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Self reported tuberculosis history among healthcare workers and infection control practices in healthcare settings in Kenya
, Timothy K. Kandie1, Samson M. Muga4, Eunice O. Omesa5, Lilian K. Kerubo1, Lorraine Nkirote Mugambi-Nyaboga4, Benson Otieno Ulo6, Jane Rahedi Ong’ang’o7, Aiban R. Ronoh1, Immaculate K. Kathure1
*Corresponding author: Adano Elema Godana, Ministry of Health, National Tuberculosis, Leprosy and Lung Disease Program, Nairobi, Kenya. agodana@nltp.co.ke
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Received: ,
Accepted: ,
How to cite this article: Godana AE, Mwirigi NM, Owiti P, Nyaboke DN, Kiende PK, Kiarie JK, et al. Self reported tuberculosis history among healthcare workers and infection control practices in healthcare settings in Kenya. J Pan Afr Thorac Soc. doi: 10.25259/JPATS_20_2025
Abstract
Objectives:
Tuberculosis (TB) remains a significant occupational hazard for healthcare workers (HCWs) in high-burden countries like Kenya. Despite their increased risk of exposure, the burden of TB and associated factors among this workforce remains inadequately documented. This study aimed to assess self-reported TB history among HCWs in Kenya and evaluate the existing TB infection prevention and control (IPC) measures in healthcare settings.
Materials and Methods:
A cross-sectional survey was conducted from May to July 2024 across 13 counties in Kenya, representing high, medium, and low TB-burden counties, based on case notification rates. Health facilities were sampled across levels two to six of healthcare. HCWs in service delivery were selected using stratified purposive sampling across cadres and facility departments. Data were collected electronically using pre-tested structured questionnaires, and analysis was done using STATA version 18. The study applied descriptive statistics (frequencies, proportions) to summarize participant characteristics, self-reported TB history, exposure patterns, and IPC practices.
Results:
Out of 640 surveyed HCWs, 19 (3%) reported a history of treatment for TB disease, four of whom were still on treatment. Among the HCWs with TB, 58% (11/19) were female, and 13 (68%) had been in service for ≥6 years. Despite 95% of HCWs reporting direct contact with known TB patients, only 23% had used TB preventive therapy (TPT). IPC practices varied widely, with 62% of facilities having written TB policies/guidelines, while 26% did not train staff on IPC.
Conclusion:
Self-reported TB history was reported among health care workers. Despite varying IPC practices and occupational exposure to TB in the health facilities, less than one-third of the HCWs had ever received TPT in their lifetime. Effective TB control in Kenya depends on safeguarding healthcare workers through the consistent application of infection prevention measures.
Keywords
Healthcare workers
Infection prevention and control
Kenya
Occupational risk
Tuberculosis
INTRODUCTION
Tuberculosis (TB) remains a challenge for healthcare systems globally, with healthcare workers (HCWs) facing a disproportionate risk due to their occupational environment. The annual risk of TB among HCWs in low and middle-income countries (LMICs) ranges from 3.9% to 14.3%.[1,2] Frequent interactions with infectious patients in high-risk healthcare settings make HCWs uniquely vulnerable, necessitating targeted prevention efforts. Inadequate infection prevention and control (IPC) measures, limited access to personal protective equipment (PPE), and suboptimal healthcare infrastructure contribute to this heightened vulnerability.
Effective TB IPC requires a multi-pronged approach encompassing administrative controls (triage, Policies), environmental control (e.g., ventilation), and PPE. In high burden settings, the failure to implement or sustain all three pillars of IPC is a primary driver of nosocomial transmission and occupational disease.
To understand the immediate burden of active illness within the workforce, this study specifically focused on health care workers’ self-reported TB history rather than latent TB infection.
The burden of TB among HCWs remains a critical concern, as they not only face direct occupational exposure but also serve as potential transmission sources to other patients, colleagues, families, and the wider community.[3] This is further complicated by the fact that reporting of TB cases among HCWs is suboptimal, driven by stigma, fear of discrimination, and inadequate workplace health surveillance. In an earlier study done in Kenya, HCWs at a national referral hospital had high rates of TB due to occupational exposure.[4] The findings demonstrated how hospital staff face increased TB risks compared to the general population, underscoring systemic gaps in workplace infection prevention.
