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author:("cablon, Anja")
1.  Occupational Screening for Tuberculosis and the Use of a Borderline Zone for Interpretation of the IGRA in German Healthcare Workers 
PLoS ONE  2014;9(12):e115322.
Healthcare workers (HCWs) in low incidence countries with contact to patients with tuberculosis (TB) are considered a high-risk group for latent TB infection (LTBI) and therefore are routinely screened for LTBI. The German Occupational TB Network data is analyzed in order to estimate the prevalence and incidence of LTBI and to evaluate putative risk factors for a positive IGRA and the performance of IGRA in serial testing.
3,823 HCWs were screened with the Quantiferon Gold in Tube (QFT) at least once; a second QFT was performed on 817 HCWs either in the course of contact tracing or serial examination. Risk factors for a positive QFT were assessed by a questionnaire.
We observed a prevalence of LTBI of 8.3%. Putative risk factors for a positive QFT result were age >55 years (OR 6.89), foreign country of birth (OR 2.39), personal history of TB (OR 6.23) and workplace, e.g. internal medicine (OR 1.40), infection ward (OR 1.8) or geriatric care (OR 1.8). Of those repeatedly tested, 88.2% (721/817) tested consistently QFT-negative and 47 were consistently QFT-positive (5.8%). A conversion was observed in 2.8% (n = 21 of 742 with a negative first QFT) and a reversion occurred in 37.3% (n = 28 of 75 with a positive first QFT). Defining a conversion as an increase of the specific interferon concentration from <0.2 to >0.7 IU/ml, the conversion rate decreased to 1.2% (n = 8). Analogous to this, the reversion rate decreased to 18.8% (n = 9).
In countries with a low incidence of TB and high hygiene standards, the LTBI infection risk for HCWs seems low. Introducing a borderline zone from 0.2 to ≤0.7 IU/ml may help to avoid unnecessary X-rays and preventive chemotherapy. No case of active TB was detected. Therefore, it might be reasonable to further restrict TB screening to HCWs who had unprotected contact with infectious patients or materials.
PMCID: PMC4277296  PMID: 25541947
2.  Occupational accident and disease claims, work-related stress and job satisfaction of physiotherapists 
Physiotherapists are exposed to diverse occupational demands. Until now, little has been known about the interaction between occupational stress and the job satisfaction of physiotherapists. This paper aims to examine their work-related stress and job satisfaction. It will analyse accidents at work and occupational diseases of physiotherapists along with work-related physical and psychosocial stress and job satisfaction.
We analysed routine data of the German Institute for Statutory Accident Insurance and Prevention in the Health and Welfare Services (BGW) on accidents at work and occurring en route to/from work as well as occupational diseases of physiotherapists. Work-related stress and job satisfaction were examined in a cross-sectional survey using a standard questionnaire to be completed by subjects themselves.
Between 2007 and 2011, 1,229 cases of occupational disease were reported to the BGW. The majority of reports involved skin diseases (73%). Stumbles and falls were the most frequent causes of accidents at work (42.9%). Eighty-five physiotherapists all over Germany took part in the survey. They experience high quantitative demands at work. The main physical demands consist of a torso posture between 45° and 90° and high hand activity. Of the 85 subjects, 51% suffer from complaints of the musculoskeletal system in the neck and thoracic spine area and 24% have skin diseases. Most physiotherapists (88%) are satisfied with their work overall. This is aided by a high degree of influence on their work and breaks, by practical application of skills and expert knowledge, high regard for their profession, varied work and a good atmosphere at work. Reservations tend to be about statutory regulations and the social benefits provided by the German healthcare system.
Overall, despite high demands and stress relating to the adequacy of resources, the majority of physiotherapists surveyed seem to be satisfied with their job. The main focus of action to promote the health of physiotherapists should be on preventing skin disease, problems of the musculoskeletal system and accidents caused by stumbles and falls.
PMCID: PMC4262239  PMID: 25505490
Working conditions; Physiotherapist; Job satisfaction; Accidents; Occupational disease
3.  Multiresistant pathogens in geriatric nursing – infection control in residential facilities for geriatric nursing in Germany 
Background: The increase of multidrug-resistant organisms (MDROs) causes problems in geriatric nursing homes. Older people are at increased a growing risk of infection due to multimorbidity and frequent stays in hospital. A high proportion of the elderly require residential care in geriatric nursing facilities, where hygiene requirements in nursing homes are similar to those in hospitals. For this reason we examined how well nursing homes are prepared for MDROs and how effectively protect their infection control residents and staff.
Methods: A cross-sectional study was performed on infection control in residential geriatric nursing facilities in Germany 2012. The questionnaire recorded important parameters of hygiene, resident and staff protection and actions in case of existing MDROs.
Results: The response was 54% in Hamburg and 27% in the rest of Germany. Nursing homes were generally well equipped for dealing with infection control: There were standards for MDROs and regular hygiene training for staff. The facilities provided adequate protective clothing, affected residents are usually isolated and hygienic laundry processing conducted. There are deficits in the communication of information on infected residents with hospitals and general practitioners. 54% of nursing homes performed risk assessments for staff infection precaution.
Conclusion: There is a growing interest in MDROs and infection control will be a challenge in for residential geriatric nursing facilities in the future. This issue has also drawn increasing attention. Improvements could be achieved by improving communication between different participants in the health service, together with specific measures for staff protection at work.
PMCID: PMC4184044  PMID: 25285266
infection control; nosocomial infections; nursing homes; elderly people; infection prevention
4.  Predictive values and other quality criteria of the German version of the Nurse-Work Instability Scale (Nurse-WIS) – follow-up survey findings of a prospective study of a cohort of geriatric care workers 
Until now there has been a lack of effective screening instruments for health care workers at risk. To counteract the forecast shortage for health care workers, the offer of early interventions to maintain their work ability will become a central concern. The Nurse-Work Instability Scale (Nurse-WIS) seems to be suitable as a screening instrument and therefore a prospective study of a cohort of nursing staff from nursing homes was undertaken to validate the Nurse-Work Instability Scale (Nurse-WIS).
