2 THE SOUTH AFRICAN SOCIETY OF OCCUPATIONAL MEDICINE MANAGEMENT OF TUBERCULOSIS IN INDUSTRY SASOM GUIDELINE 2 ISBN: ISBN: 978-1-919727-59-2 2011 by SASOM All rights are reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the copyright owner.
MANAGEMENT OF TUBERCULOSIS IN INDUSTRY 1. INTRODUCTION Tuberculosis (TB) is on the increase in South Africa, and markedly so in certain geographical areas. A general deterioration in socio-economic conditions with rising unemployment rates, increasing urbanisation without proper infra-structure, squatter settlements, diminishing health-service resources and finally, the increase in HIV infection with reduced immune response, is leading to an upsurge in the TB incidence. 1.1 At early diagnosis TB can be cured by medication without loss of time, wages or production. Late diagnosis may lead to prolonged hospitalisation with inevitable damage to lungs or other organs. Thus industry and commerce must make a major effort to detect the illness as early as possible. 1.2 TB control requires a combined effort involving the community, employers, workers, health authorities and labour. Industry has a responsibility in this regard and the workplace is an ideal place to diagnose TB and also to treat it. This applies not only to larger undertakings that employ medical staff, but also to smaller ones. 1.3 Management of TB cases in mines requires additional measures because of the occupational risk of silica dust, the high TB incidence rates, the high prevalence of nontuberculous mycobacterial (NTM) disease and because tuberculosis and silicotuberculosis are compensable diseases in terms of the ODMWA. 2. RATES OF TB IN SOUTH AFRICA 2.1 TB is still a major cause of death and disease worldwide with estimates of 9,2 million new TB cases in 2006 and 1,7 million deaths, including 200 000 in clients who were co-infected with HIV. Even though the global epidemic is on the decline with decreasing global TB prevalence and death rates, the total number of new TB cases is still rising due to population growth. The average estimated incidence 1 of TB globally is 139 cases per 100 000 of the population. The TB incidence in Africa is higher, at 363 cases per 100 000 of the population, and in South Africa it is a massive 940 per 100 000 of the population. (Quoted from the National TB management guidelines 2008). 2.2 Since many cases are not notified, the actual rates could be higher than quoted here. 3. HIGH-RISK GROUPS 3.1 Certain groups of workers may be classified as being at higher risk of contracting the disease. Active screening of these groups to detect the disease is therefore recommended. 3.2 The following is not an exhaustive list: 3.2.1 Workers from high-prevalence areas (Western Cape, Eastern Cape and Free State). Different population groups in these areas will have varying rates, and only those groups with high rates should be classified as being at a high risk. 3.2.2 TB contacts. 3.2.3 Workers previously treated for TB, as the possibility of recurrence is always present, especially if they did not complete the treatment course. 3.2.4 Chronic alcoholism and heavy alcohol consumption lead to poor nutrition and impaired resistance. SASOM Guideline 2 Revision: December 2009 Page 2 of 6
3.2.5 HIV infection leading to impaired immune response 3.2.6 Hostel dwellers and migrant workers 3.2.7 Exposure to adverse environmental conditions, eg silica in the mines and dust in foundries. 3.2.8 The risks may not be significant on their own, but when compounded, the risks are significantly increased, eg migrant workers who work in a foundry or mine, and living together in a hostel. 2 4. PREVENTION OF TB TB in adults in South Africa is due both to contact with infection, and to a breakdown in resistance as most people have unknowingly been infected with the tubercle bacilli earlier in life. Although it remains important to examine close contacts of patients found to have active TB, prevention lies more in the area of health education and avoidance of the risk factors mentioned above; such as poor nutrition, excessive alcohol usage, adverse environmental working conditions, etc. Health education of management, workers and the labour movement is necessary to increase awareness. To some extent TB is a socioeconomic disease, and provision of subsidised balanced meals at work and housing assistance for workers, will assist in TB control. 5. CASE FINDING AND MEDICAL SURVEILLANCE 5.1 Applicants for jobs initial health evaluation, including pre-employment and pre-placement examination. 5.1.1 Clinical suspicion and referral of TB is the best way of detecting TB. 5.1.2 A chest X-ray could be part of the initial health evaluation for an applicant who comes from a high-risk group. However, if there is clinical suspicion it should be followed by sputum testing. If the chest X-ray is abnormal, the person should be referred to the appropriate local authority clinic. 