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Original Research |

High Incidence of Hospital Admissions With Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis Among South African Health Care Workers

Max R. O'Donnell, MD, MPH; Julie Jarand, BSc, MD; Marian Loveday, BSc, MPhil; Nesri Padayatchi, BSc, MBChB, DCH, DTM+H, DHSM, DPH, MS(Epi); Jennifer Zelnick, MSW, ScD; Lise Werner, MSc; Kasavan Naidoo, MSc, BSc; Iqbal Master, MBChB; Garth Osburn, MBChB; Charlotte Kvasnovsky, MD, MPH; Karen Shean, MSc; Madhukar Pai, MD, PhD; Martie Van der Walt, PhD; Charles R. Horsburgh, MD, MUS; and Keertan Dheda, MBBCh, PhD
[+] Article and Author Information

From Boston University School of Medicine and School of Public Health, Boston, Massachusetts; Centre for AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa; University of Calgary, Calgary, Alberta, Canada; Medical Research Council, Cape Town, South Africa; Salem State College School of Social Work, Salem, Massachusetts; King George V Hospital, Sydenham, South Africa; Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia; University College London, London, United Kingdom; and McGill University, Montreal, Quebec, Canada.


Note: Drs. O'Donnell and Jarand contributed equally to this manuscript.

Grant Support: Dr. O'Donnell was supported by the National Institutes of Health (T32 AI52074; National Institutes of Allergy and Infectious Diseases) and an American Thoracic Society Career Development Award. In addition, Drs. O'Donnell and Padayatchi were supported by the Centre for AIDS Programme of Research. The National Institutes of Health and the U.S. Department of Health and Human Services funds the Centre for AIDS Programme of Research (A1069469). Dr. Padayatchi was also supported by Columbia University–Southern African Fogarty AIDS International Training and Research Programme funded by the Fogarty International Center, National Institutes of Health (D43TW00231). Dr. Pai is supported by a New Investigator Award from the Canadian Institutes of Health Research. These funding sources played no role in the study design or data analysis.

Potential Conflicts of Interest: Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-0897.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. O'Donnell (e-mail, max.odonnell@einstein.yu.edu). Data set: Not available.

Requests for Single Reprints: Max R. O'Donnell, MD, MPH, Division of Pulmonary Medicine, Albert Einstein College of Medicine, 1301 Morris Park Avenue, Bronx, NY 10461; e-mail, max.odonnell@einstein.yu.edu.

Current Author Addresses: Dr. O'Donnell: Division of Pulmonary Medicine, Albert Einstein College of Medicine, 1301 Morris Park Avenue, Bronx, NY 10461.

Dr. Jarand: University of Calgary, 3500 26th Avenue Northwest, Calgary, Alberta T1Y 6J4, Canada.

Ms. Loveday: Medical Research Council of South Africa, Health Systems Research Unit, Francie van Zijl Drive, Parow Valley, Cape Town, South Africa.

Dr. Padayatchi, Ms. Werner, and Mr. Naidoo: Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2nd Floor), University of KwaZulu-Natal, 719 Umbilo Road, Private Bag X7, Congella, 4013, Durban, South Africa.

Dr. Zelnick: Salem State College School of Social Work, 352 Lafayette Street, Salem, MA 01970.

Drs. Master and Osburn: 34 Holmleigh Road, Reservoir Hills, Durban, South Africa 4091.

Dr. Kvasnovsky: University of Maryland School of Medicine, 827 Saint Paul Street, Baltimore, MD 21202.

Ms. Shean and Dr. Dheda: Lung Infection and Immunity Unit, Division of Pulmonology & Clinical Immunology, University of Cape Town, Department of Medicine, H Floor, Old Main Building, Groote Schuur Hospital Observatory, Cape Town 7925, South Africa.

Dr. Pai: Department of Epidemiology & Biostatistics, 1020 Pine Avenue West, Montreal QC H3A 1A2, Canada.

Dr. Van der Walt: Tuberculosis Epidemiology and Intervention Research Unit, Private Bag X385, 0001 Pretoria, South Africa.

Dr. Horsburgh: Department of Epidemiology, Boston University School of Public Health, 72 East Newton Street, Boston, MA 02118.

Author Contributions: Conception and design: M.R. O'Donnell, M. Loveday, N. Padayatchi, I. Master, G. Osburn, M. Van der Walt, C.R. Horsburgh, K. Dheda.

Analysis and interpretation of the data: M.R. O'Donnell, J. Jarand, M. Loveday, N. Padayatchi, L. Werner, C. Kvasnovsky, M. Pai, M. Van der Walt, C.R. Horsburgh, K. Dheda.

Drafting of the article: M.R. O'Donnell, J. Jarand, N. Padayatchi, J. Zelnick, L. Werner, K. Naidoo, M. Van der Walt, K. Dheda.

Critical revision of the article for important intellectual content: M.R. O'Donnell, J. Jarand, M. Loveday, N. Padayatchi, C. Kvasnovsky, K. Shean, M. Pai, C.R. Horsburgh, K. Dheda.

Final approval of the artide: M.R. O'Donnell, J. Jarand, M. Loveday, N. Padayatchi, L. Werner, C. Kvasnovsky, M. Pai, M. Van der Walt, C.R. Horsburgh, K. Dheda.

Provision of study materials or patients: M. Loveday, N. Padayatchi, I. Master, G. Osburn, C. Kvasnovsky.

Statistical expertise: L. Werner, C.R. Horsburgh.

Obtaining of funding: C. Kvasnovsky, K. Shean.

Administrative, technical, or logistic support: M. Loveday, K. Shean, K. Dheda.

Collection and assembly of data: M.R. O'Donnell, J. Jarand, M. Loveday, C.R. Horsburgh.


Ann Intern Med. 2010;153(8):516-522. doi:10.7326/0003-4819-153-8-201010190-00008
Text Size: A A A

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.

Primary Funding Source: None.

Figures

Grahic Jump Location
Figure.
Study flow diagram.

HCW = health care worker; KGW = King George V Hospital; MDR-TB = multidrug-resistant tuberculosis; TB = tuberculosis; XDR-TB = extensively drug-resistant tuberculosis.

* Includes 261 patients in whom HCW status was missing.

Grahic Jump Location

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Summary for Patients

Incidence of Hospital Admissions With Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis Among South African Health Care Workers

The summary below is from the full report titled “High Incidence of Hospital Admissions With Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis Among South African Health Care Workers.” It is in the 19 October 2010 issue of Annals of Internal Medicine (volume 153, pages 516-522). The authors are M.R. O'Donnell, J. Jarand, M. Loveday, N. Padayatchi, J. Zelnick, L. Werner, K. Naidoo, I. Master, G. Osburn, C. Kvasnovsky, K. Shean, M. Pai, M. Van der Walt, C.R. Horsburgh, and K. Dheda.

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