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Acheampong LK, Effah K, Amuah JE, Tekpor E, Wormenor CM, Gedzah I, Kemawor S, Kachana AC, Danso PA, Essel NOM, Asomaning M, Agyiri D, Akakpo PK. Determining the prevalence of high-risk human papillomavirus infection using a novel cervical precancer screening approach in incarcerated women at the Nsawam Medium Security Prison, Ghana. Ecancermedicalscience 2021; 15:1248. [PMID: 34267804 PMCID: PMC8241459 DOI: 10.3332/ecancer.2021.1248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Indexed: 01/04/2023] Open
Abstract
Background Across Ghana, females comprise 1.2% of the entire prison population (n = 15,463). Cervical cancer screening services are however nonexistent and the prevalence of high-risk human papillomavirus (hr-HPV) and cervical precancer is undocumented. We aimed to screen and treat inmates for cervical precancer and determine the prevalence of hr-HPV using the novel AmpFire HPV detection system combined with colposcopy by trained nurses using a mobile colposcope (the Enhanced Visual Assessment (EVA) system). Methods A descriptive cross-sectional study design was employed, involving all incarcerated women at the Nsawam Medium Security Prison, Ghana. After counselling and informed consent, women underwent a structured questionnaire-based interview entered into a Microsoft Excel spreadsheet. Women were co-tested for cervical pre-cancer and hr-HPV by two trained nurses using dry brush cervical samples for 15 hr-HPV types (AmpFire HPV test) after which mobile colposcopy with the EVA system was performed. EVA images were reviewed by a gynaecologist. Frequencies and percentages were used to describe categorical data, while means, standard deviations, medians and interquartile ranges (IQRs) were used to describe continuous data. Results 75% of the women were convicts with a median sentence of 5 years (IQR: 2-10 years). Their mean age was 41.1 years (standard deviation: 15.5 years, range: 19-97 years). The self-reported prevalence rate of HIV was 13.1% (95% confidence interval (CI): 7.5%-21.9%), all of whom were receiving treatment. The hr-HPV prevalence rate was 47.6% (CI: 36.9%-58.3%) in the general population of imprisoned women and 63.6% (CI: 35.4%-84.8%) among HIV positive women. Six percent (6%) had lesions on the cervix, of which 3.6% were treated with thermal coagulation and 2.4% were treated with loop electrosurgical excision procedure. The average age of hr-HPV positive women was 37.8 years. Conclusions There is a high prevalence of hr-HPV infection among women in custody at the Nsawam Medium Security Prison. These women will benefit from structured cervical cancer prevention services, including treatment for abnormalities that are picked up during such screening.
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Affiliation(s)
- Lawrence Kofi Acheampong
- Ghana Prisons Service, Nsawam Medium Security Prison, Prisons Hospital, PO Box 305, Nsawam, Eastern Region, Ghana
| | | | | | | | | | | | | | - Ateba Cynthia Kachana
- Ghana Prisons Service, Nsawam Medium Security Prison, Prisons Hospital, PO Box 305, Nsawam, Eastern Region, Ghana
| | - Peace Afi Danso
- Ghana Prisons Service, Nsawam Medium Security Prison, Prisons Hospital, PO Box 305, Nsawam, Eastern Region, Ghana
| | | | - Mabel Asomaning
- Ghana Prisons Service, Ghana Prisons Headquarters, PO Box 129, Accra, Ghana
| | | | - Patrick Kafui Akakpo
- Department of Pathology, School of Medical Sciences, University of Cape Coast, Cape Coast Teaching Hospital, Cape Coast, Ghana
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Machado LFA, Fonseca RRDS, Queiroz MAF, Oliveira-Filho AB, Cayres-Vallinoto IMV, Vallinoto ACR, Ishak MDOG, Ishak R. The Epidemiological Impact of STIs among General and Vulnerable Populations of the Amazon Region of Brazil: 30 years of Surveillance. Viruses 2021; 13:v13050855. [PMID: 34067165 PMCID: PMC8151421 DOI: 10.3390/v13050855] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 12/13/2022] Open
Abstract
Sexually transmitted infections (STIs) represent a worldwide public health problem and, although many of them are curable, they continue to be neglected, especially in areas with a low human development index, such as in the northern region of Brazil. This review describes the results of 30 years of studies at the Virus Laboratory at the Federal University of Pará, including the prevalence and molecular epidemiology of HIV-1, HTLV-1/2, HPV, HBV, Treponema pallidum and Chlamydia trachomatis among urban and non-urban populations, and also in vulnerable groups in the Brazilian Amazon. Control strategies and challenges in preventing STIs are discussed considering this immense geographic region, where essential health services are unable to reach the entire population, especially the most vulnerable, such as female sex workers, people who use illicit drugs, remnants of quilombolos and indigenous communities.
