Compliance with Postexposure Screening and Treatment of Latent Tuberculosis Infection among Healthcare Workers in a Tertiary Care Hospital in Saudi Arabia Author(s): Hanan H. Balkhy MD, Thaddeus L. Miller DrPH, Saira Ali MD, Jennifer B. Nuzzo SM, Karine Kentenyants MD MPH, Aiman El-Saed MD PhD and Scott J. N. McNabb PhD MS Source: Infection Control and Hospital Epidemiology, Vol. 35, No. 2 (February 2014), pp. 176-181 Published by: Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/674855 Accessed: 11-02-2017 15:04 UTC JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected].

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infection control and hospital epidemiology

february 2014, vol. 35, no. 2

original article

Compliance with Postexposure Screening and Treatment of Latent Tuberculosis Infection among Healthcare Workers in a Tertiary Care Hospital in Saudi Arabia Hanan H. Balkhy, MD;1 Thaddeus L. Miller, DrPH;2 Saira Ali, MD;1 Jennifer B. Nuzzo, SM;3 Karine Kentenyants, MD, MPH;4 Aiman El-Saed, MD, PhD;1,5 Scott J. N. McNabb, PhD, MS4

background.

Controlling tuberculosis (TB) infection among occupationally exposed healthcare workers (HCWs) may be challenging.

methods. We retrospectively reviewed clinical records of HCWs who were exposed to patients diagnosed with infectious TB at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between 2008 and 2010. The collected data included baseline tuberculin skin test (TST) status, potential predictors of TST positivity, postexposure diagnosis of latent TB infection (LTBI), and postexposure compliance with LTBI therapy. results. Thirteen patients were diagnosed with infectious pulmonary TB during the study period. A total of 298 HCWs met our definition for exposure. Exposed HCWs tended to be female (62.9%), non-Saudi (83.9%), nurses (68.6%), or respiratory therapists (24.0%) working in critical care locations (72.8%). Baseline (preemployment) TST documentation existed for 41.3% (123/298). Among those with documented baseline TSTs, 51.2% (63/123) were positive, representing 21.1% (63/298) of all HCWs. Only 48.9% (115/235) of exposed HCWs who had negative or unknown preexposure TST status had their TST tested after exposure. Approximately 46.1% (53/115) of them were diagnosed with postexposure LTBI, and 92.5% (49/53) of them were prescribed LTBI therapy. Among those, 93.9% (46/49) started LTBI therapy; however, 82.6% (38/46) failed to complete the recommended course. conclusions. We found low rates of baseline TST documentation and postexposure screening among exposed HCWs. Compliance with initiating postexposure isoniazid prophylaxis among HCWs was fair, but only a small fraction of those who started prophylaxis completed the recommended course of therapy. These findings suggest substantial opportunities to implement administrative measures to enhance LTBI management among HCWs. Infect Control Hosp Epidemiol 2014;35(2):176-181

Tuberculosis (TB) remains a global public health problem with significant morbidity and mortality.1,2 In 2011, there were an estimated 8.7 million new cases of TB, and 1.4 million people died from TB.1 Individuals with latent TB infection (LTBI) represent an important source of new cases of active TB. Approximately 5%–10% of those infected will develop active disease, and most will be capable of infecting others.3 Accurate diagnosis and effective treatment of LTBI represent an important opportunity to prevent the morbidity and mortality associated with TB.4 Healthcare facilities can serve as foci for TB infections, with occupational exposure leading to active disease or LTBI among healthcare workers (HCWs).5 Therefore, HCWs represent an important group for targeted screening for LTBI.6 A number of studies have demonstrated that this group is at

an increased risk of exposure to TB infection as a result of the high level of occupational contact with infected individuals.7,8 In addition, the increasing recruitment of HCWs from countries with high TB burdens increases the possibility that TB can be introduced to healthcare settings in lower-prevalence countries.9 Such data have led to a growing interest in improving the detection and proper management of TB infection among HCWs.10 A number of studies have examined the prevalence of LTBI among HCWs in Saudi Arabia.11,12 Additionally, a recent study examined the prevalence of LTBI among college students exposed to acid-fast bacilli smear-positive cases of TB disease.13 However, studies examining the development of LTBI infection after occupational exposure in a healthcare setting as well as compliance with the recommended therapy are lack-

