TB Prevention (Literature Review)

1. Kurmanaliev Nurlanbek Kambaralyevich

https://orcid.org/0000-0002-5952-1463

2. Muruganandam Devabalan

    Sarfraz Shakeelahamed Honnutagi

    Pramod Kumar Sesma

    Priya Yadav

    Kuntal Arzu

(1. Teacher, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic

2. Students, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic)

ABSTRACT

In healthcare settings, tuberculosis remains a significant occupational danger, especially for healthcare professionals who often interact with potentially contagious patients. Focused assessments that thoroughly assess preventative strategies across all levels of prevention within healthcare settings are still lacking, despite the high occupational incidence of tuberculosis among healthcare professionals. Effective preventive measures related to tuberculosis transmission have been looked at in this review of the literature. Through protective measures like respirators, ventilation system upgrades, and the introduction of educational initiatives about infection control procedures, primary preventive interventions aim to reduce exposure. In order to identify instances and latent infections before they develop into active disease, secondary preventive treatments focus on early diagnosis and routine screening. Controlling nosocomial transmission has been made easier by advancements in diagnostic technology, which have increased detection speed and accuracy. Through tailored follow-up and interventions, tertiary preventive interventions aim to control resistant strains, manage consequences of current infection, and improve adherence to treatment procedures. However, obstacles like stigma and a lack of resources frequently make such approaches less successful. This narrative literature review emphasises the need for improved workplace regulations, more educational initiatives, and ongoing research into novel and cutting-edge therapies like the creation of new vaccines and diagnostic technologies. All of these elements work to maximise the efficacy of tuberculosis interventions and safeguard the health and well-being of medical professionals.

Keywords: Healthcare settings, healthcare workers, infection control, prevention, Tuberculosis

INTRODUCTION

In many parts of the world, tuberculosis (TB) is still a serious public health concern, particularly in healthcare facilities where healthcare workers (HCWs) are more likely to get infected. Mycobacterium tuberculosis, the highly contagious airborne pathogen that causes tuberculosis, is disseminated by aerosolised droplets that active TB patients cough into the air. Millions of people worldwide are still infected with tuberculosis (TB) despite the disease being avoidable. Over 10 million individuals have contracted TB since 2021, and the figure has been increasing ever since, according to the World Health Organization's (WHO) 2024 TB report. 10.8 million people had contracted tuberculosis as of 2023, maintaining the upward trend from 2021. The COVID-19 pandemic was mostly responsible for this increase, with the global TB incidence rate rising from 129 in 2020 to 134 in 2023—a 4.6% increase. Furthermore, during the COVID-19 pandemic, the number of TB-related deaths rose from 1.34 million in 2019 to 1.40 and 1.42 million in 2020 and 2021, respectively. The number of TB-related deaths has decreased to 1.25 million in 2023, which is a notable but still insufficient decrease because TB has once again surpassed COVID-19 as the world's top cause of death from a single agent. Since the COVID-19 pandemic, the global increase in TB infections has generally decreased and begun to stabilise, but the WHO is not on course to fulfil its 2025 targets. These results underline the critical role of effective preventative policies and reflect the substantial worldwide burden of tuberculosis, which has been made worse by the COVID-19 pandemic's aftermath.

Environmental controls, education, and the use of personal protective equipment are examples of evidence-based interventions that have demonstrated efficacy in preventing tuberculosis infections. For example, N95 respirators are more effective than surgical masks at preventing TB droplets. Additionally, the use of ultraviolet germicidal irradiation and high-efficiency particle air filtration systems are environmental treatments that are crucial for reducing the airborne transmission of tuberculosis in healthcare institutions. Additionally, training healthcare professionals encourages greater adherence to preventive measures.

Early detection of latent tuberculosis infection (LTBI) requires routine screening as part of secondary prophylaxis. Carrier individuals may develop active TB in situations where appropriate screening protocols are not followed, posing a risk to both patients and healthcare workers. Screening tests such as the interferon-gamma release assay (IGRA) and tuberculin skin test (TST) are mostly performed on populations considered to be at higher risk. Early detection with molecular diagnostic technologies like as the Xpert MTB/RIF Ultra test makes it easier to implement the necessary isolation and start treatment procedures on time, which lowers the infection's spread throughout healthcare institutions.

