Challenges Of Managing Tuberculosis In The Workplace Or Community

Infection Prevention and Control Theory

Tuberculosis is a disease of considerable severity, characterized by the potential harm inflicted upon the diseased individual’s lungs, through the aerial transmission of pathogenic bacteria (Stone et al. 2015). Tuberculosis emerged as an epidemic, during the mid 1980s, in concurrence with HIV AIDS, due to the compromised effects in immunity inflicted by the latter (Houben and Dodd 2016).

Despite its considerable reduction in the rate of reporting to 58.3 per 100, 000 citizens, the statistics stated by the Health Department of the Government of Hong Kong, still remains significantly high when compared to the European and American counterparts. In accordance to the Center for Health Protection in Hong Kong, undertaking activities aimed at prevention of tuberculosis continues to remain a challenging affair due to increasing number of aged citizens, chronic  disease victims and high disease transmission rates from neighboring nations heavily contaminated with the disease (You et al. 2016).

The following paragraphs of the report, aim to shed light on the  nature, mode of transmission and health consequences implicated by the tuberculosis bacteria, followed by the salient measures required to prevent and control the transmission and infliction of this deadly disorder. Lastly, the report focuses on the key organizational and public health policy attempts undertaken by the government of Hong Kong for the  purpose of mitigation of tuberculosis.

Pathogenecity 

Source of Infection

Tuberculosis is caused by Mycobacterium  tuberculosis, a  pathogenic bacterial strain which is air-borne. The primary causative underlying tuberculosis infliction and transmission is the M. tuberculosis complex which is composed of seven strains of bacteria closely related to M. tuberculosis. These include bacterial strains such as M. microti, M. canetti, M. africanum, M. mungi, M. bovis, M. pinnipedii and M. caprae (Getahun et al. 2015). The concerned bacterium is aerobic in nature, non-spore forming and rod shaped, consisting of a diameter of 1 to 5 microns. The cell wall of M. tuberculosis, is composed of mycolic and fatty acid, with attachments to the peptidoglycan layer in covalent bonds. The bacteria’s unique plasma membrane is the causative factor behind a majority of the detrimental complications associated with tuberculosis, such as the provision of resistance towards defense mechanisms of the host as well as by medications such as antibiotics (Merket et al. 2015).

Mode of Infection

Transmission occurs through the air, in the form of droplet nuclei produced through activities of individuals such as talking, coughing, sneezing or singing, especially by patients who are already inflicted with tuberculosis. The concerned bacteria remain suspended in the air of the surrounding vicinity, from as little as seconds to prolonged periods ranging for hours (Yates et al. 2016). The transmission of the M. tuberculosis is further associated with additional factors such as ultraviolet exposure encountered by the bacilli, occurrences of aerosolization, rate of ventilation along with the amount of bacilli and virulence rate of the concerned bacilli present in the droplets

. Upon inhalation, the pathogenic strain transmits to the pulmonary system, severely affecting the lungs, followed by possible transmission of additional associated organs causing extra-pulmonary tuberculosis such as in the joints or bones, lymphatic system, meninges and pleura (Walker et al. 2014). Hence, the transmission of tuberculosis causing bacterial strains is due to an interplay of factors associated with the environmental factors affecting bacilli concentration in the surroundings, susceptibility or immunological capacities of the inflicted victim, infectiousness or the amount harmful pathogens released by the individual and exposure characteristics such as closeness, duration and frequency in which the potential victim inhabits the infected surroundings (Yuen et al. 2015).

Pathogenecity

Pathogenesis

Upon inhalation, the droplets containing the pathogenic bacilli engagement in settlement upon the air passages. As a primary defense mechanism, the mucociliary system engages in removal of the harmful bacilli through mucous production and upward expelling movements exhibited by the cilia. However, pathogenic bacteria may bypass this mechanism, leading to their rapid dissemination towards the alveolar tissues of the pulmonary system. Such events lead to responses by the innate immune system of the body, resulting in engulfment of the pathogenic particles by the macrophages present in the alveoli (Allwood et al. 2017).

The resultant immune defense processes of phagocytosis exhibited by  the  macrophages results in possible mechanisms, which include the positive controlling of the disease which may result in latent tuberculosis, or further dissemination of the disease,  leading to tuberculosis of the progressive type.  Upon   macrophage ingestion,  the bacteria engages in gradual multiplication despite  the  defense mechanisms exhibited  by the macrophages involving the production of proteolytic enzymes and cyotokines.

