Poor continuity of care for TB diagnosis and treatment in Zambian Prisons: a situation analysis

Evaluating tuberculosis treatment outcomes in Haiti from 2018 to 2019: A competing risk analysis

Objectives

This study assesses tuberculosis (TB) treatment outcomes in Haiti.

Methods

Data from drug-susceptible patients with TB (2018-2019) were analyzed using the Fine & Gray model with multiple imputation.

Results

Of the 16,545 patients, 14.7% had concurrent HIV coinfection, with a 66.2% success rate. The median treatment duration was 5 months, with patients averaging 30 years (with an interquartile range of 22-42 years). The estimated hazard of achieving a successful treatment outcome decreased by 2.5% and 8.1% for patients aged 45 and 60 years, respectively, compared with patients aged 30 years. Male patients had a 6.5% lower estimated hazard of success than their female counterparts. In addition, patients coinfected with HIV experienced a 35.3% reduction in the estimated hazard of achieving a successful treatment outcome compared with those with a negative HIV serologic status.

Conclusions

Integrated health care approaches should be implemented, incorporating innovative solutions, such as machine learning algorithms combined with geographic information systems and non-conventional data sources (including social media), to identify TB hotspots and high-burden households.

Scaling up evidence-based approaches to tuberculosis screening in prisons

People deprived of liberty have among the highest rates of tuberculosis globally. The incidence of tuberculosis is ten times greater than the incidence of tuberculosis in the general population. In 2021, WHO updated its guidance to strongly recommend systematic screening for tuberculosis in prisons and penitentiary systems. Which case-finding strategies should be adopted, and how to effectively implement these strategies in these settings, will be crucial questions facing ministries of health and justice. In this Viewpoint, we review the evidence base for tuberculosis screening and diagnostic strategies in prisons, highlighting promising approaches and knowledge gaps. Drawing upon past experiences of implementing active case-finding and care programmes in settings with a high tuberculosis burden, we discuss challenges and opportunities for improving the tuberculosis diagnosis and treatment cascade in these settings. We argue that improved transparency in reporting of tuberculosis notifications and outcomes in prisons and renewed focus and resourcing from WHO and other stakeholders will be crucial for building the commitment and investments needed from countries to address the continued crisis of tuberculosis in prisons.

Epidemiology of TB in prisoners: a metanalysis of the prevalence of active and latent TB

BACKGROUND

Tuberculosis (TB) in prisons usually occurs at higher rates than in the general population, especially in developing countries. TB has been reported as the most common cause of death among prisoners. Studies have shown limitations for early detection of TB in prisons that seem to result from mistaken concepts about TB, delayed diagnosis mainly due to the naturalization of lack of healthcare for this population METHODS: A scoping review was performed using the methodology of the Joanna Briggs Institute to assess "What are the scientific evidences on the epidemiology of TB in the prison system?". Then, a meta-analysis was performed to assess the prevalence of TB (active and latent) TB in prisoners. The results are presented as prevalence, in percentage, through random effects models, with a confidence interval of 95%.

RESULTS

Regarding active TB, the results of the metanalysis showed that countries with a high burden of TB had a prevalence of 3.54% [2.71; 4.63], countries not considered to be high burden TB countries had a prevalence of 1.43% [0.86; 2.37]. Latent TB had a prevalence of 51.61% [39.46; 63.58] in high TB burden countries and a prevalence of 40.24% [23.51; 59.61] in countries with low TB burden. In terms of development, in low- and lower-middle-income countries, the prevalence of active TB was 3.13% [1.84; 5.29] and in high- and upper-middle income countries the prevalence was 2.25% [1.70; 2.99]. The prevalence of latent TB in high- and middle-income countries was 43.77% [28.61; 60.18] and of 49.42% [45.91; 52.94] in low and lower middle-income countries.

CONCLUSION

Our analysis suggests that TB, and probably other infectious diseases, find fertile ground in prisons where previous acquire social disadvantages seem to thrive-therefore, TB in prisons is a global public health problem and effective strategies are needed to control the disease are needed targeting the prison environment, including rapid health assessments to understand each context and to implement tailored and precision interventions.

