/ 30 March 2012

Medics suffer high exposure to TB

Medics Suffer High Exposure To Tb

Bart Willems was not a candidate for tuberculosis. He simply did not fit the ­profile. For a start, he was exceptionally fit. He cycled to work, surfed every day and swam competitively. He followed an extremely healthy lifestyle and considered his immune system to be strong. Willems did not smoke, hardly ever consumed alcohol and lived in a well-ventilated flat he shared with only one other person. Most significantly, he was a medical doctor with extensive knowledge of TB symptoms and danger signs.

But one day, while Willems was in his early 20s and completing his year of community service at Cecilia Makiwane and Frere Hospitals in the Eastern Cape, he suffered sudden chest pains. A senior doctor examined him, but said he “could not find anything wrong”.

However, after a radiologist took X-rays of his chest, Willems was told a lesion on his left lung could be the result of pneumonia or TB.

“I immediately thought: ‘This is impossible. I can’t have TB. From everything that I’ve learned in medical school and from people around me, I am not in danger of getting TB,'” he said.

Without having a definite TB diagnosis, Willems was treated with a week-long course of antibiotics for what he considered to be the more likely cause of the lung lesion: pneumonia. But then he began experiencing chest discomfort and breathing problems. When he went for a follow-up X-ray, 2.5 litres of fluid had accumulated in his left lung as a result of TB.

“It was a huge shock for me, my friends, my family and my colleagues. Here I was, a qualified, middle-class, otherwise healthy doctor — with tuberculosis,” he said.

His diagnosis caused “massive consternation” at Cecilia Makiwane Hospital. None of Willems’s colleagues thought they could contract TB, but here was one of their fittest peers proving that medical personnel were everything but immune to TB. He remembered: “Everyone rushed to go for TB sputum tests and some for X-rays. They all started thinking: ‘Maybe I’m not alright; maybe I have it too'”

Today, four years later, at least 15 doctors with whom Willems had studied have had TB. They developed symptoms during medical-school training or within the first two to three years of work.

More health workers are getting TB
The TB disease rate among health workers in South African public-health facilities is up to three times higher than that of the general population, a recent Stellenbosch University study has revealed.

“The general TB burden in South Africa is very high, so just by being a doctor or a nurse in a state facility where you would see TB patients or TB suspects on a regular basis already drastically increases your exposure and likelihood of developing the disease,” said Mareli Claassens, of the university’s Desmond Tutu TB Centre.

She said that almost eight out of 10 South African adults were infected with Mycobacterium tuberculosis (this means they have been exposed to TB, but are not necessarily sick), but only about 10 percent will develop the disease in their lifetime. The TB bacterium remains dormant in most infected people.

However, Claassens said, when an immune system is “suppressed”, especially by extreme conditions such as HIV infection but also by common factors such as mental stress or extreme fatigue, the TB germ sometimes “wakes up”, multiplies and begins attacking the body. Then it causes cavities in the body’s organs and if not treated, can be fatal.

“When I look back, I realise the long working hours, particularly at night, and stressful working environment with little supervision must have affected my immune system,” Willems reflected.

“Studying for an intensive exam that I wrote two days before my diagnosis also took its toll.”

In some respects, the young physician acknowledges he was fortunate. He developed “normal” TB.

“It could have been multidrug-resistant (MDR) or extremely drug-resistant (XDR) tuberculosis, forms of TB that are significantly more complex to treat because they are resistant to the drugs used to treat ‘normal’ TB. A bigger variety of pills and higher dosages are needed and you have to take the medication for considerably longer. My TB took six months to treat. MDR and XDR TB can take up to two years to cure and can lead to death,” he said.

TB more prevalent among young health wokers
A 2010 Kwazulu-Natal study published in the International Journal of Tuberculosis and Lung Disease found the TB infection risk to be highest among young health-care workers such as Willems as “they tend to spend greater time with patients and are less aware of exposure risks compared to senior colleagues”.

The study followed five young HIV-negative doctors, all doing internships, residencies or community service, who had MDR TB for nine years after their diagnosis.

It concluded that MDR TB had a devastating effect on these doctors and the healthcare system, and contributed to the “brain drain” in the public-health workforce.

All the doctors, bar one who was no longer able to work, opted to leave general medicine in the state sector because of TB. They mostly ended up working as specialists in the private sector in areas of medicine that did not expose them to TB.

Willems has also abandoned general medicine. He is now studying to be a specialist in public health. Such a position will reduce his exposure to TB, as he will no longer be working in hospitals, but will rather be formulating preventative health policies.

A recent study in the journal Tropical Medicine and International Health confirms TB’s contribution to the shortage of public-sector healthcare workers in South Africa. Researchers analysed information concerning 10 Eastern and Western Cape medical staff members, including nurses, a doctor and a radiographer who developed XDR TB between 1996 and 2008.

Cure rate is less than 50%
According to the World Health Organisation, the cure rate for XDR TB is only about 30%, as the disease is resistant to almost all TB drugs.

By the end of the study, four of the 10 health workers had died. The other six remained on treatment, but had missed lengthy periods of work as XDR TB requires months of hospital treatment and recovery periods are long.

“I was loyal to my work and stayed away for only a month,” Willems said. “But I would have been within my rights to take leave of absence for the entire six months of my treatment. My full salary would have had to be paid by the health department and the government would also have had to pay for a person to fill in for me. That is a huge strain on the health system, all because of TB.”

