RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DESSERTATION

1 / NAME OF THE CANDIDATE & ADDRESS / Mr. MADHU MOHAN S M
I YEAR M.sc NURSING RATHNA COLLEGE OF NURSING,
K.R.PURAM, HASSAN.
2 / NAME OF THE INSTITUTION / RATHNA COLLEGE OF NURSING, K.R.PURAM,
HASSAN.
3 / COURSE OF THE STUDY& SUBJECT / DEGREE OF MASTER OF NURSING,
MEDICAL SURGICAL NURSING.
4 / DATE OF ADMISSION / 26-6-12
5 / TITLE OF THE TOPIC / “TO EVALUATE THE EFFECTIVENESS OF VIDEO ASSISTED TEACHING PROGRAMME ON KNOWLEDGE REGARDING SELF-PROTECTIVE MEASURES AGAINST TUBERCULOSIS AMONG STAFF NURSES WORKING AT RAJEEV HOSPITAL, HASSAN.
6 / STATEMENT OF THE PROBLEM / “A STUDY TO EVALUATE THE EFFECTIVENESS OF VIDEO ASSISTED TEACHING PROGRAMME ON KNOWLEDGE REGARDING SELF-PROTECTIVE MEASURES AGAINST TUBERCULOSIS AMONG STAFF NURSES WORKING AT RAJEEV HOSPITAL,HASSAN.

BRIEF RESUME OF THE INTENDED WORK.

6.1 INTRODUCTION

“Adopt safety measures, prevent threatening tuberculosis”

Tuberculosis is one of the most common bacterial disease known to mankind. Tuberculosis kills more people world-wide than any other infectious diseases. It is estimated that the infection caused by tuberculosis ranges between 19-43% of the World population. The World Health Organization estimates that more than 8 million new cases of Tuberculosis occurs each year and approximately 3million people die from the disease.1

Throughout the world, poor people, health care workers and those from disadvantaged social groups suffer most illness and die sooner2. Tuberculosis continues to rank among the world most serious health problems despite the remarkable achievements of discovering effective diagnostics measures3,. The bacillus causing Tuberculosis, Mycobacterium tuberculi was identified and described on March 24, 1882 by Dr Robert Koch. Tuberculosis is infectious disease characterized by persistent cough. The organism primarily affects and causes pulmonary tuberculosis, and as the disease advances it spreads to other parts of the body like kidney, bones, menninges etc4.

TB infection among health care workers are common, since TB is widespread and contagious, everyone is at risk. It is potential and fatal infectious disease. One infected person is threat to every ones survival. Once the Tuberculosis bacilli have inhaled it reaches the lungs and, within approximately 6 weeks, a small infection appears that rarely gives any symptoms. The typical signs of TB which appear after six weeks are5: Chronic or persistent cough and sputum, Fatigue, Lack of appetite, Weight loss, Fever.

Tuberculosis prevention and control take two parallel approaches. In the first, people with TB and their contacts are identified and treated. Identification of infections often involves testing high-risk groups for TB. In the second approach children are vaccinated to protect them from TB5. Unfortunately, no vaccine is available that provides reliable protection for adults. Many countries use BCG vaccine as part of their TB control programmes, especially for infants. It is also used in adults after the age of 20 years who are tuberculin negative 6.

As health care workers are exposing themselves to TB, more than anybody else, they have higher risk of acquiring TB than general population. So, more preference should be given for the prevention of TB among health care workers, mainly staff nurses working in TB hospitals. Staff nurses have to maintain their health first by following protective measures without negligence while working with TB patients5.

Magnitude of the problem includes tuberculosis among adults, children and staff nurses. More women are diagnosed with tuberculosis and die from it. It mainly occurs in the reproductive ages of women. The magnitude of tuberculosis is higher in children.10-15% of the tuberculosis occurs in children. This is due to the less invention of diagnostic test for tuberculosis in children5.

Nurses and health care workers are more prone to tuberculosis as they spend more time with patients. Tuberculosis is common among nurses working in South East Asia, Japan , and many parts of Europe7.

