Skip to main content
  • Research article
  • Open access
  • Published:

Perceived risk of tuberculosis infection among healthcare workers in Swaziland

Abstract

Background

The incidence of tuberculosis (TB) in the Kingdom of Swaziland is extremely high. How healthcare workers (HCWs) in Swaziland perceive infection control (IC) measures for preventing TB transmission is unclear. This study aimed to determine perceived risk of TB infection in relation to IC measures among HCWs in three institutions of Swaziland.

Methods

A cross-sectional questionnaire survey was conducted in 2014. Demographic data and IC measures were collected from main and allied HCWs.

Results

In total, 186 HCWs (19 doctors, 99 nurses, and 68 allied HCWs) were enrolled. The multivariate logistic regression analyses revealed that nurses (OR = 39.87, 95% CI = 2.721–584.3) and other HCWs (OR =99.34, 95% CI = 7.469–1321) perceived a higher TB infection risk than did doctors. Moreover, HCWs working for <4 years at the TB department perceived a lower TB infection risk (OR = 0.099, 95% CI = 0.022–0.453). Availability of N95 respirator masks (OR = 0.055, 95% CI = 0.005–0.586) and a designated sputum collection area (OR = 0.142, 95% CI = 0.037–0.545) also carried lower TB infection risks.

Conclusion

This study depicts the current status of IC measures for TB infection in a high prevalence country. The results suggest that HCWs perceived a greater TB infection risk at inadequate environmental IC measures.

Peer Review reports

Background

Tuberculosis (TB) constitutes an important proportion of the global disease burden. Nosocomial TB transmission has been well-documented worldwide, regardless of the local TB incidence, engendering a considerable risk of TB infection among healthcare workers (HCWs) [15]. Several interventions are helpful in preventing TB transmission to HCWs [6]. Administrative infection control (IC) measures, such as educational programs, can reduce TB infection [7]. In addition, environmental control and personal protective equipment are crucial contributors to the prevention of TB transmission [1, 8]. The compliance of HCWs with IC measures is influenced by organizational, environmental, and individual factors. However, whether the perception of TB transmission is associated with these factors is unclear. Because adherence to IC measures is mostly driven by HCWs’ belief in the effectiveness of these measures, understanding how HCWs perceive IC measures for preventing TB transmission is imperative.

The incidence of TB in the Kingdom of Swaziland is extremely high [912]. Therefore, Bacillus Calmette-Guerin (BCG) vaccinations are routinely administered and TB control programs have been established. However, how HCWs perceive IC measures for preventing TB transmission is unclear [9, 11]. In the current study, we used a questionnaire survey to investigate the perceived risk and IC measures of TB infection among HCWs of three health facilities in Swaziland. We further analyzed the perceived risk of TB infection in relation to IC measures. Our results can highlight the correlation between the perceived risk and IC measures of TB infection in a high-prevalence country.

Methods

Design and participants

A structured questionnaire was developed using data from published articles and the World Health Organization’s conceptual framework and TB IC guidelines [1315]. This mixed-methods study was conducted during a 3-month period from July to September 2014.

We enrolled HCWs employed at the National TB Hospital, Raleigh Fitkin Memorial (RFM) Hospital, and Southern Africa Nazarene University (SANU) located in the Manzini Region, Swaziland. All HCWs in these three institutes were eligible for enrollment, including physicians, nurses, and allied HCWs. Workers not related with clinical health care were not included into this study. Those with age under 18 were not enrolled. The total number of eligible participants was obtained from the departments of human resources. A power calculation was not done beforehand.

The National TB Hospital is a 100-bed public hospital for the treatment of TB. The RFM Hospital is a 350-bed regional referral and teaching hospital providing daily services to approximately 500 patients in outpatient departments. SANU is a new university developed by combining three colleges, the Nazarene College of Nursing, Nazarene Teacher Training, and the Nazarene College of Theology. The study sites were classified into two categories: TB facility (National TB Hospital) and non-TB facility (RFM Hospital and SANU). TB facility was defined the referral hospital for TB and non-TB facility was defined as healthcare institute for general diseases.

Questionnaire

The survey included items for measuring the profile of IC measures for preventing TB transmission including administrative measures, environmental control, and personal protective behavior (see Additional file 1). Questions related to the risk of TB infection were rated using a 5-point Likert scale (strongly agree, agree, neutral, disagree, and strongly disagree). In addition, demographic data including age, sex, profession, work period, educational level, and marital status were obtained. The questionnaires were sent to managers of the three institutions, and they were asked to distribute them to the participants. The questionnaire was completed by the participants themselves.

