The Impact of Ventilation and Early Diagnosis on Tuberculosis Transmission in Brazilian Prisons

Drug-resistant tuberculosis: a persistent global health concern

Drug-resistant tuberculosis (TB) is estimated to cause 13% of all antimicrobial resistance-attributable deaths worldwide and is driven by both ongoing resistance acquisition and person-to-person transmission. Poor outcomes are exacerbated by late diagnosis and inadequate access to effective treatment. Advances in rapid molecular testing have recently improved the diagnosis of TB and drug resistance. Next-generation sequencing of Mycobacterium tuberculosis has increased our understanding of genetic resistance mechanisms and can now detect mutations associated with resistance phenotypes. All-oral, shorter drug regimens that can achieve high cure rates of drug-resistant TB within 6-9 months are now available and recommended but have yet to be scaled to global clinical use. Promising regimens for the prevention of drug-resistant TB among high-risk contacts are supported by early clinical trial data but final results are pending. A person-centred approach is crucial in managing drug-resistant TB to reduce the risk of poor treatment outcomes, side effects, stigma and mental health burden associated with the diagnosis. In this Review, we describe current surveillance of drug-resistant TB and the causes, risk factors and determinants of drug resistance as well as the stigma and mental health considerations associated with it. We discuss recent advances in diagnostics and drug-susceptibility testing and outline the progress in developing better treatment and preventive therapies.

Assessment of tuberculosis transmission probability in three Thai prisons based on five dynamic models

This study aimed to assess and compare the probability of tuberculosis (TB) transmission based on five dynamic models: the Wells-Riley equation, two Rudnick & Milton-proposed models based on air changes per hour (ACH) and liters per second per person (L/s/p), the model proposed by Issarow et al, and the Applied Susceptible-Exposed-Infected-Recovered (SEIR) TB transmission model. This study also aimed to determine the impact of model parameters on such probabilities in three Thai prisons. A cross-sectional study was conducted using data from 985 prison cells. The TB transmission probability for each cell was calculated using parameters relevant to the specific model formula, and the magnitude of the model agreement was examined by Spearman's rank correlation and Bland-Altman plot. Subsequently, a multiple linear regression analysis was conducted to investigate the influence of each model parameter on the estimated probability. Results revealed that the median (Quartiles 1 and 3) of TB transmission probability among these cells was 0.052 (0.017, 0.180). Compared with the pioneered Wells-Riley's model, the remaining models projected discrepant TB transmission probability from less to more commensurate to the degree of model modification from the pioneered model as follows: Rudnick & Milton (ACH), Issarow et al., and Rudnick & Milton (L/s/p), and the applied SEIR models. The ventilation rate and number of infectious TB patients in each cell or zone had the greatest impact on the estimated TB transmission probability in most models. Additionally, the number of inmates in each cell, the area per person in square meters, and the inmate turnover rate were identified as high-impact parameters in the applied SEIR model. All stakeholders must urgently address these influential parameters to reduce TB transmission in prisons. Moreover, further studies are required to determine their relative validity in accurately predicting TB incidence in prison settings.

Ventilation conditions during COVID-19 outbreaks in six California state carceral institutions

Residents of carceral facilities are exposed to poor ventilation conditions which leads to the spread of communicable diseases such as COVID-19. Indoor ventilation conditions are rarely studied within carceral settings and there remains limited capacity to develop solutions to address the impact of poor ventilation on the health of people who are incarcerated. In this study, we empirically measured ventilation rates within housing units of six adult prisons in the California Department of Corrections and Rehabilitation (CDCR) and compare the measured ventilation rates to recommended standards issued by the World Health Organization (WHO). Findings from the empirical assessment include lower ventilation rates than the recommended ventilation standards with particularly low ventilation during winter months when heating systems were in use. Inadvertent airflows from spaces housing potentially infected individuals to shared common spaces was also observed. The methodology used for this work can be leveraged for routine ventilation monitoring, pandemic preparedness, and disaster response.

Respiratory pandemic preparedness learnings from the June 2020 COVID-19 outbreak at San Quentin California State Prison

PURPOSE

This study aims to characterize the June 2020 COVID-19 outbreak at San Quentin California State Prison and to describe what made San Quentin so vulnerable to uncontrolled transmission.

DESIGN/METHODOLOGY/APPROACH

Since its onset, the COVID-19 pandemic has exposed and exacerbated the profound health harms of carceral settings, such that nearly half of state prisons reported COVID-19 infection rates that were four or more times (and up to 15 times) the rate found in the state's general population. Thus, addressing the public health crises and inequities of carceral settings during a respiratory pandemic requires analyzing the myriad factors shaping them. In this study, we reported observations and findings from environmental risk assessments during visits to San Quentin California State Prison. We complemented our assessments with analyses of administrative data.

FINDINGS

For future respiratory pathogens that cannot be prevented with effective vaccines, this study argues that outbreaks will no doubt occur again without robust implementation of additional levels of preparedness - improved ventilation, air filtration, decarceration with emergency evacuation planning - alongside addressing the vulnerabilities of carceral settings themselves.

ORIGINALITY/VALUE

This study addresses two critical aspects that are insufficiently covered in the literature: how to prepare processes to safely implement emergency epidemic measures when needed, such as potential evacuation, and how to address unique challenges throughout an evolving pandemic for each carceral setting.