6.2 NEED FOR THE STUDY

India has more TB patients than any other country and accounts for one fifth of the world's incident TB cases; the reported incidence in 2003 was 168 per 100,000. Every year, TB develops in nearly 2 million persons in India, and nearly 1 million cases are smear positive; an estimated 40% of the Indian population is latently infected with M. tuberculosis. India's Revised National TB Control Programme now provides access to DOTS for >85% of the population. Countrywide coverage is anticipated in 2006. This program is the fastest expanding DOTS program in the world and the largest in the world in terms of patients receiving initial treatment. Outside of the RNTCP, India has a large private health sector that is actively involved in providing TB care; almost half of patients with TB in India initially seek care from the private sector. Thus, because Indian healthcare workers see large numbers of TB patients and because large numbers of TB patients are hospitalized, the risk for nosocomial exposure is substantial9.

Despite the prevalence of TB in India and the expected high probability of nosocomial transmission, little is known about nosocomial TB. In fact, until 2004, no studies on nosocomial TB in India had been published the results of recent studies on TB among healthcare workers from 3 large tertiary hospitals. These studies provide some data on the incidence of active TB , prevalence of latent TB infection , risk factors for active TB, and annual risk for latent TB infection among healthcare workers. In addition, another recent study documented person-to-person transmission of TB among hospitalized patients9.

According to the centers of disease control and prevention in 2008, nearly one-third of the world’s population is infected with Tuberculosis, which kills almost 1.6 million people per year. Tuberculosis is now the second most common cause of death from infectious diseases in the world after Human Immuno Deficiency Virus. An increase in high risk, immune-suppressed individuals, particularly those infected with HIV, lead to an increase in Tuberculosis cases. Drug resistant strains of this deadly disease also contributed to the problem8.

At a rural medical school hospital in Sevagram, performed the tuberculin skin test and a whole-blood interferon-γ release assay for 726 healthcare workers; 50% were positive by either TST or IGRA. Nearly 70% of the participants reported direct contact with sputum smear–positive TB patients. Exposure was particularly high among physicians in training, attending physicians, and nurses. Increasing age and duration of employment were risk factors for latent TB infection. Nurses, nursing students, orderlies, and laboratory staff had higher prevalence of latent infection. A repeat survey of 216 medical and nursing students in this cohort enabled estimation of the annual risk for latent infection by using TST and IGRA. When both tests were used, the annual risk for latent TB infection was estimated to be 5%). The estimated community-based annual risk for infection in India is 1.5%, so the excess risk of 3.5% may be attributable to nosocomial exposure9.

Interconnected influence of the health system in transmission among staff nurses, hospital system increases the potential of nosocomial Tuberculosis transmission at hospital level. An urgent need of in-service education to the staff nurse regarding the usage of self protective measures is necessary8.

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At a tertiary care hospital in Chandigarh, Rao et al. estimated the incidence of active TB among resident physicians. Among residents already working in the hospital TB developed in 9 (2%) of 470, for an incidence of 11.2 new cases per 1,000 person years of exposure. Extra pulmonary disease developed in two thirds of the residents. Overall, this study showed a high rate of TB among those who worked in medical subspecialties. However, most cases were identified by using clinical criteria, and few were bacteriologically confirmed9.

In a retrospective review of healthcare workers who underwent anti-TB treatment in a tertiary care hospital in Vellore, Gopinath et al. identified 125 healthcare workers who had been treated for active TB between 2001 and 2011 . The annual incidence of pulmonary TB was 0.35–1.80 per 1,000 persons during this period. The annual incidence of extra pulmonary TB was 0.34–1.57 per 1,000. These rates may have been underestimated because only healthcare workers who underwent TB treatment were counted. In this hospital, a case-control study showed that low body mass index and employment in medical wards were risk factors for TB disease among healthcare workers10.

In a molecular epidemiologic study at a TB hospital in Delhi, performed DNA fingerprinting on 83 M. tuberculosis isolates from patients in 2 adjacent wards. Of these 83 isolates, 8 strains were grouped into 3 clusters by using IS6110 restriction fragment length polymorphism and spoligotyping analyses. Within each cluster, epidemiologic data showed overlapping hospitalization periods, which raises the possibility of nosocomial transmission10.

It has been identified that many nurses are affected with tuberculosis because of not taking adequate precautionary measures during exposure to the clinical area. The investigator felt the need and interesting to enhance the knowledge on self protective measures against Tuberculosis. So that incidence rate of Tuberculosis among nurses come down it is very essential to create awareness about the topic by using effective educational media.