The follow-up data was used to test the sensitivity, specificity and the predictive values of the Nurse-WIS. The participants answered a questionnaire in the baseline investigation (T1) and in a follow-up 12 month after baseline. The hypothesis was that geriatric care workers with an increased risk according to the Nurse-WIS in T1 would be more likely to have taken long-term sick leave or drawn a pension for reduced work capacity in T2.
396 persons took part in T1 (21.3% response), 225 in T2 (42.3% loss-to-follow-up). In T1, 28.4% indicated an increased risk according to the Nurse-WIS. In T2, 10.2% had taken long-term sick leave or had drawn a pension for reduced work capacity. The sensitivity is 73.9% (95%-CI 55.7%–92.3%), the specificity is 76.7% (95%-CI 71.2%–82.8%). The ROC AUC indicated a moderate precision for the scale, at 0.74 (95%-CI 0.64–0.84).
The PPV of the Nurse-WIS is 26.6%, and the NPV is 96.3%. For those with an increased risk according to the Nurse-WIS, the probability in T2 of long-term sick leave or a pension for reduced work capacity is around eight times higher (OR 8.3, 95%-CI 2.90–23.07). Persons who had indicated a long-term sick leave or made an application for a pension for reduced work capacity in T1 had a 17 times higher risk (OR 17.4, 95%-CI 3.34–90.55).
The German version of the Nurse-WIS appears to be a valid instrument with satisfactory predictive capabilities for recording an impending long-term sick leave. Whether the Nurse-WIS can be used as a screening tool which helps to design risk adjusted prevention programs for the afflicted nurse should be studied.
PMCID: PMC4265889  PMID: 25516765
Nurse-work instability scale; Nurses; Musculoskeletal disorders; Long-term sick leave
5.  MRSA carriage among healthcare workers in non-outbreak settings in Europe and the United States: a systematic review 
BMC Infectious Diseases  2014;14:363.
A recent review estimated prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in healthcare workers (HCWs) to be 4.6%. However, MRSA carriage in HCWs in non-outbreak settings is thought to be higher than in an outbreak situation, due to increased hygiene awareness in outbreaks, but valid data are missing. The goals of this paper are to summarise the prevalence of MRSA carriage amongst HCWs in non-outbreak situations and to identify occupational groups in healthcare services associated with a higher risk of MRSA colonisation.
A systematic search for literature was conducted in the MEDLINE and EMBASE databases. The methodological quality of the studies was assessed using seven criteria. Pooled prevalence rates were calculated. Pooled effect estimates were identified in a meta-analysis.
31 studies were included in this review. The pooled MRSA colonisation rate was 1.8% (95% confidence interval [CI], 1.34%-2.50%). The rate increased to 4.4% (95% CI, 3.98%-4.88%) when one study from the Netherlands was excluded. The pooled MRSA rate was highest in nursing staff (6.9%). Nursing staff had an odds ratio of 1.72 (95% CI, 1.07-2.77) when compared with medical staff and an odds ratio of 2.58 (95%, 1.83-3.66) when compared with other healthcare staff. Seven studies were assessed as being of high quality. The pooled MRSA prevalence in high quality studies was 1.1% or 5.4% if the one large study from the Netherlands is not considered. The pooled prevalence in studies of moderate quality was 4.0%.
MRSA prevalence among HCWs in non-outbreak settings was no higher than carriage rates estimated for outbreaks. Our estimate is in the lower half of the range of the published MRSA rates in the endemic setting. Our findings demonstrate that nursing staff have an increased risk for MRSA colonisation. In order to confirm this finding, more studies are needed, including healthcare professionals with varying degrees of exposure to MRSA. In order to reduce misclassification bias, standardisation of HCWs screening is warranted.
PMCID: PMC4094410  PMID: 24996225
MRSA; Colonisation; Healthcare worker
6.  Tuberculosis in healthcare workers – a narrative review from a German perspective 
Despite the decline of tuberculosis in the population at large, healthcare workers (HCW) are still at risk of infection.
In a narrative review the TB risk in HCW and preventive measures are described, with the focus on epidemiology and Occupational Safety and Health (OSH) regulations in Germany.
There is an increased risk of infection not only in pneumology and laboratories with regular contact with tuberculosis patients or infectious materials. Epidemiological studies have also verified an increased risk of infection from activities that involve close contact with patients’ breath (e.g. bronchoscopy, intubation) or close contact with patients in need of care in geriatric medicine or geriatric nursing. In occupational disease claim proceedings on account of tuberculosis, the burden of proof can be eased for insured persons who work in these or other comparable fields. Forgoing evidence of an index person as a source of infection has led to a doubling of the rate of cases of tuberculosis recognised as an occupational disease and has halved the duration of occupational disease claim proceedings in Germany. For several years now, it has been possible to use the new interferon-y release assays (IGRAs) to diagnose a latent tuberculosis infection (LTBI) with significantly greater validity than with the traditional tuberculin skin test (TST). However, variability of the IGRAs around the cut-off poses problems especially in serial testing of HCWs. At around 10%, LTBI prevalence in German healthcare workers is lower than had been assumed. It can make sense to treat a recent LTBI in a young healthcare worker so as to prevent progression into active tuberculosis. If the LTBI is occupational in origin, the provider of statutory accident insurance can cover the costs of preventive treatment. However, little is known about disease progression in HCWs with positive IGRA sofar.
TB screening in HCWs will remain an important issue in the near future even in low incidence, high income countries, as active TB in HCWs is often due to workplace exposure. The IGRAs facilitate these screenings. However, variability of IGRA results in serial testing of HCWs need further investigations.
PMCID: PMC3984703  PMID: 24625063
Tuberculosis; Provision; Occupational disease; Assessment; Healthcare; Prevention
7.  Musculoskeletal pain and effort-reward imbalance- a systematic review 
BMC Public Health  2014;14:37.