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Affiliation(s)
- Luiz Fernando Almeida Machado
- Laboratório de Virologia, Instituto de Ciências Biológica, Universidade Federal do Pará, Belém 66.075-110, Brazil; (R.R.d.S.F.); (M.A.F.Q.); (I.M.V.C.-V.); (A.C.R.V.); (M.d.O.G.I.); (R.I.)
- Correspondence:
| | - Ricardo Roberto de Souza Fonseca
- Laboratório de Virologia, Instituto de Ciências Biológica, Universidade Federal do Pará, Belém 66.075-110, Brazil; (R.R.d.S.F.); (M.A.F.Q.); (I.M.V.C.-V.); (A.C.R.V.); (M.d.O.G.I.); (R.I.)
| | - Maria Alice Freitas Queiroz
- Laboratório de Virologia, Instituto de Ciências Biológica, Universidade Federal do Pará, Belém 66.075-110, Brazil; (R.R.d.S.F.); (M.A.F.Q.); (I.M.V.C.-V.); (A.C.R.V.); (M.d.O.G.I.); (R.I.)
| | - Aldemir Branco Oliveira-Filho
- Grupo de Estudo e Pesquisa em Populações Vulneráveis, Instituto de Estudos Costeiros, Universidade Federal do Pará, Bragança 68.600-000, Brazil;
| | - Izaura Maria Vieira Cayres-Vallinoto
- Laboratório de Virologia, Instituto de Ciências Biológica, Universidade Federal do Pará, Belém 66.075-110, Brazil; (R.R.d.S.F.); (M.A.F.Q.); (I.M.V.C.-V.); (A.C.R.V.); (M.d.O.G.I.); (R.I.)
| | - Antonio Carlos Rosário Vallinoto
- Laboratório de Virologia, Instituto de Ciências Biológica, Universidade Federal do Pará, Belém 66.075-110, Brazil; (R.R.d.S.F.); (M.A.F.Q.); (I.M.V.C.-V.); (A.C.R.V.); (M.d.O.G.I.); (R.I.)
| | - Marluísa de Oliveira Guimarães Ishak
- Laboratório de Virologia, Instituto de Ciências Biológica, Universidade Federal do Pará, Belém 66.075-110, Brazil; (R.R.d.S.F.); (M.A.F.Q.); (I.M.V.C.-V.); (A.C.R.V.); (M.d.O.G.I.); (R.I.)
| | - Ricardo Ishak
- Laboratório de Virologia, Instituto de Ciências Biológica, Universidade Federal do Pará, Belém 66.075-110, Brazil; (R.R.d.S.F.); (M.A.F.Q.); (I.M.V.C.-V.); (A.C.R.V.); (M.d.O.G.I.); (R.I.)
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Colpani V, Soares Falcetta F, Bacelo Bidinotto A, Kops NL, Falavigna M, Serpa Hammes L, Schwartz Benzaken A, Kalume Maranhão AG, Domingues CMAS, Wendland EM. Prevalence of human papillomavirus (HPV) in Brazil: A systematic review and meta-analysis. PLoS One 2020; 15:e0229154. [PMID: 32084177 PMCID: PMC7034815 DOI: 10.1371/journal.pone.0229154] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/30/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES This study aimed to estimate the prevalence of genital, anal and oral HPV infection in Brazil through systematic review and meta-analysis. METHODS We searched EMBASE, LILACS, MEDLINE, Web of Science and SciELO from inception to December 2018. Original research articles that assessed the prevalence of genital (i.e., cervical, penile), anal and oral HPV infection in Brazil were selected in pairs by independent authors. No sex, age, HPV vaccination, language or date restrictions were applied. HPV prevalence was estimated and stratified according to risk factors population and by geographic area throughout the country. The study prevalence was pooled using a random effects model. Analysis was performed using R (version 3.5.2), packages meta version 4.9-4 and metaphor 2.0-0. This review is registered on PROSPERO under protocol number CRD42016032751. RESULTS We identified 3,351 references. After the screening process, 139 of them were eligible for this systematic review (57,513 total participants). Prevalence of cervical HPV was 25.41% (95% CI 22.71-28.32). Additionally, prevalence was 36.21% (95% CI 23.40, 51.33) in the penile region, 25.68% (95%CI 14.64, 41.04) in the anal region, and 11.89% (95%CI 6.26, 21.43) in the oral region. Subgroup analysis showed prevalence in each anatomic site was higher in high-risk populations. CONCLUSION The prevalence of HPV is high in the Brazilian population and varies by population risk and anatomic body site, with lower rates in the oral cavity compared to that in the cervical, penile and anal region. Studies on HPV have primarily been developed to evaluate infection and cancer in the cervical region. There is a profound lack of HPV data in many geographic regions of Brazil and for different anatomic sites.
