Nosocomial transmission has been described in extensively drug-resistant tuberculosis (XDR-TB) and HIV co-infected patients in South Africa. However, little is known about the rates of drug-resistant tuberculosis among health care workers in countries with high tuberculosis and HIV burden.
To estimate rates of multidrug-resistant tuberculosis (MDR-TB) and XDR-TB hospitalizations among health care workers in KwaZulu-Natal, South Africa.
Retrospective study of patients with drug-resistant tuberculosis who were admitted from 2003 to 2008 for the initiation of drug-resistant tuberculosis therapy.
A public tuberculosis referral hospital in KwaZulu-Natal, South Africa.
231 health care workers and 4151 non–health care workers admitted for initiation of MDR-TB or XDR-TB treatment.
Hospital admission rates and hospital admission incidence rate ratios.
Estimated incidence of MDR-TB hospitalization was 64.8 per 100 000 health care workers versus 11.9 per 100 000 non–health care workers (incidence rate ratio, 5.46 [95% CI, 4.75 to 6.28]). Estimated incidence of XDR-TB hospitalizations was 7.2 per 100 000 health care workers versus 1.1 per 100 000 non–health care workers (incidence rate ratio, 6.69 [CI, 4.38 to 10.20]). A higher percentage of health care workers than non–health care workers with MDR-TB or XDR-TB were women (78% vs. 47%; P < 0.001), and health care workers were less likely to report previous tuberculosis treatment (41% vs. 92%; P < 0.001). HIV infection did not differ between health care workers and non–health care workers (55% vs. 57%); however, among HIV-infected patients, a higher percentage of health care workers were receiving antiretroviral medications (63% vs. 47%; P < 0.001).
The study had an observational retrospective design, is subject to referral bias, and had no information on type of health care work or duration of occupational exposure to tuberculosis.
Health care workers in this HIV-endemic area were substantially more likely to be hospitalized with either MDR-TB or XDR-TB than were non–health care workers. The increased risk may be explained by occupational exposure, underlining the urgent need for tuberculosis infection–control programs.
Primary Funding Source:
World Health Organization. Global Tuberculosis Control: Surveillance, Planning, Financing. Geneva: World Health Organization; 2008. Google Scholar
Menzies D, Joshi R, Pai M. Risk of tuberculosis infection and disease associated with work in health care settings. Int J Tuberc Lung Dis. 2007;11:593-605. [PMID: 17519089] MedlineGoogle Scholar
Naidoo S, Jinabhai CC. TB in health care workers in KwaZulu-Natal, South Africa. Int J Tuberc Lung Dis. 2006;10:676-82. [PMID: 16776456] MedlineGoogle Scholar
Joshi R, Reingold AL, Menzies D, Pai M. Tuberculosis among health-care workers in low- and middle-income countries: a systematic review. PLoS Med. 2006;3:494. [PMID: 17194191] CrossrefMedlineGoogle Scholar
Pearson ML, Jereb JA, Frieden TR, Crawford JT, Davis BJ, Dooley SW, et al. Nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis. A risk to patients and health care workers. Ann Intern Med. 1992;117:191-6. [PMID: 1352093] LinkGoogle Scholar
Dooley SW, Villarino ME, Lawrence M, Salinas L, Amil S, Rullan JV, et al. Nosocomial transmission of tuberculosis in a hospital unit for HIV-infected patients. JAMA. 1992;267:2632-4. [PMID: 1573751] CrossrefMedlineGoogle Scholar
Basu S, Andrews JR, Poolman EM, Gandhi NR, Shah NS, Moll A, et al. Prevention of nosocomial transmission of extensively drug-resistant tuberculosis in rural South African district hospitals: an epidemiological modelling study. Lancet. 2007;370:1500-7. [PMID: 17964351] CrossrefMedlineGoogle Scholar
Abdool-Karim Q, Abdool-Karim SS. The evolving HIV epidemic in South Africa. Int J Epidemiol. 2002;31:37-40. [PMID: 11914290] CrossrefMedlineGoogle Scholar
- 9. Buthelezi S. Situational analysis of TB drug resistance in KwaZulu-Natal Province, Republic of South Africa. In: Program and Abstracts of the 2nd Global XDR-TB Task Force Meeting, 9–10 April 2008, Geneva, Switzerland. Google Scholar
Gandhi NR, Moll A, Sturm AW, Pawinski R, Govender T, Lalloo U, et al. Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. Lancet. 2006;368:1575-80. [PMID: 17084757] CrossrefMedlineGoogle Scholar
O'Donnell MR, Padayatchi N, Master I, Osburn G, Horsburgh CR. Improved early results for patients with extensively drug-resistant tuberculosis and HIV in South Africa. Int J Tuberc Lung Dis. 2009;13:855-61. [PMID: 19555535] MedlineGoogle Scholar
Wells CD, Cegielski JP, Nelson LJ, Laserson KF, Holtz TH, Finlay A, et al. HIV infection and multidrug-resistant tuberculosis: the perfect storm. J Infect Dis. 2007;196 Suppl 1S86-107. [PMID: 17624830] CrossrefMedlineGoogle Scholar