Musculoskeletal pain may be triggered by physical strains and psychosocial risk factors. The effort-reward imbalance model (ERI model) is a stress model which measures psychosocial factors in the working world. The question is whether workers with an effort-reward imbalance report musculoskeletal pain more frequently than those with no effort-reward imbalance. A systematic review using a best evidence synthesis approach was conducted to answer this question.
A literature search was conducted for the period from 1996 to 2012, using three databases (Pubmed, Embase and PsycINFO). The research criteria related to psychosocial, work-related stress as per the ERI model and to musculoskeletal pain. A quality score was developed using various quality criteria to assess the standard of the studies. The level of evidence was graded as in (Am J Ind Med 39:180–193, 2001).
After applying the inclusion criteria, a total of 19 studies were included in the review: 15 cross-sectional studies, three prospective studies and one case–control study. 74% of all studies exhibited good methodological quality, 53% collected data using the original ERI questionnaire, and in 42% of the studies, there was adequate control for physical working conditions. Furthermore, different cut-off points were used to classify exposed and non-exposed individuals. On the basis of 13 studies with a positive, statistically significant association, a moderate level of evidence was inferred for the association between effort-reward imbalance and musculoskeletal pain. The evidence for a role of over-commitment and for its interaction with effort-reward imbalance was rated as inconclusive - on the basis of eight and five studies, respectively.
On the basis of the available evidence, no reliable conclusion may be drawn about any association between the psychosocial factors ascertained using the ERI model and musculoskeletal pain. Before a reliable statement can be made on the association between ERI and musculoskeletal pain, additional longitudinal studies must be performed - with a standardised method for recording and classifying exposure, as well as control of physical confounders. Appropriate preventive measures can then be specified.
PMCID: PMC3898401  PMID: 24428955
Effort-reward imbalance; Musculoskeletal pain; Psychosocial work stress; Review
8.  Validation of the German version of the Nurse-Work Instability Scale: baseline survey findings of a prospective study of a cohort of geriatric care workers 
A prospective study of a cohort of nursing staff from nursing homes was undertaken to validate the Nurse-Work Instability Scale (Nurse-WIS). Baseline investigation data was used to test reliability, construct validity and criterion validity.
A survey of nursing staff from nursing homes was conducted using a questionnaire containing the Nurse-WIS along with other survey instruments (including SF-12, WAI, SPE). The self-reported number of days’ sick leave taken and if a pension for reduced work capacity was drawn were recorded. The reliability of the scale was checked by item difficulty (P), item discrimination (rjt) and by internal consistency according to Cronbach’s coefficient. The hypotheses for checking construct validity were tested on the basis of correlations. Pearson’s chi-square was used to test concurrent criterion validity; discriminant validity was tested by means of binary logistic regression.
396 persons answered the questionnaire (21.3% response rate). More than 80% were female and mostly work full-time in a rotating shift pattern. Following the test for item discrimination, two items were removed from the Nurse-WIS test. According to Cronbach’s (0.927) the scale provides a high degree of measuring accuracy. All hypotheses and assumptions used to test validity were confirmed: As the Nurse-WIS risk increases, health-related quality of life, work ability and job satisfaction decline. Depressive symptoms and a poor subjective prognosis of earning capacity are also more frequent. Musculoskeletal disorders and impairments of psychological well-being are more frequent. Age also influences the Nurse-WIS result. While 12.0% of those below the age of 35 had an increased risk, the figure for those aged over 55 was 50%.
This study is the first validation study of the Nurse-WIS to date. The Nurse-WIS shows good reliability, good validity and a good level of measuring accuracy. It appears to be suitable for recording prevention and rehabilitation needs among health care workers. If, in the follow-up, the Nurse-WIS likewise proves to be a reliable screening instrument with good predictive validity, it could ensure that suitable action is taken at an early stage, thereby helping to counteract early retirement and the anticipated shortage of health care workers.
PMCID: PMC3892029  PMID: 24330532
Nurse-work instability scale; Nurses; Musculoskeletal disorders
9.  Frequent Detection of Latent Tuberculosis Infection among Aged Underground Hard Coal Miners in the Absence of Recent Tuberculosis Exposure 
PLoS ONE  2013;8(12):e82005.
Miners are at particular risk for tuberculosis (TB) infection due to exposure to silica dust and silicosis. The objectives of the present observational cohort study were to determine the prevalence of latent TB infection (LTBI) among aged German underground hard coal miners with silicosis or chronic obstructive pulmonary disease (COPD) using two commercial interferon-gamma release assays (IGRAs) and to compare their performance with respect to predictors of test positivity.
Between October 2008 and June 2010, miners were consecutively recruited when routinely attending pneumoconiosis clinics for an expert opinion. Both IGRAs, the QuantiFERON®-TB Gold In-Tube (QFT) and the T-SPOT®.TB (T-SPOT), were performed at baseline. A standardized clinical interview was conducted at baseline and at follow-up. The cohort was prospectively followed regarding the development of active TB for at least two years after inclusion of the last study subject. Independent predictors of IGRA positivity were calculated using logistic regression.
Among 118 subjects (mean age 75 years), none reported recent exposure to TB. Overall, the QFT and the T-SPOT yielded similarly high rates of positive results (QFT: 46.6%; 95% confidence interval 37.6–55.6%; T-SPOT: 61.0%; 95% confidence interval 52.2–69.8%). Positive results were independently predicted by age ≥80 years and foreign country of birth for both IGRAs. In addition, radiological evidence of prior healed TB increased the chance of a positive QFT result fivefold. While 28 subjects were lost to follow-up, no cases of active TB occurred among 90 subjects during an average follow-up of >2 years.
Considering the high prevalence of LTBI, the absence of recent TB exposure, and the currently low TB incidence in Germany, our study provides evidence for the persistence of specific interferon-gamma responses even decades after putative exposure. However, the clinical value of current IGRAs among our study population, although probably limited, remains uncertain.