According to the World Health Organization (WHO), TB ranks as the leading cause of death from a single infectious agent and among the top 10 diseases causing deaths globally.[5] Kenya is among the 30 high-TB and TB/HIV burden countries globally. In 2023, Kenya notified 94,653 new and relapse TB cases out of an estimated 124,000 incident TB cases, reflecting a 7% increase in notification as compared to 2022.[6] The treatment coverage was 76%, resulting in 24% of cases remaining undiagnosed or unreported. The overall case notification rate was 188/100,000 population. Recognizing their occupational vulnerability, Kenya has prioritized HCWs for targeted interventions in its National Strategic Plan for TB, Leprosy, and Lung Diseases 2024–2028.[7]
A healthy workforce is essential for optimal service delivery. TB-related morbidity among HCWs contributes to workforce shortages, either due to days out of work or death, leading to disruptions in healthcare services. Current surveillance systems are inadequate for precise burden estimation among HCWs, and limited data exist on the effectiveness of preventive measures specifically tailored to this high-risk population. Without this evidence base, designing and implementing targeted interventions to protect HCWs becomes challenging. This study sought to assess self-reported TB history among HCWs as well as to establish the TB IPC practices in healthcare settings. The findings will guide targeted interventions and policies to improve TB prevention and control, enhance occupational health, and advance global TB elimination goals.
MATERIALS AND METHODS
Study design and setting
A cross-sectional study was conducted from May to July 2024 in 13 counties across Kenya, namely Garissa, Kakamega, Kiambu, Kisumu, Machakos, Makueni, Meru, Mombasa, Nairobi, Nakuru, Nandi, Narok, and Nyandarua counties.
Study population
The study population was HCWs providing services at the sampled health facilities who, by the nature of their occupations or roles, were at risk of TB exposure.
Inclusion criteria
All HCWs and trainees, regardless of age or duration of employment.
Both full-time and part-time workers present in the facility consented to participate in the study.
Exclusion criteria
HCWs working in more than one facility have already been surveyed at their primary workplace.
Staff who were absent during data collection or declined to participate.
Sample size determination
Sample size was calculated using a single population proportion formula, assuming a TB prevalence of 9% (based on South African data), a 95% confidence interval, 5% margin of error, and a design effect of 2. This yielded a minimum required sample size of 252. To enhance representativeness across different facility levels and cadres, the sample size was expanded to 753 HCWs across the 13 counties. This ensured proportional subgroup inclusion.
Sampling procedure
A multi-stage sampling approach was employed to select representative counties, health facilities, and HCWs for inclusion in the study. Kenya is divided into 47 counties distributed across diverse geographical and epidemiological zones. For this study, counties were categorized based on TB case notification rates (CNR) into three burden categories: high burden (>200 CNR), medium burden (100–199 CNR), and low burden (<100 CNR). Proportional allocation based on the national distribution of counties across these strata was used to determine the number of counties selected from each category: three counties from the high-burden category, seven from the medium-burden group, and three from the low-burden group. This resulted in a random selection of 13 counties.
Within each selected county, health facilities were sampled across levels II to VI, according to the Kenya Essential Package for Health framework. These levels represent a continuum of care from dispensaries and small clinics (Level II) to national referral and teaching hospitals (Level VI). Facilities were sampled proportionally to their national distribution: Level II (59.6%), Level III (26.9%), and Levels IV to VI (13.4%). Accordingly, each county contributed four Level II facilities, three Level III facilities, and two facilities from Levels IV to VI. This yielded a total of 118 facilities nationwide – 52 Level II, 39 Level III, and 27 Level IV to VI.
HCWs were sampled within these facilities using stratified purposive sampling based on cadre and department. The Health Labour Market Analysis for Kenya, 2023[8] was referenced to guide proportional representation of cadres, including nurses, clinical officers, medical doctors, laboratory technologists, pharmacists, nutritionists, public health officers, physiotherapists, radiographers, and others. From each selected facility, a minimum of twelve HCWs were sampled from Levels IV to VI, seven from Level III, and three from Level II facilities. This allocation was informed by the typical number of departments per facility level. Departments to be visited in each facility were predetermined to ensure coverage of all service delivery points. Staff in standalone units such as laboratories, health records, and radiology were specifically included if not already captured in the selected departments. Support staff were also randomly sampled across departments in alignment with their job roles. This comprehensive sampling design was intended to ensure robust representation across geographic areas, facility levels, professional cadres, and workplace exposure contexts.
Data collection methods and tools
Data were collected from May to July 2024 using pre-tested, structured questionnaires administered via Open Data Kit (ODK) by trained research assistants through face-to-face interviews. Variables included socio-demographics, TB exposure, screening and treatment history, IPC practices, and occupational risk factors. Semi-structured interviews were also conducted to gather qualitative insights on TB-related experiences. Data quality was ensured through training, supervision, daily reviews, and consistency checks. All data were securely stored on password-protected devices.