All questions were prepared in English and then translated into Swazi by a native speaker; subsequently, another translator fluent in both Swazi and English back-translated the questions from Swazi into English to ensure the accuracy of the translation.

Validity and reliability

Content validity was examined by four experts. The specialties of the experts included global health, infectious diseases, survey methodology, statistics, epidemiology, and tropical medicine. The internal consistency of all indices was estimated using Cronbach’s coefficient alpha. In this survey, a content validity index of 0.86 and Cronbach’s coefficient alpha of 0.88 indicated adequate validity and reliability, respectively, of all parameters in the questionnaire.

Ethical considerations

This study was approved by the Scientific and Ethics Committee of the Ministry of Health and Social Welfare in Swaziland. In addition, permissions were obtained from the three institutions. An introductory letter stating the study purpose and promising confidentiality was sent along with the questionnaire. Informed consent in written form was obtained from all the enrolled participants.

Statistical analyses

A self-rating of strongly agree or agree was considered as a favorable answer (high risk), whereas a self-rating of neutral, disagree, or strongly disagree was considered as an unfavorable answer (low risk). Statistical analyses were conducted using a commercially available program (SPSS 19.0 for Windows, SPSS, Chicago, Il, USA). Categorical variables were analyzed using the chi-squared test or Fisher’s exact test when appropriate. A multivariate logistic regression model was used to adjust for possible confounders. Odds ratios and 95% confidence intervals were calculated after adjustments for control variables. Significance was defined as P < 0.05.

Results

Demographic data of the participants

Overall, 255 HCWs were eligible for enrollment. In total, 186 valid questionnaires were returned (97 HCWs from the National TB Hospital, 57 HCWs from the RFM Hospital, and 32 HCWs from SANU), indicating a return rate of 72.9%. In specific, the response rate was 84.3% in the National TB Hospital, 87.7% in the RFM Hospital, and 42.7% in SANU. The demographic information of all the participants is listed in Table 1. We enrolled 19 medical doctors, 99 nurses (4 sisters in charge, 81 nurses, and 14 nursing assistants), and 68 allied HCWs (32 students, 8 laboratory technicians, 15 ward aides, and 13 other HCWs).

Table 1 Demographic information of the participants (n = 186)

The TB department was defined as departmental service for TB. Approximately two-third of participants worked in the TB department for less than 4 years.

Infection control for TB

Table 2 lists IC measures taken in TB and non-TB facilities. Overall, the most common IC measure was individual behavior including wearing a protective gown when taking care of patients with TB (93.0%) and washing hands in between different patients’ care (80.1%). Among the environmental control measures, the most common measures were natural ventilation (evidence of unrestricted airflow, high ceiling >3 m, vents, and windows) (88.2%) and opening windows during working hours (84.9%). The least adopted IC measures were the availability of a designated area for sputum collection (26.3%) and air purification through ultraviolet germicidal irradiation or high-efficiency particulate air filtration (29.6%).

Table 2 Infection control (IC) for TB

The IC measures, including administrative measures, environmental control, and personal behaviors, significantly differed between the TB and non-TB facilities. IC planning, routine IC training, and window opening during working hours were more common in the non-TB facilities than in the TB facility. By contrast, routine TB screening, availability of a designated area for sputum collection, mechanical and natural ventilation, air cleaning, and access to N95 respirator masks and detergents were higher in the TB facility than in the non-TB facilities. Furthermore, compared with the non-TB facilities, the HCWs in the TB facility more often wore protective gowns when contacting patients.

Perceived risk of TB infection

Overall, 143 participants (76.9%) rated that they were at risk for TB infection (Table 3). The perceived risk was lower in HCWs with the following demographic characteristics: (1) working in the National TB Hospital, (2) higher academic degree (diploma and degree), (3) men, (4) unmarried, (5) working in the TB department for <4 years, and (6) physicians and nurses. Moreover, the risk was lower in the presence of the following IC measures: (1) routine TB screening, (2) designated area for sputum collection, (3) N95 respirator mask availability, (4) detergent availability, and (5) wearing of protective gowns. By contrast, the risk was higher in the presence of an IC plan.

Table 3 Perceived risk of TB infection

Multivariate logistic regression model

Table 4 presents the results of the multivariate logistic regression analysis performed to adjust for possible confounders of the perceived TB infection risk. Wearing protective gowns was not included in the regression model because this group contained no participant. The following four characteristics were associated with the TB infection risk: two demographic characteristics (profession and work period in the TB department) and two environmental IC measures (designated area for sputum collection and N95 respirator mask availability). The TB infection risk was lower in medical doctors than in nurses and allied HCWs. In addition, the perceived TB infection risk was higher in HCWs with a work period of ≥4 years in the TB department than in those with a work period of <4 years in the TB department. With regard to environmental IC measures, the availability of N95 respirator masks and presence of a designated area for sputum collection were associated with a lower TB infection risk.

