TB remains a global health problem, infecting over 10 million people annually. Workplaces can increase risk of TB infection and transmission due to factors like overcrowding and poor ventilation. Occupational health services can play an important role in TB elimination by implementing screening, facilitating access to diagnosis and treatment, and providing support to affected workers. The level of workplace contribution depends on TB burden - in high burden settings, intensified case detection is key, while in low burden settings, detecting latent TB through screening is important. A "TB-proof workplace" implements hazard identification, risk assessment, and risk management strategies to curb TB transmission and support workers.

1. TB IN THE WORKPLACE AND
BEYOND
CONTRIBUTION OF OCCUPATIONAL HEALTH
SERVICES TO TB ELIMINATION IN THE ERA
OF MOBILE WORKFORCE
Dr. Jean-Jacques Bernatas – ADB Medical Doctor
Asian Development Bank – Manila - Philippines

2. The views expressed in this paper/presentation are the views of the author and do not
necessarily reflect the views or policies of the Asian Development Bank (ADB), or its
Board of Governors, or the governments they represent.
ADB does not guarantee the accuracy of the data included in this paper and accepts
no responsibility for any consequence of their use.
Terminology used may not necessarily be consistent with ADB official terms.
DISCLAIMER

3. Structure of the presentation
• Part 1: main facts – TB is curable – TB is preventable – TB
elimination and its main barriers. MDR/XDR-TB
• Part 2: TB and the Workplace. TB as occupational hazard –
WP for better screening, access to diagnosis and treatment
and to provide support to affected workers and families (Duty
of Care) and communities (Corporate Social Responsibility).
• Part 3: Contribution of the WP to TB elimination, depending
on the context (TB High vs. Low Burden Country)
• Conclusion: concept of TB-proof workplace.

4. PART 1: MAIN FACTS ON TB

5. TB by NUMBERS in 2016 - BURDEN OF DISEASE (1)
10.4
MILLION
NEW TB CASES
1.0
MILLION
NEW TB CHILDREN
CASES
1.2
MILLION
NEW TB AMONG
PLWHIV)
1.7
MILLION
TB DEATHS
(0.4 M. AMONG
PLWHIV)
-37%
2000
2016
• 25% of global TB burden/ India
• 64% of TB patients from 7 countries (India, Indonesia,
China, Philippines, Pakistan, Nigeria, South Africa)
TB Mortality rate

6. TB by numbers in 2016. Drug-Resistance
580 000
Drug-Resistant TB
CASES
480 000
MDR/XDR-TB
100 000
Rifampicin Resistant
(RR) TB
9.5%
XDR-TB
60% • SEA(RO)
• WP(RO)
• INDIA
• CHINA
• RUS. FED.
45%
MDR-TB treatment:
• Had a success rate of 52% in 2015
• Cost of XDR= x100 the cost of drug sensitive
TB – (cost of MDR-TB is x25 “only”)
20% only
enrolled
for
treatment

7. “TB is curable”: DOTS
• Saved 49 million lives from 2000 to 2015.
• Early detection and treatment of the most contagious cases
• 1.5us$/day for the treatment (6 months) for drug sensitive cases.
• 5 “pillars’:
• Political commitment, long-term planning, adequate human
resources, sustainable financing,
• Case detection through bacteriology, strengthening laboratory
network
• Standardized and supervised treatment,
• Effective and regular drug supply system
• Efficient monitoring system

8. TB is preventable … somehow
• Vaccination:
– Nothing new since 1921 … (BCG)!
– doesn’t prevent contagious TB to spread;
– saves children lives and disabilities by preventing meningitis and
miliary TB;
– New vaccines under study.
• Prevention of transmission:
• conditions of livelihood; air pollution, tobacco smoking, overcrowded housing
• Early detection of contagious (pulmonary) cases and effective treatment
(accessibility/affordability)= DOTS
• Prevention of progression from latent to active TB:
– Contact tracing and chimioprophylaxis
– nutrition, HIV, parasitic infections, diabetes mellitus, etc.