Affiliations: 1. Infection Prevention and Control Department, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 2. School of Public Health, University of North Texas Health Sciences Center, Fort Worth, Texas; 3. Center for Biosecurity, University of Pittsburgh Medical Center, Baltimore, Maryland; 4. Rollins School of Public Health, Emory University, Atlanta, Georgia; 5. Community Medicine Department, Mansoura University, Daqahlia, Egypt. Received August 4, 2013; accepted October 18, 2013; electronically published December 13, 2013. 䉷 2013 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3502-0011$15.00. DOI: 10.1086/674855

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screening for ltbi among hcw s

ing. The objective of the current study was to evaluate the development of LTBI infection among HCWs who were occupationally exposed to TB in a tertiary care hospital in Saudi Arabia. Additionally, we thought to examine compliance with current documentation and management policies following a known TB exposure of HCWs and to identify opportunities for policy and program improvements.

methods Location/Setting In 2009, the estimated urban population of Riyadh, the capital of Saudi Arabia, was 6.25 million among a total national population of 25.37 million.14 The World Health Organization (WHO) estimated the TB incidence in Saudi Arabia at 18 per 100,000 in 2004.15 The current study was conducted at King Abdulaziz Medical City (KAMC-R), a large urban, tertiary care hospital of 900 beds, also known as the National Guard Health Affairs main hospital. Administrative hospital statistics showed that at least 6,369 HCWs (1,357 medical, 3,327 nursing, and 1,685 allied health and clinical) served at KAMC-R in 2010. HCWs at KAMC-R include both Saudi Arabian National Guard (SANG) hires, who are all Saudi nationals and are considered governmental employees, and non-SANG hires, who are all on a yearly contract and may be Saudi nationals but are mostly non-Saudis. All hires to the National Guard fall under the same rules and regulations for TB management. The assessment of TB exposures as well as record keeping and follow-up were executed under the authority of the Infection Prevention and Control Department at KAMC-R. Local policies governing TB screening and the management of LTBI were based on the Saudi guidelines (a joint statement of 4 related Saudi societies)6 and the Centers for Disease Control and Prevention.3,4 Hiring Process and Clearance for TB and LTBI Candidates recruited for work at our institution are either international hires or local hires. All international hires need clearance from their country of origin—via an international recruitment agency—for active pulmonary disease by having a normal chest X-ray. When in doubt, the results may be shared with the hiring office at our hospital for further opinion. If the candidate is found to have active TB disease, the hiring process is withheld. On arrival, candidates have a Mantoux tuberculin skin test (TST) and a chest X-ray along with clearance for the presence of any signs or symptoms for active TB disease. This may include a repeat chest X-ray, TST, or referral to a specialist in infectious diseases or other specialties if needed. Those who are identified with LTBI are given the option to receive the LTBI prophylaxis with isoniazid for 9 months. Those who decide not to take the prophylaxis need to sign a waiver. Local hires receive a chest X-ray and a clinical visit to clear any active symptoms or signs for TB or other diseases. If the chest X-ray is suggestive of old or active TB

177

disease, a TST is done, and if identified as a case of LTBI, the individual is offered LTBI prophylaxis, as done for the international hires. Once a recruit is hired, no annual TST testing is performed. Study Design We conducted a retrospective chart review using de-identified administrative and clinical records of HCWs working at KAMC-R between January 1, 2008, and December 31, 2010. HCWs with occupational exposure to patients diagnosed with pulmonary TB after admission to KAMC-R were included in the study. Institutional review board approval was obtained before beginning this study. Definitions On the basis of the above guidelines, we set related definitions before the start of the study.3,4,6 HCWs were defined as all paid and unpaid persons working in a healthcare setting. Occupational exposure occurred when an HCW was in contact with an infectious TB patient for at least 30 minutes without wearing a mask, with 1 or more of the following patient conditions: (1) failure to cover the mouth and nose when coughing; (2) incorrect or incomplete anti-TB treatment; or (3) undergoing cough-inducing or aerosol-generating procedures, such as sputum induction, bronchoscopy, and airway suction. An infectious TB case was defined as a patient with a significant history or physical evaluation for TB disease, including (1) presence of cough lasting more than 3 weeks; (2) weight loss and night sweats; (3) cavitation on chest radiograph; (4) positive acid-fast bacilli sputum smear result; and (5) respiratory tract disease with involvement of the lung or airways, including larynx. A positive skin test was defined as an induration of 10 mm or greater following a TST. TST conversion was defined as an increase of 10 mm or greater in the size of the TST induration over a 2-year period in an HCW with documented negative (less than 10 mm) results at baseline. LTBI was defined as the presence of Mycobacterium TB bacteria in the body, as evidenced by a reaction to a TST without the manifestation of symptoms or signs. Data Collection We identified and abstracted TST status before exposure (at the preemployment examination of KAMC-R), potential risk factors, and data on postexposure LTBI therapy. These data included age, gender, citizenship, country of origin, work location, baseline (preemployment) TST screening results, and postexposure new diagnosis of LTBI, as well as the prescription, acceptance, and compliance with postexposure therapy for those diagnosed with LTBI. Statistical Analyses The prevalence of LTBI was estimated as the percentage of those who had a positive TST among exposed HCWs. The

