Beyond tuberculosis: a person-centred and rights-based approach to screening for household contacts.

Households affected by tuberculosis have syndemic vulnerability, reflecting a concentration of and interactions between multiple biomedical, psychosocial, and structural determinants of health. Traditional approaches to tuberculosis screening do not address pre-existing risks, such as undernutrition and other chronic conditions, or the indirect effects of tuberculosis, such as loss of livelihood. These pre-existing risks and consequences not only perpetuate the global tuberculosis epidemic but, for those affected, lead to poor health and deepen poverty. We propose reimagining tuberculosis screening as an opportunity to deliver a contextually relevant package of services that address the needs of households affected by tuberculosis. This approach puts people and their rights at the centre of efforts to end tuberculosis, and has equity at the core. This approach could support progress towards universal health coverage, benefiting communities and health systems. Leadership, flexibility in funding allocation, and innovative care models will be required to realise this approach at scale.

Health Screening Strategies for Artisanal and Small-Scale Miners for Tuberculosis, Human Immunodeficiency Virus and Silicosis: A Case of the USAID-Supported Kunda Nqob'iTB Project in Zimbabwe.

Artisanal and small-scale mining is characterized by excessive exposure to physical, chemical, ergonomic, psychosocial and biological hazards. There is a high burden of tuberculosis (TB), human immunodeficiency virus (HIV) infections and silicosis among artisanal and small-scale miners (ASMs). The aim of this project report is to describe lessons learned from strategies implemented to reach ASMs with screening services for TB, HIV and silicosis in Zimbabwe through the Kunda-Nqob'i TB (KNTB) project supported by the United States Agency for International Development (USAID). The intervention package for screening ASMs for TB, HIV and silicosis included service provision through two occupational health clinics at two provincial hospitals and a mobile workplace-based screening (WBS) facility at the mining sites. From 1 October 2020 to 30 September 2023, 10,668 ASMs were screened, with a high number of cases of silicosis (21%) and TB (7.4%). There was a high burden of HIV (30%) in ASMs attending the occupational health clinics. The two occupational health clinics screened 3453 ASMs, while the mobile WBS activities screened 7215 ASMs during the period. A total of 370 healthcare workers (doctors/clinical officers, nurses, environmental health technicians and district tuberculosis and Leprosy control officers) were trained on TB and the fundamental diagnostic principles of silicosis. The KNTB project has been successful in reaching out to many ASMs operating in remote and hard-to-reach mining areas. The KNTB project has brought to light the positive health-seeking behavior of ASMs operating in remote areas. The project has brought to the fore the effectiveness of multi-stakeholder engagement and collaboration in reaching out to ASMs in remote areas with health screening services. There is a high burden of TB, HIV and silicosis in ASMs. Screening for TB, HIV and silicosis using workplace-based screening and occupational health clinics is an effective strategy and should be rolled out to all areas with high artisanal and small-scale mining activity.

Prevalence of chronic conditions and multimorbidity among healthcare workers in Zimbabwe: Results from a screening intervention.

The burden of non-communicable diseases (NCDs) in southern Africa is expanding and is superimposed on high HIV prevalence. Healthcare workers are a scarce resource; yet are vital to health systems. There are very limited studies on the burden of chronic conditions among healthcare workers in Africa, and none exploring multimorbidity (≥2 chronic conditions). We describe the epidemiology of infectious (HIV) and non-communicable chronic conditions, and multimorbidity, among Zimbabwean healthcare workers. Healthcare workers (≥18 years) in eight Zimbabwean provinces were invited to a voluntary, cross-sectional health-check, including HIV, diabetes, hypertension and mental health screening. Statistical analyses described the prevalence and risk factors for multimorbidity (two or more of HIV, diabetes, hypertension or common mental disorder) and each condition. Missing data were handled using multiple imputation. Among 6598 healthcare workers (July 2020-July 2022) participating in the health-check, median age was 37 years (interquartile range 29-44), 79% were women and 10% knew they were living with HIV. Half had at least one chronic condition: 11% were living with HIV, 36% had elevated blood pressure, 12% had elevated HbA1c and 11% had symptoms of common mental disorder. The overall prevalence of multimorbidity was 15% (95% CI: 13-17%); 39% (95% CI: 36-43%) among people aged 50 and older. Whilst most HIV was diagnosed and treated, other chronic conditions were usually undiagnosed or uncontrolled. Limiting our definition of multimorbidity to two or more screened conditions sought to reduce bias due to access to diagnosis, however, may have led to a lower reported prevalence than that found using a wider definition. Half of healthcare workers screened were living with a chronic condition; one in seven had multimorbidity. Other than HIV, most conditions were undiagnosed or untreated. Multisectoral action to implement contextually relevant, chronic disease services in Africa is urgently needed. Specific attention on health workers is required to protect and retain this critical workforce.

