Tuberculosis among health-care workers in low- and middle-income countries: a systematic review.
Tuberculosis among health-care workers in low- and middle-income countries: a systematic review.
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DOI：
10.1371/journal.pmed.0030494
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发表时间：
2006-12
期刊：
影响因子：
15.8
通讯作者：
Pai M
中科院分区：
文献类型：
--
作者：
Joshi R;Reingold AL;Menzies D;Pai M
在许多低收入和中等收入国家 (LMIC)，结核分枝杆菌从患者传播给医护人员 (HCW) 的风险是一个被忽视的问题。这些国家的大多数医疗机构缺乏预防结核病院内传播的资源。我们进行了系统回顾，总结了中低收入国家医护人员中潜伏结核感染（LTBI）和疾病的发病率和患病率的证据，并评估了已尝试的各种预防策略的影响。为了确定相关研究，我们检索了电子数据库和期刊，并联系了该领域的专家。我们确定了 42 篇文章，其中包括 51 项研究，并提取了有关医护人员 LTBI 和疾病的发病率、患病率和危险因素的数据。医护人员中 LTBI 的患病率平均为 54%（范围为 33% 至 79%）。 LTBI 的年风险估计范围为 0.5% 至 14.3%，医护人员中结核病的年发病率范围为每 10 万人 69 至 5,780 例。与一般人群相比，医务人员患结核病的归因风险为每年每 10 万人 25 至 5,361 人。感染结核病的较高风险与某些工作地点（住院结核病设施、实验室、内科和急诊设施）和职业类别（放射技术人员、病人护理人员、护士、病房服务员、护理人员和临床官员）有关。总之，我们的审查表明，结核病是中低收入国家医护人员中的一个重大职业问题。现有证据强调需要在这些国家的卫生保健机构中设计和实施简单、有效且负担得起的结核病感染控制计划。系统评价表明，结核病是低收入和中等收入国家卫生保健工作者的一个重要职业问题。世界上三分之一的人口感染了结核分枝杆菌，这种细菌会导致结核病 (TB)。对于许多人来说，这种细菌不会引起健康问题——它仍然是潜伏的。但大约 10% 的感染者会出现活跃的、可能致命的结核病，通常发生在肺部。活动性肺结核患者很容易通过咳嗽或打喷嚏时产生的细小空气飞沫将感染传播给其他人，包括医护人员 (HCW)。在美国等高收入国家，制定了指导方针以尽量减少医疗机构中结核病的传播。行政控制（例如，针对疑似或确诊结核病患者的标准治疗计划）旨在减少医护人员与结核病患者的接触。环境控制（例如，使用特殊隔离室）旨在防止传播并减少空气中传染性飞沫的浓度。最后，呼吸保护控制措施（例如，护理人员的个人呼吸器）旨在降低结核分枝杆菌暴露不可避免的高浓度时的感染风险。这三层控制共同降低了高收入国家医护人员的结核病发病率（每年感染结核病的人数）。但世界上 90% 以上的结核病病例发生在低收入和中等收入国家 (LMIC) 呢？在这里，甚至没有足够的资金来实施减少医疗机构中结核病传播的低成本策略，那么结核病对于这些国家的医护人员来说有多重要呢？在这项研究中，研究人员系统地回顾了已发表的论文，以了解中低收入国家医务人员活动性结核病和潜伏性结核病感染 (LTBI) 的发病率和患病率（人群中有多少人患有某种特定疾病）。他们还调查了高收入国家使用的预防策略是否已被证明可以减轻较贫穷国家医护人员的结核病负担。为了确定有关中低收入国家医护人员结核病传播的研究，研究人员检索了电子数据库和期刊，并联系了结核病传播专家。然后，他们提取并分析了结核病发病率、患病率、危险因素和控制措施的相关数据。根据 51 项已确定研究的平均结果，54% 的医护人员患有 LTBI。在大多数研究中，年龄的增加和在医疗机构工作时间的增加（表明累积接触感染的时间更长）与 LTBI 患病率升高相关。在医学和护理学生的一个亚群体中也出现了同样的趋势。在考虑了相关一般人群的结核病发病率后，不同研究中由于医护人员而导致的结核病超额发病率范围为每年每 100, 000 人 25 至 5,361 例。此外，感染结核病的风险较高与在特定地点（例如住院结核病设施或诊断实验室）工作以及特定职业（包括护士和放射科服务员）有关；已发表的研究中检查的大多数医疗机构没有制定具体的结核病感染控制计划。与所有系统评价一样，这些研究结果的准确性可能受到原始研究某些方面的限制，例如如何测量 LTBI 的发生率。此外，研究人员错过了一些相关已发表的研究，或者只发表了医护人员结核病高发的研究，也可能会影响本研究的结果。尽管如此，他们认为结核病是中低收入国家医务人员的一种重要职业病，而最容易感染结核病的医务人员是接触最多结核病患者的医务人员。降低这种风险应该成为重中之重，因为职业性结核病会导致重要的、熟练的医护人员的流失。不幸的是，很少有数据可以表明应该如何做到这一点。因此，研究人员得出结论，迫切需要精心设计的实地研究来评估减少高收入国家医护人员结核病传播的结核病控制措施是否在中低收入国家有效且可负担。请通过此摘要的在线版本访问这些网站：http://dx.doi.org/10.1371/journal.pmed.0030494。 • 美国国家过敏和传染病研究所关于结核病的患者情况说明书 • 美国疾病控制和预防中心为患者和专业人员提供的结核病信息 • MedlinePlus 结核病百科全书条目 • NHS Direct Online，来自英国国家卫生服务中心，有关结核病的患者信息 • 美国国家职业健康与安全研究所，为医护人员提供的有关结核病的信息• 美国肺脏协会有关结核病和医护人员的信息
The risk of transmission of Mycobacterium tuberculosis from patients to health-care workers (HCWs) is a neglected problem in many low- and middle-income countries (LMICs). Most health-care facilities in these countries lack resources to prevent nosocomial transmission of tuberculosis (TB). We conducted a systematic review to summarize the evidence on the incidence and prevalence of latent TB infection (LTBI) and disease among HCWs in LMICs, and to evaluate the impact of various preventive strategies that have been attempted. To identify relevant studies, we searched electronic databases and journals, and contacted experts in the field. We identified 42 articles, consisting of 51 studies, and extracted data on incidence, prevalence, and risk factors for LTBI and disease among HCWs. The prevalence of LTBI among HCWs was, on average, 54% (range 33% to 79%). Estimates of the annual risk of LTBI ranged from 0.5% to 14.3%, and the annual incidence of TB disease in HCWs ranged from 69 to 5,780 per 100,000. The attributable risk for TB disease in HCWs, compared to the risk in the general population, ranged from 25 to 5,361 per 100,000 per year. A higher risk of acquiring TB disease was associated with certain work locations (inpatient TB facility, laboratory, internal medicine, and emergency facilities) and occupational categories (radiology technicians, patient attendants, nurses, ward attendants, paramedics, and clinical officers). In summary, our review demonstrates that TB is a significant occupational problem among HCWs in LMICs. Available evidence reinforces the need to design and implement simple, effective, and affordable TB infection-control programs in health-care facilities in these countries. A systematic review demonstrates that tuberculosis is an important occupational problem among health care workers in low and middle-income countries. One third of the world's population is infected with Mycobacterium tuberculosis, the bacterium that causes tuberculosis (TB). In many people, the bug causes no health