6.3 REVIEW OF LITERATURE

Review of literature is divided into three parts:

6.3.1 Review of literature related to incidence and prevalence of Tuberculosis

6.3.2 Review of literature related to usage of self protective measures against Tuberculosis

6.2.3 Review of literature related to the effect of educational programs to prevent tuberculosis

6.3.1 Review of literature related to incidence and prevalence of Tuberculosis

A study was conducted to analyze the importance of the examination of, education on, and infection control of tuberculosis in medical school hospitals in Japan in the year 2002.They selected 180 staff nurses by purposive sampling technique from 80 medical school hospitals. Two sets of questionnaires were prepared and delivered to doctors in these hospitals. One set mainly asked about the status of TB examination and education, and other mainly asked about the status of TB infection control. The result revealed that 89.3% of staff nurses in MSHs believed that they required TB rooms exclusively for TB patients who have some underlying diseases, and for TB education. 70.5% of nurses considered MSHs should be able to provide treatment to TB patients. About 40% of these hospitals over the past few years had experienced nosocomial TB infection. The study recommended that great deal of effort still needs to be expanded to establish efficient and effective TB education and infection control systems11.

A case-control study was carried in sub-Saharan Africa, high rates of tuberculosis among health care workers. To identify factors associated with TB disease among staff of an 1800-bed hospital in Kenya. They calculated TB incidence among staff where cases were staff diagnosed with TB and controls were randomly selected staff without recent TB. The result revealed that annual incidence of TB from 2001 to 2005 ranged from 645 to 1115 per 100000 populations. Factors associated with TB disease were additional daily hours spent in rooms with patients, working in areas where TB patients received care , HIV infection, and living in a slum or hospital-provided low-income housing. They concluded that Hospital exposures were associated with TB disease among staff at this hospital regardless of their job designation, even after controlling for living conditions, suggesting transmission from patients. Health care facilities should improve infection control practices, provide quality occupational health services and to encourage staff12

A study was conducted on tuberculosis institute and a general hospital in Delhi, India. To investigate the awareness of nurses about tuberculosis and to evaluate the differences in awareness, if any, between nurses working in tuberculosis and those in a general hospital. A pretested questionnaire survey was performed on 213 nurses. The study showed that a substantial number of nurses have inadequate knowledge regarding causative factors, the importance of sputum examination, correct doses of routinely used short-course chemotherapy drugs, the minimum duration of short-course chemotherapy, instructions at discharge, and health education for patients and family members. If responding correctly to 75% of the questions asked is taken as the criterion for satisfactory awareness, only 40.2% of tuberculosis nurses and 10.7% of general hospital nurses had a satisfactory level of awareness. There was no effect of increasing age or years of experience on the level of awareness. They conclude that lack of knowledge regarding various aspects of tuberculosis among nurses. Active interventions are required to improve awareness for a better implementation of the revised national tuberculosis control programme in India13.

A retrospective study was conducted to assess the prevalence of tuberculosis infection among staff nurses. The result reveals that, the subsequent development of tuberculosis among staff nurses was 12% of the 25 staff nurses with tuberculin reaction above 20 mm. They concluded that the tuberculosis infection was developed over period of 2 years compared to only 0.3% among the 341 staff nurses with tuberculin reaction 20mm or less.14

A self administered survey, clinical interview and tuberculin skin testing was conducted to assess the risk of tuberculosis in correctional health care workers. The objective of this study was to determine the prevalence, incidence & risk factors for occupational infection with tuberculosis among nursing staff employed in correctional facilities. The result reveals that, the overall tuberculin skin test point prevalence rate was 17.7%, the reactivity rate was 2.2% and the annual incidence was 1.3%. At the multivariate level, after controlling for bacilli calmette-Guerin vaccination, only origin of birth remained significantly associated with prevalence of tuberculosis infection. They concluded that, although the prevalence of tuberculin reactivity was high in this population, the risk factors were predominantly demographic rather than occupational. The health care workers were warranted for the continued vigilance to control occupational exposure to tuberculosis and other respiratory pathogens13.

6.3.2Review of literature related to usage of self protective measures against tuberculosis

A study from Brazil, a cross-sectional tuberculin survey determined the baseline LTBI prevalence in four hospitals. Hospital A initiated administrative controls and provided N95 respirators for all HCWs required to enter a TB-isolation room. Hospital B had initiated administrative controls 3 mo before the baseline TST testing and, at the onset of the study, had introduced N95 respirators and had began construction of negative-pressure isolation rooms. Hospitals C and D had no TB-control measures in place throughout the study. Baseline TST positivity was significantly different in the four hospitals. After 1 year, the incidence of LTBI significantly lower in hospitals A and B, which had implemented multiple infection-control measures, compared with the other two hospitals15.