Academic journal article Bulletin of the World Health Organization

Preventing Tuberculosis among Health Workers in Malawi. (Research)

Academic journal article Bulletin of the World Health Organization

Preventing Tuberculosis among Health Workers in Malawi. (Research)

Article excerpt


Nosocomial outbreaks of tuberculosis (TB) in industrialized countries have focused attention on the need to control the transmission of the disease in hospitals (1-3). Control measures such as the improvement of ventilation systems, the use of protective face masks, and the individual protection of staff were introduced in United States and European hospitals and successfully protected health workers against acquiring TB in the workplace (1, 4, 5).

The high prevalences of TB and human immunodeficiency virus (HIXO infection in sub-Saharan Africa suggest that the risk of nosocomial transmission of TB is substantial (6). Nosocomial transmission certainly occurs in Africa (7), where tuberculous infection in health workers is related to the level of exposure to TB patients (8). The incidence of TB among health workers is high and in the last 10 years has been increasing mainly as a result of the coincident HIV epidemic (9, 10).

In Malawi there has been a high incidence of TB among health workers (11, 12). The country's National Tuberculosis Control Programme responded in mid-1998 by producing written guidelines on the control of TB infection in hospitals. These were distributed to all hospitals and in the same year a seminar was conducted in each hospital for hospital-based health workers on ways to prevent the transmission of the disease. The guidelines were produced after consultation with stakeholders (12) and took account of what could realistically be achieved in a setting with very limited resources. The main technical aspects of the guidelines (Table 1) follow some of the recent recommendations issued by the Centers for Disease Control and Prevention, the International Union Against Tuberculosis and Lung Disease, and WHO (13). The emphasis was on rapid diagnosis of patients with smear-positive pulmonary TB, administrative attempts to isolate infectious patients, and the education of patients on cough hygiene. Hospitals were requested to consider offering confidential counselling and HIV testing to their staff and to advise those who were HIV-seropositive against working on general wards and TB wards.

Between 1998 and 2000 the National Tuberculosis Control Programme carried out a series of studies to determine whether: the guidelines for TB infection control had been adopted in district and mission hospitals; there had been a consequent reduction in the interval between the admission and diagnosis and between admission and treatment of patients with smear-positive pulmonary TB in hospital wards; and the annual TB case notification rate among health workers had decreased and was comparable to that of a group of people who were not exposed to the disease in their work setting.



In Malawi there are 22 district hospitals and 18 mission hospitals which register and treat TB patients. In all of them the general wards are multipurpose, treating medical and surgical cases. The diagnosis is made either in the outpatient department or during admission to the general wards. Persons suspected of having pulmonary TB submit three sputum specimens within 24 h. Smear examinations for acid-fast bacilli are performed on these specimens in hospital laboratories on weekdays only. Allowing for the admission of patients at weekends, most smear-positive pulmonary TB patients should be diagnosed, registered, and started on anti-TB treatment within five days of admission. If a hospital has a special TB ward, registered patients are transferred to it for the initial phase of treatment.

The 40 hospitals were visited in 1997 in order to collect the TB case notification data on various categories of health worker for 1996 (12). The same hospitals were revisited in order to conduct operational research studies between 1999 and 2000.

Adoption of TB control guidelines in hospitals

Visits were made to all the hospitals in 1999, when a structured form was used in interviews with patients and staff about the adoption of the guidelines for the control of TB infection. …

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