Are healthcare workers in England and Wales at increased risk of tuberculosis?

BMJ 1996;313:522-525 (31 August)

Papers

Are healthcare workers in England and Wales at increased risk of tuberculosis?

Sarah Meredith, lecturer in public health,^a John M Watson, consultant epidemiologist,^b Kenneth M Citron, consulting physician,^c Anne Cockcroft, consultant in occupational health,^d Janet H Darbyshire, head ^e

^a Department of Epidemiology and Medical Statistics, London Hospital Medical College, London E1 4NS, ^b Public Health Laboratory Service Communicable Disease Surveillance Centre, London NW9 5EQ, ^c Royal Brompton Hospital, London SW3 6NP, ^d Royal Free Hospital and School of Medicine, London NW3 2QG, ^e Medical Research Council HIV Clinical Trials Centre, University College London Medical School, London WC1E 6AU

Correspondence to: Dr Sarah Meredith, Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232-2637, USA.sarah.meredith{at}mcmail. vanderbilt.edu.

Abstract

Objective: To determine whether healthcare workers in Englandand Wales are at increased risk of tuberculosis and to examinethe frequency of drug resistance in this population.
Design: Comparison of notification rates by occupation obtainedfrom national tuberculosis notification surveys in 1988 and1993, with denominators from the 1991 census.
Subjects: People with notified tuberculosis in professionaland associate professional occupations from the two surveys.
Main outcome measures: Rates of notified tuberculosis in healthprofessionals (mainly doctors) and health associate professionals(mainly nurses) compared with rates in other professional andassociate professional occupations, adjusted for ethnic group,sex, and age.
Results: 119 cases of tuberculosis were identified in healthcareworkers, including 61 nurses and 42 doctors. The crude notificationrate in healthcare workers was 11.8 per 100 000 per year (95%confidence interval 9.8 to 14.1) compared with 3.3 per 100 000per year (2.9 to 3.6) in other professional and associate professionaloccupations; rate ratios were higher (range 1.7 to 3.2) in allethnic groups. The relative risk adjusted for ethnic group,sex, and age was 2.4 (95% confidence interval 2.0 to 3.0), slightlyhigher for health professionals (2.7 (1.9 to 3.8)) than forassociate professionals (2.0 (1.5 to 2.6)). No multiple drugresistant strains of tuberculosis were identified in healthcareworkers.
Conclusions: Better detection and notification of cases of tuberculosisin healthcare workers may account for some of the apparent increasedrisk, but these findings imply that tuberculosis remains a hazardfor healthcare workers and highlight the importance of ensuringthat occupational health monitoring and protection workers arenot neglected.

Key messages

This study shows that rates of notified tuberculosis in healthcare workers in England and Wales were two to three times those in other socio- economically comparable occupational groups
As many healthcare workers are unlikely to be exposed to tuberculosis infection, those who are may be at much greater risk than has been estimated
No multiple drug resistant tuberculosis was found in healthcare workers
It is important that health service commissioners and occupational health services are aware of the risks and ensure that the recommendations for the control of tuberculosis in health service staff and students are complied with

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