Data management and analysis
Data was extracted from the ODK system and exported to Microsoft Excel. Data quality checks for completeness and accuracy were conducted. Quantitative data were analyzed using STATA version 18 (StataCorp LLC, USA), applying descriptive statistics (frequencies, proportions) to summarize participant characteristics, self-reported TB history, exposure patterns, and IPC practices.
Ethical considerations
Ethical approval was obtained from the African Medical Research Foundation Ethics and Scientific Review Committee (AMREF-ESRC P1586-2023) and the National Commission for Science, Technology and Innovation (NACOSTI/P/24/34710). Administrative approvals were secured from County Directors of Health, facility in-charges, and other relevant authorities. Written informed consent was obtained from all participants. Data confidentiality and participant anonymity were maintained by research assistants so as to minimize the potential breach of privacy. To further ensure confidentiality, no personal identifiers were collected during data collection, and data were securely stored on password-protected servers. Research Assistants maintained confidentiality throughout and after their interactions with the respondents.
RESULTS
Characteristics of study participants
A total of 640 HCWs participated in the study, representing a 85% response rate. The majority (57.5%) of the participants were female [Table 1]. In terms of work experience, most participants had been in service between 2 and 5 years (28.4%), followed by those between 6 and 10 years (23.6%). A smaller proportion had <1 year (15.2%) of work experience.
| Characteristic | Category | Frequency, n=640 | Percentage (%) |
|---|---|---|---|
| Sex | Male | 272 | 42.5 |
| Female | 368 | 57.5 | |
| Work experience (years) | <1 | 97 | 15.2 |
| 1–<2 | 80 | 12.5 | |
| 2–5 | 182 | 28.4 | |
| 6–10 | 151 | 23.6 | |
| ≥10 | 130 | 20.3 | |
| Primary work area | Clinical services | 242 | 37.8 |
| Laboratory services | 67 | 10.5 | |
| Administration | 80 | 12.5 | |
| Support services | 182 | 28.4 | |
| Other specialized services | 69 | 10.8 |
Participants were drawn from a range of primary work areas within the health facilities. Clinical services had the largest representation (37.8%), followed by support services (28.4%), administration (12.5%), and laboratory services (10.5%). A further 10.8% of participants worked in other specialized departments such as radiology, pharmacy, and public health.
Reported TB among the HCWs
Of the 640 participants, 19 (3%) reported having had TB disease. Among these, 4 (21%) were on treatment for drug-susceptible TB at the time of interview. Among the 19 HCWs with a previous or current history of TB, 11 (58%) were females. A general increase in TB proportion was observed with increasing duration of service, with the highest burden (68%, n = 13) found among personnel with six or more years of experience [Table 2]. No TB cases were reported among those with <1 year of work experience.
| TB status | Years of work experience (n=640) (%) | Total | ||||
|---|---|---|---|---|---|---|
| <1 year | 1–<2 years | 2–5 years | 6–10 years | ≥10 years | ||
| Previous or current TB | 0 (0) | 2 (10.5) | 4 (21.1) | 7 (36.8) | 6 (31.6) | 19 |
| No TB | 97 (15.6) | 78 (12.6) | 178 (28.7) | 144 (23.2) | 124 (20.0) | 621 |
| Total | 97 (15.2) | 80 (12.5) | 182 (28.4) | 151 (23.6) | 130 (20.3) | 640 |
Percentages within each column (years of work experience group) sum to 100%. They represent the proportion of healthcare workers in that experience group who reported a history (or no history) of TB.
By cadre, most of the reported TB was among the casual workers (n = 4, 21.1%) and pharmacy staff (n = 3, 15.8%), followed by nurses/midwives, nutritionists, and community health assistants/promoters (n = 2, 10.5% each). The staff working in the HIV departments reported the highest number of TB cases (n = 4, 21.1%), followed by outpatient departments, chest/TB clinics, and pharmacy (n = 2, 15.8% each).
The majority of the TB reported was diagnosed in public health facilities (n = 14, 74%), followed by faith-based facilities (n = 3, 16%), and the remaining (2, 11%) in private facilities. Notably, 74% (n = 14) of the affected HCWs sought treatment outside their workplace, indicating potential concerns about workplace stigma and/or confidentiality.
TB risk factors among health care workers
TB exposure patterns
A substantial majority of the respondents (608, 95%) reported direct contact with patients diagnosed with TB in the preceding year. Most exposures occurred within healthcare facilities (462; 76%), with 128 (21%) contacts occurring outside the household setting and 18 (3%) reporting exposure within their own households.