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Affiliation(s)
- Verônica Colpani
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | | | - Maicon Falavigna
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Adele Schwartz Benzaken
- Tropical Medicine Foundation Heitor Vieira Dourado, Manaus, Amazonas, Brazil
- Aids Health Care Foundation, Manaus, Amazonas, Brazil
| | | | | | - Eliana Márcia Wendland
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
- Department of Community Health, Federal University of Health Science of Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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Escobar N, Plugge E. Prevalence of human papillomavirus infection, cervical intraepithelial neoplasia and cervical cancer in imprisoned women worldwide: a systematic review and meta-analysis. J Epidemiol Community Health 2019; 74:95-102. [DOI: 10.1136/jech-2019-212557] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 09/27/2019] [Accepted: 09/30/2019] [Indexed: 11/04/2022]
Abstract
Background and objectivesImprisoned women have higher rates of abnormalities at cervical screening and some studies suggest that cervical cancer is the most common cancer in this population. The aim of this work was to summarise the current evidence on the prevalence of human papilloma virus (HPV) infection, cervical cancer and precancerous lesions in women in prison worldwide and to compare these rates with the general population.MethodsWe systematically searched and reviewed published and unpublished data reporting the prevalence of any HPV infection, cervical intraepithelial neoplasia (CIN) and cervical cancer in imprisoned women. We created forest plots with prevalence estimates from studies with comparable outcomes and of prevalence ratios using data from national screening programmes as a comparison group.FindingsA total of 53 533 imprisoned women from 10 countries and 35 studies were included in the review. The prevalence of HPV among prisoners ranged from 10.5% to 55.4% with significant heterogeneity. The prevalence of CIN diagnosed by cytology in prisoners ranged from 0% to 22%. Ratios comparing the prevalence of CIN in imprisoned women to that in the community ranged from 1.13 to 5.46. Cancer prevalence estimates were at least 100 times higher than in populations participating in national screening programmes.ConclusionImprisoned women are at higher risk of cervical cancer than the general population. There is a high prevalence of HPV infection and precancerous lesions in this population. Targeted programmes for control of risk factors and the development of more effective cervical screening programmes are recommended.PROSPERO registration numberCRD42014009690.
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Diversity of human papillomavirus typing among women population living in rural and remote areas of Brazilian territory. PAPILLOMAVIRUS RESEARCH 2019; 8:100186. [PMID: 31539646 PMCID: PMC6804508 DOI: 10.1016/j.pvr.2019.100186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 07/04/2019] [Accepted: 09/16/2019] [Indexed: 12/09/2022]
Abstract
Objectives Genotyping HPV from samples tested positive to careHPV™ assay in rural and remote areas of Brazilian territory. Methods A total of 5079 women were enrolled in an opportunistic screening from the Barretos Cancer Hospital, through mobile units or ambulatory unit. All careHPV™ hr-HPV positive samples were tested by a Luminex-based protocol in order to evaluate the HPV infecting types. Results Positive hr-HPV results were obtained in 10.6% (536/5068) of women. Among these cases, HPV-56 and HPV-51 were the most common types detected in 32.3% and 31.4%, respectively. HPV-53 (20.5%), HPV-18 (18.5%), HPV-58 (17.6%), HPV-52 (16.0%) and HPV-16.6%) were the other most frequent types detected. These frequencies represent prevalences of 2.35%, 2.12%, 2.02%, 1.84% and 1.80% respectively, within the population studied. Regarding low-risk HPVs, HPV-6 was detected in 12.9% of the samples. The less frequent types (<3%) were: HPV-70, HPV-11 and HPV-26. Conclusions The most frequent types detected were: HPV-56, HPV-51, HPV-53, HPV-18, HPV-58, HPV-52 and HPV-16 according to decreasing rates.
