BACK TO BASICS

Work-related infections –
Part 1: Risks of exposure to
infectious agents in the workplace
Tanusha Soogreem Singh,1,2 Onnicah Matuka1,2
1
National Institute for Occupational Health, National Health Laboratory Services, Immunology & Microbiology Section
2
Department of Immunology, School of Pathology, University of the Witwatersrand

Correspondence: Tanusha S Singh, National Institute for Occupational Health, Immunology & Microbiology Section,
PO Box 4788, Johannesburg, South Africa, 2000. tel: +27 (0)11 712 6475, fax: 086 610 4506,
e-mail: tanusha.singh@nioh.nhls.ac.za

ABSTRACT
Workers in many different jobs may be exposed to various infectious biological agents either intentionally
or accidentally. This paper provides information on the risk of exposure to infectious biological agents in the
work environment as well as the occupational risk group. The paper also examines the impact of emerging and
re-emerging biological risks in the South African workplace. An overview of the proximate sources of exposure
and the routes of transmission is presented.

Keywords: exposure risk, hazardous biological agents, infectious disease, work-related, occupational, zoonoses

INTRODUCTION international travel (e.g. armed forces posted in endemic

Work-related infectious disease is referred to as disease
that is caused or aggravated by occupational exposure
to biological agents including bacteria, fungi, viruses and
parasites (helminths, protozoa) through human, animal and/
or environmental contact.1-2 The risk of infection depends
on the pathogenicity of the biological agent of occupational
aetiology, worker susceptibility, dose required to initiate
infection, the mode of transmission, route of entry into the
body and the presence of reservoirs or vectors.3
Although biological hazards in the work environments
have been around for more than a century, several events
in the last decade such as severe acute respiratory syn-
drome (SARS) and the 2009 influenza A (H1N1) pandemic,
have renewed concerns of workers safety.4 During the last
two decades, occupationally acquired hepatitis B, human
immunodeficiency virus (HIV) infection, multidrug-resistant
tuberculosis (MDR-TB) and viral haemorrhagic fevers,
among others, have killed or debilitated thousands of work-
ers, however the exact numbers of fatal infections is not
known. 5-6
This risk is particularly high in South Africa where
enteric (diarrhoeal) infections, hepatitis B, HIV/AIDS, malaria,
measles and tuberculosis are endemic in certain areas.7
The workplace provides an ideal place for the proliferation
of microorganisms and the spread of diseases as people
8
spend approximately 90% of their time indoors. Congregate
settings (e.g. prisons), poor personal hygiene habits (e.g.
hand hygiene and inadequate best practices of coughing
and sneezing), and the quick spread of disease through
areas) all lead to the increased likelihood of disease being
introduced into the work environment. This is more evident
in organisations that have insufficient environmental or engi-
neering controls and those that tolerate employees reporting
to work when they are sick.9
This paper is the first of a three-part series on work-
related infectious diseases. Part 1 focuses only on the risk of
exposure to infectious microbial agents in the workplace.
ESTIMATES OF THE BURDEN OF WORK-
RELATED INFECTIOUS DISEASE
Work-related infection has been reported in the literature as
the third leading cause of occupational disease. Globally,
an estimated 320 000 workers die annually from infectious
diseases caused by bacterial, viral, animal and insect related
biological hazards.10 The rate of infection varies widely by
occupational setting and group. For example, healthcare
workers (HCWs) who are most often at the frontline of
outbreaks of emerging agents and infectious patients are
more at risk.3 The World Health Organization11 estimates
the global burden of diseases as a result of work exposure
among this group to be 40% for Hepatitis B and C infections
and 2.5% for HIV infections, with 90% of occupational expo-
sures being in the developing countries.12 Information on the
extent of work-related infectious diseases in South Africa
is limited due to lack of comprehensive population-based
estimates and only a few occupational groups with evidence
of exposure to infectious pathogens are reported.