9. TB elimination is achievable …
• SDG #3.3: « By 2030, end the epidemics of AIDS,
tuberculosis, malaria and neglected tropical diseases … »
• Pre-requisites:
– sustained high case detection rate of contagious TB cases (SS+
CDR >70%);
– Sustained success treatment rate of contagious TB cases
(>85%)
– Control on M/XDR-TB, with specific case detection rate >85%
– … and an effective vaccine against PTB

10. … but elimination requires adequate and
integrated TB services
• Case detection and adequate treatment accessible and reaching out the
most vulnerable:
– LTBI (TST vs. IGRA);
– C-XR (returning on the first line, while dropped decades ago);
– Adherence to treatments: improved if shorter and with less side effects;
– Adequate early diagnostic of M/XDR-TB (GenXpert® and similar tests based on
identification of genes of resistance);
– Adequate treatment: right set of drugs for the right period – from 6 months for d
rug-sensitive TB up to 24 months for M/XDR-TB. (recent breakthrough w/ 9-
months “Bangladesh” MDR-TB treatment), including lung surgery for some XDR-
TB cases;
– TB in Children.
• Social support and counseling for better adherence to treatment.

11. Main barriers
• Misconception and inadequate patients management:
– Stigma
– Misdiagnosis and its consequences whether it is over- or under-diagnosed
– Unavailable/Inadequate treatment (content/duration), main driver for ….:
• … DR-TB:
– In China (2), estimated proportion of XDR-TB among MDR-TB in 2015 is
(20%)=2X the average global figures.
– In Central Asia: MDR-TB >25% of new lung TB cases (Azerbaijan, Uzbekistan) !!
– per patient cost for XDR-TB:
• = 4x MDR-TB
• = 100x drug-sensitive TB [estimated 60% of the total cost / hospitalization – data from
study conducted in South Africa (3)].

12. PART 2: TB AND THE WORKPLACE

13. The (Work)place to get sick with TB
• TB= Industrial biological hazard of uneven importance depending on TB
prevalence in the local community.
• Low/Middle Income Countries, with high TB prevalence (TB High Burden Countries –
TB HBC, TB/HIV HBC, TB MDR HBC – StopTB
• Overcrowded workplace, lack of ventilation: mines,
textile factories, public transports, bus riding
/driving (4)
• Spread into families and local
communities.
•  Affecting the workforce: In Indonesia,
(5) total economic burden/TB = 2.1 US$billions,
with 63% due to loss of productivity
by premature deaths in 2011.
Textile factory in Bangladesh

14. The (Work)place to get tested
• Proper screening: pre-employment, regular medical check
(annual physical examination), medical clearances (return to
work, resignation, retirement, …), contact investigation
around a TB case.
• Tests: medical history, C-XR, TST, IGRA
• Sensitivity, specificity (intrinsic performances of tests
unaffected by local prevalence) but also positive predictive
value, which is linked to TB prevalence
Relationship between disease prevalence and predictive value in a test with 95%
sensitivity and 85% specificity.
(From Mausner JS, Kramer S: Mausner and Bahn Epidemiology: An Introductory Text.
Philadelphia, WB Saunders, 1985, p. 221.) – accessed at:
https://onlinecourses.science.psu.edu/stat507/node/71 on 25 April 2018

15. The (Work)place to get treated and supported
• Return to work policy on TB:
– Confirmation of non contagious status
– Necessary paid sick leave. TB shouldn’t be a reason for a worker to
lose her/his job.
• Access to TB treatment: referral to DOTS unit
• Medical insurance covering extra-medical costs
(hospitalization costs, additional imaging, lab tests,
management of side-effects): UHC? Corporate insurance?
• Duty of Care

16. The (Work)place elsewhere: TB and Migration
• Migration is often work-related, especially from poor country with high TB burden.
• ECDC TB report [(6) cases notified in 2016]:
– 32.7% of all TB cases in EU originating from countries other than reporting ones (55.6%
in France, 89.8% in Sweden)
• TB travels with migrants (7), (8), (9), (10), (11).
– Mobile populations between Myanmar and Thailand  poor treatment outcomes among
mobile TB patients, mainly represented by workers from Myanmar (MSF).
– Seasonal migration of Uzbek workers to Kazakhstan:  treatment interruption  risk
factor for MDR-TB; vulnerable population exposed to greater risk of infection and
reactivation. ==>
– Cross-border tuberculosis prevention program among migrant workers in 2015,
(Kazakhstan, the Kyrgyz Republic, Tajikistan and Uzbekistan,) with Project HOPE,
USAID, and The Global Fund.
• Internal migration, also work-related: (In Myanmar a Mobile TB Active Case Finding
Clinics implemented (IOM)  internal migrants living
in the outskirts of Yangon.