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Rodrigues LLS, Morgado MG, Sahasrabuddhe VV, De Paula VS, Oliveira NS, Chavez-Juan E, Da Silva DM, Kast WM, Nicol AF, Pilotto JH. Cervico-vaginal self-collection in HIV-infected and uninfected women from Tapajós region, Amazon, Brazil: High acceptability, hrHPV diversity and risk factors. Gynecol Oncol 2018; 151:102-110. [PMID: 30087059 PMCID: PMC6151287 DOI: 10.1016/j.ygyno.2018.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 07/23/2018] [Accepted: 08/01/2018] [Indexed: 01/13/2023]
Abstract
OBJECTIVE We evaluated acceptability of cervico-vaginal self-collection (CVSC) and prevalence of human papillomavirus (HPV) in Human immunodeficiency virus (HIV)-infected and HIV-uninfected women living in the Tapajós region, Amazon, Brazil. METHODS Cross-sectional study recruited 153 non-indigenous women (HIV-uninfected, n = 112 and HIV-infected, n = 41) who voluntarily sought assistance in health services. Peripheral blood for HIV screening and cervical scraping (CS) for HPV detection were collected. Women who accepted to perform CVSC received instructions and individual collection kits. Risk factors for high-risk HPV genotypes (hrHPV) were identified by uni- and multivariate analyses. RESULTS The overall acceptability of CVSC was 87%. Only HIV-infected women had cytological abnormalities (12.2%). Prevalence of any HPV and hrHPV infection was 42.9% and 47.9% for HIV-uninfected and 97.6% and 77.5% for HIV-infected women, respectively. There was significant agreement in the detection of HPV (88%, 0.76, 95% confidence interval [CI], 0.65-0.87) and hrHPV (79.7%, 0.56, 95% CI, 0.41-0.71) between self-collected and clinician-collected samples. The most prevalent hrHPV types were HPV16 and HPV18 in HIV-uninfected and HPV16, HPV51 and HPV59 in HIV-infected women. HIV-infected women with hrHPV infection had multiple hrHPV infections (p = 0.005) and lower CD4 count (p = 0.018). Risk factors for hrHPV infection included being HIV-infected and having five or more sexual partners. CONCLUSIONS CVSC had high acceptability and high prevalence of hrHPV types in women living in the Tapajós region, Amazon, Brazil.
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Affiliation(s)
- Luana L S Rodrigues
- Laboratório de AIDS e Imunologia Molecular, IOC-FIOCRUZ, Rio de Janeiro, Brazil; Instituto de Saúde Coletiva, Universidade Federal do Oeste do Pará, Santarém, Pará, Brazil.
| | - Mariza G Morgado
- Laboratório de AIDS e Imunologia Molecular, IOC-FIOCRUZ, Rio de Janeiro, Brazil.
| | | | | | - Nathália S Oliveira
- Programa de Pós-Graduação em Patologia, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil
| | - Elena Chavez-Juan
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Diane M Da Silva
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA; Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - W Martin Kast
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA; Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Department of Molecular Microbiology and Immunology, University of Southern California, Los Angeles, CA, USA
| | - Alcina F Nicol
- Instituto Nacional de Infectologia Evandro Chagas, INI-FIOCRUZ, Rio de Janeiro, Brazil; Laboratório Interdisciplinar de Pesquisas Médicas, IOC-FIOCRUZ, Rio de Janeiro, Brazil
| | - José H Pilotto
- Laboratório de AIDS e Imunologia Molecular, IOC-FIOCRUZ, Rio de Janeiro, Brazil
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Clinical, laboratory and epidemiological aspects of HPV infection in a low-income population from South Bahia, Brazil. Epidemiol Infect 2017; 145:3398-3404. [PMID: 29166976 DOI: 10.1017/s0950268817002448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The aim of this study was to determine the prevalence and risk factors for human papillomavirus (HPV) infection in the Southern region of the State of Bahia, evaluating the performance of alternative complementary methods for cervical lesion detection. Cervical samples from women who attended healthcare units were collected and diagnosed by visual inspection, cervical cytology and nested polymerase chain reaction (PCR). Moreover, hemi-nested PCR was performed to detect different HPV genotypes. The prevalence of HPV infection was 47·7%, with genotype 16 detected in most cases. Infection was associated with dyspareunia and bleeding (P < 0·001, odds ratio (OR) 5·6, 95% confidence interval (CI) 2·815-11·14) and hormonal contraceptive use (P = 0·007, OR 2·33, 95% CI 1·25-4·34). There was a positive correlation between positive PCR and positive visual inspection, cervical cytology and symptoms reported. Furthermore, visual inspection was twice as specific, and had a greater positive predictive value than cytology. We showed a high prevalence of HPV infection in Southern Bahia, with HPV 16 being the most common type, and visual inspection being most effective at detecting HPV lesions, corroborating the suggestion that it can be applied in routine gynecologic examinations for low-income populations.