Such defense mechanisms range consist of a time frame of over 12 weeks, within which the pathogenic strains engage in multiplication of considerable sufficiency, for surpassing the immune mechanisms of the body (Kilborn, van Rensburg and Candy 2015). However, according to Bragina et al. (2014), additional microbial mechanisms are formed for individuals whose cell-mediated immune system continues remain active. These include creation of lesions or nodules or  granulomas  characterized  by  accumulation  of T –lymphocytes  and  macrophages  which  result in adaptation by the bacilli to survive, leading to transformation of phenotype expression emphasized by regulation of proteins.

Impact

The associated signs and symptoms in tuberculosis occurs on the basis of the location or concerned organ system inflicted with the pathogenic strain. However, the major signs and symptoms associated with tuberculosis occur in the lungs. These include, chest pain, frequent cough lasting for a prolonged time of almost 3 weeks or more and the presence of phlegm or blood in the cough of the inflicted individual (Nliwasa et al. 2018). According to Craig, Joly and Zumla (2014), the disease also negatively impacts the health of the individual through the occurrences of additional symptoms such as fever, nocturnal sweating, loss of weight, fatigue or malaise, loss of appetite and fever accompanied with chills. However, in the situation of infliction with latent tuberculosis, the concerned individual does not show any of the above signs and symptoms.

Infection Prevention and Control

In accordance to the guidelines stipulated by international organizations such as World Health Organization and Centers for Disease Control and Prevention, the following practices are to be followed for the prevention and control of tuberculosis infection:

Audit

Due to its infectious nature, the transmission of tuberculosis has been found to be the most prevalent in employed individuals particularly in healthcare settings characterized by contact amongst coworkers and the diseased patients. Hence, for the adequate prevention of future disease occurrences, every work place must ensure the presence of a tuberculosis risk management program which must comprise of an auditing procedure for the purpose of testing its efficiency and credibility (Gizwa, Alemu and Kibret 2015). An audit plan for tuberculosis management comprised of appropriate inspection procedures which must aim to evaluate the effectiveness of the tuberculosis infection prevention and control policy proposed by the concerned workplace (Van  Cutsem et al. 2016).

Nature of the Infection and its Spread

In accordance to the guidelines suggested by the World Health Organization, an audit plan for tuberculosis prevention and control must inspect the presence and working of a number of factors. These include: the nature of infection management training provided, the number of employees who have been trained, the strategies used for tuberculosis screening and patient management, the nature and qualitative features of the tuberculosis diagnostic procedures involved, the provision of healthcare support and ethical considerations for diseases victims, the procedures involved for the recording, reporting and monitoring of infection prevention, control and management policies undertaken and the provision of optimum health promotion strategies utilized within the workplace as well as with the nearest community center resulting in appropriate dissemination of public health information on the principles underlying tuberculosis transmission, pathology, prevention and management (Falzon et al. 2017).

Surveillance

The surveillance for tuberculosis must involve procedures such as monitoring and analysis of data about the tuberculosis as well as diseases associated with tuberculosis occurrence or presenting symptoms similar to it. Surveillance data of tuberculosis must also include information on demographic characteristics of the infection, its geographical nature of transmission and diagnostic procedures involved for disease identification and intervention (Woodruff, Miner and Miramontes 2018).

Hence, according to Mlotshwa et al. 2017, for the purpose of conducting high quality prevention, control and treatment of tuberculosis, healthcare or occupational settings must execute optimum surveillance procedures comprising of timely reporting and identification of infections with accuracy. Appropriate surveillance of tuberculosis conducted by public health or clinical settings leads to identification of individuals inflicted with or exhibiting a susceptibility to tuberculosis, determination of a specified area’s rates of prevalence and incidence of tuberculosis and assistance of clinicians for the purpose of disease evaluation of concerned patients or associated communities. Hence, adequate tuberculosis surveillance must be incorporated since it will improve the activities of the community health clinics and practitioners for the purpose of reducing disease transmission, development of intervention strategies and responding to situations characterized by tuberculosis infection exposure (Asadi et al. 2017).

Risk Management

Risk management strategies concerned with controlling, preventing and treating the infection, must include three salient steps, which will include: measures in administration, controls at the environmental level and usage of equipment meant for respiratory protection. The first steps involved in administration pose to be as highly essential since they aim to decrease the transmission and exposure of individuals towards tuberculosis infection (Lewinsohn et al. 2017). These will include strategies such as: conductance of tuberculosis risk assessments, development and implementation of plans concerned with tuberculosis control, assuring the provision of required diagnostic procedures required for.

the purpose infection analyzing and reporting, assurance of optimum conductance of sterilization and disinfection of possible contaminated items in the organizational setup, imparting adequate training and education to workers about tuberculosis infection prevention, screening of employees for risk of tuberculosis, implementation of visual instructions and aid for imparting etiquette knowledge of preventive coughing habits, coordination of workplace tuberculosis prevention strategies with associated national, state or community healthcare services located surrounding at the vicinity (Lönnroth et al. 2015).