Evaluation of a comprehensive health check offered to frontline health workers in Zimbabwe.

Health workers are essential for a functioning healthcare system, and their own health is often not addressed. During the COVID-19 pandemic health workers were at high risk of SARS-CoV-2 infection whilst coping with increased healthcare demand. Here we report the development, implementation, and uptake of an integrated health check combining SARS-CoV-2 testing with screening for other communicable and non-communicable diseases for health workers in Zimbabwe during the COVID-19 pandemic. Health checks were offered to health workers in public and private health facilities from July 2020 to June 2022. Data on the number of health workers accessing the service and yield of screening was collected. Workshops and in-depth interviews were conducted to explore the perceptions and experiences of clients and service providers. 6598 health workers across 48 health facilities accessed the service. Among those reached, 5215 (79%) were women, the median age was 37 (IQR: 29-44) years and the largest proportion were nurses (n = 2092, 32%). 149 (2.3%) healthcare workers tested positive for SARS-CoV-2. Uptake of screening services was almost 100% for all screened conditions except HIV. The most common conditions detected through screening were elevated blood pressure (n = 1249; 19%), elevated HbA1c (n = 428; 7.7%) and common mental disorder (n = 645; 9.8%). Process evaluation showed high acceptability of the service. Key enablers for health workers accessing the service included free and comprehensive service provision, and availability of reliable point-of-care screening methods. Implementation of a comprehensive health check for health workers was feasible, acceptable, and effective, even during a pandemic. Conventional occupational health programmes focus on infectious diseases. In a society where even health workers cannot afford health care, free comprehensive occupational health services may address unmet needs in prevention, diagnosis, and treatment for chronic non-communicable conditions.

Knowledge, Attitudes, and Practices of Artisanal and Small-Scale Miners regarding Tuberculosis, Human Immunodeficiency Virus, and Silicosis in Zimbabwe.

In Zimbabwe, artisanal and small-scale miners (ASMs) have a high prevalence of tuberculosis (TB), human immunodeficiency virus (HIV), and silicosis. Previous studies on ASMs utilised programme data, and it was not possible to understand reasons for the high prevalence of these comorbidities. We conducted a cross-sectional study to investigate the knowledge, attitudes, and practices of ASMs regarding TB, HIV, and silicosis. We enrolled a convenience sample of 652 ASMs. Their mean (standard deviation) age was 34.2 (10.8) years. There were 602 (92%) men and over 75% had attained secondary education. A total of 504 (80%) of the ASMs knew that TB is a curable disease, and 564 (87%) knew that they were at higher risk of TB than the general population. However, they were less likely to know that HIV increases the risk of TB disease, 340 (52%), with only 226 (35%) who perceived the risk of TB infection to be high among ASMs. Only 564 (59%) were aware that silica dust causes permanent and incurable lung diseases. Six hundred and twenty (97%) showed a positive attitude towards healthcare when they were sick, and 97% were willing to use special respirators to prevent dust inhalation. On practices, only 159 (30%) reported consistent use of either cloth or respirators to prevent dust inhalation. Three hundred and five (49%) ASMs reported consistent use of condoms outside their homes and 323 (50%) reported use of water to suppress dust. Only 480 (75%) of ASMs sought healthcare services when sick. ASMs cited challenges of accessing healthcare services due to lack of money to pay for healthcare (50%), long distances to clinics (17%), and the shortage of medicines at clinics (11%). Effective control of TB, silicosis, and HIV among ASMs requires addressing the identified knowledge gaps and barriers that are faced by ASMs in accessing personal protective equipment and healthcare services. This will require multisector collaboration and the involvement of ASMs in co-designing a package of healthcare services that are tailored for them.

