Mycobacterium tuberculosis infection among community health workers involved in TB control* Infecção por Mycobacterium tuberculosis entre agentes comunitários de saúde que atuam no controle da TB

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  Mycobacterium tuberculosis infection among community health workers involved in TB control* Infecção por Mycobacterium tuberculosis entre agentes comunitários de saúde que atuam no controle da TB
   J Bras Pneumol. 2009;35(4):351-358 Mycobacterium tuberculosis   infection among community  health workers involved in TB control*  Infecção por Mycobacterium tuberculosis entre agentes comunitários de saúde que atuam no controle da TB Patrícia Marques Rodrigues, Tiago Ricardo Moreira, Andressa Karla Luz de Moraes, Rafael da Cruz Araújo Vieira, Reynaldo Dietze,  Rita de Cassia Duarte Lima, Ethel Leonor Noia Maciel Abstract Objective:  To evaluate the incidence of Mycobacterium tuberculosis   infection, using tuberculin skin test, among community health agents (CHAs) monitoring TB patients in the city of Cachoeiro de Itapemirim, Brazil.  Methods:  We included 30 CHAs acting in the Family Health Program and 30 of their family members residing in the same household. The tuberculin skin test results of each CHA were compared with those of the corresponding family member.  Results:  Of the 30 CHAs, 27 (90.0%) were female, compared with 23 (76.7%) of the 30 family members (p = 0.299). The mean age of the CHA group and of the family member group was, respectively, 36.8 and 39.7 years. No statistically significant difference was found between the groups regarding the level of education.  Regarding M. tuberculosis   exposure, the same number of participants in the two groups reported having known or had contact with a TB patient (17 individuals; 56.7%). There was a statistically significant difference regarding positive tuberculin skin test results (26.7% in the CHA group and 3.3% in the family member group; p = 0.011). Conclusions:   M. tuberculosis   infection was significantly higher among CHAs than among their family members, fueling the debate on the occupational risk involved in the activities of these professionals.  Keywords:  Community health aides; Tuberculosis; Tuberculin test.  Resumo Objetivo:  Avaliar a incidência de infecção por Mycobacterium tuberculosis   através da prova tuberculínica em agentes comunitários de saúde (ACS) que acompanham pacientes em tratamento de TB no município de Cachoeiro de Itapemirim (ES).  Métodos:  Incluímos 30 ACS que atuam no Programa de Saúde da Família e 30 de seus fami-liares residentes no mesmo domicílio. Comparamos o resultado do teste tuberculínico de cada ACS e do membro familiar correspondente.  Resultados:  Entre os 30 ACS, 27 (90,0%) eram do sexo feminino, ao passo que entre os 30 familiares, 23 (76,7%) eram do sexo feminino (p = 0,299). A idade média do grupo ACS e do grupo dos familiares foi, respectivamente, 36,8 e 39,7 anos. Não houve diferença estatística no nível de escolaridade entre os grupos estudados. Na investigação da exposição ao M. tuberculosis  , o mesmo número de indivíduos nos dois grupos afirmou conhecer ou já ter tido algum contato com paciente com TB (17 indivíduos; 56,7%). Houve dife-rença estatisticamente significativa quanto ao resultado positivo da prova tuberculínica nos dois grupos (26,7% no grupo ACS e 3,3% no grupo de familiares; p = 0,011). Conclusões:  A infecção por M. tuberculosis   entre os ACS foi significativamente maior que entre seus familiares, e isso contribui para o debate em torno do risco ocupacional envolvido nas atividades destes profissionais.  Descritores:  Auxiliares de saúde comunitária; Tuberculose; Teste tuberculínico. * Study carried out at the Federal University of Espírito Santo Infectious Diseases Center, Vitória, Brazil.Correspondence to: Ethel Leonor Noia Maciel. Laboratório de Epidemiologia, Núcleo de Doenças Infecciosas, Universidade Federal do  Espírito Santo, Av. Marechal Campos, 1468, Maruípe, CEP 29040-090, Vitória, ES, Brasil.Tel 55 27 3335-7210. E-mail: Financial Support: This study received financial support via Mandate MCT/CNPq/MS-DAB/SAS no. 49/2005 and from the International Clinical Operational and Health Services Research and Training Award, Mandate ICOHRTA 5 U2R TW006883-02.Submitted: 5 September 2008. Accepted, after review: 8 October 2008. Original Article  352 Rodrigues PM, Moreira TR, Moraes AKL, Vieira RCA, Dietze R, Lima RCD et al.  J Bras Pneumol. 