PMCID: PMC3846790  PMID: 24312620
10.  Serial IGRA testing of trainees in the healthcare sector in a country with low incidence for tuberculosis – a prospective cohort study 
Background: Healthcare workers (HCW) are a risk group for tuberculosis (TB). That is why interferon-gamma release assay (IGRA) serial testing is performed on HCWs repeatedly exposed to infectious patients or materials. However, the variability of IGRA in serial testing is not yet well understood. We therefore analysed the prevalence of positive IGRA results as well as conversion and reversion rates in the serial testing of healthcare trainees in a low-incidence country.
Methods: In a prospective cohort study, all trainees (n=194) who began training as a nurse or healthcare worker at the Vivantes Healthcare Training Institute in Berlin on 1 October 2008 or 1 April 2009 were IGRA-tested at three different times during the three years of training. Socio-demographic data and possible risk factors (e.g., TB contacts, time spent abroad, area of work) were recorded by means of a standardised questionnaire. The QuantiFERON Gold In-Tube (QFT) was used as an IGRA.
Results: At the beginning of the training the cohort comprised 194 trainees. 70% were female. Their average age was 23. The prevalence of positive QFT was 2.1% (4/194). In the first follow-up test, 2 out of 154 (1.3%) tested IGRA-positive, 151 (98%) had constantly negative results. One IGRA was constantly positive (0.6%) and there was one conversion and one reversion (0.6% respectively). In the second follow-up (n=142) there was again one conversion (0.7%), one reversion and the one constantly positive test result in all three QFT. This trainee had active TB in 2002. All other test results were constantly negative (n=139; 98%). No case of active tuberculosis was diagnosed over the three-year observation period. Contact with TB patients was reported by 42 (29.6%) trainees during the follow-up. The two trainees with a conversion in QFT had no known contact with TB patients. Discordant results in the three consecutive QFT were observed in three trainees (2.1%). Using a borderline zone from 0.2–0.7 IU/mL reduced the number of trainees with discordant results from three to one – a reversion.
Conclusion: The prevalence rate of latent TB infection is low in healthcare trainees without known risk factors for TB infection in their history. The infection risk seems to be low in this population even though contacts with TB patients during the training were reported. Introducing a borderline zone for the interpretation of reversions and conversions in this cohort appears to be safe and reduces the number of discordant results and helps to avoid unnecessary chest X-rays and preventive treatment.
PMCID: PMC3857277  PMID: 24327943
tuberculosis; serial testing; interferon-gamma release assay; healthcare workers; students; occupational disease; latent tuberculosis infection
11.  Frequency and consequences of violence and aggression towards employees in the German healthcare and welfare system: a cross-sectional study 
BMJ Open  2012;2(5):e001420.
In this study, the frequency and consequences of aggressive assaults on employees in the German healthcare and welfare system were investigated.
A retrospective cross-sectional study.
Employees in the German healthcare system and their experiences of violence and aggression were examined in this study.
The sample consisted of 1973 employees from 39 facilities (6 facilities for the disabled, 6 hospitals and 27 outpatient and inpatient geriatric care facilities) who have regular contact with patients or clients.
Main outcome measures
The frequency of physical and verbal violence towards employees and the consequences of aggressive assaults were analysed.
56% of respondents had experienced physical violence and 78% verbal aggression. The highest frequency of physical violence was in inpatient geriatric care (63%) (p=0.000). Younger workers run a higher risk of being affected by physical violence than older colleagues (OR 1.8, 95% CI 1.3 to 2.4). There is also an increased risk of experiencing physical violence in inpatient geriatric care (OR 1.6, 95% CI 1.2 to 2.0). Around a third of workers feel seriously stressed by the violence experienced. The better the facility trained employees for dealing with aggressive and violent clients, the less risk employees ran of experiencing either verbal aggression (OR 0.5, 95% CI 0.4 to 0.7) or physical violence (OR 0.7, 95% CI 0.6 to 0.9). Training by the facility has a positive effect on experienced stress (OR 0.6, 95% CI 0.4 to 0.8).
Violence towards nursing and healthcare personnel occurs frequently. Every third respondent feels severely stressed by violence and aggression. Occupational support provisions to prevent and provide aftercare for cases of violence and aggression reduce the risk of incidents and of perceived stress. Research is needed on occupational support provisions that reduce the risk of staff experiencing verbal and physical violence and the stress that is associated with it.
PMCID: PMC3488706  PMID: 23087013
Epidemiology; Public Health
12.  Interferon-gamma release assays for the tuberculosis serial testing of health care workers: a systematic review 
Interferon-gamma release assays (IGRAs) are increasingly used in the tuberculosis (TB) screening of health care workers (HCWs). However, comparatively high rates of conversions and reversion as well as growing evidence of substantial within-subject variability of interferon-gamma responses complicate their interpretation in the serial testing of HCWs.
We conducted a systematic review on the repeat use of the two commercial IGRAs, the QuantiFERON-TB Gold or In-Tube version (QFT) and the T-SPOT.TB (T-SPOT), in the serial testing and its with-subject variability among HCWs in order to provide guidance on how to interpret serial testing results in the context of the periodic screening of subjects with an increased occupational risk of latent TB infection (LTBI) in countries with low and intermediate TB incidence rates. The Medline, Embase, and Cochrane databases were searched without restrictions. Retrieved articles were complemented by additional hand searched records. Only studies that used commercial IGRAs among HCWs apart from contact and outbreak investigations and those fulfilling further predefined criteria were included.
Overall, 20 studies, five using the T-SPOT and 19 using the QFT assay, were included. Fifteen studies met eligibility criteria for serial testing and five studies for within-subject variability. Irrespective of TB incidence rates in the study’s country of origin, reversion rates were consistently higher than conversion rates (range 22–71% vs. 1–14%). Subjects with baseline results around the diagnostic threshold were more likely to show inconsistent results on retesting. The within-subject variability of interferon-gamma responses was considerable across all studies systematically assessing it.
On the basis of reviewed studies we advocate using a borderline zone from 0.2–0.7 IU/ml for the interpretation of repeat QFT results in the routine screening of HCWs with an increased LTBI risk. Subjects with QFT results within this borderline zone, with suspected fresh infection, and those who are considered for preventive chemotherapy should be retested with the QFT within a period of about four weeks before preventive chemotherapy is recommended. However, the available data regarding the use of the T-SPOT in the serial testing of HCWs is remarkably limited and warrants further research.
