Screening and treatment removes TB as additional punishment in prisons

Innovative tuberculosis control programmes in prisons have reduced the prevalence of TB, and successfully provided isoniazid preventive therapy and treatment for both drug-sensitive and drug-resistant TB, researchers reported at the 42nd Union World Conference on Lung Health held in Lille last month.

Many countries have reported very high TB prevalence in prisoners, and prisoners have a very high risk of TB acquisition and development of active TB whilst in jail.

According to the World Health Organisation (WHO), the level of TB in prisons has been reported to be up to 100 times higher than that of the civilian population and TB in prisons may account for up to 25% of a country’s burden of TB.

Prisons act as a reservoir for TB, as the disease spreads quickly through overcrowded and poorly ventilated prisons to the prisoners, and to the broader population through staff, visitors and inadequately treated former inmates. It is estimated globally that there are 8 to 10 million people living in prisons every day, however 4 to 6 times this number pass through prisons each year, because of the high turnover of the population.

For example, a TB screening programme of prisoners in Azerbaijan has found that for every 8300 prisoners screened, 263 TB cases would be found (a case notification rate of 3168 per 100 000), including 232 new cases of TB. TB suspects are also screened for drug-resistant TB (DR TB). Of the first 150 prisoners diagnosed with DR TB, 108 (72 %) were cured, 12 (8%) died, 15 (10%) defaulted and 12 (8%) were treatment failures.

This compared to the Ukonga prison in Tanzania where the Three I’s (Intensified case finding, TB infection control and Isoniazid preventative therapy) have been implemented, where 121 cases of TB were identified in the prison population of 6200 (a case notification rate of 1951 per 100,000 for all forms of TB). The national rate for all forms of TB in Tanzania of TB is 146 per 100 000. The notification rate of new smear or bacteriological-positive TB in Ukonga prison was 806 per 100 000. The treatment success rate in Ukonga prison for all forms of TB is 80%.

Azerbaijan’s prison population of 15,000 is made up of 52 penitentiary institutions. TB hospitals support the prison system by providing the necessary healthcare supply and training prison personnel and following up TB patients once they have been released from prison. The prison system of Azerbaijan, which has been hailed as a success in terms of TB control, has a long history of collaborating with TB institutions and funders such as the Global Fund for AIDS, TB and Malaria (GFATM) who provided funding for a Gene Expert diagnostic machine and for a second level laboratory which is currently in the design phases. The Global Fund also provides funding for DR-TB treatment, infection control activities and the reconstruction of the TB and HIV departments, according to WHO guidelines for the prevention of TB in prisons.

Since 1995, 11,067 TB drug-sensitive have been placed on treatment in Azerbaijan prisons, and treatment for drug-resistant TB has been provided for 418 patients since 2007. Each prisoner is given a clinical examination on entrance and regular mass screenings for TB, by questionnaire, are conducted annually in all the prisons with laboratory examination of all TB suspects’ sputum samples. 

Tanzania’s prison average occupancy is 45,000 inmates, although there is only authorised accommodation for 27 653 inmates. Tanzania hosts one of the highest absolute numbers of prisoners in sub-Saharan Africa, after Ethiopia and Kenya respectively. There is a high proportion of smear-negative TB prevalence and higher HIV prevalence in Tanzania, and researchers believe that that many TB patients within Tanzanian prisons are either diagnosed late or are missed.

Tanzania ranks 14^th out of the 22 TB high burden countries, with an estimated 50% of TB patients being HIV co-infected. The national adult HIV prevalence is estimated to be 5.7%. The Ukonga prison implements the 3 I’s in line with the existing TB screening algorithm of the national TB programme.  A TB screening questionnaire is used for all HIV-infected prisoners and all TB suspects are assessed using smear microscopy and chest x-ray. “This package leads to judicious treatment and the interruption of the TB transmission cycle”, said Jan van den Hombergh from Tanzania.

TB services and HIV counselling, testing, care and treatment are offered through a one-stop service at Ukonga, with support from PharmAccess International under a grant from USAID. 2010 prisoners had been tested for HIV and received their result with 747 patients currently on ARVs. 88 HIV-infected prisoners had started TB treatment and 94 people were receiving IPT since July 2011.

The Tanzanian authorities aim to have integrated TB and HIV screening, diagnosis and treatment services at least in each regional main prisons and for all prison sites to be fully computerised for recoding and monitoring and evaluation purposes. Following the success of the Ukonga prison, the 3 I’s will be implemented in the three main prisons in Tanzania. A longitudinal study of the impact of early and regular TB screening and the implementation of the 3I’s strategy is being planned.