Tuberculosis control at a South African correctional centre: Diagnosis, treatment and strain characterisation

Background

Correctional centres provide ideal conditions for tuberculosis (TB) transmission and disease progression. Despite the high TB incidence and incarceration rate in South Africa, data from South African correctional centres are scarce. Thus, the study evaluated TB diagnosis, treatment initiation and completion, and identified prevalent Mycobacterium tuberculosis strains among detainees entering a South African correctional centre.

Methods

This study was a prospective observational study that enrolled participants between February and September 2017 from a correctional centre located in the Western Cape, South Africa. All adult male detainees who tested positive for TB during admission screening were eligible to participate in the study. Sputum samples from enrolled participants underwent smear microscopy and culture. Strain typing was performed on culture-positive samples. The time between specimen collection and diagnosis, the time between diagnosis and treatment initiation, and the proportion of detainees completing TB treatment at the correctional centre were calculated.

Results

During the study period, 130 TB cases were detected through routine admission screening (126 male, 2 female, 2 juvenile). Out of the 126 eligible male detainees, 102 were enrolled in the study (81%, 102/126). All TB cases were detected within 30 hrs of admission screening. The majority (78%, 80/102) of participants started treatment within 48 hrs of TB diagnosis. However, only 8% (9/102) of participants completed treatment at the correction centre. Sputa from 90 of the 102 participants were available for smear and culture. There was a high smear positivity, with 49% (44/90) of isolates being smear positive. The Beijing family was the most frequent lineage (55.2%) in the study.

Conclusion

The strengths of the current TB control efforts at the correctional centre include rapid detection of cases through admission screening and prompt treatment initiation. However, a high number of detainees exiting before treatment completion highlights the need to strengthen links between correctional TB services and community TB services to ensure detainees complete TB treatment after release and prevent TB transmission.

Prevalence of multidrug-resistant tuberculosis in prisons: Systematic review and meta-analysis

BACKGROUND

In the context of prisons, multidrug-resistant tuberculosis (MDR-TB) is a major problem. In this article, we estimate the prevalence of MDR-TB among the population deprived of freedom from countries in South America, Europe, Asia and Africa.

METHODS

The articles were retrieved through systematic search at four databases (EMBASE, CINAHL, LILACS and MEDILINE). The meta-analysis was developed by the random effect model, using the Mantel-Haenszel method, with presentation of the aggregated results through the forest plot. The degree of heterogeneity between the studies was verified using Cochran's Q test and I².

RESULTS

Of the 102 articles analyzed, 21 were included in this systematic review. The analysis showed heterogeneity indicated by the Q test (P ​< ​0.001) and I² statistics (I² ​= ​50.52%). The funnel graph and Egger test (P ​< ​0.830) showed symmetry between investigations. The grouped prevalence of MDR-TB was 0.48% (95% CI: 0.02 to 1.32), advancing to 1.15 (95% CI: 0.15 to 2.73) when culture and sensitivity test were considered by the authors. No specific characteristics were significantly associated with differences in prevalence rates in the population deprived of freedom.

CONCLUSION

The study reaffirms the magnitude of MDR-TB in the population deprived of freedom in the world context. Political and technical-scientific efforts should be mobilized to mitigate TB and MDR-TB in prisons and for successful national and international disease control programs.

Tuberculosis Case Finding Cascade and Treatment Outcomes among Male Inmates in Two Prisons in Zimbabwe

Design

A cohort study using programmatic data was undertaken to assess TB diagnostic cascade in one of the study prisons for 2018. Treatment outcomes among male inmates with TB were assessed over a period of four years, in two study prisons.

Results

A total of 405 (11%) inmates with presumptive TB were identified, and 370 (91%) of these were evaluated for TB, mostly using rapid molecular testing of sputum specimens. Twenty-five inmates were diagnosed with TB resulting in a prevalence of 649/100,000 population. Of these, 16 (64%) were started on treatment. Nine (36%) were lost to follow-up before treatment initiation. From 2015 to 2018, 280 adult male inmates with TB were started on treatment. Of these, 212 (76%) had pulmonary disease that was bacteriologically confirmed. Almost all (276/280, 99%) had known HIV status, 65% were HIV-infected, and 80% of these were on antiretroviral treatment. The TB treatment success rate (cured or treatment completed) was recorded for 209 (75%) inmates, whilst 14 (5%) died and 11 (4%) were lost to follow-up. The frequency of unfavourable treatment outcomes (death, lost to follow-up, and not evaluated) was higher (54%) among inmates ≥ 60 years than those in the age group of 45-59 years (17%).