Despite the high exposure risk, uptake of TB preventive therapy (TPT) was notably low, with only 147 (23%) participants reporting ever using TPT, 487 (76%) had never used it, while 6 participants (1%) were uncertain about their TPT status. Among those who had used TPT, the weekly rifapentine/isoniazid for 3 months (3HP) regimen was most common (64%; 94/147), followed by the daily isoniazid for 6 months (6H) regimen (19%, 28/147), and only 1% reporting use of the 4-month daily dose of rifampicin (4R) regimen.
Comorbidities and risk factors
All four HCWs on treatment for TB at the time of the study had been tested for HIV, with one reporting HIV-positive status. Similarly, one reported comorbid diabetes. Two of those on TB treatment at the time of the study were active smokers, and one reported alcohol use.
Barriers to working with TB patients
While 608 (95%) of the HCWs reported willingness to work with known TB patients, 32 (5%) were reluctant. Reasons cited for the reluctance included: fear of infection (23 respondents), lack of PPE (19), insufficient information about TB (12), not having taken TPT (9), lack of current TB updates (6), low immunity (4), and comorbidities (3).
IPC practices
Facility-level administrative IPC measures
Of the 102 facilities assessed, 63 (62%) had written IPC policies covering TB, and 89 (87%) had designated personnel responsible for IPC implementation [Table 3]. However, the frequency of policy review varied, with 30% reviewing annually, 6% semi-annually, 43% quarterly, 13% monthly, while 8% reported no regular review process.
| IPC practice | Category | Frequency (n=102) | Percentage (%) |
|---|---|---|---|
| Written IPC policy for TB | Yes | 63 | 62 |
| No | 39 | 38 | |
| Designated IPC personnel | Yes | 89 | 87 |
| No | 13 | 13 | |
| Staff training frequency | Monthly | 24 | 24 |
| Quarterly | 22 | 22 | |
| Semi- annually | 11 | 11 | |
| Annually | 18 | 18 | |
| None | 27 | 26 | |
| Educational programs on TB and IPC | Yes | 81 | 79 |
| No | 21 | 21 |
IPC: Infection prevention and control, TB: Tuberculosis
Staff training in IPC practices showed significant gaps: 24% of facilities conducted training monthly, 22% quarterly, 11% semi-annually, 18% annually, while 26% provided no training at all. Most facilities (79%) reported having regular educational programs regarding TB and IPC.
Respiratory and environmental prevention measures
Most facilities implemented multiple respiratory and environmental IPC measures to prevent TB: 94% provided PPE, 79% had ventilation measures, and 39% had isolation rooms for TB patients. However, one facility (1%) reported having no IPC measures in place. For waste management, 88% used burning/incineration, 22% utilized waste disposal companies, and 9% practiced burying. Specific protocols for disinfection of equipment used by TB patients existed in 78% of facilities.
Resources
Assessed facilities reported varying availability of resources for IPC implementation: 48% had sufficient human resources, 40% had adequate equipment (including PPE), and only 28% had sufficient financial resources. Nearly half (44%) reported inadequate resources across all categories. The majority (61%) of facilities did not have specific budget allocations for IPC activities. Most facilities (71%) had reporting systems for incidents related to breaches in IPC measures.
HCW engagement in TB IPC
Nurses and midwives were most frequently identified as involved in TB IPC activities in 46% of assessed facilities, followed by laboratory staff in 25% of facilities and clinical officers in 15% of facilities [Table 4]. Environmental officers, TB treatment supporters, medical officers, administrative staff, dentists, and pharmacy staff comprised smaller proportions of TB IPC responders. Notably, casual workers and medical interns, despite being present in the study population, were not identified as having TB IPC responsibilities in any of the assessed facilities.
| Cadre | Frequency (n=102) | Percentage (%) |
|---|---|---|
| Nurse/Midwife | 47 | 46 |
| Laboratory staff | 25 | 25 |
| Clinical officers | 15 | 15 |
| Environmental officers | 4 | 4 |
| TB treatment supporters | 4 | 4 |
| Administrative staffs | 4 | 21.1 |
| Support staffs | 1 | 5.3 |
| Other cadres | 7 | 6 |
IPC: Infection prevention and control, TB: Tuberculosis
DISCUSSION
This study presents self-reported TB history among health care workers in Kenya and provides valuable insights into the occupational risk factors, preventive practices, and infection control measures within health facilities. The findings reveal several important patterns that have significant implications for TB control policies and occupational health strategies. This study revealed the presence of TB disease among the HCW population through self-reporting.