17. PART 3: THE WORKPLACE AND ITS
CONTRIBUTION TO TB CONTROL AND
ELIMINATION

18. TB – THE GLOBAL CHALLENGE
(12) In: Rieder HL. Epidemiologic basis of tuberculosis control. 1. ed. Paris: International Union Against Tuberculosis and
Lung Disease; 1999. 162 p. Accessed at https://www.theunion.org/what-we-do/publications/technical on 30 May 2018
A MODEL FOR TB CONTROL ACTIVITIES
INCLUDING ON THE WORKPLACE
↓ exposure to risk
factors for infection
↓ exposure to TB
bacteria
↓ exposure to risk
factors for progressing
to active TB
Early detection if LTBI
Early diagnostic of
active TB
Early adequate
treatment fully
completed

19. THE (WORK)PLACE CONTRIBUTION TO TB CONTROL
• ↓ exposure to TB bacteria
• ↓ exposure to risk factors for
infection
• early detection if LTBI
• ↓ exposure to risk factors for
progressing to active TB
• ↑ early diagnostic of active TB
• ↑ early adequate treatment
fully completed
Duty of Care / Corporate Social
Responsibility
ACTIVITY WORKPLACE CONTRIBUTION
Cover extra-medical expenses
OHS: Hazard Identification (TB prevalence in the
country, in various communities) Risk Assessment
Risk Management (ventilation, human density)
Promotion of adequate nutrition
Link with HIV voluntary counseling and testing
Link with Health Promotion activities
Smoking: tobacco-free workplace, quitting programs
Diabetes Mellitus
Facilitate access to timely diagnosis and adequate treatment
Facilitate safe return to work
Support families and affected communities:
corporate social responsibilities
Support affected workers
and families
Collaborate with MoH/MoLE for NTP/DOTS
implementation
Silicosis
as WRI

20. THE (WORK)PLACE CONTRIBUTION TO TB ELIMINATION
• Context of SDG – SDG 3.3
• TB High Burden Country:
– Urgent scaling up of TB control activities. Intensify detection of active contagious cases.
– Take advantage of higher positive predictive value of cough (+) +/- C-XR for active TB
screening (low specificity, but higher PPV in the context of TB HBC)
– Relevancy of TST and IGRA (affordability?) in settings where TB infection prevalence is
high?
• TB Low Burden Country: faster track to elimination.
– Ex. of EU countries: TB prevalence decreasing, but for TB elimination the annual TB
incidence rate decline should be >10% while it was only 4.2% over the periode 2007-16
– Early detection of LTBI with IGRA (affordable in this context): safe and effective.
[Kowada, 2011 (21)]
– Low value of C-XR (intrensic low specificity – independent from TB prevalence - and low
PPV in the context of TB LBC.
– Identify population at higher risk (workers from TB HBC) and use appropriate tools as for
TB High Burden setting to detect active TB and treat them

21. CONCLUSION: CONCEPT OF « TB-
PROOF WORKPLACE »

22. Concept of TB-Proof Workplace
• Hazard Identification – Risk Assessment – Risk Management:
ventilation, indoor air pollution, workspace, density
• Assure proper individual TB risk assessment:
– Previous possible exposure: country of origin, travel/long stay in TB
HBC; family/community TB contacts
– Current possible active TB: chronic cough (more valuable if high TB
prevalence)
– Regular physical examination (annual?)
• Referral system in place to TB DOTS centers
• Awareness raising (WTD), patient education, cough etiquette
• Support workers and families – Duty of Care
• Corporate Social Responsibility

23. THANK YOU TO:
• Dra. Marilou RENALES,
• Dr. Ricardo BALAGOT
• Philippine College of Occupational Medicine
• ADB Health Sector Group
Contact: jjbernatas@gmail.com

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