series of healthcare workers in SA with extensively drug-resistant tuberculosis and to determine whether XDR-TB was prevalent among them," Dheda noted.

The study was based on a chart review of 270 patients in South Africa with passively detected XDR-TB, including 11 healthcare workers.

Of those 11, eight were working in district hospitals, 10 had been treated for TB at least once previously, and eight were negative for HIV.

At the time these workers were diagnosed with XDR-TB, there were no standard infection control measures in place at the facilities where they were employed. In separate presentations O'Donnell and Dheda will present their findings from Kwa-Zulu Natal and four treatment centres in SA, respectively.

XDR-TB threatening global TB control
Dheda noted that although tuberculosis is a well-recognised occupational risk for healthcare workers in both low- and high-income countries, the prevalence and natural history of XDR-TB in these workers is unknown.

"The emergence and progression of XDR-TB is threatening to destabilise global tuberculosis control," he said. "The negative impact of XDR-TB is further exacerbated by a global shortage of healthcare workers, a shortage which has reached crisis levels in most of sub-Saharan Africa."

"XDR-TB is an important risk for healthcare workers globally, particularly for those who work or travel to high-burden areas, regardless of HIV status," Dheda added.

"Implementation of infection control measures and rapid diagnostic testing for all healthcare workers suspected of TB needs to be undertaken urgently to minimise the risk of drug-resistant TB." – (EurekAlert, May 2009)

The strike by public sector doctors over remuneration and working conditions had spread to two other hospitals, the Democratic Alliance said.

Spokesman Jack Bloom said Tembisa and Jubilee hospitals were also affected by a doctors' strike with problems at the Tembisa outpatients department reported.

"The situation is most dire at George Mukhari (hospital), where virtually all departments are closed and patients are being diverted to other hospitals," Bloom said. "I worry that patients are suffering because doctors' justifiable grievances have not been attended to.

"Whilst I sympathise with the doctors, they must give the current negotiations a chance to produce results as patients are the first priority," Bloom said.

Unclear if strike affecting hospitals
Department of health spokesman Fidel Hadebe said a meeting was scheduled for 3pm on Tuesday at the national department of health offices in Pretoria to discuss the strike and address doctors' grievances. He was unable to confirm whether the strike was affecting the Tembisa and Jubilee hospitals.

The two hospitals were unable to confirm whether doctors were striking because media liaison officers were not immediately available.

The SA Medical Association (Sama), which acts as a trade union for some public sector doctors, was also unavailable to confirm whether the strike had spread to the two hospitals.

Sama said on Monday it did not organise or sanction the strike, but understood the doctors' frustrations. "The strike is by a number of frustrated individuals who are saying they have had enough," said spokeswoman Phophi Ramathuba.

"They should have seen the OSD (Occupational Specific Dispensation) implemented last July but they haven't even begun negotiations," she said.

The OSD was an additional payment designed to make up for public sector doctors' poor pay and difficult working conditions, but was not implemented by last year's July deadline. – (Sapa, April 2009)

What is post-exposure prophylaxis?
Post-exposure prophylaxis or PEP is taking action to prevent an infection, after a person has already been exposed to that infection. In the case of exposure to HIV, PEP involves a course of treatment with antiretroviral drugs.

HIV PEP is usually used when there has been accidental or involuntary exposure to HIV in a medical worker, such as a needlestick injury or blood splash in the eye. Non-medical people may similarly be exposed to HIV at accident sites or in work-related injuries.

HIV PEP is also used when a person has had an involuntary sexual exposure to HIV such as through rape. Sometimes PEP is requested when a person has had other kinds of risky sexual exposure, such as unprotected intercourse with a sex worker or a “one-night-stand”.

HIV exposure in the work place (occupational exposure)
Medical workers can accidentally injure themselves with a needle that has been used to take a blood sample from an HIV infected person or to give an HIV infected person an injection or drip. This is called a "needlestick injury".

Injuries with this kind of “hollow bore” needle are the highest risk category for HIV exposure because there is potentially more blood transfer than when an injury occurs with a solid sharp object such as a scalpel blade. Overall the chance of contracting HIV through a needlestick injury is about 1 in 300. A splash of blood to the eye or mouth, or blood contact with a cut or abrasion of the skin is in the lowest risk category.

Sometimes non-medical people put themselves at similar risk to medical personnel, for example assisting at an accident. If the HIV status of the source patient is positive or unknown, then PEP should be started as soon as possible.

HIV exposure through rape
There is no doubt that HIV infection occurs through sexual contact and through rape. It is not known exactly what the chances are of a man or woman contracting HIV when he or she is raped by an HIV infected person.