2009;35(4):351-358 as a liaison, the CHAP representative bridges the gaps between health care services and the community, readily identifying its problems, facilitating the prevention of diseases and the promotion of health. (6) Although community health workers are definitively incorporated into the control of TB in many parts of the world, especially where there is broad DOTS high coverage, (1) little is known regarding the occupational conditions of CHAP representatives working within the PNCT in the state of Espírito Santo, or in Brazil in general.It has long been known that TB patient care, an activity listed among those carried out  by CHAP representatives, increases the risk of infection for the health professionals involved. This problem, long neglected, returns to current discussion, with many studies highlighting the elevated risk of M. tuberculosis   infec-tion for health professionals and students in this area when compared with the risk for the general population. (7,8)  However, there are no reports in the literature that describe the risk of M. tuberculosis   infection for CHAP repre-sentatives. Since these professionals play a fundamental role in TB control and are in close contact with the susceptible population, we felt that it would be useful to create an occupational profile of CHAP representatives working within the FHP in the city of Cachoeiro de Itapemirim.The present study was designed to evaluate M. tuberculosis   infection, using the tuberculin skin test, in the CHAP representatives who  work under the auspices of the FHP to monitor patients undergoing TB treatment in Cachoeiro de Itapemirim. Since the CHAP representatives live in the same community as the TB patients, and exposure might also take place within the community (outside the work environment), the tuberculin skin test result for the CHAP repre-sentative was compared with that of a family member residing in the same household.  Methods This was an observational hybrid study of prevalent cases with retrospective evaluation of the exposure. Two groups, defined by their expo-sure to the occupational risk, were identified at the beginning of the investigation: exposed (for a minimum of 3 months); and unexposed.  Data on past exposure and on outcomes were collected after the study outset.  Introduction Currently, TB is one of the leading causes of morbidity and mortality worldwide. From an epidemiological point of view, it has been observed that approximately one third of the  world population is infected with Mycobacterium tuberculosis  , the etiologic agent of TB, which is capable of promoting the development of the active form of the disease in the infected individual. (1,2)  During the course of the active disease, each patient infects an average of ten other individuals, perpetuating the chain of TB transmission in the community. (2) According to the Case Registry Database, 1,400 cases of TB are reported annually in the state of Espírito Santo, Brazil. In 2004, the incidence of new cases of TB was 39.4/100,000 inhabit-ants, and 25.3/100,000 were infectious cases. The directly observed treatment, short-course (DOTS) strategy has been implemented in 123 of the 1,097 health care clinics in the state, repre-senting 11.2% of the total. (3) In the city of Cachoeiro de Itapemirim, which has an estimated population of 198,150 inhab-itants (according to the Brazilian Institute of Geography and Statistics), the incidence and prevalence of TB are high. Therefore, it is included on the Brazilian Plano Nacional de Controle da Tuberculose   (PNCT, National Tuberculosis Control Plan) list of cities considered priorities for control of the disease. (4)  In 2006, 80 new cases  were reported in the city, with an incidence of approximately 40 cases/100,000 inhabitants. (3) As a means of dealing with this situation, the  PNCT has relied on the strategies of the Family  Health Program (FHP) and of the Community  Health Agent Program (CHAP), in the hope that this partnership will contribute to the expan-sion of the TB control interventions, since these strategies have the family and the home as the tools of their trade. With this in mind, emphasis is given to the FHP and CHAP team activities,  which are aimed at increasing the detection of cases, improving treatment adherence and reducing treatment abandonment. (5) In this context, the CHAP representatives stand out. These professionals, in addition to residing in the community where they work, have shown themselves to be familiar with its values, habits and language, therefore being able to produce a mixture between the use of technology/ biomedical knowledge and local beliefs. Acting  Mycobacterium tuberculosis   infection among community health workers involved in TB control  J Bras Pneumol. 