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 PEER REVIEWED

INFECTIOUS PATHOGEN HAZARD and miners).2 Trends in globalisation, including expansion

CLASSIFICATION
In South Africa, the Hazardous Biological Agents (HBAs)
13
Regulation emphasises the identification, control and
monitoring of the risk posed by biological agents (bac-
teria, viruses and parasites) of occupational aetiology,
thus protecting workers health. The biological agents are
classified into four groups according to the risk of infection
to a healthy worker, namely: Group 1: unlikely to cause
human disease; Group 2: may cause human disease in
exposed persons, is unlikely to spread to the community
and effective prophylaxis and treatment is usually available;
Group 3: may cause severe human disease in exposed
persons and may present a risk to the community but effec-
tive prophylaxis and treatment is available; and Group 4:
causes severe human disease in exposed persons and
may present a high risk to the community for which effective
prophylaxis and treatment is unavailable. The shortcom-
ing of the Regulation is that it makes no reference to fungi
that cause infection, except in its definition of a biological
agent. In addition, the hazard group classification of the
Regulation does not allow for additional risks like pre-
existing disease, the effects of medication, co-exposure in
the workplace, immune-compromised persons or pregnant
or breastfeeding females. The multiplicative effect of HIV,
tuberculosis (TB) and silicosis in the mining sector is evi-
dent of this drawback.14
in international travel and trade, fuel the spread of infectious
diseases.4,16-17 The spread of SARS across 26 countries
“Although biological hazards in the work
environments have been around for more than
a century, several events . . . have renewed
concerns of workers safety.”
over a period of approximately six months is a classic
example of the latter.18 There are some occupational groups
particularly vulnerable to biological risks, either intentionally
or accidentally.3 These include those groups:
− intentionally working with microorganisms (e.g. laboratory
and research workers);
− having contact with infected people (e.g. HCWs, mortuary
workers);
− having contact with animals that may be reservoirs or
vectors of certain infectious agents (e.g. agricultural
workers, veterinary workers);
Continued on page 8

MAIN OCCUPATIONAL RISK FACTORS FOR

INFECTIOUS DISEASE
There are no anatomical or pathological differences between
infections arising at work and those arising from non-work
related exposures. Identification of at-risk occupations is
further complicated because the sources of exposure are
varied and involve people, animals and the environment.3
Employees in many lines of work may be exposed to infec-
tious agents putting them at risk of disease.3,15 Table 1 (see
page 6) lists a range of broad occupational groups which
are exposed to both common and rare infectious pathogens
according to their proximate sources of exposure and routes
of transmission. Some occupational groups are associated
with an array of infectious pathogens; particularly HCWs,
farm workers and cleaning staff depending on the depart-
ment they are employed in. It should be stressed that not
every worker will develop infection in a given occupational
group as the risk of infection can differ within the same
work category. For example a psychiatric nurse may have
a lower risk of infection than a nurse working in the infec-
tious disease unit. In addition, the risk of infection may not
be directly related to the work but rather as a result of the
mobile or migratory nature of their work and opportunities for
multiple sex partners (e.g. truck drivers, military personnel

OCCUPATIONAL HEALTH SOUTHERN AFRICA WWW.OCCHEALTH.CO.ZA Vol 19 No 2 March/April 2013 5

 Table 1. Work-related infectious pathogens by broad occupational groups according to proximate sources of
exposure and route of transmission2-3,30,51-52

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 Table 1. (continued)

Key: C – contact, I – inhalation, Ig – ingestion, V – vector (arthropod)

Data reported reflects the period 1984-2012.

