Healthcare workers are at high risk of contracting TB: Lesotho is working to help them stay healthy

Lesotho has the second highest tuberculosis (TB) incidence rate in the world.

It is estimated that a person falls ill every 35 minutes, and one dies every 2 hours due to TB in Lesotho.

Known as the “Mountain Kingdom”, Lesotho faces unique challenges in delivering essential health services to remote villages scattered across its mountainous terrain, which cover more than two-thirds of the country. In these remote villages, access to the nearest health facility can take over half a day on foot due to the limited road infrastructure and the rugged terrain that makes it impossible to transverse directly from point A to point B. Often, it’s only the fittest that can make this trip – a critical challenge for a country grappling with the double burden of both TB and HIV/ AIDs. It is not easy for healthcare workers to follow-up with patients for timely laboratory diagnosis and initiation of treatment, and for addressing community transmission of TB through undiagnosed cases.

Globally, TB is a pressing health emergency and Africa contributes to 23% (2.5 million people) of new cases and 31% of TB-related deaths (500,000), despite making up only 15% of the world’s population. The Southern Africa subregion has some of the highest TB case rates on the Africa continent–exceeding 50% in some areas–and has been at the epicenter of the global HIV/AIDS epidemic with elevated TB/ HIV coinfection rates. In Lesotho, approximately 73% of TB patients are co-infected with HIV, and out of the 3,800 TB deaths that occurred in 2022, 2,400 were co-infected with HIV/ AIDs. This is exacerbated by the large numbers of migrant workers crossing national borders in search of better economic opportunities, especially in South African mines, which further facilitate the spread of disease.

In settings with high TB burden, healthcare workers are one of the highest risk groups, due to their frequent exposure to undiagnosed and untreated TB patients, knowledge gaps in TB infection control practices, and the rise in drug-resistant TB cases. TB transmissions to health workers in healthcare settings alone can surpass the community TB transmission rate and pose high risks for the local community due to high turnover and mobility of patients after seeking care. For example, a cross-sectional study conducted in the Maluti Adventist Hospital in Lesotho estimated the 2009 incidence of new TB cases among healthcare workers at 3,111 per 100,000 healthcare workers–almost three times higher than the TB incidence rate in the general population in that same year. This major occupational hazard is further compounded by Lesotho’s high HIV prevalence, which sharpens the progression of TB infection to active disease. The ability of frontline healthcare workers to provide effective care to patients, with any illness, is greatly hindered if TB is not adequately addressed in such situations.

With support from the World Bank, under the Southern Africa Tuberculosis and Health Systems Support Project, and in recognition of the unique challenges faced by frontline health workers, Lesotho has invested in the establishment of wellness centers in all hospitals with infection prevention and control capacity. A range of occupational health interventions that vary by hospital are provided by these centers, and they prioritize a preventative approach while still offering curative guidance to health worker wellbeing, on TB and across a number of medical conditions. Periodic TB testing is provided including: (i) diagnostic tests ranging from GeneXpert, smear microscopy, and the TB LAM antigen test, which tests for active TB in HIV positive patients; (ii) TB treatment with provision of free TB drugs on-site; and (iii) contact tracing of TB cases (especially among family members and neighbors). Wellness centers also include support for mental health conditions, physiotherapy, chronic disease management, redeployment support, cooking demonstrations, social events, all to help ensure healthcare workers can maintain their own health, and better serve their patients. To date, six wellness centers have been established and are functional in the following hospitals: Quthing, Nts’ekhe, Berea, Maluti, Motebang, and Paray.

^{Patients walk for miles to access the Mapholaneng Health Center in Mokhotlong, Lesotho. Photo: Annie Liang}

The wellness center in Maluti Adventist Hospital, situated in the Berea District of Lesotho and located 70 km south of the capital city of Maseru, was established in 2018. Within the first few months of operation, the center identified eight healthcare workers with TB–among which five were asymptomatic. Early TB diagnosis of these infected healthcare workers was essential for the effective management of healthcare-associated TB cases, and preventing onward TB transmission from healthcare workers to patients and the local community. Today, the Maluti Adventist Hospital Wellness Center provides comprehensive health services to over 300 healthcare workers, as well as their dependents conducting both periodic screenings for health workers in direct contact with patients every 6 months, as well as comprehensive annual check-ups.

While most consultations at the Wellness Center deal with common maladies such as colds, flus, vomiting, and diarrhea, it has also supported better overall psychological and mental wellbeing of healthcare workers, and helping to prevent any long-term complications arising from untreated illness. This initiative has boosted local healthcare workers’ morale, staff absenteeism, and ability to deal with stress in an environment with ever-increasing patient loads, as they trust the program to provide care with confidentiality. As noted by Mrs. Moliehi Mokoteli, Occupational Health Nurse/Clinician and Coordinator of the program during a recent World Bank field visit, “The health staff have been facing a prolonged overpopulation of patients, and it feels better to have some better environment to cope with daily stresses.”

Some of the healthcare workers have shared with her:

“Knowing that someone is concerned about your wellbeing while we are concerned about our patients' wellbeing helps us to provide the best care we can.”

“The services are convenient and individualized, treating us holistically with our family members. They are very helpful during working hours, knowing that someone provides our families with care even in our absence. It makes us feel our wellbeing is valued by our employers.”

At a larger scale, the barriers preventing effective infection, prevention, and control (IPC) implementation for TB in hospital settings include inadequate individual level personal protections; lack of a national regulatory framework and associated operational budget; lack of management support; failure to triage or screen patients; insufficient infrastructure and equipment (i.e. isolation spaces and personal protective equipment); deficient ventilation; inadequate staffing and training; poor functioning of infection control committees; and neglect of exposed non-clinical staff.

To close these gaps, the SATBHSSP supported the Government of Lesotho in strengthening the regulatory framework protecting Basotho workers, like healthcare workers, against occupational diseases like TB–a major achievement for the fight against TB. The Government of Lesotho, through the Ministry of Labor and Employment and in collaboration with various labor organizations, developed and disseminated the National Occupational Safety and Health Policy in 2019, showing the government’s high-level commitment to preventing occupational accidents, injuries, and diseases such as TB from occurring, and to minimize hazards inherent to the working environments in Lesotho.

The SATBHSSP has spearheaded a regional approach to tackling TB and occupational lung diseases while strengthening critical dimensions of health systems in four countries in the Southern African Development Community (SADC) block: Lesotho, Malawi, Mozambique, and Zambia. These four countries represent some of the countries hardest hit by TB, based on the burden of disease, co-infection with HIV, and the risk of multi-drug-resistant tuberculosis. Since the project’s launch in 2016, the Government of Lesotho, with support from the World Bank, including IDA grants totaling $36 million, has identified 14,398 cases from active TB case finding, and increased the TB treatment success rate among both new and relapse TB cases from 71 to 81%.

Through the support of SATBHSSP, Lesotho has invested in the building blocks necessary for better TB control, including the establishment of well-equipped district-level mobile teams to pursue active TB case finding at the community level, strengthening district-level TB expertise, training health care workers and village health workers about TB, and streamlining a process for collection and transport of sputum samples from remote health facilities through the engagement of non-governmental actors, helping TB patients get care and live healthy and productive lives.