Table 4 Risk assessment for TB infection by the multivariate logistic regression model

Discussion

In this study, we investigated the perception of HCWs regarding IC measures for TB prevention in Swaziland. In addition, we evaluated the correlation of their perceived TB infection risk with IC measures. In our study, approximately half of the participants stated that administrative and environmental measures were not adhered to. In addition to the problems of building design, we observed that almost a half of HCWs reported a shortage of relevant equipment, including N95 respirator mask and detergent, in three health institutions of Swaziland. These results are in accordance with those of previous reports that have revealed failure in compliance with IC measures in resource-limited settings [13, 1618]. There is evidence confirming that the TB infection risk appears to be particularly high in institutions with inadequate IC measures [14]. Environmental IC measures are considered the most effective methods for reducing the risk of TB infection. Our study results indicate that environmental IC measures are the most critical factors contributing to the perceived TB infection risk. These findings are consistent with those of previous studies [6, 7, 19]. Because of the high TB burden in Swaziland, ensuring compliance with required measures for TB prevention is imperative.

The availability of personal protective equipment and engineering control has been a critical factor related to safety in hospital environments [20]. In this study, we observed a correlation between the perceived TB risk and the availability of N95 respirator masks. N95 respirator masks provide a high filtration barrier and protect HCWs from TB infection. Therefore, it is recommended that HCWs should wear N95 respirator masks when taking care of patients with TB or those surmised to have TB [21]. However, adherence to the use of facial N95 respirator masks is not always observed in clinical practice because of their inadequate availability [8].

Safety in working environments has been a growing concern. However, quantitative methods investigating the perception of HCWs’ safety from TB infection is rare [2224]. In our study, most HCWs believed that they were in an unsafe environment with a great risk of TB infection. The results are similar to those of a study conducted in Ethiopia that reported that 71% of HCWs perceived a high risk of occupational acquisition of TB [22]. We consider that the most likely reason is the failure of administrative and environmental IC measures. These measures are regarded as the most crucial defenses against TB infection. Thus, individual IC measures might not be effective when administrative and environmental measures are inadequate [18, 24].

Patients with TB are highly common in the National TB Hospital of Swaziland since this hospital is mainly responsible for the control of TB. Nevertheless, HCWs in this hospital perceived a low TB infection risk than those in other facilities did. This may be because environmental control measures and personal behaviors were more favorable in the National TB Hospital. Therefore, although HCWs in the National TB Hospital cared for patients with TB, they believed that they were safer.

Sputum collection is the standard practice for TB diagnosis [25]. Induced sputum can increase the microbiological diagnostic yield in patients surmised to have TB by stimulating sputum expectoration [26]. Sputum induction is a safe procedure for patients even in resource-poor settings [27]. During the procedure of sputum induction, protective measures are required for HCWs. In our study, HCWs involved in sputum induction and collection did not perceive a higher TB infection risk, suggesting that they believed that their protective measures were adequate.

In our study, the univariate analysis showed HCWs with IC plan perceived more risk of TB infection than those without IC plan. However, there was no significant difference by the multivariate logistic regression model. Therefore, we speculate that, despite of the presence of IC plan, HCWs perceived greater risk of TB infection when the environmental control was inadequate.

Our study has limitations that should be addressed. First, this was a self-administered survey and not an audit of actual practice. Hence, a discrepancy between self-reported and actual IC measures may be present [17]. However, our study design could accurately reflect the perceived risk. Second, the perceived risk is not equal to the real risk of TB infection. The risk of TB infection between HCWs and general population in Swaziland has not been determined yet. Nevertheless, healthcare quality could be influenced if HCWs perceived a high TB infection risk [19]. Third, our study did not investigate the correlation of HIV with TB infection. Further studies are needed to identify the perceived risk of TB infection among HIV-positive HCWs.

Conclusions

Our study has clinical implications for strategy development to prevent TB infection of HCWs. The findings provide crucial information on the current status of IC measures for TB infection in Swaziland. We have identified HCWs perceived a greater TB infection risk with inadequate environmental IC measures. A significant correlation between environmental IC measures and the perceived TB infection risk was observed. HCWs perceived a high TB infection risk owing to the inadequate implementation of environmental IC measures. To maintain a safe workplace for HCWs, improving IC measures should be a top priority in Swaziland. First, N95 respirator masks should be available for all HCWs with risk of TB infection. Second, a designated area for sputum collection should be mandatory in order to decrease the TB infection of HCWs.

