Examining pulmonary TB patient management and healthcare workers exposures in two public tertiary care hospitals, Bangladesh.

Implementation of tuberculosis (TB) infection prevention and control (IPC) guidelines in public tertiary care general hospitals remain challenging due to limited evidence of pulmonary TB (PTB) patients' duration of hospital stay and management. To fill this evidence gap, this study examined adult PTB patient management, healthcare workers' (HCWs) exposures and IPC practices in two public tertiary care hospitals in Bangladesh.Between December 2017 and September 2019, a multidisciplinary team conducted structured observations, a hospital record review, and in-depth interviews with hospital staff from four adult medicine wards.Over 20 months, we identified 1,200 presumptive TB patients through the hospital record review, of whom 263 were confirmed PTB patients who stayed in the hospital, a median of 4.7 days without TB treatment and possibly contaminated the inpatients wards. Over 141 observation hours, we found a median of 3.35 occupants present per 10 m2 of floor space and recorded a total of 17,085 coughs and 316 sneezes: a median of 3.9 coughs or sneezes per 10 m2 per hour per ward. Only 8.4% of coughs and 21% of sneezes were covered by cloths, paper, tissues, or by hand. The HCWs reportedly could not isolate the TB patients due to limited resources and space and could not provide them with a mask. Further, patients and HCWs did not wear any respirators.The study identified that most TB patients stayed in the hospitals untreated for some duration of time. These PTB patients frequently coughed and sneezed without any facial protection that potentially contaminated the ward environment and put everyone, including the HCWs, at risk of TB infection. Interventions that target TB patients screening on admission, isolation of presumptive TB patients, respiratory hygiene, and HCWs' use of personal protective equipment need to be enhanced and evaluated for acceptability, practicality and scale-up.

Implementation status of national tuberculosis infection control guidelines in Bangladeshi hospitals.

In response to the World Health Organization (WHO) recommendation to reduce healthcare workers' (HCWs') exposure to tuberculosis (TB) in health settings, congregate settings, and households, the national TB control program of Bangladesh developed guidelines for TB infection prevention and control (IPC) in 2011. This study aimed to assess the implementation of the TB IPC healthcare measures in health settings in Bangladesh. Between February and June 2018, we conducted a mixed-method study at 11 health settings. The team conducted 59 key-informant interviews with HCWs to understand the status of and barriers impeding the implementation of the TB IPC guidelines. The team also performed a facility assessment survey and examined TB IPC practices. Most HCWs were unaware of the national TB IPC guidelines. There were no TB IPC plans or committees at the health settings. Further, a presumptive pulmonary TB patient triage checklist was absent in all health settings. However, during facility assessment, we observed patient triaging and separation in the TB specialty hospitals. Routine cough-etiquette advice was provided to the TB patients mentioned during the key-informant interviews, which was consistent with findings from the survey. This study identified poor implementation of TB IPC measures in health settings. Limited knowledge of the guidelines resulted in poor implementation of the recommendations. Interventions focusing on the dissemination of the TB IPC guidelines to HCWs along with regular training may improve compliance. Such initiatives should be taken by hospital senior leadership as well as national policy makers.

A tuberculin skin test survey among healthcare workers in two public tertiary care hospitals in Bangladesh.

In Bangladesh, there is currently no data on the burden of latent TB infection (LTBI) amongst hospital healthcare workers (HCWs). This study aimed to determine the prevalence of LTBI and compare the prevalence among HCWs in two public tertiary care hospitals. Between September 2018 and August 2019, we conducted a cross-sectional study in two public tertiary care general hospitals. Using a survey and tuberculin skin test (TST), we assessed risk factors for LTBI, adjusting for known and plausible confounders. In addition, a facility assessment was undertaken to understand the implementation of relevant IPC measures. The prevalence of LTBI among HCWs was 42%. HCWs spent a median of 6 hours (SD = 1.76, IQR 2.00) per day and attended an average of 1.87 pulmonary TB patients per week. HCWs did not receive any TB IPC training, the wards lacked a symptom checklist to screen patients for TB, and no masks were available for coughing patients. Seventy-seven percent reportedly did not use any facial protection (masks or respirators) while caring for patients. In the multivariable model adjusting for hospital level clustering effect, TST positivity was significantly higher among HCWs aged 35-45 years (aOR1.36, 95% CI: 1.06-1.73) and with >3 years of service (aOR 1.67, 95% CI: 1.62-1.72). HCWs working in the medicine ward had 3.65 (95% CI: 2.20-6.05) times, and HCWs in the gynecology and obstetrics ward had 2.46 (95% CI: 1.42-4.27) times higher odds of TST positivity compared to HCWs working in administrative areas. This study identified high prevalence of LTBI among HCWs. This may be due to the level of exposure to pulmonary TB patients, and/or limited use of personal protective equipment along with poor implementation of TB IPC in the hospitals. Considering the high prevalence of LTBI, we recommend the national TB program consider providing preventative therapy to the HCWs as the high-risk group, and implement TB IPC in the hospitals.