World TB day: a new opportunity to reimagine workplace health.

The COVID-19 pandemic is forcing employers around the world to do more to protect and maintain the health of their workforce.

This renewed attention on workplace health provides a unique opportunity for the private sector to make investments that could improve outcomes for tuberculosis (TB), which prior to the COVID-19 pandemic, claimed more lives every year than any other infectious disease.

With COVID-19, there is an opportunity to capitalize on new mandates to go beyond prior protective measures and implement better workplace TB control strategies.

Addressing workplace risk of TB, especially in high burden countries must be a global priority if progress in TB control is to be restored.

The COVID-19 crisis has led to rapidly changing working patterns for many people, including new forms of remote working, flexible working, social distancing at work and shift work. Unfortunately, COVID-19 has also exposed profound inequities in workplace health risks; those working lower paid jobs carrying the greatest risk. In particular, this pandemic has also shone a light on the problem of presenteeism, that is, the phenomenon of people working when they are sick.1 Here, we outline why presenteeism is such an important global health problem, why the COVID-19 pandemic provides a unique opportunity to implement policies to address it, and how those policies could have important implications for tuberculosis (TB) control programmes.

Presenteeism has profound, although largely hidden, economic cost. While employers often consider absenteeism (being off sick) as a greater cost, many researchers agree that the costs of presenteeism are far higher.2 In addition to the economic impact, presenteeism poses substantial public health risks; working while sick, even with mild symptoms, has led to widespread COVID-19 transmission in diverse work settings.3 Although, many employers overlook the hidden economic costs of ill health of other diseases, COVID-19 is forcing companies to do more to protect and maintain the health of their workforce. This renewed attention on workplace health provides a unique opportunity for the private sector to make investments that could improve outcomes for TB, which prior to the COVID-19 pandemic, claimed more lives every year than any other infectious disease.

In addition to its devastating human impact, the economic losses due to TB are huge; welfare losses from TB between now and 2050 are in the range of US$17.5 trillion.4 Work absences necessitated by treatment and poor health make a large contribution to these costs. Much of the spread of the disease also happens in crowded workplaces, impacting productivity of workers and the health of surrounding communities. Prior calls for intersectoral partnership such as the 2003 WHO and the International Labour Organization guidelines for TB Control in the Workplace have aimed to protect workers and employers from productivity losses by reducing occupational exposures.5 With COVID-19, there is an opportunity to capitalise on new mandates to go beyond prior protective measures and implement better workplace TB control strategies.

Even modest investments in workplace TB programmes could have profound impacts in high burden countries. Leveraging previous analysis,6 we estimate that an annual 1% increase in the National TB budget in India (US$5.8 million), that could be achieved through greater employer engagement in TB control activities, might avert TB-related disability and therefore presenteeism in 2.4 million individuals (assuming an incremental cost effectiveness ratio of US$66 per disability-adjusted life-year (DALYs) averted6 achieved through expanding workplace TB diagnosis and treatment). In Vietnam, if TB spending was augmented by US$7 million via the engagement of employers (10% of the 2020 national TB budget of US$70.52), with additional spending allocated towards active case finding, then it would be possible to avert 12 868 DALYs annually, with a corresponding reduction in presenteeism.

Further strengthening the economic case for employer engagement are the potential savings possible due to COVID-19-related employer mandates. Novel public–private partnership models that have burgeoned out of necessity to combat COVID-19 further enable employer engagement, could be leveraged to improve TB case detection and care-seeking in high TB burden settings. Extending occupational safety measures, such as workplace screening strategies postpandemic, are likely to reap long term dividends for TB programmes. Supporting companies to build pandemic resilient workplace health programmes for their workforce and supply chains is also likely to have immediate impact and protected against other lethal respiratory pathogens.

There are signs that many multinational companies are recognising that they have to step up in regard to the health of their workforce. The Ending Workplace TB initiative, launched in January 2020, is building a global network of companies dedicated to TB care and prevention, and provides technical support to help companies strengthen their workplace health programmes. Nonetheless, global TB case detection has fallen by nearly 25% due to COVID-19 and is likely to lead to an increase in TB mortality in the coming years if urgent action is not taken.7 Addressing workplace risk of TB, especially in high burden countries must be a global priority if progress in TB control is to be restored.