Raviglione MC, Smith IM. XDR tuberculosis—implications for global public health. N Engl J Med. 2007;356:656-9. [PMID: 17301295] CrossrefMedlineGoogle Scholar
Reisner BS, Gatson AM, Woods GL. Evaluation of mycobacteria growth indicator tubes for susceptibility testing of Mycobacterium tuberculosis to isoniazid and rifampin. Diagn Microbiol Infect Dis. 1995;22:325-9. [PMID: 8582137] CrossrefMedlineGoogle Scholar
Rüsch-Gerdes S, Pfyffer GE, Casal M, Chadwick M, Siddiqi S. Multicenter laboratory validation of the BACTEC MGIT 960 technique for testing susceptibilities of Mycobacterium tuberculosis to classical second-line drugs and newer antimicrobials. J Clin Microbiol. 2006;44:688-92. [PMID: 16517840] CrossrefMedlineGoogle Scholar
Centers for Disease Control. Notice to Readers: Revised Definition of Extensively Drug-Resistant Tuberculosis MMWR. MMWR Morb Mortal Wkly Rep. 2006;55:1176. Google Scholar
- 17. Statistics South Africa. South African National Population Census 2001. Accessed at www.statssa.gov.za/census01/html/default.asp on 23 August 2010. Google Scholar
- 18. Statistics South Africa. South African Community Survey 2007. Accessed at www.statssa.gov.za/community_new/content.asp on 23 August 2010. Google Scholar
- 19. Health Systems Trust. South African Health Review 2007. Accessed at www.hst.org.za/publications/711 on 23 August 2010. Google Scholar
Basu S, Galvani AP. The transmission and control of XDR TB in South Africa: an operations research and mathematical modelling approach. Epidemiol Infect. 2008;136:1585-98. [PMID: 18606028] CrossrefMedlineGoogle Scholar
Abdool Karim SS, Churchyard GJ, Abdool Karim Q, Lawn SD. HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response. Lancet. 2009;374:921-33. [PMID: 19709731] CrossrefMedlineGoogle Scholar
Galgalo T, Dalal S, Cain KP, Oeltmann J, Tetteh C, Kamau JG, et al. Tuberculosis risk among staff of a large public hospital in Kenya. Int J Tuberc Lung Dis. 2008;12:949-54. [PMID: 18647456] MedlineGoogle Scholar
James P, Christopher DJ, Balamugesh T, Gupta R. Death of a health care worker with nosocomial extensively drug-resistant tuberculosis in India [Letter]. Int J Tuberc Lung Dis. 2009;13:795-6. [PMID: 19460260] MedlineGoogle Scholar
Cleveland JL, Kent J, Gooch BF, Valway SE, Marianos DW, Butler WR, et al. Multidrug-resistant Mycobacterium tuberculosis in an HIV dental clinic. Infect Control Hosp Epidemiol. 1995;16:7-11. [PMID: 7897177] CrossrefMedlineGoogle Scholar
Sotgiu G, Arbore AS, Cojocariu V, Piana A, Ferrara G, Cirillo DM, et al. High risk of tuberculosis in health care workers in Romania. Int J Tuberc Lung Dis. 2008;12:606-11. [PMID: 18492325] MedlineGoogle Scholar
World Health Organization. WHO policy on TB infection control in health-care facilities, congregate settings and households. Geneva: World Health Organization; 2009. Google Scholar
Askew GL, Finelli L, Hutton M, Laraque F, Porterfield D, Shilkret K, et al. Mycobacterium tuberculosis transmission from a pediatrician to patients. Pediatrics. 1997;100:19-23. CrossrefMedlineGoogle Scholar
Dimitrova B, Hutchings A, Atun R, Drobniewski F, Marchenko G, Zakharova S, et al. Increased risk of tuberculosis among health care workers in Samara Oblast, Russia: analysis of notification data. Int J Tuberc Lung Dis. 2005;9:43-8. MedlineGoogle Scholar
Dheda K, Shean K, Zumla A, Badri M, Streicher EM, Page-Shipp L, et al. Early treatment outcomes and HIV status of patients with extensively drug-resistant tuberculosis in South Africa: a retrospective cohort study. Lancet. 2010;375:1798-807. CrossrefMedlineGoogle Scholar
Zelnick J, O'Donnell M. The impact of the HIV/AIDS epidemic on hospital nurses in KwaZulu Natal, South Africa: nurses' perspectives and implications for health policy. J Public Health Policy. 2005;26:163-85. CrossrefMedlineGoogle Scholar
Gandhi NR, Shah NS, Andrews JR, Vella V, Moll AP, Scott M, et al; Tugela Ferry Care and Research (TF CARES) Collaboration. HIV coinfection in multidrug- and extensively drug-resistant tuberculosis results in high early mortality. Am J Respir Crit Care Med. 2010;181:80-6. CrossrefMedlineGoogle Scholar
Author, Article and Disclosure Information
From Boston University School of Medicine and School of Public Health, Boston, Massachusetts; Centre for AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa; University of Calgary, Calgary, Alberta, Canada; Medical Research Council, Cape Town, South Africa; Salem State College School of Social Work, Salem, Massachusetts; King George V Hospital, Sydenham, South Africa;
Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia; University College London, London, United Kingdom; and McGill University, Montreal, Quebec, Canada.
