Protecting those who care for others

A higher occurrence of tuberculosis (TB) among health care workers (HCWs) in South Africa and elsewhere has been described previously. A record linkage study published earlier this year reported a TB incidence rate of almost 1500 per 100 000 population among South African HCWs, approximately twice the rate in the general population.¹ An even greater relative risk for HCWs was previously observed for multi-drug-resistant and extensively drug-resistant TB, with the associated increased costs and sub-optimal treatment outcomes.² In light of the increased TB risk faced by HCWs, calls have been made for improved infection control measures in hospital settings. These measures include administrative controls, environmental controls and personal protective equipment (PPE). Specifically, the importance of continual training of health care workers in TB and human immunodeficiency virus prevention, treatment, care and support has been highlighted.³

In this issue of Public Health Action, Malotle and colleagues report on several aspects related to TB infection prevention and control practices in a South African provincial tertiary care hospital.⁴ First and foremost, the authors report extensive exposure to TB patients among HCWs, including some regular exposure in 50% of support workers. Among other findings of concern, almost two thirds of responding HCWs were unaware of the hospital's tuberculosis management protocol. Importantly, of those HCWs who reported contact with tuberculosis patients, fewer than half had received any training related to TB infection prevention and control. Even fewer—one in five—had received instruction in the use of PPE. Importantly, Malotle and colleagues report that HCWs who received TB-specific training were much more likely to use PPE than those who received no such training. In contrast, generic, employment-initiation training was only weakly associated with use of PPE. Finally, the authors report a failure to utilize PPE related to lack of equipment availability.

The importance of adequate and appropriate training is clear. Moreover, the results related to generic infection control orientation at the time of initiating employment reinforces the need for ongoing, TB-specific education. This training must also be geared to the specific HCW category. The exposures faced by hospital support workers in this study remind us that our obligations to protect HCWs in hospital settings go beyond clinical personnel to support workers—porters, cleaning staff and security personnel—those arguably most vulnerable due to limited knowledge and job insecurity. Finally, at the risk of stating the obvious, if the recommended equipment is not easily available and accessible, no amount of training or knowledge will lead to the desired outcome, as it relates to PPE.

Although much is known about measures to protect HCWs from TB in hospital settings, a gap remains in the translation of this knowledge into routine practice. This knowledge-practice gap in TB infection prevention and control must be urgently addressed to protect those who care for others.