OCCUPATIONAL HEALTH SOUTHERN AFRICA WWW.OCCHEALTH.CO.ZA Vol 19 No 2 March/April 2013 7

 Continued from page 5
− working in endemic areas for certain infectious diseases
(e.g. outbreak and emergency response teams, military
personnel); and
− accidentally exposed from processes which involve many
different microorganisms entering into the body (e.g.
recycling and waste handlers).19-26
OCCUPATIONAL ZOONOTIC DISEASES
Zoonotic diseases are emerging at a phenomenal rate due
to changes in farming practices, extensive human-wildlife
interaction, increased land usage and current socio-economic
conditions in South Africa.27-28 An animal pathogen which
jumps species infecting a human may be transmitted directly
from the animal or water and soil source contaminated by
infected animal urine, faeces or other bodily fluids. Workers
involved in animal handling (farmers, veterinarians, techni-
cians, abattoir workers, animal carers and hunters) are
predominantly exposed to zoonotic pathogens. This is an
important risk group in South Africa since agriculture and
farming is one of the main economic sectors. Anthrax is a
well known zoonotic disease caused by the spores of Bacillus
anthracis. Over 95% of human infections are cutaneous
as a result of highly resistant spores entering through skin
wounds and abrasions.2 The disease has attracted interna-
tional attention because of its use as a potential biological
weapon. In 2001 an attack in the United States involving
postal workers resulted in 22 cases and 4 deaths. Farm
workers, veterinarians, tannery and wool workers are also
at risk.29
Coxiella burnetii a bacterium causing q-fever and
Leptospira species causing Leptospirosis are common
zoonotic diseases reported worldwide and are a re-emerging
public health concern particularly in large urban areas of
30
developing countries.
MODES OF TRANSMISSION OF INFECTIOUS
AGENTS
Transmission of infection occurs when the infectious agent
leaves the source or reservoir (e.g. human, animal, envi-
ronment: soil or water) and is conveyed by some mode of
transmission (e.g. contact, inhalation, ingestion or through
inoculation and vectors) and enters through an appropriate
portal of entry (e.g. skin or mucous membrane, respiratory
tract, gastro-intestinal tract or uro-genital tract) of a susceptible
worker.1-3,26,30 Transmission routes for certain occupational
groups may be multiple, for example HCWs may be exposed
through the skin, respiratory route and gastro-intestinal sys-
tem.3 Furthermore, the undiagnosed TB infected worker may
very well be the exit port of the infectious agent.
Contact transmission
Occupational infection may occur through contact with an
infected source or contaminated material in the workplace.
8 Vol 19 No 2 March/April 2013
Credit should be given to a worker on a
South African poultry farm who participated
in the project entitled “Allergic sensitisation
and work-related asthma among poultry
workers in South Africa”. Picture depicts
viral warts as a consequence of working with
unprocessed meat.
The pathogen may enter the body through wounds and
lacerations on the skin, mucous membranes of the con-
junctiva, or through the mucosa of the oral, respiratory or
uro-genital tracts.2
Human: Even though funeral service providers share a
similar risk with HCWs, their exposures have been under-
represented. The embalming of corpses and aspiration of
blood and other body fluids put this group at risk of direct
contact with blood-borne exposure.15,31 Sex workers are
also at risk of contracting HIV and Hepatitis C. The median
HIV prevalence in sex workers in South Africa in 2000 was
as high as 50%.2
Animal: Transmission of viral haemorrhagic fevers by
direct contact with infected animals is a major risk factor
among veterinarians and farm workers. Performing animal
autopsies was significantly associated with acute infection.17
Poultry workers are at increased risk of acquiring the avian
influenza (H5N1) virus through direct contact with infected
poultry, or surfaces and objects contaminated by their drop-
pings. The risk of exposure is considered highest during