Note: Drs. O'Donnell and Jarand contributed equally to this manuscript.
Grant Support: Dr. O'Donnell was supported by the National Institutes of Health (T32 AI52074; National Institutes of Allergy and Infectious Diseases) and an American Thoracic Society Career Development Award. In addition, Drs. O'Donnell and Padayatchi were supported by the Centre for AIDS Programme of Research. The National Institutes of Health and the U.S. Department of Health and Human Services funds the Centre for AIDS Programme of Research (A1069469). Dr. Padayatchi was also supported by Columbia University–Southern African Fogarty AIDS International Training and Research Programme funded by the Fogarty International Center, National Institutes of Health (D43TW00231). Dr. Pai is supported by a New Investigator Award from the Canadian Institutes of Health Research. These funding sources played no role in the study design or data analysis.
Disclosures: Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-0897.
Reproducible Research Statement:Study protocol and statistical code: Available from Dr. O'Donnell (e-mail, max.
Corresponding Author: Max R. O'Donnell, MD, MPH, Division of Pulmonary Medicine, Albert Einstein College of Medicine, 1301 Morris Park Avenue, Bronx, NY 10461; e-mail, max.
Current Author Addresses: Dr. O'Donnell: Division of Pulmonary Medicine, Albert Einstein College of Medicine, 1301 Morris Park Avenue, Bronx, NY 10461.
Dr. Jarand: University of Calgary, 3500 26th Avenue Northwest, Calgary, Alberta T1Y 6J4, Canada.
Ms. Loveday: Medical Research Council of South Africa, Health Systems Research Unit, Francie van Zijl Drive, Parow Valley, Cape Town, South Africa.
Dr. Padayatchi, Ms. Werner, and Mr. Naidoo: Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2nd Floor), University of KwaZulu-Natal, 719 Umbilo Road, Private Bag X7, Congella, 4013, Durban, South Africa.
Dr. Zelnick: Salem State College School of Social Work, 352 Lafayette Street, Salem, MA 01970.
Drs. Master and Osburn: 34 Holmleigh Road, Reservoir Hills, Durban, South Africa 4091.
Dr. Kvasnovsky: University of Maryland School of Medicine, 827 Saint Paul Street, Baltimore, MD 21202.
Ms. Shean and Dr. Dheda: Lung Infection and Immunity Unit, Division of Pulmonology & Clinical Immunology, University of Cape Town, Department of Medicine, H Floor, Old Main Building, Groote Schuur Hospital Observatory, Cape Town 7925, South Africa.
Dr. Pai: Department of Epidemiology & Biostatistics, 1020 Pine Avenue West, Montreal QC H3A 1A2, Canada.
Dr. Van der Walt: Tuberculosis Epidemiology and Intervention Research Unit, Private Bag X385, 0001 Pretoria, South Africa.
Dr. Horsburgh: Department of Epidemiology, Boston University School of Public Health, 72 East Newton Street, Boston, MA 02118.
Author Contributions: Conception and design: M.R. O'Donnell, M. Loveday, N. Padayatchi, I. Master, G. Osburn, M. Van der Walt, C.R. Horsburgh, K. Dheda.
Analysis and interpretation of the data: M.R. O'Donnell, J. Jarand, M. Loveday, N. Padayatchi, L. Werner, C. Kvasnovsky, M. Pai, M. Van der Walt, C.R. Horsburgh, K. Dheda.
Drafting of the article: M.R. O'Donnell, J. Jarand, N. Padayatchi, J. Zelnick, L. Werner, K. Naidoo, M. Van der Walt, K. Dheda.
Critical revision of the article for important intellectual content: M.R. O'Donnell, J. Jarand, M. Loveday, N. Padayatchi, C. Kvasnovsky, K. Shean, M. Pai, C.R. Horsburgh, K. Dheda.
Final approval of the artide: M.R. O'Donnell, J. Jarand, M. Loveday, N. Padayatchi, L. Werner, C. Kvasnovsky, M. Pai, M. Van der Walt, C.R. Horsburgh, K. Dheda.
Provision of study materials or patients: M. Loveday, N. Padayatchi, I. Master, G. Osburn, C. Kvasnovsky.
Statistical expertise: L. Werner, C.R. Horsburgh.
Obtaining of funding: C. Kvasnovsky, K. Shean.
Administrative, technical, or logistic support: M. Loveday, K. Shean, K. Dheda.
Collection and assembly of data: M.R. O'Donnell, J. Jarand, M. Loveday, C.R. Horsburgh.