Conclusion

The findings revealed a threefold burden of TB in prisons, compared with what is reported by national survey. To decrease transmission of TB bacilli, it is essential to promote efforts that address missed opportunities in the TB diagnostic cascade, prompt treatment initiation, and ensure that tracking and documentation of treatment outcomes for all inmates are intensified.

Tuberculosis treatment outcomes among prisoners and general population in Zomba, Malawi

BACKGROUND

TB remains a major global health problem. It is particularly prevalent in prisons in sub-Saharan Africa due to overcrowding, malnutrition, high HIV prevalence and insufficient medical services. Prisoners have experienced worse TB treatment outcomes than the general population. The researchers investigated the TB treatment outcomes and predictors of unsuccessful treatment outcomesamong prisoners and the general population in Zomba, Malawi.

METHODS

We retrospectively reviewed TB registers of prisoners and the general population diagnosed with TB from January 2011 to December 2016 at Zomba Maximum Central Prison and Zomba Central Hospital, Malawi. The study used routinely collected data extracted from national, standardized TB treatment monitoring tools. Successful treatment outcome was classified as the total for cured and completed treatment while unsuccessful treatment outcome was classified as the total of deaths and treatment failures. We used descriptive statistics to compare the demographics and TB treatment parameters among prisoners and non - prisoners and computed multivariate analysis to predict the independent factors of unsuccessful treatment outcomes.

RESULTS

Of 1652 registered cases, 27% were prisoners (all males) and 72% were non-prisoners (58% males). The median age was 35 years (IQR: 29-42); 76% were Pulmonary TB cases (78% among prisoners vs 75% among general population); 83% were new TB cases (77% among prisoners vs 86% among general population); and 65% were HIV positive (50% among prisoners vs 71% among general population). Regarding treatment outcome, 1472 (89%) were cured and/or completed treatment (93% among prisoners vs 88% among general population), 2(0.2%) were treatment failures, 122 (8%) died (5% among prisoners vs 8% among general population) and 55 (3%) were not evaluated (1% among prisoners vs 4% among general population). Unsuccessful TB treatment outcomes were associated with age greater than 35 years (aOR = 0.68: 95% C.I: 0.58-0.80), Extra-Pulmonary TB (aOR = 1.69: 95% C.I: 1.08-2.63) andHIV positive status (aOR = 0.63: 95% C.I: 0.42-0.94).

CONCLUSION

Maximum prisons provide a stable population that can be easily monitored throughout the course of TB treatment. Good TB treatment outcomes which are comparable to the general population can be achieved among Malawian prisoners despite the challenging prison conditions.

Coordinating the prevention, treatment, and care continuum for HIV-associated tuberculosis in prisons: a health systems strengthening approach

PURPOSE OF REVIEW

To advance a re-conceptualized prevention, treatment, and care continuum (PTCC) for HIV-associated tuberculosis (TB) in prisons, and to make recommendations for strengthening prison health systems and reducing HIV-associated TB morbidity and mortality throughout the cycle of pretrial detention, incarceration, and release.

RECENT FINDINGS

Despite evidence of increased HIV-associated TB burden in prisons compared to the general population, prisoners face entrenched barriers to accessing anti-TB therapy, antiretroviral therapy, and evidence-based HIV and TB prevention. New approaches, suitable for the complexities of healthcare delivery in prisons, have emerged that may address these barriers, and include: novel TB diagnostics, universal test and treat for HIV, medication-assisted treatment for opioid dependence, comprehensive transitional case management, and peer navigation, among others.

SUMMARY

Realizing ambitious international HIV and TB targets in prisons will only be possible by first addressing the root causes of the TB/HIV syndemic, which are deeply intertwined with human rights violations and weaknesses in prison health systems, and, second, fundamentally re-organizing HIV and TB services around a coordinated PTCC. Taking these steps can help ensure universal access to comprehensive, good-quality, free and voluntary TB/HIV prevention, treatment, and care, and advance efforts to strengthen health resourcing, staffing, information management, and primary care access within prisons.