defeathering, slaughtering and butchering.32
Environment: An outbreak of Sporotrichosis, a subcuta-
neous fungal infection caused by a pathogenic fungus called
Sporothrix schenkii recently occurred. The disease was first
diagnosed in the South African gold mines in 1914,33 and
re-emerged in 2011 in a mine in Mpumalanga as a result
of contaminated soil and untreated, rotting wood, where 17
confirmed and probable cases were identified.34 The environ-
ment is an undisputed source of infection among agricultural
workers who are primarily affected when working in contami-
nated water. Schistosomiasis (Bilharzia) is the second most
prevalent tropical disease in Africa after malaria and is caused
by a parasitic blood fluke, Schistosoma, from the water snails
which then contaminates water sources.2 Another occupational
group at risk of contact with many different infectious agents
are informal workers who pick on illegal waste dumps.35
Inhalation transmission
Airborne pathogens may be inhaled by susceptible workers
OCCUPATIONAL HEALTH SOUTHERN AFRICA WWW.OCCHEALTH.CO.ZA
 causing infection of the respiratory tract. In some instances Inoculation and arthropod vector transmission
the pathogens are carried on droplet nucleic generated from Pathogenic microorganisms may be transmitted through
coughing or sneezing of an infected individual or from sprays accidental inoculation from needle-stick injuries and
and mists generated during processing. These droplet nuclei bites of arthropods among certain occupational groups.2
can remain suspended for long periods and may be carried Occupational exposure through contact with blood-borne
by air currents for considerable distances.2 pathogens and other body fluids remains common, despite
Human: Mycobacterium tuberculosis (MTB) which is the use of various anti-exposure devices and education
spread primarily through inhalation may also be hazardous programmes.44
across several occupations (e.g. mining, healthcare, public
transport, correctional services, funeral services, laboratory “. . . extreme weather patterns as a
workers and cleaning staff).3 Tuberculosis has long repre-
sented an occupational threat to mine workers.36-37 Whilst, consequence of climate change may result
the risk among HCWs became particularly evident during the
Tugela Ferry outbreak in KwaZulu-Natal, when nosocomial in outbreaks of . . . diseases; posing a threat to
outbreaks of XDR-TB occurred.38 Support staff in healthcare
are also at risk of exposure to TB12 as well as community- emergency service and relief aid workers.”
based healthcare researchers. The latter demonstrated a
2.34 times higher TB incidence than the community, but this Needle-stick: Needle-stick injuries predispose both
is often not addressed.39 Data from a national survey of TB healthcare and laboratory workers to blood-borne pathogens
drug resistance to date suggests that South Africa has one such as Hepatitis B and C and HIV in South Africa.3, 21 Intern
11
of the highest MDR-TB burdens in the world. and medical student exposure to blood is extremely common,
Animal: Veterinarians and workers in pet shops, poultry but is markedly under-reported.45 A study showed that 69%
farms, abattoirs and processing plants are at risk from of interns reported one or more percutaneous exposures to
airborne exposure to biological agents found in birds or blood during the intern year.46
their droppings and feathers causing Bird Fancier’s Lung
(hypersensitivity pneumonitis). Workers may also develop
Psittacosis a condition caused by inhalation of the bacteria
Chlamydia psittaci.2
Environment: Some microorganisms such as Legionella
may be transmitted via aerosols from poorly maintained
air-conditioners or water distribution systems. Anyone who
works in a building is at risk of acquiring the disease which
is often wrongly assumed to be flu-like illness.2 Two cases
of Legionnaires’ disease were confirmed at a paper mill in
Mpumalanga in 2007.40 Outbreaks of Legionnaires’ disease
have also been reported in automotive plants, factories
that used water as a coolant and waste-water treatment
facilities.41-43