Despite these preventive efforts, early identification and optimal prevention are delayed by obstacles like stigma, fear of professional assessment, and limited access to services. Reducing the risk of workplace-associated tuberculosis requires efforts to remove these obstacles through the implementation of efficient workplace regulations, secure reporting protocols, and early access to diagnostic services. Without major adjustments, future estimates indicate that TB prevalence will only decrease by 1% to 2% per year, which is insufficient to satisfy the objectives of the End TB Strategy.

Presenting a comprehensive analysis of TB preventive strategies in various hospital settings is the goal of this review. Effective tactics to lower TB transmission among healthcare workers and the function of current infection control methods to lower exposure at work are major topics covered in this review. In order to lower the risk of TB infection among healthcare workers, the study emphasises the significance of strict adherence to infection control procedures, early diagnosis, and targeted screening initiatives.

PRIMARY PREVENTION

1.Basics of primary prevention

The first line of defence against infectious tuberculosis droplets is respiratory protection equipment, the most popular of which is surgical masks. However, because of their inadequate filters, they offer little protection. However, respirators with high-efficiency particulate air (HEPA) filters, such the N95 mask, provide superior protection. Surgical masks barely stopped 18.4% of particles, but the N95 mask showed a filtration efficacy of 97.4%. Additionally, N95 masks showed better protection against droplet-transmitted infections (RR 0.26; 95% CI 0.16–0.42, p < 0.001) than surgical masks (RR 0.65; 95% CI 0.41–1.04), according to a research by MacIntyre et al. In healthcare settings, ventilation systems are an essential and economical technique for preventing the spread of tuberculosis. Even though they are inexpensive, their performance frequently depends on a number of climatic variables, including humidity and temperature, which may change the dynamics of airflow. Additional interventions, such as air cleaning methods like HEPA filtering and UVGI, can be used in situations where adequate ventilation cannot be established.

Maintaining good cleanliness is a straightforward yet efficient way to prevent infections. In order to prevent the spread of tuberculosis, infection control groups have placed a strong emphasis on respiratory hygiene and appropriate cough etiquette in hospital settings. Additionally, even though aerosol particles are the main way that tuberculosis is spread, practicing excellent hand hygiene by using soap and water and an efficient handwashing technique is a straightforward yet crucial infection prevention strategy to prevent tuberculosis.

2. Healthcare Worker Behaviours and Barriers Towards Infection Control

HCW adherence, comprehension, and attitudes toward the aforementioned preventive measures are critical to their implementation, as are other infection control policies. Poor adherence will always be a barrier to their effectiveness. In light of this, comprehending the obstacles that keep healthcare workers from following infection control procedures is a preventive step in and of itself. Twenty papers that studied the perspectives and experiences of nurses, physicians, and other healthcare workers when dealing with highly contagious respiratory infections, such as tuberculosis, were included in a Cochrane systematic review by Houghton et al. Organisational factors, environmental variables, and individual factors are the three broad sectors in which the study's findings were presented. Organisational factors that were thought to be the biggest obstacles to adherence included things like a lack of perceived support from their management, lengthy, unclear, and unworkable guidelines, inconsistent workplace policies with international policies or with prior training, and increased workload, especially with regard to the use of PPE. In terms of environmental considerations, the primary obstacles in that area were inadequate room for patient isolation and inadequate protective gear. These obstacles were typically ascribed to a lack of financing. Finally, HCW adherence was hampered by a failure to acknowledge the significance of utilising PPE and the discomfort that comes with extended use.

TB is still stigmatised even though it is a treatable illness. The majority of the time, coworkers in the healthcare industry stigmatise healthcare workers who have tuberculosis (TB), primarily because of the perceived danger of transmission. Despite having an extremely minimal risk of infection, HCWs with TB diagnoses are frequently avoided or excluded. Additionally, TB has been linked to HIV, poverty, and malnutrition, which may raise questions about the immunological state and overall lifestyle of HCWs and exacerbate the stigma. However, patients may stigmatise themselves by experiencing feelings of loneliness and shame, which are frequently linked to the requirement to wear a mask in order to prevent transmission. Internal or external stigma of this kind may make infected healthcare workers reluctant to provide care.