PMCID: PMC3377540  PMID: 22537915
Interferon-γ release assay; Health care workers; Latent tuberculosis infection; Occupational disease; Serial testing; Tuberculosis; Within-subject variability
13.  Systematic review of cost and cost-effectiveness of different TB-screening strategies 
Interferon-γ release assays (IGRAs) for TB have the potential to replace the tuberculin skin test (TST) in screening for latent tuberculosis infection (LTBI). The higher per-test cost of IGRAs may be compensated for by lower post-screening costs (medical attention, chest x-rays and chemoprevention), given the higher specificity of the new tests as compared to that of the conventional TST. We conducted a systematic review of all publications that have addressed the cost or cost-effectiveness of IGRAs. The objective of this report was to undertake a structured review and critical appraisal of the methods used for the model-based cost-effectiveness analysis of TB screening programmes.
Using Medline and Embase, 75 publications that contained the terms "IGRA", "tuberculosis" and "cost" were identified. Of these, 13 were original studies on the costs or cost-effectiveness of IGRAs.
The 13 relevant studies come from five low-to-medium TB-incidence countries. Five studies took only the costs of screening into consideration, while eight studies analysed the cost-effectiveness of different screening strategies. Screening was performed in high-risk groups: close contacts, immigrants from high-incidence countries and healthcare workers. Two studies used the T-SPOT.TB as an IGRA and the other studies used the QuantiFERON-TB Gold and/or Gold In-Tube test. All 13 studies observed a decrease in costs when the IGRAs were used. Six studies compared the use of an IGRA as a test to confirm a positive TST (TST/IGRA strategy) to the use of an IGRA-only strategy. In four of these studies, the two-step strategy and in two the IGRA-only strategy was more cost-effective. Assumptions about TST specificity and progression risk after a positive test had the greatest influence on determining which IGRA strategy was more cost-effective.
The available studies on cost-effectiveness provide strong evidence in support of the use of IGRAs in screening risk groups such as HCWs, immigrants from high-incidence countries and close contacts. So far, only two studies provide evidence that the IGRA-only screening strategy is more cost-effective.
PMCID: PMC3196701  PMID: 21961888
14.  Specificity of a whole blood IGRA in German nursing students 
BMC Infectious Diseases  2011;11:245.
Interferon-gamma release assays (IGRA) are used for tuberculosis (TB) screening in healthcare workers (HCWs). However, data on specificity of IGRA in serial testing of HCWs is sparse. Therefore the specificity and the negative predictive value of the IGRA - QuantiFERON-TB Gold In-Tube (QFT) - in German nursing students was investigated.
194 nursing students at the start of their professional career were tested with the QFT. 14 nursing students were excluded from the specificity analysis, due to exposure to mycobacterium tuberculosis. Two of these subjects were QFT- positive. None of them developed disease during the year of follow-up. A study group of 180 students, all with very low risk of prior TB infection, remained in the specificity analysis. Subjects were monitored for at least two years with respect to the development of active TB disease. IGRA was performed at the start of the training and after one year.
The mean age of the study group (n = 180) was 23 years (range 18-53) with 70.9% female and 99.4% German born. The specificity of QFT was 98.9% (178/180; 95% CI 0.96-0.99); lowering the cut-off from 0.35 IU/ml to 0.1 IU/ml would have decreased specificity only slightly to 97.8% (176/180; 95% CI 0.94-0.99). Of the 154 nursing students available for re-testing, one student who initially scored positive reverted to negative, and one student initially negative converted to positive. None of the monitored group with initially negative QFT results developed TB disease, indicating a high negative predictive value of the IGRA in this population.
Following our data, QFT can serve as an effective tool in pre-employment TB screenings for HCWs. As its negative results were stable over time, specificity of the QFT in serial testing of HCWs is high. As the risk of acquiring TB infection in the German healthcare system appears to be low, our data supports the recommendation of performing TB screening only in those HCWs with known contact to TB patients or infectious materials.
PMCID: PMC3189894  PMID: 21929799
15.  The occupational risk of Helicobacter pylori infection among gastroenterologists and their assistants 
BMC Infectious Diseases  2011;11:154.
Helicobacter pylori is a widely spread bacterium that mainly inhabits the gastric mucosa and can lead to serious illnesses such as peptic ulcer disease, gastric carcinoma and gastric MALT lymphoma. The oral-oral route seems to be the main transmission route. The fact that endoscopes are contaminated after being used to perform a gastroscopy leads one to question whether gastroenterologists and endoscopy nurses and assistants run a higher risk of infection.
A systematic search for literature was conducted in the MEDLINE and EMBASE databases and further publications were found in reference lists of relevant articles. Epidemiological studies on the occupational exposure of endoscopy personnel were collected and their quality was assessed. Pooled effect estimates were identified in a meta-analysis.
Of the 24 studies included in the analysis, 15 were considered to be methodologically good. Of these 15 studies, eight single studies showed a statistically significant increased risk of infection for gastroenterologists, and five for their assistants. Meta-analysis across all methodologically good studies found a statistically significant risk of 1.6 (95%CI 1.3-2.0) for doctors. The pooled effect estimates also indicated a statistically significant risk of Helicobacter pylori infection (RR 1.4; 95%CI 1.1-1.8) for assistants too.
When studies are stratified by medical and non-medical control groups, statistically significant risks can only be recognised in the comparison with non-medical controls.
In summary, our results demonstrated an increased risk of Helicobacter pylori infection among gastroenterological personnel. However, the choice of control group is important for making a valid assessment of occupational exposure risks.
PMCID: PMC3123572  PMID: 21627778
16.  MRSA prevalence in european healthcare settings: a review 
BMC Infectious Diseases  2011;11:138.
