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Background 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. Methods 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. Results 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. Conclusions 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.

Background 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. Methods 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'. Results 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. Conclusions 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.

Background 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. Methods 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. Results 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. Conclusion 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.

Background 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. Methods 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. Results 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. Conclusions 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.

Background 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. Methods 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. Results 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. Conclusions 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.

Background 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. Methods 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. Results 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. Conclusion 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

Background Little is known about the prevalence of latent tuberculosis infections (LTBI) in health care workers (HCW) in low-incidence countries especially in hospitals for pulmonary diseases. With Interferon-gamma release assays (IGRA), a new method for diagnosis of LTBI is available which is more specific than the tuberculin skin test (TST). Objectives The study was designed to estimate prevalence of LTBI among 270 HCW in a Hospital of Pulmonary Diseases routinely screened for TB. Methods LTBI was assessed by the QuantiFERON-Gold In Tube (QFT-IT). Information on gender, age, workplace, job title, BCG vaccination and history of both TB and TST were collected using a standardised questionnaire. Adjusted odds ratios for potential risk factors for LTBI were calculated. Results The prevalence of LTBI was 7.2%. In HCW younger than 30 years LTBI prevalence was 3.5% and in those older than 50 years 22%. Physicians and nurses showed a higher prevalence rate than other professions (10.8% to 4.5%). The putative risk factors for LTBI were age (>50 year OR 9.3, 95%CI 2.5–33.7), working as physicians/nurses (OR 3. 95%CI 1.2–10.4) and no previous TST in medical history (OR 4.4, 95%CI 1.01–18.9) when compared to those with a negative TST. Conclusion Prevalence of LTBI assessed by QFT-IT is low, this indicates a low infection risk even in hospitals for pulmonary diseases. No statement can be made regarding the occupational risk as compared to the general population because there are no LTBI prevalence data from Germany available. The higher LTBI prevalence rate in older HCWs might be due to the cohort effect or the longer time at risk.

BACKGROUND: With the Interferon-gamma release assays (IGRA) a new method for the diagnosis of latent tuberculosis infections (LTBI) is available. Due to the lack of a gold standard for the diagnosis of LTBI, the IGRA is compared to the Mantoux Tuberculin Skin Test (TST), which yields discordant results in varying numbers. Therefore we assessed to which extent discordant results can be explained by potential risk factors such as age, BCG vaccination and migration. METHODS AND FINDINGS: In this pooled analysis, two German studies evaluating the Quantiferon-Gold In-Tube test (QFT) by comparison with the TST (RT23 of SSI) were combined and logistic regressions for potential risk factors for TST+/QFT- as well as THT-/QFT+ discordance were calculated. The analysis comprises 1,033 participants. Discordant results were observed in 15.4%, most of them being TST+/QFT- combinations. BCG vaccination or migration explained 85.1% of all TST+/QFT- discordance. Age explained 49.1% of all TST-/QFT+ discordance. Agreement between the two tests was 95.6% in German-born persons younger than 40 years and not BCG-vaccinated. CONCLUSIONS: After adjustment for potential risk factors for positive or negative TST results, agreement of QFT and TST is excellent with little potential that the TST is more likely to detect old infections than the QFT. In surveillance programs for LTBI in high-income, low TB incidence countries like Germany the QFT is especially suited for persons with BCG vaccination or migrants due to better specificity and in older persons due to its superior sensitivity.

Background 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. Method 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. Results 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%. Conclusion 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.

Einleitung: Beschaftigte im Gesundheitswesen werden regelmasig auf Tuberkulose untersucht. Systematische Auswertungen der Ergebnisse dieser Untersuchungen gibt es bisher aber nicht. Mit der Einfuhrung der Interferon-γ Release Assays (IGRA) wurde ein TB-Netz fur Betriebsarzte aufgebaut, um die Erfahrungen mit dem IGRA bei den Vorsorgeuntersuchungen systematisch zu sammeln. Methode: Bisher liegen die Daten von 2028 Vorsorgeuntersuchungen vor. Auserdem stehen die Daten von Vorsorgeuntersuchungen in Frankreich (n = 148) und Portugal (n = 2889) fur eine kombinierte Analyse zur Verfugung. In den drei Kohorten wurde der QuantiFERON-TB ® Gold in Tube sowie der Tuberkulin-Hauttest mit RT23 eingesetzt. Ergebnisse: Die Pravalenz der latenten Tuberkulose-Infektion (LTBI) ist abhangig vom Alter und vom Land. Von den jungen Beschaftigten ( Diskussion: Bei jungen Beschaftigten im Gesundheitswesen ist die Pravalenz der LTBI gering. Ein positiver IGRA nach einem engen Kontakt zu einem infektiosen Patienten spricht hier fur das Vorliegen einer frischen Infektion. Ansonsten scheinen alte Infektionen zu uberwiegen, da es eine starke Abhangigkeit der IGRA-Ergebnisse vom Alter gibt, und das Progressionsrisiko nach positivem IGRA scheint in den untersuchten Kollektiven eher gering zu sein. Die Indikation fur eine Chemotherapie sollte daher zuruckhaltend gestellt werden.

Introduction 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. Methods 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. Results 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. Conclusion 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.

Background: 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). Methods: 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. Results: 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). Conclusion: The German version of the Nurse-WIS appears to be av alid 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.

Background 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. Methods 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. Results 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. Conclusions 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.

Background 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). Methods 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). Results 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). Conclusion 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.

Background 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. Method 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. Results 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. Conclusion 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.