Ingestion transmission
Pathogenic microorganisms may be ingested by the workers
through contaminated food or drink.2 Poor hand hygiene from
inadequate hand washing is an important exposure source
among HCWs.3 HCWs may also acquire typhoid fever
caused by Salmonella typhi from infected patients which is
transmitted through the faecal-oral route. Laboratory and
sewer workers and other occupations that come into con-
tact with human faeces may be at higher risk of infection.
Hepatitis A virus may also be transmitted through the faecal-
oral route (e.g. child minders).2 Funeral service workers may
also be exposed to enteric pathogens through direct contact
when manipulating corpses leading to transmission via the
faecal-oral route.15

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 Credit should be given to staff and students of South African Public Sector Dental Institutions who participated in the
project entitled “Work-related asthma associated with endotoxin exposure among dental workers in South Africa”.
Vectors: Malaria is a common vector-borne dis-
ease caused by Plasmodium species. The organism
is transmitted to the host via mosquito bites. Dengue
fever is also transmitted via mosquitoes. Agricultural
and forestry workers working in endemic areas are at
risk of exposure.2 A recent outbreak of Rift Valley fever
(RVF) (2008-2011) in South Africa also transmitted by
mosquitoes resulted in 13.4% (302/2 262) confirmed
cases. A total of 32 laboratory-confirmed human RVF
infections were identified from 1 January to 20 May 2011.
Most cases worked regularly with animals within the
farming (n=24, 75%), veterinary (n=4, 13%) or hunting
(n=2, 6%) sectors.47
CHALLENGES TO IDENTIFYING
WORK-RELATED INFECTIONS
Although some work-related infectious diseases occur
26
almost exclusively in certain occupations others are
less connected to the work environment. The interactions
between the worker, biological agent and the environment
are complex. The link between disease and work is often
10 Vol 19 No 2 March/April 2013
obscured by the lack of distinctive characteristics of work-
related infectious diseases leading to missed diagnosis
and under-reporting.3 Diseases may also be missed as
workers may not always have access to occupational
healthcare; occupational health doctors may not have
access to proper diagnostic tools; monitoring programmes
may not cover the entire workforce, or may be restricted to
certain diseases; and some industries may prioritise food
safety over occupational health issues.3 In addition, the
relatively long incubation period (several weeks) between
exposure and onset of disease means that establishing
a relation between infection and work may be problem-
atic. Rare occupational infections may easily be missed
unless there is a high index of suspicion combined with
an understanding of infectious diseases.26 This is further
compounded in diseases which can occur in both the work
and non-work environments.26
CONTEMPORARY AND EMERGING ISSUES
The resurgence of certain diseases and the emergence
of new or previously unrecognised microorganisms
OCCUPATIONAL HEALTH SOUTHERN AFRICA WWW.OCCHEALTH.CO.ZA
 is gaining momentum. 26 In most situations, mixed
exposures occur in the workplace, leading to difficulty
in identifying the causative agent. 48 Also, different
occupational groups may have similar exposure patterns.
For example gardeners may be infected with Francisella
tularensis, however this pathogen was not reported
for crop growers who are also exposed to soil-borne
pathogens and have a similar occupational risk profile.
It is also plausible that certain diseases (e.g. national
priority areas, specific research interests of different
researchers and/or institutions) get more reported than
others (e.g. zoonoses), and that some studies are not
accessible to the scientific community. Overuse or
misuse of antibiotics has resulted in certain microor-
ganisms such as Methicillin-resistant Staphylococcus
aureus developing resistance to some anti-microbial
agents. This jeopardises the containment of infection
and treatment of the disease (e.g. multi and extreme drug
resistant TB) which not only increases the incidence and
severity of illness but also the health costs.49 In addition,
extreme weather patterns as a consequence of climate
change may result in outbreaks of water-, mosquito- and
rodent-borne diseases; posing a threat to emergency
service and relief aid workers.50
CONCLUSION
Work-related infectious diseases involve a broad
spectrum of pathogenic agents across various occu-
pational groups. It is known that workers die annually
from occupationally acquired infections, however the
mortality figures are mere estimates due to problems
engendered by the lack of association between disease
and workplace exposure.
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LESSONS LEARNED
• The risk of infection depends on the pathoge-
nicity of the biological agent of occupational
aetiology, worker susceptibility, dose required
to initiate infection, the mode of transmission,
route of entry into the body and the presence of
reservoirs or vectors.
• Identification of work-related infections is often
confounded by the diversity of infectious agents
in the workplace, the long latency periods from
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obscure links with work.
• Occupational infectious diseases are misdiag-
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• Healthcare workers must assess infections in the
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disease.

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