The health system accountability impact of prison health committees in Zambia

Background

From 2013, the Zambian Corrections Service (ZCS) worked with partners to strengthen prison health systems and services. One component of that work led to the establishment of facility-based Prison Health Committees (PrHCs) comprising of both inmates and officers. We present findings from a nested evaluation of the impact of eight PrHCs 18 months after programme initiation.

Methods

In-depth-interviews were conducted with 11 government ministry and Zambia Corrections Service officials and 6 facility managers. Sixteen focus group discussions were convened separately with PrHC members (21 females and 51 males) and non-members (23 females and 46 males) in 8 facilities. Memos were generated from participant observation in workshops and meetings preceding and after implementation. We sought evidence of PrHC impact, refined with reference to Joshi’s three domains of impact for social accountability interventions – state (represented by facility-based prison officials), society (represented here by inmates), and state-society relations (represented by inmate-prison official relations). Further analysis considered how project outcomes influenced structural dimensions of power, ability and justice relating to accountability.

Results

Data pointed to a compelling series of short- and mid-term outcomes, with positive impact on access to, and provision of, health services across most facilities. Inmates (members and non-members) reported being empowered via a combination of improved health literacy and committee members’ newly-given authority to seek official redress for complaints and concerns. Inmates and officers described committees as improving inmate-officer relations by providing a forum for information exchange and shared decision making. Contributing factors included more consistent inmate-officer communications through committee meetings, which in turn enhanced trust and co-production of solutions to health problems. Nonetheless, long-term sustainability of accountability impacts may be undermined by permanently skewed power relations, high rates of inmate (and thus committee member) turnover, variable commitment from some officers in-charge, and the anticipated need for more oversight and resources to maintain members’ skills and morale.

Conclusion

Our study shows that PrHCs do have potential to facilitate improved social accountability in both state and societal domains and at their intersection, for an extremely vulnerable population. However, sustained and meaningful change will depend on a longer-term strategy that integrates structural reform and is delivered through meaningful cross-sectoral partnership.

Evaluation of a health system strengthening initiative in the Zambian prison system

Introduction

In 2013, the Zambian Correctional Service (ZCS) partnered with the Centre for Infectious Disease Research in Zambia on the Zambian Prisons Health System Strengthening project, seeking to tackle structural, organisational and cultural weaknesses within the prison health system. We present findings from a nested evaluation of the project impact on high, mid-level and facility-level health governance and health service arrangements in the Zambian Correctional Service.

Methods

Mixed methods were used, including document review, indepth interviews with ministry (11) and prison facility (6) officials, focus group discussions (12) with male and female inmates in six of the eleven intervention prisons, and participant observation during project workshops and meetings. Ethical clearance and verbal informed consent were obtained for all activities. Analysis incorporated deductive and iterative inductive coding.

Results

Outcomes: Improved knowledge of the prison health system strengthened political and bureaucratic will to materially address prison health needs. This found expression in a tripartite Memorandum of Understanding between the Ministry of Home Affairs, Ministry of Health (MOH) and Ministry of Community Development, and in the appointment of a permanent liaison between MOH and ZCS. Capacity-building workshops for ZCS Command resulted in strengthened health planning and management outcomes, including doubling ZCS health professional workforce (from 37 to78 between 2014 and 2016), new preservice basic health training for incoming ZCS officers and formation of facility-based prison health committees with a mandate for health promotion and protection. Mechanisms: continuous and facilitated communication among major stakeholders and the emergence of interorganisational trust were critical. Enabling contextual factors included a permissive political environment, a shift within ZCS from a ‘punitive’ to ‘correctional’ organisational culture, and prevailing political and public health concerns about the spread of HIV and tuberculosis.

Conclusion

While not a panacea, findings demonstrate that a ‘systems’ approach to seemingly intractable prison health system problems yielded a number of short-term tactical and long-term strategic improvements in the Zambian setting. Context-sensitive application of such an approach to other settings may yield positive outcomes.