5.1.3 There is no reason why a prospective worker with TB without physical impairment cannot be employed in situations where there is no or little environmental hazard such as dust. Once he or she receives ambulatory treatment, the worker will only be infective for a short period (about three days to two weeks) and can perform a normal job function and will almost certainly be completely cured after a course of treatment. 5.2 Passive case finding 5.2.1 This term denotes a situation where workers seek treatment because of symptoms such as persistent coughing, coughing up blood, loss of weight and appetite, night sweats, lassitude, or presented to the health service on the instigation of supervisors, co-workers or friends who observe them to be not well, or are identified by medical staff. 5.2.2 Passive case finding is widely recommended as the most effective form of identifying individuals with TB. Chest X-ray followed by sputum examination (including culture where available) is the standard approach. 5.2.3 The principal aim is early diagnosis, resulting from community and worker education programmes. This should lead to early referral to local authority clinics. 5.3 Active case finding 5.3.1 Indiscriminate large-scale chest X-ray campaigns at the workplace are not cost effective. However, in addition to passive case finding, an active case-finding SASOM Guideline 2 Revision: December 2009 Page 3 of 6
programme for selected high-risk individuals or groups of workers is justified. The methods of choice for this are monthly weight monitoring, and periodic chest X-rays by law as required by the Occupational Diseases in Mines and Works Act. 5.3.2 Monthly weighing is a cheap and simple test and a two to three kilogram loss may indicate reactivation. At the time of weighing, the worker may also be asked about cough and general well-being. All ex-tb cases should be routinely weighed. 5.3.3 Contact tracing and follow-up of contacts is a simple procedure in workers. Prolonged close association with an infectious co-worker may occur in certain work situations, but is more common in hostel dwellers who share a room. 5.3.4 Sputum investigation can be carried out at reasonably low cost. Microscopy will confirm infection, which poses the greatest threat for spread of the disease, while bacterial culture will identify another 25-50 % of cases with active disease. 6. TREATMENT 6.1 TB is an emotive issue, and all patients should be cared for with sympathy, tolerance and patience. 6.2 Ambulatory treatment while remaining at work is appropriate if early diagnosis has been made and the patient is supervised daily by medical staff or even a foreman or colleague DOTS. However, if the disease is advanced, the worker might need admission to a TB hospital for three to six months. During this period support and regular contact with the worker are essential. 6.3 Treatment of TB is provided free of charge by local authorities. The Department of Health subsidises expenditure incurred by local authorities for hospitalisation and/or treatment of TB sufferers, and are usually prepared to delegate supervision of treatment to medical staff at the workplace. Thus close cooperation between occupational health staff and health authorities is essential. One major problem in treating TB is compliance with the treatment for the entire period. The worker with TB should be seen to take his or her medication every day, and the workplace is the best place to arrange daily supervision of this. 6.4 Once placed on treatment, an active pulmonary TB patient is no longer contagious to others after 3 days to 2 weeks. If he or she is fit to work, there is no need to dismiss such a worker. It is likely that during the treatment period, the attendance record will be very good as a result of the daily supervision of the treatment. 6.5 If the worker is exposed to environmental hazards such as dust, chemicals, etc, then the worker may have to be removed temporarily until the condition has cleared. 7. TB AND HIV INFECTION 7.1 The relationship between TB and HIV infection is well established and a specific strategy in relation to HIV and TB is required. 7.2 The clinical presentation of TB in an HIV infected person may differ from that in people with normal cellular immunity. X-ray presentation may also be atypical. Pulmonary TB in the upper lung zones with cavitation (a common presentation) is less common and patients may present with infiltrates in any lung zone, often associated with enlarged lymph nodes elsewhere. 7.3 All patients with TB and, in particular those with atypical presentations, should be tested for HIV. The Department of Health recommends that all TB patients with indications of multiple drug resistance should be tested for HIV. SASOM Guideline 2 Revision: December 2009 Page 4 of 6