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hospital (eg, critical care and emergency care), and the majority were nurses (68.6%), followed by respiratory therapists (24.0%). Baseline TST status (based on a 1-step TST) was known for 41.3% (123/298) of the occupationally exposed HCWs (Figure 1). Among those with documented baseline TST, 51.2% (63/123) had a positive TST, and 48.8% (60/123) had a negative TST. HCWs with known positive baseline TST results (LTBI) represented 21.1% (63/298) of all occupationally exposed HCWs. Baseline TST positivity was statistically associated with the country of origin; those born in the Eastern Mediterranean (including Saudi Arabia) had lower TST positivity than those in other world regions (Table 2). Postexposure TST status was confirmed in 58.1% (173/298) of exposed HCWs and was not confirmed in 41.9% (125/298). HCWs with confirmed postexposure TST status included the majority (92.1%; 58/63) of those who had preexposure positive TST and nearly half (48.9%; 115/235) of those who had negative or unknown preexposure TST status. Fifty-three out of 115 (46.1%) exposed HCWs who had either negative (13/ 60) or unknown (40/175) preexposure TST status were di-

figure 1. Baseline (preemployment) and postexposure tuberculin skin test (TST) status and isoniazid (INH) prophylaxis among healthcare workers (HCWs; n p 298) at King Abdulaziz Medical City, Riyadh, Saudi Arabia, 2008–2010. TB, tuberculosis.

frequency of initiation of isoniazid prophylaxis was estimated as the percentage of those who began isoniazid prophylaxis out of those with LTBI who were prescribed isoniazid. The frequency of isoniazid prophylaxis completion was estimated as the percentage of those who completed the recommended isoniazid prophylaxis out of those who started isoniazid prophylaxis. The demographic and occupational characteristics of exposed HCWs were compared between those who had positive and negative TST. Fisher exact or x2 tests, as appropriate, were used to test for significant differences between the 2 groups. All P values were 2 tailed, and P ! .05 was considered significant. SPSS software (release 19.0; SPSS) was used for all statistical analyses.

results We identified 13 patients diagnosed with infectious TB who were linked to exposure to HCWs during the study period. All cases were pulmonary TB with no identified cases of laryngeal TB. An investigation of 13 index cases revealed a total of 298 contacts (Figure 1). As shown in Table 1, most of the exposed HCWs were female (62.9%) and non-Saudi (83.9%). The majority (61.0%) of exposed HCWs were from the Western Pacific WHO region, followed by the Eastern Mediterranean WHO region (26.1%). The majority (72.8%) of exposed HCWs were assigned to high-risk patient units in the

table 1. Demographic Characteristics of Healthcare Workers (n p 298) Occupationally Exposed to Infectious Tuberculosis Patients at King Abdulaziz Medical City, Riyadh, Saudi Arabia, 2008–2010 Characteristic

No. (%)

Age, mean (range), years Sex Female Male Citizenship Non-Saudi Saudi WHO region (country of origin) Western Pacific Eastern Mediterranean Africa Europe Southeast Asia Americas Occupation Nurse Respiratory therapist Physician Rehabilitation Administrative Work station Critical care Noncritical care Semicritical care Employment type Non-SANG SANG

37 (19–58) 176 (62.9) 104 (37.1) 229 (83.9) 44 (16.1) 166 71 18 8 7 2

(61.0) (26.1) (6.6) (2.9) (2.6) (0.7)

166 58 15 1 2

(68.6) (24.0) (6.2) (0.4) (0.8)

217 (72.8) 44 (14.8) 37 (12.4) 228 (83.8) 44 (16.2)

note. Data are no. (%), unless otherwise indicated. SANG, Saudi Arabian National Guard; WHO, World Health Organization.

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table 2. Demographic Characteristics of Healthcare Workers (n p 123) Occupationally Exposed to Infectious Tuberculosis Patients by Preemployment Tuberculin Skin Test (TST) Status at King Abdulaziz Medical City, Riyadh, Saudi Arabia, 2008–2010

Gender Female Male WHO region (country of origin) Western Pacific Eastern Mediterranean Africa Other Citizenship Non-Saudi Saudi Employment Status Non-SANG SANG

No.