During the past two decades, methicillin-resistant Staphylococcus aureus (MRSA) has become increasingly common as a source of nosocomial infections. Most studies of MRSA surveillance were performed during outbreaks, so that results are not applicable to settings in which MRSA is endemic. This paper gives an overview of MRSA prevalence in hospitals and other healthcare institutions in non-outbreak situations in Western Europe.
A keyword search was conducted in the Medline database (2000 through June 2010). Titles and abstracts were screened to identify studies on MRSA prevalence in patients in non-outbreak situations in European healthcare facilities. Each study was assessed using seven quality criteria (outcome definition, time unit, target population, participants, observer bias, screening procedure, swabbing sites) and categorized as 'good', 'fair', or 'poor'.
31 observational studies were included in the review. Four of the studies were of good quality. Surveillance screening of MRSA was performed in long-term care (11 studies) and acute care (20 studies). Prevalence rates varied over a wide range, from less than 1% to greater than 20%. Prevalence in the acute care and long-term care settings was comparable. The prevalence of MRSA was expressed in various ways - the percentage of MRSA among patients (range between 1% and 24%), the percentage of MRSA among S. aureus isolates (range between 5% and 54%), and as the prevalence density (range between 0.4 and 4 MRSA cases per 1,000 patient days). The screening policy differed with respect to time points (on admission or during hospital stay), selection criteria (all admissions or patients at high risk for MRSA) and anatomical sampling sites.
This review underlines the methodological differences between studies of MRSA surveillance. For comparisons between different healthcare settings, surveillance methods and outcome calculations should be standardized.
PMCID: PMC3128047  PMID: 21599908
17.  Serial testing with an interferon-γ release assay in German healthcare workers 
Aim: Data concerning conversion and reversion rates in the serial testing of healthcare workers (HCWs) is rare. So far, there is no consensus on how to define and interpret interferon-gamma release assays (IGRA) conversions and reversions, or how to deal with such results. We analysed conversion and reversion rates in the serial testing of HCWs using an IGRA.
Methods: The study population comprises 287 HCWs, who participated in routine occupational safety and health screening for latent tuberculosis infection (LTBI) with the QuantiFERON-TB® Gold In-Tube assay (QFT). Four different definitions for conversion and reversion were applied: 1) transgression or regression above/below the cut-off; 2) increase from <0.2 to >0.7 IU/ml or decrease from >0.7 to <0.2 IU/ml; 3) transgression or regression above/below the cut-off plus change of ≥0.50 IU/ml; and 4) transgression or regression above/below the cut-off plus change of ≥0.70 IU/ml.
Results: The highest conversion and reversion rates of 6.1% (95% CI 3.5 to 9.9) and 32.6% (95% CI 19.1 to 48.5) respectively were observed with the least stringent definition of negative to positive. The most stringent definition of an increase of ≥0.7 IU/ml above the cut-point produced the lowest conversion rate of 2.5% (95% CI 0.9 to 5.3). Using an uncertainty zone from 0.2 to 0.7 IU/ml gave low conversion (2.6%) and reversion rates (15.4%).
Conclusion: Our data confirmed the findings of previous studies that suggest that a simplistic dichotomous negative to positive definition of the IGRA might be deceptive because of the high number of spontaneous conversions and reversions. Therefore using an uncertainty zone around the cut-point (e.g. 0.2 to 0.7 IU/ml) could improve the discrimination between unspecific variation around the diagnostic cut-off and true conversion or reversion.
PMCID: PMC2951105  PMID: 20941341
serial testing; interferon-gamma release assay; latent TB infection; healthcare workers
18.  Fertility disorders and pregnancy complications in hairdressers - a systematic review 
Hairdressers often come into contact with various chemical substances which can be found in hair care products for washing, dyeing, bleaching, styling, spraying and perming. This exposure can impair health and may be present as skin and respiratory diseases. Effects on reproduction have long been discussed in the literature.
A systematic review has been prepared in which publications from 1990 to 2010 were considered in order to specifically investigate the effects on fertility and pregnancy. The results of the studies were summarised separately in accordance with the type of study and the examined events.
A total of 2 reviews and 26 original studies on fertility disorders and pregnancy complications in hairdressers were found in the relevant databases, as well as through hand searches of reference lists. Nineteen different outcomes concerning fertility and pregnancy are analysed in the 26 original studies. Most studies looked into malformation (n = 7), particularly orofacial cleft. Two of them found statistically significant increased risks compared to five that did not. Small for gestational age (SGA), low birth weight (LBW) and spontaneous abortions were frequently investigated but found different results. Taken together the studies are inconsistent, so that no clear statements on an association between the exposure as a hairdresser and the effect on reproduction are possible. The different authors describe increased risks of infertility, congenital malformations, SGA, LBW, cancer in childhood, as well as effects from single substances.
On the basis of the identified epidemiological studies, fertility disorders and pregnancy complications in hairdressers cannot be excluded. Although the evidence for these risks is low, further studies on reproductive risks in hairdressers should be performed as there is a high public health interest.
PMCID: PMC2933705  PMID: 20723211
19.  Predictors of persistently positive Mycobacterium-tuberculosis-specific interferon-gamma responses in the serial testing of health care workers 
BMC Infectious Diseases  2010;10:220.
Data on the performance of Mycobacterium-tuberculosis-specific interferon-(IFN)-γ release assays (IGRAs) in the serial testing of health care workers (HCWs) is limited. The objective of the present study was to determine the frequency of IGRA conversions and reversions and to identify predictors of persistent IGRA positivity among serially tested German HCWs in the absence of recent extensive tuberculosis (TB) exposure.
In this observational cohort-study HCWs were prospectively recruited within occupational safety and health measures and underwent a tuberculin skin test (TST) and the IGRA QuantiFERON®-TB Gold In-Tube (QFT-GIT) at baseline. The QFT-GIT was repeated 18 weeks later in the median. QFT-GIT conversions (and reversions) were defined as baseline IFN-γ < 0.35 IU/ml and follow-up IFN-γ ≥ 0.35 IU/ml (and vice versa). Predictors of persistently positive QFT-GIT results were calculated by logistic regression analysis.