It is a reasonable assumption that the risk is greater than when a person engages in voluntary sex because of the trauma to the genitalia during rape. Forced sex frequently involves microscopic and even visible tearing of the vagina or anus, which gives the virus easier access to the tissues or bloodstream. If the HIV status of the rapist is positive or unknown, then PEP should be started as soon as possible.

Which antiretrovirals are used for HIV PEP?

For occupational exposure A healthcare worker will usually receive a combination of AZT (retrovir) 200mg eight- hourly or 300mg 12-hourly and 3TC (lamivudine) 100mg 12-hourly for 28 days after an HIV exposure. In some circumstances, a third drug such as indinavir is added to this treatment. A person who has had occupational exposure to HIV should be managed by experienced health personnel.

For HIV exposure through rape
A person who has been raped should receive a minimum of AZT (retrovir) 200mg eight- hourly or 300mg 12-hourly for 28 days as HIV PEP. At some centres, additional drugs such as 3TC (lamivudine) may be used. A person who has been raped should also receive antibiotics for PEP against other STDs such as syphilis and gonorrhoea. A person who has been raped should be treated by a health care professional who is experienced in the medical and medico-legal aspects of rape.

For more information on what to do if you are raped, go to http://www.speakout.org.za/

How soon after exposure must PEP be taken?
There is no definite answer to the question of how soon PEP needs to be taken in order to be effective. What is certain is that the sooner PEP is taken the better, “soon” being within two hours of an exposure. Most experts agree that PEP should still be given up to 72 hours after an exposure, but beyond this time it is probably not of benefit.

Where to get PEP
Medical and paramedical personnel who have occupational exposure are usually able to obtain PEP through the medical service where they work. All hospitals and clinics should have antiretroviral drugs available for this purpose. If this is not the case, a person who has had occupational exposure should be referred to the staff health facility at a large hospital.

A non-medical person who believes they may have been exposed to HIV through an accident or work-related injury should request treatment at the casualty department of a large hospital.

In South Africa, the Department of Health has recently agreed that HIV PEP should be given to people who have been raped. This means that all hospitals and clinics should have antiretroviral drugs available for this purpose. In practice this may not be the case, so a person who has been raped may need to seek help at a rape centre or at a large hospital in order to obtain PEP.

Antiretroviral drugs for PEP are available in private healthcare through some pharmacies. These drugs require a prescription from a doctor.

Does HIV PEP work?
The evidence that PEP works comes from one important analysis of hundreds of needlestick exposures and the relatively small numbers of HIV infections that occurred in health care workers through these exposures. Although it is difficult to analyse data that is collected by looking back at these incidents and gathering information about the circumstances, sometimes months or years after the event, the conclusion of the analysis was that PEP reduced the risk of HIV infection by 79%. Put another way, this means that a person who has a needlestick exposure and does not take PEP has a five times greater chance of contracting HIV than someone who does take PEP.

Other evidence that PEP works comes from studies in which PEP successfully reduced transmission of HIV to newborn babies delivered to HIV infected mothers. There are other situations where PEP has prevented very probable infection, such as when people have accidentally received blood transfusions with blood from an HIV infected person.

It is very difficult to obtain data on whether PEP is effective for HIV exposure through rape because it is not ethical to perform a “controlled study” about this question. All the evidence points to the fact that HIV PEP will be effective, so researchers cannot deprive some people of PEP while treating others in order to answer the question about how well PEP works after rape.

Written by Dr Jane Yeats MBChB, BSc(Med)(Hons)Biochem, FCPath (SA)Virol Specialist and lecturer, Department of Virology, University of Cape Town and Groote Schuur Hospital.

Tuberculosis infection is widespread among healthcare workers in South African hospitals, clinics and laboratories. This message was repeatedly brought home at the country's first ever TB Conference held in Durban earlier this month.

In South Africa TB has reached epidemic proportions – last year 337 641 people were reported to be living with the disease, and this figure is expected to rise to over 500 000 in 2008. According to the World Health Organization (WHO), South Africa is ranked as the country with the fourth highest TB burden in the world, and Statistics South Africa has calculated that TB is the leading cause of natural death in the country.

Caregivers at risk
Now evidence is emerging that TB - including the vicious drug-resistant strains – is not only rife among hundreds of thousands of poor South Africans, but is hitting the caregivers assigned to helping them.

Our minister of health, Dr Manto Tshabalala-Msimang rightfully admitted that "TB is a disease of poverty", with those living in crowded, low-income settings bearing the brunt of the country's TB epidemic. For this reason, most TB sufferers cannot afford private health care, and consequently flock to the country's over-burdened public healthcare facilities. In these low-resource settings, patients sometimes wait for hours on end to receive treatment, all the while exposing other patients and healthcare staff to the disease.