Willems admitted he had been “very concerned” about returning to work and even “angry” that “nothing” was being changed at the hospitals as a result of healthcare workers getting TB.

Patient waiting areas remained overcrowded and poorly ventilated. Access to face masks that could prevent medical staff from inhaling TB germ droplets was “limited”, Willems said.

In the International Journal of Tuberculosis and Lung Disease MDR study, doctors were also rarely provided with the masks, known as respirators or N95 masks. The equipment, it concluded, was mostly secured by hospital management and locked away after hours.

Claassens said the reality was that even when such masks were available to health workers, they were more often than not impractical in a South African context, especially in the warmer regions of the country.

She explained: “They fit very tightly over your nose and you can hardly speak through them. In South Africa, because of all our different languages and also the many foreign doctors, doctors usually use interpreters. If both the doctor and the interpreter are wearing respirators and the patient also wears a mask because he or she is a TB suspect, communication becomes extremely difficult. So people end up removing the masks.”

According to the MDR study, some of the doctors who were being treated for TB bought adequate masks privately on their return to work, but quickly realised they were the only healthcare workers wearing the respirators and consequently felt isolated from their co-workers and patients.

Not enough personal-protection measures
Researchers found that even when health workers were aware of the TB risks at their places of work, their implementation of personal-protection measures was shockingly low.

Claassens agreed: “There is a lot of apathy among healthcare workers. I don’t think they are scared enough of TB to actually wear masks. They have an attitude that it won’t happen to them. They also don’t raise their voices to say: ‘We don’t want to work in conditions where we get TB.'”

But Willems maintains that, in general, overburdened state hospital environments are simply “not conducive” to TB prevention and that health workers themselves, without support from management, are not able to change that.

“Overcrowded and badly ventilated patient waiting areas are common everywhere. This is a major factor in exposing healthcare workers and patients to TB and has not changed since my days as a young doctor. As long as such conditions continue, doctors and nurses will keep getting TB. Our entire TB awareness and prevention programme needs to be scaled up to come into balance with the severe health burden TB is causing in South Africa.”

Mia Malan works for the Discovery Health Journalism Centre at Rhodes University
Occupational hazard for nurses
Sharon Mbaba says she will “never forget” a weekday morning in 2009 at a clinic on the outskirts of Cape Town.

“I had to wear a mask when waiting in line for a TB test. My name was written loud and clear on the TB noticeboard,” she recalls.

“It felt like everyone was staring at me. Everyone knew who the TB patients were because we all had to wait in one corner. People looked afraid of us.”

Mbaba felt “out of place” in more ways than one. At the time, she was a research nurse recruiting participants for TB trials at Stellenbosch University’s Desmond Tutu TB Centre.

But on that day in 2009 she was “literally on the other side of the fence”.

Mbaba suspected she had TB.

“I felt so uncomfortable. For the first time, I realised how stigmatised people with TB must feel.”

Those testing for TB were also offered an HIV test. HIV infection makes people more vulnerable to TB as the virus weakens the immune system. Research shows that up to six out of 10 people with TB also have HIV.

“I obviously knew about the TB-HIV association, but I still thought: ‘Oh, my word, now an HIV test as well?’ And I already felt so marginalised,” Mbaba says.

A few weeks before, Mbaba had begun to feel extremely tired. She had started losing weight and said she had endured “night sweats around the chest area”.

After excluding several other illnesses, she tested for TB. After 43 “long” days, she received the results: she had tested positive.

Mbaba says she was “petrified, angry and frustrated”.

Pondering the reasons for her contracting TB, the nurse remembered how she had seen “streams” of TB patients in a tiny office and how she had been forced to move there when her bigger office was flooded.

“There were four staff members in that little room. In the winter, it was very cold. Because of that, we would switch on heaters and close all the windows. I realised that was the mostly likely place where I was infected. The ventilation was bad, yet my exposure to TB was high. That is a bad mix.”

She was “angry” with her employer for letting her work in a “dangerous” environment.

“If they had given me a bigger space to work, I think I would not have got TB,” she says.

In a recent study, the Desmond Tutu TB Centre found a high TB rate among community-based health researchers, almost two and a half times higher than among the residents in the communities in which they worked. One out of five of the female researchers in the study developed TB.

“It was a huge concern for us, because we obviously did not want our researchers to develop TB,” says study leader Mareli Claassens.

Because of the study results, the centre developed occupational-health guidelines to curb TB­disease rates.

“We trained researchers on their risk of developing TB and on the importance of good air flow when dealing with TB suspects and patients. Windows at site offices are now labelled with stickers reading ‘Stop TB — open the windows’,” Claassens says.

Staff members are also given protective masks and an occupational nurse regularly monitors researchers for TB symptoms and tests them if necessary.

“The measures have had a significant impact and our rate of new TB cases has consequently decreased from 11 cases out of 250 researchers to only three people over the past year,” Claassens says.

Mbaba’s work environment has changed.

“The windows are now always open, no matter how cold it is. I would rather freeze than get TB again,” she says.

She also no longer sees TB patients in groups, but calls them in one by one. And her employer has provided her with “special cleaning kits” to disinfect her hands after she has examined patients.

“I wear protective masks more often now, even if it is uncomfortable,” says Mbaba. “And I emphasise to my patients the importance of taking your medication every day until the end of the course. It is the only way to be cured.

“Before I got TB, this was just a job to me. Now, what I do is much more than earning money. I realise that I am on the frontline of the war against TB in this country.” — Mia Malan