TST negative

TST positive

P

85 38

42 (49.4) 18 (47.4)

43 (50.6) 20 (52.6)

.834

89 17 10 7

41 14 2 3

48 3 8 4

(53.9) (17.6) (80.0) (57.1)

.010

(46.1) (82.4) (20.0) (42.9)

115 6

54 (47.0) 4 (66.7)

61 (53.0) 2 (33.3)

.603a

115 8

54 (47.0) 6 (75.0)

61 (53.0) 2 (25.0)

.242a

note. Data are no. (%), unless otherwise indicated. SANG, Saudi Arabian National Guard; WHO, World Health Organization. a Fisher exact test, otherwise x2 test.

agnosed with postexposure LTBI (Figure 1). On referral and evaluation, all 53 HCWs had a normal chest X-ray and no signs or symptoms of active TB disease. Thirteen out of 53 (24.5%) postexposure LTBI diagnoses were confirmed TST converters, which also represented 21.7% (13/60) of those who had negative baseline TST results. The average conversion time was 2.8 years (range, 1.2–3.2; standard deviation, 2.3). On the other hand, 75.5% (40/53) of the HCWs diagnosed with postexposure LTBI lacked preexposure TST records, which represented 22.9% (40/175) of those who had no identified baseline TST results. Interestingly, 51.1% (120/ 235) of exposed HCWs who had negative or unknown preexposure TST status did not have their postexposure TST tested because of failure to contact, refusal, or no clinic show. There were no cases of TB developed among those who were identified with LTBI; hence, no secondary cases developed in the hospital. A standard 9-month course of isoniazid therapy was the only prescribed regimen for 92.5% (49/53) of the HCWs diagnosed with postexposure LTBI (without prior LTBI history). The reasons for not prescribing isoniazid prophylaxis to a few (n p 4) HCWs were as follows: refusal to take isoniazid for 9 months (1/4), pregnancy (2/4), and previous completion of anti-TB therapy (1/4). Forty-six out of 49 (93.9%) HCWs who were prescribed isoniazid prophylaxis already started LTBI therapy (Figure 1); the duration of LTBI therapy is shown in Figure 2. Among the HCWs who began LTBI therapy, only 17.4% (8/46) completed the recommended 9-month course within the following 12 months. On the other hand, 82.6% (38/46) of the HCWs who began LTBI therapy did not complete the treatment course because of nonadherence (22/46), lack of follow-up (9/46), or physician advice to discontinue LTBI therapy (7/46). This discontinuation was

due to the development of peripheral neuropathy (1/7), allergy (2/7), pregnancy (3/7), or inappropriate prescription (1/ 7). Finally, HCWs who were of Saudi citizenship were 4.8 times more likely to complete LTBI therapy than noncitizens (confidence interval, 1.6–14.2).

discussion We reported the TST status before and after occupational exposure to TB infection as well as postexposure management of LTBI in a culturally mixed population of HCWs at King Abdulaziz Medical City, National Guard Hospital in Riyadh, Saudi Arabia. We conducted this evaluation as part of a larger

figure 2. Duration of therapy for latent tuberculosis infection among 37 occupationally exposed healthcare workers (HCWs) at King Abdulaziz Medical City, Riyadh, Saudi Arabia, 2008–2010. INH, isoniazid.