3.Suggested solutions

The London School of Hygiene and Tropical Medicine started the Umoya Omuhle project in 2017 with the goal of creating efficient treatments that can aid in removing the obstacles noted in the earlier research. The study used an interdisciplinary approach, concentrating on topics including ethnographic research, policy analysis, epidemiological studies, geographical mapping, and infrastructure assessment. A patient's likelihood of being contagious, the number of contacts made during each visit, and the length of the interaction were all taken into account. People's movements within clinics and how lines or outpatient waiting rooms were arranged were also taken into consideration. Several strategies that might enhance infection control in these environments were created using a mathematical model based on these data. The purpose of the study was to evaluate the practicality and effectiveness of putting these treatments into practice in public health clinics. Clinics in the South African provinces of KwaZulu-Natal and Western Cape were chosen in order to maintain consistency with the Umoya Omuhle project. Opening doors and windows decreased the transmission rate by 55% (IQR 25–72%), clinic retrofits by 45% (IQR 16–64%), UVGI installation by 77% (IQR 64–85%), surgical mask-wearing patients by 47% (IQR 42–50%), and a queue management system plus outdoor waiting areas by 83% (IQR 76–88%). It's interesting to note that queue management techniques, such appointments and outdoor waiting rooms, have demonstrated the most efficacy in lowering transmission, even among clinic employees who aren't healthcare workers.

While appropriate staffing, clinic facilities, and protective gear are essential for infection control, they are not enough to address the crucial role that healthcare worker behaviour and workplace culture play. Increasing financing can solve the former, but it won't have the same effect on the latter. Developing solutions to these behaviours can be aided by comprehending their motivations. Certain behavioural patterns in both reviews aligned with a number of behavioural theories, including the social-cognitive theory and the health belief model. The health belief model states that people change their behaviour when they are aware of the hazards, have low barriers to protection, and believe that taking action will benefit them greatly. This can be encouraged by making sure HCWs have proper training and lowering barriers to protection, as was accomplished in the Umoya Omuhle initiative. It is noteworthy, though, that although training was a common trend in both reviews, a review by Ward D. J. found that although more training does increase knowledge, it does not always successfully alter practice. This has been linked to a gap between knowledge and application, which is a common occurrence in the healthcare industry and a recurrent subject in Tan et al.'s review. Therefore, in order to reap the benefits of further training, it is imperative that the proper procedures be implemented; otherwise, it becomes ineffective.

4.Role of vaccines

The Bacillus Calmette-Guerin (BCG) vaccine was authorised for therapeutic use against tuberculosis in 1921. For this indication, it is still the only vaccination that has been approved. The BCG vaccine was added to the WHO's extended immunisation program in 1974, but only a few nations with significant TB burdens have incorporated it into their universal vaccination plans; in other nations, it is advised for high-risk populations. The vaccine's questionable efficacy in preventing tuberculosis is the primary reason for its lack of widespread adoption. According to a meta-analysis conducted by Martinez et al., the BCG vaccine's overall effectiveness was 18% (aOR 0.82, 95% CI 0.74–0.91). The BCG vaccine was most efficacious in children aged five or younger when stratified by age (aOR 0.63, 95% CI 0.49–0.81). Due to the BCG vaccine's inability to protect elderly populations, these data highlight the need for new vaccination regimens.

The emergence of COVID-19 peptide-based vaccines in 2020 and the quick development of bioinformatics technology in 2010 caused a significant shift in focus toward peptide vaccines for tuberculosis. Peptide vaccines are potential vaccination candidates due to a number of qualities, including the capacity to elicit a robust immune response via immunodominant epitopes, good stability, low cost, simplicity of storage and transportation, and fewer adverse effects. The M72/AS01e's Phase IIb clinical trial results, which showed an overall effectiveness of 54% (95% CI 2.1–74.2), were released in 2019. Numerous other peptide vaccines are presently being developed or tested in clinical settings. Further information about the efficacy, safety, and generalisability of peptide-based vaccines across various populations can be obtained as these trials' findings are released.