Impact of Infection

There must be adoption of appropriate environmental controls, aimed at preventing the transmission and decreasing the amount of infectious droplet nuclei in the surrounding environment. Risk management control measures at the environmental level must occur as primary or secondary (Brooks-Pollock, Roberts and Keeling 2014). For the purpose of conducting primary level of risk management, strategies must aim at regulating sources of possible infection transmission. This will involve adoption of optimum ventilation strategies for the purpose of filtering and diluting infected air through installation of exhausts, booths, tents or hoods. The measures of secondary control in the organizational environment must aim to redirect or regulate the flow of air from locations suspected to posses high concentration of droplet nuclei. This requires implementation of technologically efficient equipment such as ultraviolet germicidal irradiation or high efficiency particular air filtration (Nahid et al. 2016).

Employees must engage in usage of equipment or clothing accessories with respiratory control abilities. This will prevent the inhalation of infected air upon coming in contact with infected patients or contaminated air. Along with usage of respiratory protective equipment, a workplace must aim at implementation of a program aimed at respiratory protection, providing appropriate training to workers on respiratory protection and imparting education on maintenance of appropriate personal hygiene and coughing habits (Dheda et al. 2014).

Impact of Infection Prevention and Control Policies at Local Communities

As stated by Theron et al., (2015), despite the prevalence of adequate policies and principles, the disease condition of tuberculosis continues to remain one of the leading ten causes of mortality at the global level. During the year 2017, over a million individuals and over 10 million children succumbed to death due to this disease. A stated by Aguirre et al., (2017), existing policies and principles continue to yield low impacts on the local communities, especially amongst indigenous and aboriginal communities who are inflicted with inequitable distribution of health resources along with residing in unhygienic and insanitary conditions. Further as stated by Falzon et al., 2017, considering the prevalent usage of anti-tuberculosis medications, multi-drug resistant infections continue to prevail in the communities. Considering this alarming situation, the World Health Organization formulated the ‘TB Infection Control in Health-Care Facilities,

Congregate Settings and Households’, which local communities and healthcare organizations can formulate and include various infection control and respiratory control procedures at the managerial, administrative and environmental levels. As researched by Lönnroth and Raviglione (2016), considering the Sustainable Development Goals of eradicating tuberculosis by 2030, the World Health Organization and the United Nations is undertaking active participation to infiltrate their policies at the local level hence, resulting in a 2% reduction in the incidence rate and treatment of over 54 million individuals between the years 2000 and 2017 worldwide.

Organizational Infection Control and Public Health Policies: Hong Kong Government

As researched by Chang et al. (2018), there has been a reported decrease in the reporting of tuberculosis in Hong Kong over the last 4 to 5 decades. The rates of tuberculosis reporting displayed an alarming peak in the year 1952, with a rate of 697.2 per 100, 000 and a subsequent reduction to 110.9 during the year 1995. This was further followed by fluctuations and then a stagnancy in the commencing years followed by a positive result in the year 2004, amounting to a rate of 90.6 per 100, 000 or 6, 238 disease scenarios. Hence, Hong Kong continues to be country reflecting a tuberculosis burden at the intermediate level due to its availability of optimum medical and clinical infrastructure.

Preventing the Spread of Infection – Infection Prevention and Control Measures

As stated by Leung et al. (2016), due to the high rates of transmission reported in tuberculosis infection, as per the air-borne characteristics of the concerned pathogenic strain of M. tuberculosis. Hence, for this reason, tuberculosis transmission is reported to highest amongst employees engaged in healthcare settings, due to their frequent exposure to contaminated air or patients infected with tuberculosis infection. For this purpose, the government of Hong Kong has specified has highlighted salient strategies concerning the organizational control of tuberculosis at the workplace, as mentioned in the following paragraphs, which have been formulated and undergo assessment by the Labour Department, Quarantine and Prevention of Disease Ordinance and Occupational Safety and Health Ordinance.

Measures for Infection Control

For the effective and timely diagnosis of suspected tuberculosis, the workplace must conduct procedures such as proper collection of specimen like sputum or smear microscopy. In a situation an individual infected with tuberculosis, the concerned individual  must be kept in isolation, with the provision of open window arrangement facilitating natural ventilation procedures, in accordance to the guidelines specified by the World Health Organization (Chen et al. 2015).

Further measures for infection control in the workplace must involve adequate reviewing of the availability of rooms for isolation by the organizational management followed by avoidance of placing tuberculosis patients in wards containing additional victims of HIV or diseases characterized by compromised immune systems. Further, the workplace must ensure the isolation of the tuberculosis patient for at least 14 days upon commencement of the disease diagnosis (Ai et al. 2016).