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quality improvement initiative for TB management at KAMC-R because the load of annually diagnosed TB cases in the hospital was considered significant. For example, hospital statistics during the study years (2008–2010) estimated an average of 81 new TB cases diagnosed per year. Our study identified 13 index cases and 298 exposed HCWs during a 3-year period. We reported unacceptably low rates (approximately 40%) of baseline documentation of TST results among our exposed HCWs. The lack of baseline TST status may be partially explained by those who were hired before 2004, the year where preemployment TST status was mandated. Driver et al16 showed that unknown TST status at hire is approximately 21% among HCWs working in New York. Such screening among HCWs serves a vital function not only for identifying persons with LTBI but also for establishing a baseline for later evaluation of new infections once an exposure occurs. Additionally, despite the presence of local policies that require postexposure testing, more than half of the exposed HCWs never did. This emphasizes the need of administrative enforcement of postexposure testing and probably mandating postexposure clearance before yearly recontracting. More than half (51%) of the HCWs in the current study who had confirmed preemployment TST results were TST positive. The majority of these HCWs were born in high endemic countries, which is why the current rate was similar to rates from low- and middle-income countries (average, 54%; range, 33%–79%).17 However, the current results were much higher than reported (11%) among HCWs in 4 local hospitals in Riyadh.11 Approximately 22% of our HCWs had TST conversion within an average of 2.8 years. The annual risk of LTBI among HCWs ranged from 0.5% to 14.3% in a review from low- and middle-income countries17 and was 1% in a study from the United States.18 However, unlike the current study, these studies used mainly 2-step TSTs. Therefore, the comparison should be interpreted cautiously, since our conversion rate may be overestimated. HCWs with recent TST conversion are at a high risk of progression to active TB disease, especially HCWs with debilitating comorbidity.4 Despite the proven effectiveness of LTBI therapy,4 those diagnosed with LTBI often decline treatment, and many who begin treatment do not complete.19-22 We reported fair rates of initiation but poor rates of LTBI therapy completion. In the current study, 93% of those who were offered isoniazid had already started treatment. Similarly, in the United States and Canada, the majority (82%–91%) of patients who had positive TST started LTBI therapy.19-21 The low rates of completion of LTBI therapy observed in the current study (17% for a 9-month course and 59% if a 6-month course were considered) were even lower than rates reported elsewhere.19-22 In these studies, 39%–62% of patients who accepted treatment completed the recommended treatment duration of 6–9 months. Interestingly, the compliance with LTBI therapy among HCWs was shown to be even worse than non-HCWs exposed to TB in other settings.16,19 Many reasons for poor treatment acceptance and adherence were described. For example, the following risk factors have

been linked to failure of LTBI therapy: longer duration of treatment course; development of adverse effects of used medications; certain occupations, such as HCWs; lack of insurance; pregnancy; certain ethnicities, such as Asian and black patients; injection drug users; and patients living in nursing homes or far from the clinic.19-22 Failure to complete the recommended 9-month course of LTBI therapy among our HCWs was due to nonadherence, lack of follow-up, or development of side effects. Because the study design was a retrospective chart review, we were unable to identify the reasons behind noncompliance, which most likely require a separate prospectively designed study. LTBI is asymptomatic, and cases may never develop TB disease.3 Therefore, offering the patients a choice of regimen improves their compliance.23 Additionally, choosing a shorter course duration improves compliance and reduces the development of side effects.23,24 Our study addressed the challenges in protecting HCWs once exposed to infectious TB cases at a tertiary care hospital. Additionally, the current findings indirectly evaluated our LTBI prevention program and highlighted areas of potential improvement. Nevertheless, we acknowledge some limitations. The retrospective nature of our study may be an important reason for the considerable amount of missing data. We were unable to assess trends and conduct multivariate and stratified analyses. Being a single-center study may limit the generalizability of the findings. Since baseline TST status was not based on a 2-step method of testing, the results of TST conversion should be interpreted cautiously. Further, it has been difficult to verify history of TB-related issues among international hires in their home countries (eg, receiving bacillus Calmette-Gue´rin vaccine, history and results of TST tests, and regimen and duration of LTBI management, if any) as well as information on quitting LTBI treatment because of turnover and out-migration. Despite these limitations, we believe that documenting these deficiencies may be instructive to improve occupational and infection control measures at our institution and others in the region with similar challenges. In conclusion, we reported low rates of preemployment and postexposure screening for TB and fair rates of initiating but poor rates of completion of LTBI therapy among exposed HCWs at KAMC-R. We recommend administrative steps to minimize the risk of TB transmission at KAMC-R. These steps include mandating preemployment TB screening for all employees, enforcing evaluation of all HCWs following exposure to an infectious TB case, encouraging the initiation of shorter and patient-oriented courses of LTBI therapy, improving documentation and a means of follow-up with exposed HCWs, and finally initiating a program for annual evaluation of HCWs for TB and LTBI.

acknowledgments Potential conflicts of interest. All authors report no conflicts of interest relevant to this article. All authors submitted the ICMJE Form for Disclosure

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screening for ltbi among hcw s

of Potential Conflicts of Interest, and the conflicts that the editors consider relevant to this article are disclosed here.

12. Address correspondence to Hanan H. Balkhy, MD, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 22490, Riyadh 11426, Saudi Arabia ([email protected]).

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Compliance with postexposure screening and treatment of latent tuberculosis infection among healthcare workers in a tertiary care hospital in Saudi Arabia.

Controlling tuberculosis (TB) infection among occupationally exposed healthcare workers (HCWs) may be challenging...
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