In total, 18 (9.9%) and 15 (8.2%) of 182 analyzed HCWs were QFT-GIT-positive at baseline and at follow-up, respectively. We observed a strong overall agreement between baseline and follow-up QFT-GIT results (κ = 0.70). Reversions (6/18, 33.3%) occurred more frequently than conversions (3/162, 1.9%). Age and positive prior and recent TST results independently predicted persistent QFT-GIT positivity. Furthermore, the chance of having persistently positive QFT-GIT results raised about 3% with each additional 0.1 IU/ml increase in the baseline IFN-γ response (adjusted odds ratio 1.03, 95% confidence interval 1.01-1.04). No active TB cases were detected within an observational period of more than two years.
The QFT-GIT's utility for the application in serial testing was limited by a substantial proportion of reversions. This shortcoming could be overcome by the implementation of a borderline zone for the interpretation of QFT-GIT results. However, further studies are needed to clearly define the within-subject variability of the QFT-GIT and to confirm that increasing age, concordantly positive TST results, and the extend of baseline IFN-γ responses may predict the persistence of QFT-GIT positivity over time in serially tested HCWs with only a low or medium TB screening risk in a TB low-incidence setting.
PMCID: PMC2916913  PMID: 20653946
20.  Bladder cancer among hairdressers: a meta-analysis 
Occupational risks for bladder cancer in hairdressers by using hair products have been examined in many epidemiological studies. But owing to small sample sizes of the studies and the resulting lack of statistical power, the results of these studies have been inconsistent and significant associations have rarely been found.
We conducted a meta-analysis to determine summary risk ratios (SRRs) for the risk of bladder cancer among hairdressers. Studies were identified by a MEDLINE, EMBASE, CENTRAL search and by the reference lists of articles/relevant reviews. Statistical tests for publication bias and for heterogeneity as well as sensitivity analysis were applied. In addition, the study quality and the risk of bias were assessed using six criteria.
42 studies were included and statistically significantly increased risks around 1.3–1.7 were found for all but one analysis. The SRR increased with duration of employment from 1.30 (95% CI 1.15 to 1.48) for ‘ever registered as hairdresser’ to 1.70 (95% CI 1.01 to 2.88) for ‘job held ≥10 years’. No difference was found between the risk for smoking-adjusted data (SRR 1.35, 95% CI 1.13 to 1.61) and no adjustment (SRR 1.33, 95% CI 1.18 to 1.50). Studies assessed as being of high quality (n=11) and of moderate quality (n=31) showed similar SRRs. There was no evidence of publication bias or heterogeneity in all analyses.
In summary, our results showed an increased and statistically significant risk for bladder cancer among hairdressers, in particular for hairdressers in jobs held ≥10 years. Residual confounding by smoking cannot be totally ruled out. Because of the long latency times of bladder cancer it remains an open question whether hairdressers working prior to 1980 and after 1980, when some aromatic amines were banned as hair dye ingredients, have the same risk for bladder cancer.
PMCID: PMC2981018  PMID: 20447989
Urinary bladder neoplasms [MeSH]; occupational exposure; hairdresser; hair dyes; aromatic amines; epidemiology; occupational health practice; public health; cancer; urological
21.  Risk of latent TB infection in individuals employed in the healthcare sector in Germany: a multicentre prevalence study 
BMC Infectious Diseases  2010;10:107.
Healthcare workers are still recognised as a high-risk group for latent TB infection (LTBI). Therefore, the screening of people employed in the healthcare sector for active and LTBI is fundamental to infection control programmes in German hospitals. It was the aim of the study to determine the prevalence and putative risk factors of LTBI.
We tested 2028 employees in the healthcare sector with the QuantiFERON-Gold In-tube (QFT-IT) test between December 2005 and May 2009, either in the course of contact tracing or in serial testing of TB high-risk groups following German OSH legislation.
A positive IGRA was found in 9.9% of the healthcare workers (HCWs). Nurses and physicians showed similar prevalence rates (9.7% to 9.6%). Analysed by occupational group, the highest prevalence was found in administration staff and ancillary nursing staff (17.4% and 16.7%). None of the individuals in the trainee group showed a positive IGRA result. In the different workplaces the observed prevalence was 14.7% in administration, 12.0% in geriatric care, 14.2% in technicians (radiology, laboratory and pathology), 6.5% in admission ward staff and 8.3% in the staff of pulmonary/infectious disease wards. Putative risk factors for LTBI were age (>55 years: OR14.7, 95% CI 5.1-42.1), being foreign-born (OR 1.99, 95% CI 1.4-2.8), TB in the individual's own history (OR 4.96, 95% CI 1.99-12.3) and previous positive TST results (OR 3.5, 95% CI 2.4-4.98). We observed no statistically significant association with gender, BCG vaccination, workplace or profession.
The prevalence of LTBI in low-incidence countries depends on age. We found no positive IGRA results among trainees in the healthcare sector. Incidence studies are needed to assess the infection risk. Pre-employment screening might be helpful in this endeavour.
PMCID: PMC2877045  PMID: 20429957
22.  Aggression and violence against health care workers in Germany - a cross sectional retrospective survey 
Although international scientific research on health issues has been dealing with the problem of aggression and violence towards those employed in health care, research activities in Germany are still at an early stage. In view of this, the aim of this study was to examine the frequency and consequences of aggressive behaviour towards nurses and health care workers in different health sectors in Germany and to assess the need for preventive measures.
We conducted a cross-sectional retrospective survey. Nurses and health care workers from two nursing homes, a psychiatric clinic and a workshop for people with disabilities were interviewed using a standardised questionnaire. The sample covered 123 individuals (response rate 38.8%). The survey assessed the frequency, the type and the consequences of aggressive behaviour, and social support in connection with coping with aggression in the workplace. Odds ratios (OR) and 95% confidence intervals (CI) for putative risk factors which may influence the stress induced by aggression at the workplace were calculated using conditional logistic regression.