Precautions by Staff

Imparting adequate education and training outlining the principles of tuberculosis transmission, symptoms, control and screening forms the cornerstones of inculcating precautionary habits in the concerned workforce. Additional precautionary measures will require screening the workforce members for the presence of tuberculosis through tests such as tuberculin and subsequent reporting to the Department of Labour by employees who have diagnosed with the infection. Usage of chemotherapy and N95 masks by the staff is of utmost importance especially during the performance of activities characterized by coughing such as bronchoscopy or sputum induction edotracheal intubation. Workers must also wear gloves during handling of possible contaminated specimen such as sputum (Tam, Yang and Meyers 2018).

Precautions by the Patient 

As stated by Siu 92015), the risk management precautions which must be inculcated in the patient for appropriate infection control, should first start with educating the victims on the key characteristics of tuberculosis and necessity of maintenance of adequate personal hygiene. Patients while coughing must keep their mouth covered and the resultant sputum so expelled must be disposed immediately and adequately, followed by thorough hand washing and disinfection. Respiratory protective equipment such as masks must be adorned by patients while usage of common workplace facilities to prevent the transmission of infectious droplet nuclei in the surrounding air.

Contact Management and Public Health Policies

As stated by Li et al. (2017), individuals who have undergone contact with patients suffering from tuberculosis along with individuals exhibiting similar signs and symptoms, must be examined thoroughly, comprising of tuberculin testing and Chest X-rays. This may be followed by the implementation of adequate educational training which will aid individuals in the timely recognition of infection signs and symptoms. In Hong Kong, tuberculosis cases are managed in a total of over 17 chest clinics which also provide high quality ambulatory care. Likewise, the Labour Department, Quarantine and Prevention of Disease Ordinance and Occupational Safety and Health Ordinance are the key public bodies in Hong Kong concerned with tuberculosis infection prevention and management in Hong Kong.

Organisational Issues underpinning Infection Prevention and Control Policy and Practice in Hong Kong

Concluding Remarks: Impact of Tuberculosis Policies

Considering the disease management of tuberculosis infection in Hong Kong, the major administrative body responsible for deliverance of primary health services is the Department of Health, supplied over a total of 18 chest clinics. A total of 5 chest hospitals, managed administratively by the Hospital Authority, provides secondary level outpatient care. Further, the specimens for tuberculosis analysis are conducted by the Yung Fuu Shee TB Laboratory (Chang and Tam 2017). Lastly, as stated by Tsang et al. (2015),

the salient administrative body responsible for tuberculosis surveillance, case analysis, supervision of chemotherapy, tracing of treatment and screening defaulters, provision of vaccination and health promotion  is The Tuberculosis and Chest Service. For efficient control of tuberculosis, case identification is a key requirement for which mass screening and passive search strategies are undertake by the above administrative body. Further government treatment procedures include chemotherapy, Bacillus Calmette-Guerin (BCG) vaccination and directly observed treatment short course (DOTS). The above infection mitigation procedures have hence resulted in a positive health status in the population of Hong Kong, as observed in the low rates of tuberculosis reporting.

However, according to Lam et al. 2016, despite the execution of such effective public health policies, the rates of tuberculosis reporting have maintained considerable stagnancy, which has encouraged sufficient concern as reports from the year 2017, indicate a total 4412 cases. Hence this indicates limited impact of the existing public health policies. Such infection reporting trends might be due to the rising ageing population.

The reported 11.9% increase in life expectancy results in the increased susceptibility of age-associated disease acquisition such as diabetes mellitus, renal infections, compromised immune and cardiopulmonary system, which further puts senior citizens at a risk for tuberculosis infection. Further trends which reflect limited public policy impact on the health of communities, is the recent increase in the immigrant population in Hong Kong, as reflected in the reporting of over 200 cases of tuberculosis amongst Chinese or Vietnamese immigrants in the country. Additionally, recent emerging trends in shifting of the population resulting in increased movement of Hong Kong citizens within and beyond the country, which may have detrimental effects due to the rapid, air-borne transmitting characteristics of tuberculosis infection (Li et al. 2017).

Hence, it can be concluded that tuberculosis, despite the recent medical treatment advances, continues to remain a disease of considerable severity, requiring strengthened efforts of infection prevention control and management. Despite the commendable efforts by the Hong Kong government resulting in appreciable reductions in the disease, the significant stagnancy and high reporting rates as compared to Europe, continue to reflect the inadequacies of the existing public health policies, hence requiring future amendments and improvements.

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