Coping with drug resistant tuberculosis alongside COVID-19 and other stressors in Zimbabwe: A qualitative study.

Households in low-resource settings are more vulnerable to events which adversely affect their livelihoods, including shocks e.g. death of family members, droughts and more recently COVID-19. Drug Resistant Tuberculosis (DR-TB) is another shock that inflicts physical, psychological and socioeconomic burden on individuals and households. We describe experiences and coping strategies among people affected by DR-TB and their households in Zimbabwe during the COVID-19 pandemic, 2020-2021. We purposively selected 16 adults who had just completed or were completing treatment for DR-TB for in-depth interviews. We transcribed audio-recordings verbatim and translated the transcripts into English. Data were coded both manually and using NVivo 12 (QSR International), and were analysed thematically. Health seeking from providers outside the public sector, extra-pulmonary TB and health system factors resulted in delayed DR-TB diagnosis and treatment and increased financial drain on households. DR-TB reduced productive capacity and narrowed job opportunities leading to income loss that continued even after completion of treatment. Household livelihood was further adversely affected by lockdowns due to COVID-19, outbreaks of bird flu and cattle disease. Stockouts of DR-TB medicines, common during COVID-19, exacerbated loss of productive time and transport costs as medication had to be accessed from other clinics. Reversible coping strategies included: reducing number of meals; relocating in search of caregivers and/or family support; spending savings; negotiating with school authorities to keep children in school. Some households adopted irreversible coping strategies e.g. selling productive assets and withdrawing children from school. DR-TB combined with COVID-19 and other stressors and pushed households into deeper poverty and vulnerability. Multisectoral approaches that combine health systems and socioeconomic interventions are crucial to mitigate diagnostic delays and suffering, and meaningfully support people with DR-TB and their households to compensate the loss of livelihoods during and post DR-TB treatment.

Coping with drug resistant tuberculosis alongside COVID-19 and other stressors in Zimbabwe: a qualitative study.

Background: Households in low-resource settings are more vulnerable to events which adversely affect their livelihoods, including shocks such as the death of a family member, inflation, droughts and more recently COVID-19. Drug Resistant Tuberculosis (DR-TB) is also another shock that inflicts physical, psychological and socioeconomic burden on individuals and households. We describe experiences and coping strategies among people affected by DR-TB and their households in Zimbabwe during the COVID-19 pandemic, 2020 to 2021. Methods: We conducted 16 in-depth interviews with adults who had just completed or were completing treatment. Interview themes included health seeking behaviour, impact of DR-TB on livelihoods and coping strategies adopted during treatment. We analysed data using thematic analyses. Results: Health seeking from providers outside the public sector, extra-pulmonary TB and health system factors resulted in delayed DR-TB diagnosis and treatment and increased financial drain on households. DR-TB reduced productive capacity and narrowed job opportunities leading to income loss that continued even after completion of treatment. Household livelihood was further adversely affected by lockdowns due to COVID-19, outbreaks of bird flu and cattle disease. Stockouts of DR-TB medicines, common during COVID-19, exacerbated loss of productive time and transport costs as medication had to be accessed from other clinics that were further away. Reversible coping strategies included: reducing number of meals; relocating in search of caregivers and/or family support; spending savings; negotiating with school authorities to keep children in school. Some households had to adopt irreversible coping strategies such as selling productive assets and withdrawing children from school. Conclusion: DR-TB combined with COVID-19 and other stressors pushed households into deeper poverty, and vulnerability. Multi-sectoral approaches that combine health systems, psychosocial and economic interventions are crucial to mitigate diagnostic delays and suffering, and meaningfully support people with DR-TB and their households to compensate the loss of livelihoods during and post DR-TB treatment.

The Triple Burden of Tuberculosis, Human Immunodeficiency Virus and Silicosis among Artisanal and Small-Scale Miners in Zimbabwe.