problems—it remains latent. But about 10% of infected people develop active, potentially fatal TB, often in their lungs. People with active pulmonary TB readily spread the infection to other people, including health-care workers (HCWs), in small airborne droplets produced when they cough or sneeze. In high-income countries such as the US, guidelines are in place to minimize the transmission of TB in health-care facilities. Administrative controls (for example, standard treatment plans for people with suspected or confirmed TB) aim to reduce the exposure of HCWs to people with TB. Environmental controls (for example, the use of special isolation rooms) aim to prevent the spread and to reduce the concentration of infectious droplets in the air. Finally, respiratory-protection controls (for example, personal respirators for nursing staff) aim to reduce the risk of infection when exposure to M. tuberculosis is unavoidably high. Together, these three layers of control have reduced the incidence of TB in HCWs (the number who catch TB annually) in high-income countries. But what about low- and middle-income countries (LMICs) where more than 90% of the world's cases of TB occur? Here, there is little money available to implement even low-cost strategies to reduce TB transmission in health-care facilities—so how important an occupational disease is TB in HCWs in these countries? In this study, the researchers have systematically reviewed published papers to find out the incidence and prevalence (how many people in a population have a specific disease) of active TB and latent TB infections (LTBIs) in HCWs in LMICs. They have also investigated whether any of the preventative strategies used in high-income countries have been shown to reduce the TB burden in HCWs in poorer countries. To identify studies on TB transmission to HCWs in LMICs, the researchers searched electronic databases and journals, and also contacted experts on TB transmission. They then extracted and analyzed the relevant data on TB incidence, prevalence, risk factors, and control measures. Averaged-out over the 51 identified studies, 54% of HCWs had LTBI. In most of the studies, increasing age and duration of employment in health-care facilities, indicating a longer cumulative exposure to infection, was associated with a higher prevalence of LTBI. The same trend was seen in a subgroup of medical and nursing students. After accounting for the incidence of TB in the relevant general population, the excess incidence of TB in the different studies that was attributable to being a HCW ranged from 25 to 5,361 cases per 100, 000 people per year. In addition, a higher risk of acquiring TB was associated with working in specific locations (for example, inpatient TB facilities or diagnostic laboratories) and with specific occupations, including nurses and radiology attendants; most of the health-care facilities examined in the published studies had no specific TB infection-control programs in place. As with all systematic reviews, the accuracy of these findings may be limited by some aspects of the original studies, such as how the incidence of LTBI was measured. In addition, the possibility that the researchers missed some relevant published studies, or that only studies where there was a high incidence of TB in HCWs were published, may also affect the findings of this study. Nevertheless, they suggest that TB is an important occupational disease in HCWs in LMICs and that the HCWs most at risk of TB are those exposed to the most patients with TB. Reduction of that risk should be a high priority because occupational TB leads to the loss of essential, skilled HCWs. Unfortunately, there are few data available to indicate how this should be done. Thus, the researchers conclude, well-designed field studies are urgently needed to evaluate whether the TB-control measures that have reduced TB transmission to HCWs in high-income countries will work and be affordable in LMICs. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030494. • US National Institute of Allergy and Infectious Diseases patient fact sheet on tuberculosis • US Centers for Disease Control and Prevention information for patients and professionals on tuberculosis • MedlinePlus encyclopedia entry on tuberculosis • NHS Direct Online, from the UK National Health Service, patient information on tuberculosis • US National Institute for Occupational Health and Safety, information about tuberculosis for health-care workers • American Lung Association information on tuberculosis and health-care workers