To our knowledge, this study is the first survey to assess the perceived risk of TB infection among HCWs in Swaziland. This study verified the current status of IC measures for TB infection in Swaziland. A majority of HCWs in Swaziland perceived risk of TB infection. Environmental IC measures were regarded as the most important factor of TB infection. Thus, ensuring compliance with TB prevention measures is important to reduce the risk of nosocomial TB infection among HCWs in Swaziland.

Abbreviations

HCWs:

Healthcare workers

IC:

Infection control

RFM Hospital:

Raleigh Fitkin Memorial Hospital

SANU:

Southern Africa Nazarene University

TB:

Tuberculosis

References

  1. Welbel SF, French AL, Bush P, DeGuzman D, Weinstein RA. Protecting health care workers from tuberculosis: a 10-year experience. Am J Infect Control. 2009;37(8):668–73.

    Article  PubMed  Google Scholar 

  2. 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(12):e494.

    Article  PubMed  PubMed Central  Google Scholar 

  3. de Vries G, Sebek MM, Lambregts-van Weezenbeek CS. Healthcare workers with tuberculosis infected during work. Eur Respir J. 2006;28(6):1216–21.

    Article  PubMed  Google Scholar 

  4. Cuhadaroglu C, Erelel M, Tabak L, Kilicaslan Z. Increased risk of tuberculosis in health care workers: a retrospective survey at a teaching hospital in Istanbul, Turkey. BMC Infect Dis. 2002;2:14.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Do AN, Limpakarnjarat K, Uthaivoravit W, Zuber PL, Korattana S, Binkin N, Mastro TD, Jarvis WR. Increased risk of Mycobacterium tuberculosis infection related to the occupational exposures of health care workers in Chiang Rai, Thailand. Int J Tuberc Lung Dis. 1999;3(5):377–81.

    CAS  PubMed  Google Scholar 

  6. Jensen PA, Lambert LA, Iademarco MF, Ridzon R. Cdc: Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005;54(RR-17):1–141.

    PubMed  Google Scholar 

  7. da Costa PA, Trajman A, Mello FC, Goudinho S, Silva MA, Garret D, Ruffino-Netto A, Kritski AL. Administrative measures for preventing Mycobacterium tuberculosis infection among healthcare workers in a teaching hospital in Rio de Janeiro, Brazil. J Hosp Infect. 2009;72(1):57–64.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Nichol K, McGeer A, Bigelow P, O’Brien-Pallas L, Scott J, Holness DL. Behind the mask: Determinants of nurse’s adherence to facial protective equipment. Am J Infect Control. 2013;41(1):8–13.

    Article  PubMed  Google Scholar 

  9. van Schalkwyk C, Mndzebele S, Hlophe T, Garcia Calleja JM, Korenromp EL, Stoneburner R, Pervilhac C. Outcomes and impact of HIV prevention, ART and TB programs in Swaziland--early evidence from public health triangulation. PLoS One. 2013;8(7):e69437.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Sanchez-Padilla E, Dlamini T, Ascorra A, Rusch-Gerdes S, Tefera ZD, Calain P, de la Tour R, Jochims F, Richter E, Bonnet M. High prevalence of multidrug-resistant tuberculosis, Swaziland, 2009-2010. Emerg Infect Dis. 2012;18(1):29–37.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Haumba S, Dlamini T, Calnan M, Ghazaryan V, Smith-Arthur AE, Preko P, Ehrenkranz P. Declining tuberculosis notification trend associated with strengthened TB and expanded HIV care in Swaziland. Public Health Action. 2015;5(2):103–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. WHO 2015 global tuberculosis report. Geneva: World Health Organization; 2015.

  13. Malangu N, Mngomezulu M. Evaluation of tuberculosis infection control measures implemented at primary health care facilities in Kwazulu-Natal province of South Africa. BMC Infect Dis. 2015;15:117.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 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(6):593–605.

