Jennifer Zelnick

High Incidence of Hospital Admissions with Multidrug Resistant and Extensively Drug Resistant Tuberculosis among South African Health Care Workers

BACKGROUND Nosocomial transmission has been described in extensively drug-resistant tuberculosis (XDR-TB) and HIV co-infected patients in South Africa. However, little is known about the rates of drug-resistant tuberculosis among health care workers in countries with high tuberculosis and HIV burden. OBJECTIVE To estimate rates of multidrug-resistant tuberculosis (MDR-TB) and XDR-TB hospitalizations among health care workers in KwaZulu-Natal, South Africa. DESIGN Retrospective study of patients with drug-resistant tuberculosis who were admitted from 2003 to 2008 for the initiation of drug-resistant tuberculosis therapy. SETTING A public tuberculosis referral hospital in KwaZulu-Natal, South Africa. PARTICIPANTS 231 health care workers and 4151 non-health care workers admitted for initiation of MDR-TB or XDR-TB treatment. MEASUREMENTS Hospital admission rates and hospital admission incidence rate ratios. RESULTS Estimated incidence of MDR-TB hospitalization was 64.8 per 100,000 health care workers versus 11.9 per 100,000 non-health care workers (incidence rate ratio, 5.46 [95% CI, 4.75 to 6.28]). Estimated incidence of XDR-TB hospitalizations was 7.2 per 100,000 health care workers versus 1.1 per 100,000 non-health care workers (incidence rate ratio, 6.69 [CI, 4.38 to 10.20]). A higher percentage of health care workers than non-health care workers with MDR-TB or XDR-TB were women (78% vs. 47%; P < 0.001), and health care workers were less likely to report previous tuberculosis treatment (41% vs. 92%; P < 0.001). HIV infection did not differ between health care workers and non-health care workers (55% vs. 57%); however, among HIV-infected patients, a higher percentage of health care workers were receiving antiretroviral medications (63% vs. 47%; P < 0.001). LIMITATION The study had an observational retrospective design, is subject to referral bias, and had no information on type of health care work or duration of occupational exposure to tuberculosis. CONCLUSION Health care workers in this HIV-endemic area were substantially more likely to be hospitalized with either MDR-TB or XDR-TB than were non-health care workers. The increased risk may be explained by occupational exposure, underlining the urgent need for tuberculosis infection-control programs.

Double Jeopardy: The Impact of Neoliberalism on Care Workers in the United States and South Africa:

Many researchers have explored how neoliberal restructuring of the workplace has reduced the standard of living and increased workplace stress among private sector employees. However, few have focused on how neoliberal restructuring of public policy has had similar effects on the public sector workforce. Using original case study research, the authors examine how two iconic pieces of neoliberal policy—the 1996 welfare reform bill in the United States and the GEAR macroeconomic policy in South Africa—affected public/nonprofit human service workers in New York City, United States, and public sector nurses in KwaZulu-Natal, South Africa. The authors argue that in both situations, despite national differences, these policies created a “double jeopardy,” in which patients/clients and care workers are adversely affected by neoliberal public policy. This “double jeopardy” creates significant hardship, but also the opportunity for new social movements.

Health-care workers' perspectives on workplace safety, infection control, and drug-resistant tuberculosis in a high-burden HIV setting

Drug-resistant tuberculosis (TB) is an occupational hazard for health-care workers (HCWs) in South Africa. We undertook this qualitative study to contextualize epidemiological findings suggesting that HCWs’ elevated risk of drug-resistant TB is related to workplace exposure. A total of 55 HCWs and 7 hospital managers participated in focus groups and interviews about infection control (IC). Participants discussed caring for patients with drug-resistant TB, IC measures, occupational health programs, also stigma and support in the workplace. Key themes included: (i) lack of resources that hinders IC, (ii) distrust of IC efforts among HCWs, and (iii) disproportionate focus on individual-level personal protections, particularly N95 masks. IC programs should be evaluated, and the impact of new policies to rapidly diagnose drug-resistant TB and decentralize treatment should be assessed as part of the effort to control drug-resistant TB and create a safe workplace.

Re-inventing adherence : toward a patient-centered model of care for drug-resistant tuberculosis and HIV.

BACKGROUND Despite renewed focus on molecular tuberculosis (TB) diagnostics and new antimycobacterial agents, treatment outcomes for patients co-infected with drug-resistant TB and human immunodeficiency virus (HIV) remain dismal, in part due to lack of focus on medication adherence as part of a patient-centered continuum of care. OBJECTIVE To review current barriers to drug-resistant TB-HIV treatment and propose an alternative model to conventional approaches to treatment support. DISCUSSION Current national TB control programs rely heavily on directly observed therapy (DOT) as the centerpiece of treatment delivery and adherence support. Medication adherence and care for drug-resistant TB-HIV could be improved by fully implementing team-based patient-centered care, empowering patients through counseling and support, maintaining a rights-based approach while acknowledging the responsibility of health care systems in providing comprehensive care, and prioritizing critical research gaps. CONCLUSION It is time to re-invent our understanding of adherence in drug-resistant TB and HIV by focusing attention on the complex clinical, behavioral, social, and structural needs of affected patients and communities.

Extensively Drug-Resistant Tuberculosis in Women, KwaZulu-Natal, South Africa

To determine whether women in KwaZulu-Natal, South Africa, with drug-resistant tuberculosis (TB) were more likely than men to have extensively drug-resistant TB, we reviewed 4,514 adults admitted during 2003–2008 for drug-resistant TB. Female sex independently predicted extensively drug-resistant TB, even after we controlled for HIV infection. This association needs further study.

Training social workers to enhance patient-centered care for drug-resistant TB-HIV in South Africa

KwaZulu-Natal, South Africa, is the epicenter of an epidemic of drug-resistant tuberculosis (DR-TB) and human immunodeficiency virus (HIV) co-infection, characterized by low rates of medication adherence and retention in care. Social workers may have a unique role to play in improving DR-TB-HIV outcomes. We designed, implemented and evaluated a model-based pilot training course on patient-centered care, treatment literacy in DR-TB and HIV coinfection, patient support group facilitation, and self-care. Ten social workers participated in a 1-day training course. Post-training questionnaire scores showed significant overall gains (P = 0.003). A brief training intervention may be a useful and feasible way to engage social workers in patient-centered care for DR-TB and HIV coinfection.

Social policy education for change: South African student perspectives on the Global Agenda for Social Work and Social Development

Social work students deal with complex social problems such as poverty, unemployment and the devastating effects of HIV and AIDS in their practice, education and training and it is important to acknowledge that these developmental challenges have global dimensions. The four foundational pillars in the Global Agenda on Social Work and Social Development provide a framework for social work policy education. A project using this framework was implemented in South Africa and the United States. This article discusses the findings of an exploratory qualitative research project based on 58 student final papers from South Africa.

Caring for Care Workers

Carework—the paid and unpaid work in healthcare, education, childcare, mental health, elder care, families, and social services—is linked by the social and ethical obligation to care for vulnerable populations and is a major economic sector and important source of employment internationally. This special issue of New Solutions focuses on understanding working conditions and workplace health and safety in carework professions and for seeking solutions to these dilemmas. As members of the Carework Network Steering Committee, we reflect on the importance of the topics raised in this special issue and describe next steps for carework research and scholarship.