During the previous twelve months 70.7% of the respondents experienced physical and 89.4% verbal aggression. Physical aggression more frequently occurred in nursing homes (83.9% of the employees) and verbal aggression was more common in the psychiatric clinic (96.7% of the employees). The proportion of the individuals affected in the workshop for people with disabilities was lower (41.9% and 77.4% respectively). The incidents impaired the physical (55%) and emotional well-being (77.2%) of the employees. The frequency of incidents (weekly: OR 2.7; 95% CI 1.1-6.4) combined with the lack of social support (OR 2.8; 95% CI 1.2-6.6) increased the probability of higher stress due to aggression.
This study corroborates previous reports of frequent physical and verbal aggression towards care workers in the various areas of health care. The present study highlights differences between various areas of health care in Germany and the aggravating effect of prevention neglect such as missing social support at the workplace. Therefore our data suggest the need for improved target group specific prevention of aggressive incidents towards care workers and the need for effective aftercare in Germany.
PMCID: PMC2837654  PMID: 20184718
23.  Evaluation of the tuberculin skin test and the interferon-γ release assay for TB screening in French healthcare workers 
Using French cut-offs for the Tuberculin Skin Test (TST), results of the TST were compared with the results of an Interferon-γ Release Assay (IGRA) in Healthcare Workers (HCW) after contact to AFB-positive TB patients.
Between May 2006 and May 2007, a total of 148 HCWs of the University Hospital in Nantes, France were tested simultaneously with IGRA und TST. A TST was considered to indicate recent latent TB infection (LTBI) if an increase of >10 mm or if TST ≥ 15 mm for those with no previous TST result was observed. For those with a positive TST, chest X-ray was performed and preventive chemotherapy was offered.
All HCWs were BCG-vaccinated. The IGRA was positive in 18.9% and TST ≥ 10 mm was observed in 65.5%. A recent LTBI was believed to be highly probable in 30.4% following TST. Agreement between IGRA and TST was low (kappa 0.041). In 10 (16.7%) out of 60 HCWs who needed chest X-ray following TST the IGRA was positive. In 9 (20%) out of 45 HCWs to whom preventive chemotherapy was offered following TST the IGRA was positive. Of those considered TST-negative following the French guidelines, 20.5% were IGRA-positive. In a two-step strategy - positive TST verified by IGRA - 18 out of 28 (64.3%) IGRA-positive HCWs would not have been detected using French guidelines for TST interpretation.
The introduction of IGRA in contact tracings of BCG-vaccinated HCWs reduces X-rays and preventive chemotherapies. Increasing the cut-off for a positive TST does not seem to be helpful to overcome the effect of BCG vaccination on TST.
PMCID: PMC2790451  PMID: 19948042
24.  In-hospital contact investigation among health care workers after exposure to smear-negative tuberculosis 
Smear-negative pulmonary tuberculosis (TB) accounts for a considerable proportion of TB transmission, which especially endangers health care workers (HCW). Novel Mycobacterium-tuberculosis-specific interferon-γ release assays (IGRAs) may offer the chance to define the burden of TB in HCW more accurately than the Mantoux tuberculin skin test (TST), but the data that is available regarding their performance in tracing smear-negative TB in the low-incidence, in-hospital setting, is limited. We conducted a large-scale, in-hospital contact investigation among HCW of a German university hospital after exposure to a single case of extensive smear-negative, culture-positive TB with pulmonary involvement. The objective of the present study was to evaluate an IGRA in comparison to the TST and to identify risk factors for test positivity.
Contacts were prospectively enrolled, evaluated using a standardized questionnaire, the IGRA QuantiFERON®-TB Gold in Tube (QFT-GIT) and the TST, and followed-up for two years. Active TB was ruled out by chest x-ray in QFT-GIT-positive subjects. Independent predictors of test positivity were established through the use of logistic regression analysis.
Out of the 143 subjects analyzed, 82 (57.3%) had close contact, but only four (2.8%) experienced cumulative exposure to the index case >40 hours. QFT-GIT results were positive in 13 subjects (9.1%), while TST results were positive in 40 subjects (28.0%) at an induration >5 mm. Overall agreement was poor between both tests (kappa = 0.15). Age was the only predictor of QFT-GIT-positivity (Odds ratio 2.7, 95% confidence interval 1.32–5.46), while TST-positivity was significantly related to Bacillus Calmette-Guérin vaccination and foreign origin. Logistic regression analysis showed no relation between test results and exposure. No secondary cases of active TB were detected over an observational period of two years.
Our findings suggest a low contagiosity of the particular index case. The frequency of positive QFT-GIT results may in fact reflect the pre-existing prevalence of latent TB infection among the study population. TB transmission seems unlikely and contact tracing not generally warranted after cumulative exposure <40 hours. However, the substantially lower frequency of positive QFT-GIT results compared to the TST may contribute to enhanced TB control in health care.
PMCID: PMC2698921  PMID: 19505310
25.  Psychosocial stress, demoralization and the consumption of tobacco, alcohol and medical drugs by veterinarians 
In this cross-sectional study the association between psychosocial stress, demoralization and the consumption of psychotropic substances in veterinarians was examined using data from a sample of 1,060 subjects (52.7% response).
Multiple logistic regression models were used to determine risk factors for psychosocial stress, demoralization, tobacco consumption (≹ 10 items/day), high-risk alcohol consumption (men > 20 g pure alcohol/day, women > 10 g pure alcohol/day), binge drinking, problem drinking according to CAGE and regular medical drug intake (at least weekly).
Intense psychosocial stress is a risk factor for binge drinking and for regular drug use. High demoralization values are associated with tobacco consumption, problem drinking and regular drug intake. The probability of a high demoralization value increased with intense psychosocial stress.
Practicing veterinarians are more frequently affected by psychosocial stress and have a greater risk of alcohol or drug consumption than veterinarians working in a non-clinical area of work (e.g. Department of Veterinary Services, Industry).
The findings support the hypothesis of complex interrelationships between psychosocial stress, demoralization and the consumption of psychotropic substances in the veterinary profession and underscore the need of further research.
PMCID: PMC2651184  PMID: 19243579

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