Apart from peptide vaccines, a number of additional innovative TB vaccines have reached the clinical trial stage and are currently being assessed. Clinical assessment is currently underway for two live vaccines: VPM1002, a genetically improved BCG vaccine, and MTBVAC, a genetically attenuated Mtb (NCT04975178 and NCT04351685, respectively). Additionally, a significant mRNA TB vaccine, BNT164a1/BNT164b1, is presently completing Phase 1 clinical trials (NCT05547464/NCT05537038). Whether these new technologies will be incorporated into primary TB prevention is still up in the air.

SECONDARY PREVENTION

1.Routine screening

A noteworthy study carried out in Rome offers important insight into the application of a two-step diagnostic process to demonstrate realistic ways to TB screening among HCWs. Over the course of three years, this study examined TB screening among healthcare workers at a nearby teaching hospital. This study's main goal was to assess how well a two-step screening method identified latent tuberculosis infections. The study yielded a number of important conclusions. First, 2290 healthcare workers were first examined using the tuberculin skin test as part of the screening protocol; 141 (6.1%) of them tested positive. QuantiFERON-TB Gold (QFT), an interferon gamma release assay (IGRA), was used to further analyse those who had a positive test result. Of them, the majority tested negative, but 16 instances (16.1%) were proven positive.

The study then highlighted the importance of IGRA in screening, showing how it may be used with higher specificity than TST. False positive rates decreased as specificity improved, especially in people that had previously received a BCG vaccination. Lastly, the study demonstrated the effectiveness and efficiency of using TST as a first-step screening approach followed by an IGRA as confirmatory testing in low-prevalence environments. Although universal TB screening for healthcare workers is advised worldwide, its implementation in healthcare facilities is still far from uniform. Research from both high-income and low-income nations reveals that inconsistent testing schedules, inadequate occupational health coverage, and weak monitoring systems make it difficult to follow up with positive cases.

2.Early diagnosis

Preventing tuberculosis (TB) requires early diagnosis, especially in medical settings. Delays in diagnosis can have disastrous outcomes in these situations, such as hospital-acquired tuberculosis among susceptible patient groups (e.g., immunocompromised individuals: patients undergoing chemotherapy, HIV/AIDS, or organ transplant candidates). In the end, delaying the diagnosis of infectious infections raises the possibility of transmission, increasing the risk for patients and healthcare workers alike. For HCWs working in high-risk departments including pulmonology, critical care, and TB clinics, routine testing with TST or IGRA is still crucial for identifying latent TB infection before it progresses to active disease. It has been demonstrated that early identification greatly lowers workplace transmission rates and allows for timely intervention.

However, despite its significance, a number of obstacles prevent widespread implementation. HCWs may delay screening or hide symptoms because to stigma, fear of being alone, worries about confidentiality, and scheduling conflicts. These difficulties highlight the necessity of private, institutionally backed screening guidelines and focused instructional programs that normalise testing and raise healthcare workers' understanding of tuberculosis. The significance of incorporating affordable diagnostic techniques into early detection initiatives is further shown by recent findings. The best option is heavily influenced by baseline TB prevalence, according to comparative economic analyses of molecular diagnostic instruments as Xpert Ultra, TB-LAMP, and TB-LAM.

3.Role of rapid diagnostics

The usefulness of the Xpert MTB/RIF Ultra (Xpert Ultra, an improved molecular diagnostic instrument) in enhancing TB detection in clinical settings was emphasised in a recent study. Xpert Ultra showed better sensitivity and high specificity when compared to the regular Xpert MTB/RIF assay, especially in smear-negative and HIV-positive patients. Faster and more accurate detection of tuberculosis (TB) is made possible by this improvement in diagnostic performance, which is important in healthcare settings where vulnerable patients and healthcare workers are at higher risk of exposure. Xpert Ultra improves infection control protocols and helps lower tuberculosis spread in healthcare institutions by facilitating earlier detection.

Simultaneously, new developments in artificial intelligence (AI) have improved TB screening even more. Deep learning models have surpassed human radiologists in high-burden scenarios and met WHO triage guidelines with diagnostic accuracy above 92% sensitivity and specificity when applied to chest X-rays. Their use could result in a 50% decrease in reliance on confirmatory molecular tests like GeneXpert. Furthermore, the management of drug-resistant tuberculosis is changing because to whole-genome sequencing (WGS). Over 13,000 alterations were identified in a global WHO examination of 38,000 samples, including 1149 linked to resistance to 13 anti-TB medications. Resistance prediction is now supported by this extensive mutation database, which may be included into standard diagnostic procedures to direct individualised treatment.