    CAS  PubMed  Google Scholar 

  15. WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households. Geneva: World Health Organization; 2009.

  16. Claassens MM, van Schalkwyk C, du Toit E, Roest E, Lombard CJ, Enarson DA, Beyers N, Borgdorff MW. Tuberculosis in healthcare workers and infection control measures at primary healthcare facilities in South Africa. PLoS One. 2013;8(10):e76272.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Buregyeya E, Nuwaha F, Verver S, Criel B, Colebunders R, Wanyenze R, Kalyango JN, Katamba A, Mitchell EM. Implementation of tuberculosis infection control in health facilities in Mukono and Wakiso districts, Uganda. BMC Infect Dis. 2013;13:360.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Ogbonnaya LU, Chukwu JN, Uwakwe KA, Oyibo PG, Ndukwe CD. The status of tuberculosis infection control measures in health care facilities rendering joint TB/HIV services in “German Leprosy and Tuberculosis Relief Association” supported states in Nigeria. Niger J Clin Pract. 2011;14(3):270–5.

    Article  CAS  PubMed  Google Scholar 

  19. Woith W, Volchenkov G, Larson J. Barriers and motivators affecting tuberculosis infection control practices of Russian health care workers. Int J Tuberc Lung Dis. 2012;16(8):1092–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Gershon RR, Karkashian CD, Grosch JW, Murphy LR, Escamilla-Cejudo A, Flanagan PA, Bernacki E, Kasting C, Martin L. Hospital safety climate and its relationship with safe work practices and workplace exposure incidents. Am J Infect Control. 2000;28(3):211–21.

    Article  CAS  PubMed  Google Scholar 

  21. Zelnick JR, Gibbs A, Loveday M, Padayatchi N, O’Donnell MR. Health-care workers’ perspectives on workplace safety, infection control, and drug-resistant tuberculosis in a high-burden HIV setting. J Public Health Policy. 2013;34(3):388–402.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Tenna A, Stenehjem EA, Margoles L, Kacha E, Blumberg HM, Kempker RR. Infection control knowledge, attitudes, and practices among healthcare workers in Addis Ababa, Ethiopia. Infect Control Hosp Epidemiol. 2013;34(12):1289–96.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Sissolak D, Marais F, Mehtar S. TB infection prevention and control experiences of South African nurses--a phenomenological study. BMC Public Health. 2011;11:262.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Brouwer M, Coelho E, Mosse C, Brondi L, Winterton L, van Leth F. Healthcare workers’ challenges in the implementation of tuberculosis infection prevention and control measures in Mozambique. PLoS One. 2014;9(12):e114364.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Geldenhuys HD, Whitelaw A, Tameris MD, Van As D, Luabeya KK, Mahomed H, Hussey G, Hanekom WA, Hatherill M. A controlled trial of sputum induction and routine collection methods for TB diagnosis in a South African community. Eur J Clin Microbiol Infect Dis. 2014;33(12):2259–66.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Zar HJ, Hanslo D, Apolles P, Swingler G, Hussey G. Induced sputum versus gastric lavage for microbiological confirmation of pulmonary tuberculosis in infants and young children: a prospective study. Lancet. 2005;365(9454):130–4.

    Article  PubMed  Google Scholar 

  27. Ugarte-Gil C, Elkington PT, Gotuzzo E, Friedland JS, Moore DA. Induced sputum is safe and well-tolerated for TB diagnosis in a resource-poor primary healthcare setting. Am J Trop Med Hyg. 2015;92(3):633–5.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

We are grateful to healthcare workers at study sites who took the time to complete the questionnaire for this study.

Funding

This work was supported by research grants from the Ministry of Science and Technology (MOST 104-2314-B-182A-138-, MOST 104-2410-H-038-006-SSS, and MOST 105-2410-H-038-011-SSS).

Availability of data and materials

The data will not be shared. The questionnaire is available (see Additional file 1).

Authors’ contributions

YHW, PTB, CYY, and YWC conceived and developed the study. PTB, HYC and YWC assisted with coordinating the study and participated in data collection. YHW and YWC were responsible for the statistical analysis. All the authors were involved in drafting the manuscript. The final manuscript was read and approved by all the authors.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

We have obtained consent to publish from the participants. All of the authors grant the publisher permission to publish their work.

Ethics approval and consent to participate

This study was approved by the Scientific and Ethics Committee of the Ministry of Health and Social Welfare in Swaziland. In addition, permissions were obtained from the National TB Hospital, Raleigh Fitkin Memorial Hospital, and Southern Africa Nazarene University. An introductory letter stating the study purpose and promising confidentiality was sent along with the questionnaire. Informed consent was obtained from all the enrolled participants.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Ya-Wen Chiu.

Additional file

Additional file 1:

Questionnaire in English. (PDF 223 kb)

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Weng, YH., Bhembe, P.T., Chiou, HY. et al. Perceived risk of tuberculosis infection among healthcare workers in Swaziland. BMC Infect Dis 16, 697 (2016). https://doi.org/10.1186/s12879-016-2029-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12879-016-2029-6

Keywords