This finding may be attributed to the fact that HCWs face heightened TB occupational risk, consistent with evidence from other high TB burden countries where HCWs experience a 2–6 times greater risk of TB infection than the general population.[1,9]
The distribution of TB cases by cadre revealed a disproportionate risk among support staff (casual workers) and pharmacy personnel, despite nurses forming the largest proportion of participants. This may reflect disparities in IPC training access, PPE use, or workplace exposure intensity. These findings align with Galgalo et al., who also noted higher TB rates among support staff compared to clinical cadres in a large Kenyan hospital.[4]
A clear relationship was also observed between duration of employment and TB diagnosis, with nearly 70% of TB cases occurring in HCWs who had worked for six or more years. This cumulative exposure effect supports findings from South Africa’s KwaZulu-Natal region,[10], reinforcing the need for periodic screening and TPT provision for HCWs. The absence of TB cases among those with <1 year of service further strengthens this dose-response observation.
Comorbidities such as HIV, diabetes, smoking, and alcohol use were present among several HCWs with TB, consistent with known TB risk enhancers. Workplace health programs must therefore adopt a holistic approach that includes managing individual-level vulnerabilities alongside occupational exposure.
Despite 95% of participants reporting direct exposure to known TB patients, only one-quarter had ever received TPT. This is particularly concerning given national recommendations prioritizing TPT for health workers. The preference for shorter regimens like 3HP indicates growing acceptability and potential for wider uptake if access barriers are addressed.
Another notable finding was that three-quarters of HCWs with reported TB history sought treatment outside their workplaces, likely due to stigma, confidentiality concerns, or limited internal support. This behavior has been observed in other settings[11] and highlights the need for robust, stigma-free workplace health services.
IPC practices varied widely across facilities. While most had PPE and ventilation measures, only 39% had isolation rooms, and 26% did not offer IPC training. This variability exposes HCWs to preventable risk, particularly in high-volume service areas. As Harries et al. emphasized, even in resource-constrained settings, training remains a cost-effective and essential IPC strategy.[12]
Resource availability for IPC implementation remains a major constraint. Fewer than one-third of facilities reported sufficient financial resources, and fewer than half had adequate human resources or equipment. This mirrors findings in Malawi and across LMICs,[13,14] highlighting the systemic investment gaps in occupational safety infrastructure.
This study’s strengths include its diverse geographic and facility-level representation, mixed-methods design, and focus on both clinical and non-clinical staff. Limitations include its cross-sectional design, which precludes causal inference, and reliance on self-reported TB history, which may be subject to recall bias.
Despite these limitations, our findings reveal the presence of TB disease among Kenyan HCWs and point to critical gaps in protection. These insights are essential for informing targeted policies, including reinforcing TPT, routine screening, and strengthening IPC infrastructure.[15-18]
CONCLUSION
The findings of this study highlight that HCWs in Kenya report a history of TB and identify several system-level gaps in prevention and control, specifically demonstrating low uptake of TPT and variable adherence to IPC practices. These findings identify critical areas for targeted policy and programmatic attention, such as improving TPT access, strengthening IPC training, and establishing supportive workplace policies for routine screening and stigma-free care. Addressing these reported challenges and prioritizing health workers in TB control efforts is an aspirational step toward achieving national and global end TB strategy goals by 2035.
Acknowledgments:
We acknowledge the utmost assistance of the respective subnational TB coordinators who facilitated entry into the facilities by the research assistants and introduced the participants. Much appreciation also to the HCWs who agreed to participate in this study, thus enabling insights into TB disease in this group.
Authors’ contributions:
AG, NM, PO, DN, JK, MG, SKM, SM, EO, LK, BU, LM, JO, AR, IK: Conception and or design of the study; AG, NM, PO, DN, PK, JK, MG, GM, SKM, EM, TK, SM, EO, LK, JO, AR, IK: Analysis of the data and or its interpretation; AG: Led the preparation of the first draft with the assistance of NM, DN, PK, JK, SKM, SM, LK, BU, LM, AR, and IK. All the other authors critically reviewed the drafts. All authors gave approval for publication of the final draft and agree to be accountable for all aspects of the work.
Ethical approval:
The research/study was approved by the Institutional Review Board at African Medical Research Foundation Ethics and Scientific Review Committee, number AMREF-ESRC P1586-2023, dated February 15th, 2024.
Declaration of patient consent:
Patient’s consent is not required as there are no patients in this study.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: This survey was carried out with the support of Global Fund for AIDS, TB, and Malaria funds under the Government of Kenya National Treasury (TB program) as Principal Recipient 1. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Grant number: KEN--T-TNT-4148.
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