COST-EFFECTIVENESS AND REAL-WORLD APPLICABILITY

Clinical efficacy is just as important to the success of TB prevention in healthcare institutions as the practicality and affordability of therapies. Environmental management strategies like better ventilation, UVGI systems, and administrative actions shown cost-effectiveness in lowering nosocomial transmission at the primary level. Even small ventilation improvements can significantly reduce emissions for comparatively low cost in poor- and middle-income nations, where infrastructure is frequently inadequate. In high-income environments, however, optimising current systems and making sure they are maintained results in larger long-term savings. Cost-effectiveness in secondary prevention is heavily influenced by the type and frequency of diagnostic tools used. Research indicates that although IGRA is more sensitive than TST, consistent yearly testing is not financially feasible in high-income, low-incidence nations.

On the other hand, in environments with limited resources, risk-based or focused screening strategies are more practical and effective. In both situations, early detection is improved while remaining financially feasible when inexpensive triage techniques, like symptom-based screening or AI-assisted chest radiography with molecular diagnostics, are included. Health systems can maximise diagnostic yield in accordance with their resource capacity thanks to this adaptable strategy. Innovative adherence techniques, like VOT, save operating costs and preserve treatment compliance at the tertiary level, demonstrating viability in both high-resource and low-resource settings. In the end, incorporating affordable, context-sensitive interventions guarantees that tuberculosis prevention is both attainable and long-lasting. Aligning these strategies with the CDC TB screening guidelines (2024) and the WHO End TB Strategy (2023) enhances institutional capacity, safeguards healthcare workers, and promotes long-term progress toward TB elimination.

DISCUSSIONS AND CONCLUSION

For healthcare workers, tuberculosis (TB) is still a major workplace risk, particularly in settings with limited resources and inadequate infection control procedures. The foundational layer of defence consists of primary measures like respiratory protection equipment, environmental controls, and workplace hygiene practices. However, HCWs' behaviour, knowledge, and adherence ultimately determine how effective these treatments are. Inadequate resources, ambiguous regulations, and persistent stigma are some of the behavioural and systemic barriers to effective infection management.

In order to reduce the spread of tuberculosis in healthcare settings, secondary preventive strategies including routine screening, early diagnosis, and quick molecular testing are crucial. AI-based radiography screening and improved diagnostic tools like the Xpert MTB/RIF Ultra provide notable advancements in early identification and focused intervention.

Adherence supervision (including DOT and VOT), rehabilitation interventions, and nutrition supplements are examples of tertiary interventions that are important in reducing disease complications, managing drug-resistant disease, and enabling HCWs to resume clinical work safely and effectively. Furthermore, new vaccines—especially those based on peptides and mRNA—represent a promising development in TB prevention, particularly in adult populations where BCG treatments are inadequate. TB prevention requires a multifaceted, integrated strategy at several levels. Since the health of healthcare workers is essential to the upkeep and sustainability of efficient healthcare delivery systems, preventing tuberculosis among healthcare workers is both an ethical obligation and a public health necessity.

It is advised that healthcare facilities implement a more integrated prevention approach that incorporates administrative, behavioural, and environmental strategies to lower occupational tuberculosis transmission in light of the available data. The effectiveness of these tactics still depends on encouraging adherence among HCWs via ongoing education and a positive work environment. Utilising structured monitoring systems and digital adherence technology could improve treatment completion rates and screening uniformity even more. The current WHO Consolidated Guidelines on Tuberculosis: Module 1 Prevention (2024) and the CDC tuberculosis screening, testing, and treatment of U.S. health care personnel guidelines, which place a strong emphasis on risk-based screening, quick diagnosis, and HCW protection, are closely aligned with this review. Nevertheless, there are still significant gaps between these international guidelines and how they are used in clinical settings. The lack of institutional and behavioural mechanisms to guarantee compliance, variable adherence to infection control methods, and limited diagnostic infrastructure in low-resource settings continue to be major obstacles. These disparities highlight how crucial it is to modify global recommendations to fit the capabilities of regional health systems in order to maintain the viability and sustainability of preventative measures in actual healthcare settings.

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