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Lorenzi AT, Fregnani JHT, Possati-Resende JC, Antoniazzi M, Scapulatempo-Neto C, Syrjänen S, Villa LL, Longatto-Filho A. Can the careHPV test performed in mobile units replace cytology for screening in rural and remote areas? Cancer Cytopathol 2016; 124:581-8. [DOI: 10.1002/cncy.21718] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 03/03/2016] [Accepted: 03/07/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Adriana T. Lorenzi
- Institute of Education and Research and Molecular Oncology Center, Barretos Cancer Hospital; Pio XII Foundation; Barretos São Paulo Brazil
| | - José Humberto T. Fregnani
- Institute of Education and Research and Molecular Oncology Center, Department of Researcher Support, Barretos Cancer Hospital; Pio XII Foundation; Barretos São Paulo Brazil
| | - Júlio César Possati-Resende
- Institute of Education and Research and Molecular Oncology Center, Department of Prevention, Barretos Cancer Hospital; Pio XII Foundation; Barretos São Paulo Brazil
| | - Márcio Antoniazzi
- Institute of Education and Research and Molecular Oncology Center, Department of Prevention, Barretos Cancer Hospital; Pio XII Foundation; Barretos São Paulo Brazil
| | - Cristovam Scapulatempo-Neto
- Institute of Education and Research and Molecular Oncology Center, Department of Pathology, Barretos Cancer Hospital; Pio XII Foundation; Barretos São Paulo Brazil
| | - Stina Syrjänen
- Medicity Research Laboratory and Department of Oral Pathology, Institute of Dentistry, Faculty of Medicine; University of Turku; Turku Finland
- Department of Pathology; Turku University Central Hospital; Turku Finland
| | - Luisa L. Villa
- Faculty of Medical Sciences of Santa Casa of São Paulo; São Paulo Brazil
- Department of Radiology and Oncology, Faculty of Medicine; Universidade de São Paulo; São Paulo Brazil
| | - Adhemar Longatto-Filho
- Institute of Education and Research and Molecular Oncology Center, Barretos Cancer Hospital; Pio XII Foundation; Barretos São Paulo Brazil
- Laboratory of Medical Investigation 14, Faculty of Medicine; Universidade de São Paulo; São Paulo Brazil
- Life and Health Sciences Research Institute, School of Health Sciences; University of Minho; Braga Portugal
- Life and Health Sciences Research Institute/3Bs-PT Government Associate Laboratory; Braga Portugal
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Sequera VG, Valencia S, García-Basteiro AL, Marco A, Bayas JM. Vaccinations in prisons: A shot in the arm for community health. Hum Vaccin Immunother 2015; 11:2615-26. [PMID: 26158401 PMCID: PMC4685700 DOI: 10.1080/21645515.2015.1051269] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/27/2015] [Accepted: 05/10/2015] [Indexed: 02/08/2023] Open
Abstract
From the first day of imprisonment, prisoners are exposed to and expose other prisoners to various communicable diseases, many of which are vaccine-preventable. The risk of acquiring these diseases during the prison sentence exceeds that of the general population. This excess risk may be explained by various causes; some due to the structural and logistical problems of prisons and others to habitual or acquired behaviors during imprisonment. Prison is, for many inmates, an opportunity to access health care, and is therefore an ideal opportunity to update adult vaccination schedules. The traditional idea that prisons are intended to ensure public safety should be complemented by the contribution they can make in improving community health, providing a more comprehensive vision of safety that includes public health.
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Affiliation(s)
| | - Salomé Valencia
- Preventive Medicine and Epidemiology Service; Hospital Clínic of Barcelona; Barcelona, Spain
| | - Alberto L García-Basteiro
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB); Hospital Clínic - Universitat de Barcelona, Rossello, Barcelona, Spain
- Centro de Investigação em Saude de Manhiça (CISM); Maputo, Mozambique
| | - Andrés Marco
- Health Services of Barcelona Men's Penitentiary Center; Barcelona, Spain
| | - José M Bayas
- Preventive Medicine and Epidemiology Service; Hospital Clínic of Barcelona; Barcelona, Spain
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB); Hospital Clínic - Universitat de Barcelona, Rossello, Barcelona, Spain
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