2009;35(4):351-358 353 The data obtained through the question-naires were transferred to a Microsoft Excel T spreadsheet. In the statistical analyses, we used the Stata program, version 9.0 (Stata Corp., College Station, TX, USA). Means and standard deviations were calculated for the age and level of education of the CHAP representatives,  whereas their length of professional service was expressed as the median. Absolute and rela-tive values were calculated for each variable. In the comparative evaluation of the dichotomous  variables studied between the groups, we used  Fisher’s exact test; Student’s t-test was used for quantitative variables. The level of significance  was set at 5% (p < 0.05) for both.The project was previously authorized by the Cachoeiro de Itapemirim Municipal Health  Department and was approved by Research  Ethics Committee of the Espírito Santo Federal  University Health Sciences Center, protocol no 127/06. All study participants gave written informed consent, and their anonymity was guaranteed. The study participants who were strong reactors to the tuberculin skin test (indu-ration ≥  10 mm) were investigated at the local referral facility for TB control.  Results The results are presented in accordance  with the categories of the instrument used, as follows: demographic data, clinical history and occupational history.As for the gender of the interviewees, it was observed that, of the 30 CHAP representatives, 27 (90.0%) were female, as were 23 (76.7%) of their family members (p = 0.299). The mean age of the CHAP representative group was 36.8 ±  8.7 years (range, 20-58 years), compared  with 39.7 ±  11.7 years (range, 16-73 years) in The study population was composed of all CHAP representatives who worked within the  FHP in the city of Cachoeiro de Itapemirim,  Brazil, and who had TB patients under treat-ment in the area served. At the time of data collection, the city had 40 working CHAP repre-sentatives. Since adherence to the study was  voluntary, 9 CHAP representatives declined to participate in the study, and 1 left the job during this period. Therefore, the final sample was composed of 30 CHAP representatives. A non-health professional family member of each CHAP representative, residing in the same household,  was selected for the comparison between the professional exposure and the prevalence of the tuberculin skin test. Therefore, 30 CHAP repre-sentatives and 30 CHAP representative family members who were not health professionals participated in the study, completing the ques-tionnaire provided. All study participants gave  written informed consent.A self-report questionnaire was applied, and the tuberculin skin test was performed in all CHAP representatives and family members participating in the study between February and  May of 2007. In the tuberculin skin test, PPD  RT23 tuberculin was delivered intradermally in the middle third of the anterior face of the left forearm. The test was read 72 h after its appli-cation. The maximum transverse diameter of the area of palpable induration was measured  with a millimeter ruler, in accordance with the Tuberculosis Control Guidelines. (2)  An induration equal to or larger than 10 mm was considered a positive result to the tuberculin skin test, as recommended by the Brazilian National Ministry of Health (NMH). (9) The questionnaire completed by the CHAP representatives contained questions designed to collect personal and demographic data (name, date of birth, gender and level of education), as  well as questions related to clinical and occu-pational history. For the family member group, the questionnaire contained the same questions designed to collect personal and demographic data (name, date of birth, gender and level of education) and clinical history, but the remaining questions were related to the history of contact  with any TB case. With the exception of the occupational contact data for the CHAP repre-sentatives, all data were collected in a similar manner in both groups. Table 1 -  Distribution of the subjects surveyed according to variables related to demographic data. Demographic  variableCHA groupFamily member groupp  Female, n/N (%)27/30 (90.0)23/30 (76.7)0.299*Age, years (mean ±  SD)36.8 ±  8.739.7 ±  11.70.272**Schooling, years (mean ±  SD)10.8 ±  1.89.4 ±  3.30.073** CHA: community health agent. *Fisher’s exact test; and **Student’s t-test.  354 Rodrigues PM, Moreira TR, Moraes AKL, Vieira RCA, Dietze R, Lima RCD et al.  