Reciprocal obligations for prevention of occupationally acquired tuberculosis among healthcare workers

As I began my work on occupationally acquired tuberculosis (TB), I was perturbed by a series of media reports on TB among healthcare workers (HCWs) in India (1, 2, 3). This included a report on the death of a resident doctor who was suffering from multidrug-resistant (MDR) TB. The risk of occupationally acquired TB is well documented. A few studies have reported an increased risk of TB among HCWs in developing countries, including India (4).

Ethical perspectives

Do HCWs have an ethical obligation to provide care to patients, even if it involves some degree of risk? This question is addressed in a World Health Organisation (WHO) document, entitled “Guidance on ethics of tuberculosis prevention, care and control” (5). Considering the risk faced by HCWs of acquiring TB, the document focuses on ensuring their safety.

The WHO document states that HCWs have an ethical obligation to provide care to patients. However, this obligation does not exist in isolation, as it assumes reciprocal obligations on the part of other stakeholders. It is equally important to consider the reciprocal obligations of governments and healthcare facilities to provide the minimum standards of safety for their HCWs (5). Their safety can be enhanced, for example, by training, the provision of supplies, equipment and support, the availability of infrastructure, and access to facilities for the diagnosis and treatment of TB. It is also important that HCWs are made aware of their working conditions, their roles and the risks they face. Further, they should be provided appropriate compensation, including insurance, for their services.

Public health perspectives

The newspaper reports that I came across highlighted a poor diet, poor living conditions, the strain of overwork and stress as responsible for the increased risk of TB among HCWs in India. A protein-rich diet and better living conditions were recommended to tackle the problem of TB transmission among HCWs. In this regard, it is important to understand the difference between TB as an infection and TBas a disease. Reducing the workload and improving the diet may help to reduce the risk of disease, but will not prevent infection. Hence, along with the interventions mentioned already, it is important to provide equipment, introduce procedures and create working conditions that will reduce the risk of TB infection. The guidelines of WHO and the Government of India make mention of administrative controls, environmental controls and personal protective equipment. The guidelines are summarised in Table 1 (6, 7). These interventions have the collateral benefits of preventing the transmission of TB to other patients and offering protection from other airborne infections.

These interventions constitute the reciprocal obligations which need to be fulfilled by the healthcare system for the prevention of TB among HCWs. If the interventions for infection control are not in place, HCWs should appeal to the senior authorities to do the needful. It is the responsibility of the government and healthcare system to ensure that patients should have no difficulty receiving care. If we expect HCWs to care for patients, the healthcare system should understand and acknowledge the reciprocal obligation to take proactive steps to provide safe working conditions for the HCWs.