7.4 It is assumed that local authorities who are responsible for the treatment of TB, and who diagnose patients with HIV will inform the relevant company medical departments subject to normal ethical considerations to enable medical staff to counsel such workers and treat other possible medical complications. 7.5 Prevention of sexually transmitted infections by education and supply of condoms could lead to a reduction in HIV infection, and subsequently reduce TB risk. 2 7.6 All patients with HIV should be put on TB prophylaxis and permanently be removed from high-risk TB areas. 8. EDUCATION Health education of management and workers is essential for prevention, early detection and effective treatment of TB. It has been shown that inadequate knowledge of the disease and its treatment in the community, are key factors in the failure to control TB. Moral support and assurance to the TB sufferer of his or her relevance to the company is essential, especially as a diagnosis of TB may sometimes lead to dismissal or relocation to another job. 9. COMPANY RESPONSIBILITY 9.1 A company has an important responsibility in helping to combat TB. 9.2 A written TB guideline or policy, agreed to by both management and worker representatives, and which includes a commitment to health surveillance, DOTS and where possible job protection is essential for a TB control programme to be successful. 9.3 The document should be readily available, and all workers should have some knowledge of its contents. It should include aspects such as the following: 9.3.1 Education about the disease to ensure early detection in those with symptoms (passive case finding). 9.3.2 Commitment to DOTS. 9.3.3 Access to health authorities for routine check-ups, etc. 9.3.4 Job protection as far as reasonably practicable. 9.3.5 Adequate sick pay provisions according to company policy. 9.3.6 Relocation to other work to avoid exposure to lung contaminants such as dust, chemicals, etc, when necessary. 9.3.7 Pension on the grounds of ill-health similar to any other chronic disease if any worker suffers damage to the extent the he or she cannot continue to work. 10. WORKER AND UNION RESPONSIBILITY 10.1 Workers and their representatives have an important responsibility to observe company guidelines or policies with regard to TB, and must help to ensure that workers are familiar with its contents. Unions can also embark on TB control programmes. This will be of great assistance. 10.2 It is important that during strikes and lock-outs, workers with TB should have continual access to their medication, and that arrangements are made to ensure that the course of treatment is not interrupted. SASOM Guideline 2 Revision: December 2009 Page 5 of 6
11. CONCLUSION TB is a major problem in South Africa, and due to factors such as poor socio-economic conditions, rapid urbanisation, etc, the situation is deteriorating. Infection with the HIV virus is another dimension that will result in a further deterioration of this problem. The control of TB is everyone s problem, and efforts by companies, their workers and unions, are required to assist in combating it. 12. SUMMARY 12.1 Tuberculosis (TB), a disease linked to poor socio-economic conditions, is rife in South Africa and figures show that it is increasing. The number of daily deaths from this disease is in excess of 20. 12.2 The advent of infection with Human Immuno-deficiency Virus (HIV) and AIDS has added a new dimension to the TB problem as the diminished resistance to disease leads to a significant increase in TB. The association between HIV and TB is very high in Africa, where in some areas 50 % of TB patients are also infected with HIV. 12.3 The workplace is the preferred place not only to detect TB, but also to treat it without loss of production and earnings in the majority of cases. 12.4 Diagnoses and treatment are provided free of charge to the worker by the local authority. 12.5 Identification of high-risk groups and case findings based on a high level of awareness will pay dividends for all. 12.6 Providing management and workers with information on the causes, signs and symptoms, as well as the seriousness of TB, is essential for prevention, early detection and effective treatment. 12.7 No worker with TB needs to be dismissed, unless he or she has lung damage that is severe enough to warrant retirement on the grounds of ill-health. On the contrary, supervised treatment at work will result in a cure, and may improve the performance of the worker. BIBLIOGRAPHY 1. Guidelines for the Management of Tuberculosis in Industry, SASOM Newsletter 10, May 1986 2. Dr D Rees, Personal Communication, NCOH, Johannesburg, 1990 Epidemiological Comments. 3. Tuberculosis Control Programme, Volume 18, 8 August 1991 4. Dr PB Fourie, Personal Communication, MRC, National Tuberculosis Research Programme 5. SA National Tuberculosis Guidelines 2008 6. National TB Infection Control Guidelines June 2007 7. Tuberculosis Strategic Plan For South Africa 2007-2011 NOTE The SASOM guidelines are active working documents that are reviewed regularly or as changes take place in legislation, the work or the workplace. Your inputs and comments are therefore regarded as most valuable. Please send them to info@sasom.org. SASOM Guideline 2 Revision: December 2009 Page 6 of 6