J Bras Pneumol. 2009;35(4):351-358 in Table 3, although they are not compared with  variables of the family members group.The median time of service as a CHAP repre-sentative was 23 months (range, 4-108 months). The proportion of CHAP representatives who had some degree of training in TB/DOTS was 26/28 (92.9%; Table 3). When asked about the means of transmission of the TB bacillus, all (100%) answered “saliva droplets” (airborne transmission); however, 2 (6.66%) answered that the transmission also occurred by means of contact with personal belongings of the patient. The participants were allowed to select more than one response to that question. At the time of the survey, 22/26 (84.6%) of the CHAP representatives were monitoring TB patients (Table 3), the number of patients per CHAP representative ranging from 1 to 3. Of those, 19/26 (73.1%) were applying the DOTS strategy (Table 3). As for the use of personal protec-tive equipment during the performance of the activities and monitoring of the TB patients, the study revealed that none of the CHAP represent-atives wore masks during the visits. In addition, 12/29 (41.4%) reported that the locales where the visits or DOTS implementation took place  were closed or stuffy (Table 3).  Discussion The CHAP representative is a professional active in two important NMH programs: the CHAP and the FHP. As described in Law no. 10.507, issued on 10 July 2002, the CHAP repre-sentative is licensed to perform activities related to disease prevention and health promotion in the home and the community (individual and collective interventions), developed in accord-ance with the Brazilian Unified Health Care System guidelines and under the supervision of the local administrator of the latter. This profes-sional instructs and monitors families in relation the family member group. The mean level of education among the CHAP representatives was 10.8 ±  1.8 years of schooling, higher than the 9.4 ±  3.3 years of schooling among the family members (Table 1).As for the clinical history, the presence of scarring due to the application of the BCG  vaccination was detected in most participants of the study, and was present in 28 (93.3%) of the CHAP representatives and in 24 (80.0%) of the family members. There was no significant difference between the groups. When ques-tioned about the application of a prophylactic  BCG vaccination booster, 2 (6.66%) of the CHAP representatives and 4 (13.33%) of the family members responded affirmatively. As for previous tuberculin skin testing, 15 (50.0%) of the CHAP representatives and 4 (13.33%) of the family members had been submitted to the test, and the proportional differences were statisti-cally significant between the groups (p = 0.002).  None of those 19 participants had tested positive on the previous tuberculin skin tests. However, in the investigation of exposure to M. tuberculosis  ,  we asked the participants whether they knew or had ever had contact with a TB patient, and the result was identical in both groups (17 in each group; 56.66%; Table 2).As for the result of the tuberculin skin test carried out in the study, 8 (26.66%) of the CHAP representatives tested positive result (induration ≥  10 mm), whereas it was positive in 1 family member (3.33%), the difference between the two groups being statistically significant (p = 0.011; Table 2).It is important to highlight that, of the 8 CHAP representatives testing positive and referred for investigation, 1 was diagnosed with active TB and initiated the treatment during the study.The variables related to the occupational history of the CHAP representatives are presented Table 2 -  Distribution of the subjects surveyed according to variables related to clinical history.Clinical variableCHA groupFamily member groupp*  BCG scar28/3024/300.129 Prophylactic BCG booster2/304/300.389 Previous tuberculin skin testing15/304/300.002 Has known or had contact with a TB patient17/3017/301.00 Positive tuberculin skin test result8/301/300.011 CHA: community health agent. *Fisher’s exact test.  Mycobacterium tuberculosis   infection among community health workers involved in TB control  J Bras Pneumol. 