Annual Tuberculosis screening for Health Care Workers – A strategy to ensure a healthy workforce in Zambia

A Mwinga1, B Kayumba2, MS Carias3, M Washington3

  1. Zambia AIDS Related Tuberculosis Project (ZAMBART), Lusaka, Zambia
  2. Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
  3. Centers for Disease Control, Atlanta, USA

 Correspondence: Alwyn Mwinga (mwinga.alwyn@gmail.com)


Citation style for this article: Mwinga A, Kayumba B, Carias MS, Washington M. Annual Tuberculosis screening for Health Care Workers: A strategy to ensure a healthy workforce in Zambia. Health Press Zambia Bull. 2017;1(2), [Inclusive page numbers]


The incidence of Tuberculosis (TB) in Health Care Workers (HCWs) can be as high as twice that in the general population One undiagnosed TB patient can infect up to 10 individuals each year. Undiagnosed TB among HCWs may result in the transmission of infection to family members, colleagues, and patients. Annual screening of TB in a HCW can identify 76% more cases and prevent 35% more secondary cases.
 The Problem
TB is an ongoing public health problem that is easily spread from person to person. The source of infection stems from an untreated person with TB.  Reducing TB transmission in hospital or clinical settings occurs by improving ventilation, isolating patients with TB, and ensuring that all patients who may have TB are screened and put on treatment [1]. TB is common in Zambia: approximately 6 out of every 1,000 Zambians has TB (0.6%).  In 2014 the National TB Program reported 37,931 cases of TB. However, the World Health Organization has estimated 84,000 TB cases in Zambia [2], meaning that there are many undiagnosed TB cases in the community.  Notably, the prevalence of TB among HCWs is 1.5 to 3 times higher than the general population. A study done in the University Teaching Hospital in Lusaka in 2005 [3] showed that 1.8% of the nurses were treated for TB while another study that screened HCW in Ndola found that 1.02% had TB [4].
Policy options
Implementing a mandatory annual TB screening program for all HCW will ensure the early diagnosis and treatment of disease, improve the outcome of treatment, reduce the possibility of transmission of TB to other HCWs and/or patients, and helps maintain a healthy workforce.
Annual TB Screening for Health Care Workers
WHAT: The intervention would require re-establishing occupational health clinics, access to x-ray facilities, and access to laboratory testing for sputum using the GeneXpert.  Providing this for all health care workers will have a large cost, yet also an impact in terms of numbers of cases of TB diagnosed.  Using a 3-step process to identify those who are most likely to have TB will reduce the number of HCWs needing chest x-ray and sputum tests.  After a screening questionnaire, HCW with the presence of any symptoms typically associated with TB will have a chest x-ray, and those with an abnormal x-ray will give a sputum sample (secretions from the lungs) to test for TB.
WHY: The costs associated with implementing a mandatory screening program for all HCWs are $66,000, while in the absence of a screening program, the costs associated with diagnosing and treating TB among HCW are $204,983.  Implementation of the screening program will result in fewer missed cases of TB than associated with the status quo (168 compared to 259), thus leading to fewer additional TB cases.
The opportunity costs associated with implementation of the screening program are much greater than those associated with TB diagnosis and treatment in the absence of a screening program ($526,352 compared to $131,509). Although the cost of missing TB patients are not included in these calculations, a potential additional 910 new TB case will occur under the no screening program compared to the mandatory annual screening program.

No Screening Program Mandatory Annual Screening Percent Change
Zambia HCW 31,962
TB cases detected and treated 124 215 76%
False positive TB cases detected and treated 121 8 -93%
TB cases missed** 260 169 -35%
Number of averted cases 5200 in 12 months
2600 in 6 months
3360 in 12 months
1680 in 6 months
-35%
Program costs
(cost/patient detected)
$204,983
($1,653)
$66,000
($307)
-68%
(-81%)
Operational costs* $131,509 $526,352 300%
Total Cost $336,192 $592,352 76%

*  Includes the time and cost for a healthcare worker to participate in the screening and treatment
*Does not include the cost of not identifying and treating these patients. 
FEASIBILITY: Annual health screening is already a requirement for health workers. However, currently, there is no systematic enforcement of this requirement. We suggest linking TB screening to staff’s annual appraisal as a way of ensuring that HCWs undergo the TB screening.  This strategy will thus use existing facilities and staff, and take advantage of staff gatherings at healthcare facilities, such as at workshops, trainings and meetings to provide the screening. Mandatory health screenings should be presented in a manner to avoid stigmatization of staff found with TB.
Recommendations
We recommend screening of all HCWs.  This strategy will make it possible to identify TB cases earlier than the current situation, thus reducing transmission of infection and secondary TB cases.
The Policy will be presented to the National TB Program for feedback. We will also request this strategy to be included in the 2017 -2021 National TB Strategic Plan currently being developed.
The policy brief will be presented to Senior Management of MOH and other stakeholders such as the General Nursing Council, the Health Professions Council, and the Zambia Medical Association to obtain approval and support.
Implementation of the program can begin with an initial pilot targeting the nurses in Lusaka, as a way of understanding implementation challenges in order to guide a wider national rollout.
Available literature

  1. Claassens MM, van Schalkwyk C, du Toit E, Roest E, Lombard CJ, et al. (2013) Tuberculosis in Healthcare Workers and Infection Control Measures at Primary Healthcare Facilities in South Africa. PLoS ONE 2013 8(10): e76272.
  2. WHO Global Tuberculosis Report 2015
  3. Chanda, D., Gosnell, D., (January 31, 2006). “The Impact of Tuberculosis on Zambia and the Zambian Nursing Workforce”. Online Journal of Issues in Nursing. Vol. 11, No. 1, Manuscript 3.
  4. Ndola District TB IC Project Demonstration Project Final Report. October 2014

 
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