Artisanal and small-scale mining is characterized by an excessive exposure to silica-containing dust, overcrowding, poor living conditions and limited access to primary health services. This poses a risk to tuberculosis, HIV infection and silicosis. The main purpose of the study is to evaluate the burden of tuberculosis, HIV and silicosis among artisanal and small-scale miners. We conducted a cross sectional study on 3821 artisanal and small-scale miners. We found a high burden of silicosis (19%), tuberculosis (6.8%) and HIV (18%) in a relatively young population, with the mean age of 35.5 years. Men were 1.8 times more likely to be diagnosed with silicosis compared to women, adjusted prevalence ratio [aPR = 1.75 (95% CI: 1.02-2.74)]. Artisanal and small-scale miners who were living with HIV were 1.25 times more likely to be diagnosed with silicosis compared to those who were negative, [aPR = 1.25 (1.00-1.57)]. The risk of silicosis increased with both duration as a miner and severity of exposure to silica dust. The risk of tuberculosis increased with the duration as a miner. Zimbabwe is currently experiencing a high burden of TB, silicosis and HIV among artisanal and small-scale miners. Multi-sectoral and innovative interventions are required to stem this triple epidemic in Zimbabwe.

Tuberculosis and Silicosis Burden in Artisanal and Small-Scale Gold Miners in a Large Occupational Health Outreach Programme in Zimbabwe.

Artisanal and small-scale miners (ASMs) labour under archaic working conditions and are exposed to high levels of silica dust. Exposure to silica dust has been associated with an increased risk of tuberculosis and silicosis. ASMs are highly mobile and operate in remote areas with near absent access to health services. The main purpose of this study was to evaluate the prevalence of tuberculosis, silicosis and silico-tuberculosis among ASMs in Zimbabwe. A cross-sectional study was conducted from 1 October to 31 January 2021 on a convenient sample of 514 self-selected ASMs. We report the results from among those ASMs who attended an outreach medical facility and an occupational health clinic. Data were collected from clinical records using a precoded data proforma. Data variables included demographic (age, sex), clinical details (HIV status, GeneXpert results, outcomes of chest radiographs, history of tuberculosis) and perceived exposure to mine dust. Of the 464 miners screened for silicosis, 52 (11.2%) were diagnosed with silicosis, while 17 (4.0%) of 422 ASMs were diagnosed with tuberculosis (TB). Of the 373 ASMs tested for HIV, 90 (23.5%) were sero-positive. An HIV infection was associated with a diagnosis of silicosis. There is need for a comprehensive occupational health service package, including TB and silicosis surveillance, for ASMs in Zimbabwe. These are preliminary and limited findings, needing confirmation by more comprehensive studies.

Comprehensive occupational health services for healthcare workers in Zimbabwe during the SARS-CoV-2 pandemic.

BACKGROUND: Healthcare workers are disproportionately affected by COVID-19. In low- and middle- income countries, they may be particularly impacted by underfunded health systems, lack of personal protective equipment, challenging working conditions and barriers in accessing personal healthcare. METHODS: In this cross-sectional study, occupational health screening was implemented at the largest public sector medical centre in Harare, Zimbabwe, during the "first wave" of the country's COVID-19 epidemic. Clients were voluntarily screened for symptoms of COVID-19, and if present, offered a SARS-CoV-2 nucleic acid detection assay. In addition, measurement of height, weight, blood pressure and HbA1c, HIV and TB testing, and mental health screening using the Shona Symptom Questionnaire (SSQ-14) were offered. An interviewer-administered questionnaire ascertained client knowledge and experiences related to COVID-19. RESULTS: Between 27th July and 30th October 2020, 951 healthcare workers accessed the service; 210 (22%) were tested for SARS-CoV-2, of whom 12 (5.7%) tested positive. Clients reported high levels of concern about COVID-19 which declined with time, and faced barriers including lack of resources for infection prevention and control. There was a high prevalence of largely undiagnosed non-communicable disease: 61% were overweight or obese, 34% had a blood pressure of 140/90mmHg or above, 10% had an HbA1c diagnostic of diabetes, and 7% had an SSQ-14 score consistent with a common mental disorder. Overall 8% were HIV-positive, with 97% previously diagnosed and on treatment. CONCLUSIONS: Cases of SARS-CoV-2 in healthcare workers mirrored the national epidemic curve. Implementation of comprehensive occupational health services during a pandemic was feasible, and uptake was high. Other comorbidities were highly prevalent, which may be risk factors for severe COVID-19 but are also important independent causes of morbidity and mortality. Healthcare workers are critical to combatting COVID-19; it is essential to support their physical and psychological wellbeing during the pandemic and beyond.