(TB is spread mainly through the air. When infectious people cough, sneeze, talk, laugh or spit, droplets containing the bacteria are sprayed into the air. Others inhale these bacteria and also become infected.)

Study results
A 2006 study by the Centre for Occupational and Environmental Health at the Nelson R Mandela School of Medicine in KwaZulu-Natal found the incidence of TB-infection among healthcare workers in eight public sector hospitals to be alarmingly high. Infection occurred in 1 133/100 000 population healthcare workers, compared to 998/100 000 population in the general public.

The study also showed that the risk of developing TB among healthcare workers is much higher among paramedical staff (including laboratory technicians, radiographers and physiotherapists) and nurses, who are the first point of contact and continuously with patients.

In addition, TB-infection was highest amongst healthcare workers between the ages of 25 and 29 years.

HIV-positive employees at health care facilities are at an even greater risk of acquiring TB, as a compromised immune system makes one vulnerable to active TB–infection.

High-risk settings
"There is growing evidence of [TB] infection in healthcare workers," said Mr Mark Heywood of the Aids Law Project at the recent TB Conference. "There are reports of high levels of MDR- and XDR-infection among nurses and doctors."

Although very little official data exists on what the actual incidence of TB-infection among healthcare workers is, studies have shown that healthcare workers in the developing world are at a greater risk of infection than the general population.

"Those at risk include not only healthcare providers, but also any staff [at these facilities]… including porters, cleaners, educators and councillors," reads the Department of Health's (DoH) National Infection Prevention and Control Policy.

Additional danger
There are obvious dangers associated with TB-infection among healthcare workers – the primary concern is for the health of the person.

A secondary concern is the fact that healthcare staff spend a lot of time around people who are already sick. And having a compromised immune systems makes one more susceptible to acquiring TB-infection when exposed to the germ.

The high incidence of HIV-infection in South Africa adds a dangerous element to this equation. The risk of developing active TB is increased tenfold by HIV, according to the WHO.

And, with hoards of HIV-positive patients flocking to public healthcare facilities for treatment, exposure to a TB-infected staff member could put each of these patients at an alarmingly high risk of becoming co-infected with both of these deadly diseases.

Infection control measures
The best way to manage TB-infection among healthcare workers is to develop and implement strict infection control measures at public healthcare facilities.

"A recent study showed that a relatively low number of South African health facilities pass international infection control norms and standards," the Treatment Action Campaign (TAC) stated in their Guidelines to the Prevention, Early Diagnosis, Treatment and Cure of Tuberculosis document.

The DoH has developed an infection control policy, but "the proper implementation of this policy needs to occur in all health facilities and must be monitored.

"This policy, which is based on the WHO's infection control policy, needs to be adapted to the South African specific context, and specific plans also need to be developed for congregated settings such as prisons, mines, schools and detention centres," said the TAC.

According to the National Infection Control Policy there are two main ways in which even settings with limited resources can reduce the chances that TB will spread, these include (i) work practice and administrative control measures, and (ii) environmental control measures.

Work practice and administrative control measures require that each healthcare facility have an infection prevention control plan where suspected TB patients are identified early (prolonged cough), separated from crowded areas, and taught respiratory etiquette (covering their nose and mouth when coughing, or wearing a face mask).

Another work practice that has shown to greatly reduce the risk of TB-infection is to train all staff on TB and the TB infection prevention and control plan.

The TAC agrees on this point: "Healthcare workers… should be educated on infection control policies, on the occupational risk of TB and how to protect themselves from exposure. In addition, all people who are working in these settings, including administrative staff, security guards and cleaning staff should be educated on infection control measures."

In the National Infection Control Policy the DoH states that "although many environmental control measures require resources not available in resource-limited settings, some can be implemented, and staff can be trained in their purpose, capabilities, proper operation, and maintenance."

Although ventilation, filtration and ultraviolet germicidal irradiation is mentioned as environmental control measures in the infection control policy, only in rare cases are mechanical environmental modifications in place to control infection, and most facilities have to rely on natural ventilation (opening windows and doors).

However, during a recent TB Clinical Forum at the Tygerberg Hospital in Cape Town, clinical staff pointed out the flaws in this method. They complained that during winter months, with temperatures dropping below 10 degrees Celsius, the clinics' windows and doors have to be closed in order to create a feasible work environment, and to protect already sick patients from the harsh elements. Thus ruling out natural ventilation as a measure to control TB infection.

The DoH admits that "the risk to staff will never be zero," and encourages staff to have themselves tested for TB at the first sign of possible infection.

- (Wilma Stassen, Health24, July 2008)