2009;35(4):351-358 355 those working in the city of São Paulo, 36.7% have finished high school, and 27.3% are soon to graduate from high school. (14)  The CHAP repre-sentatives working in the city of Porto Alegre have had 9-11 years of schooling. (10) In Brazil, it is recommended that the primary  BCG vaccination be administered as early as possible (as soon as the infant weighs more than 2,000 g), and it is obligatory that this  vaccination be administered during the first  year of life, (15)  which explains the fact that most of the study participants presented the vacci-nation scar. However, the absence of the scar does not indicate that the vaccination was not administered. The presence of the vaccination scar represents a history of BCG vaccination, and there is no evidence in the literature of an asso-ciation between the presence of the scar and protection or immunity against TB. However, the NMH, through the National Immunization  Program, recommends the vaccination of chil-dren who do not present the vaccination scar, even of those with a history of BCG vaccination, due to the theoretical possibility that nonviable  vaccination units were administered, resulting in the absence of skin reactivity. (16) The World Health Organization recommends the use of one dose of BCG for protection against TB, considering the absence of evidence to justify the use of additional doses of BCG. (17)  Some countries, such as Russia, Portugal, Chile and Hungary, have adopted the use of multiple doses of BCG for the control of pulmonary TB, based on the assumption that the protec-tion provided by the BCG vaccination wanes over time. In a case-control study conducted in Chile, additional doses of BCG were not found to confer additional protection. (18)  In Finland, the use of the second dose of BCG vaccination in PPD non-reactive children was discontinued in 1990, and no increase in the number of cases  was subsequently observed, when compared  with the cohort of children revaccinated with  BCG. (19)  Randomized controlled studies of the revaccination in schoolchildren in two Brazilian state capitals, Salvador and Manaus, showed the absence of protection of the second dose of  BCG against pulmonary TB. (20,21)  Consequently, the authors recommended the discontinuation of this practice. This explains the low percentage of people who were revaccinated for BCG in this cares with their own health and also with the health of the community. (6)  The CHAP repre-sentatives undoubtedly present particularities, since they work within their own communities,  becoming references for the populations served.In the present study, females predominated, in the CHAP representative group as in the family member group. Surveys involving CHAP representatives in various other Brazilian cities have obtained similar results. (10,11) This can be intimately associated with the caretaker role that  women play in society, being the ones primarily responsible for the upbringing and feeding of children, as well as for the care given to elderly family members. (12)  Of the 170,000 CHAP repre-sentatives in Brazil, 140,000 are women, which confirms the result obtained in the present study. (13)  One of the prerequisites of the NMH is that the agents be over 18 years of age, although there is no set maximum age. (13) A determined level of education was not required by the NMH for the function of agent; it was only necessary that the candidate knew how to read and write. (13)  However, Federal Law no. 10,507, which regulates the CHAP profes-sion, requires that CHAP agents have completed  junior high. Having a higher level of education, CHAP representatives are more apt to incorpo-rate new knowledge and to instruct the families under their care. In the present study, the mean level of education of the CHAP representatives  was higher than that of their family members, although the difference was not statistically significant. In other Brazilian cities, CHAP repre-sentatives have a high level of education. Among Table 3 -  Distribution of the subjects surveyed according to variables related to occupational history.Occupational history variableCHAs evaluated, n/N Values  Median time of service, months30/3023 Underwent training in TB/ DOTS, %26/2892.9 Monitored TB patients, %22/2684.6 Performed DOTS, %19/2673.1 Wore a mask during visits, %0/290.0 Performed visits/DOTS in closed or stuffy environments, %12/2941.4 CHAs: community health agents; and DOTS: directly observed treatment, short-course.
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