Tuberculosis in Prisons: Importance of Considering the Clustering in the Analysis of Cross-Sectional Studies

The level of clustering and the adjustment by cluster-robust standard errors have yet to be widely considered and reported in cross-sectional studies of tuberculosis (TB) in prisons. In two cross-sectional studies of people deprived of liberty (PDL) in Medellin, we evaluated the impact of adjustment versus failure to adjust by clustering on prevalence ratio (PR) and 95% confidence interval (CI). We used log-binomial regression, Poisson regression, generalized estimating equations (GEE), and mixed-effects regression models. We used cluster-robust standard errors and bias-corrected standard errors. The odds ratio (OR) was 20% higher than the PR when the TB prevalence was >10% in at least one of the exposure factors. When there are three levels of clusters (city, prison, and courtyard), the cluster that had the strongest effect was the courtyard, and the 95% CI estimated with GEE and mixed-effect models were narrower than those estimated with Poisson and binomial models. Exposure factors lost their significance when we used bias-corrected standard errors due to the smaller number of clusters. Tuberculosis transmission dynamics in prisons dictate a strong cluster effect that needs to be considered and adjusted for. The omission of cluster structure and bias-corrected by the small number of clusters can lead to wrong inferences.

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.

New insights on tuberculosis transmission dynamics and drug susceptibility profiles among the prison population in Southern Brazil based on whole-genome sequencing

BACKGROUND

The rate of tuberculosis (TB) infection among the prison population (PP) in Brazil is 28 times higher than that in the general population, and prison environment favors the spread of TB.

OBJECTIVE

To describe TB transmission dynamics and drug resistance profiles in PP using whole-genome sequencing (WGS).

METHODS

This was a retrospective study of Mycobacterium tuberculosis cultivated from people incarcerated in 55 prisons between 2016 and 2019; only one isolate per prisoner was included. Information about movement from one prison to another was tracked. Clinical information was collected, and WGS was performed on isolates obtained at the time of TB diagnosis.

RESULTS

Among 134 prisoners included in the study, we detected 16 clusters with a total of 58 (43%) cases of M. tuberculosis. Clusters ranged from two to seven isolates with five or fewer single nucleotide polymorphism (SNP) differences, suggesting a recent transmission. Six (4.4%) isolates were resistant to at least one anti-TB drug. Two of these clustered together and showed resistance to rifampicin, isoniazid, and fluoroquinolones, with 100% concordance between WGS and phenotypic drug-susceptibility testing. Prisoners with clustered isolates had a high amount of movement between prisons (two to eight moves) during the study period.

CONCLUSIONS

WGS demonstrated the recent transmission of TB within prisons in Brazil. The high movement among prisoners seems to be related to the transmission of the same M. tuberculosis strain within the prison system. Screening for TB before and after the movement of prisoners using rapid molecular tests could play a role in reducing transmission.

How do temperature, humidity, and air saturation state affect the COVID-19 transmission risk?

Environmental parameters have a significant impact on the spread of respiratory viral diseases (temperature (T), relative humidity (RH), and air saturation state). T and RH are strongly correlated with viral inactivation in the air, whereas supersaturated air can promote droplet deposition in the respiratory tract. This study introduces a new concept, the dynamic virus deposition ratio (α), that reflects the dynamic changes in viral inactivation and droplet deposition under varying ambient environments. A non-steady-state-modified Wells-Riley model is established to predict the infection risk of shared air space and highlight the high-risk environmental conditions. Findings reveal that a rise in T would significantly reduce the transmission of COVID-19 in the cold season, while the effect is not significant in the hot season. The infection risk under low-T and high-RH conditions, such as the frozen seafood market, is substantially underestimated, which should be taken seriously. The study encourages selected containment measures against high-risk environmental conditions and cross-discipline management in the public health crisis based on meteorology, government, and medical research.

Epidemiology and control strategies for tuberculosis in countries with the largest prison populations

Tuberculosis (TB) is a serious infectious disease, and its control is considered a challenge, especially among vulnerable populations such as prisoners. The occurrence of TB in prisons is an alarming public health problem in many countries. This integrative review aims to describe the epidemiology of TB and control strategies for this disease in countries with the largest prison populations. Studies have shown that it is essential to know the prevalence of TB in prisons of each country. This is because it can serve as an indication of the need for action in prisons to reduce TB rates, including improving the structure of prison environments, rapidly and accurately diagnosing new cases, identifying drug-resistant strains, and implementing effective and directly observed treatment for TB.

Environmental factors associated with the time to tuberculosis diagnosis in prisoners in São Paulo, Brazil

BACKGROUND

Environmental conditions play an important role in the high incidence of tuberculosis in prisons. We estimated the effect of environmental factors, including measurements based on cell dimensions, on the time to tuberculosis diagnosis in prison population of Brazil.

METHODS

This is a retrospective cohort of 2,257 prisoners diagnosed with tuberculosis in 2014 and 2015. We collected environmental data from 105 prisons and linked with routine tuberculosis surveillance and prison data. We estimated tuberculosis-free survival time with Cox risk models, guided by a validated directed acyclic graph.

RESULTS

The median disease-free time was 1.71 years (95% confidence interval [95% CI] 1.64-1.78). Each 50% increase in occupancy-rate, increased the tuberculosis speed incidence by 16% (95% CI 8%-25%) in the first 2 years, and 9% (95% CI 3%-16%) up to 5 years. An increase in the cell area per person (ln[m2/person]) reduced the hazard of tuberculosis by 13% (95% CI 3%-23%) for up to 2, and 12% (95% CI 3%-21%) for up to 5 years.

DISCUSSION

Most tuberculosis cases were diagnosed within 2 years of incarceration. Prison overcrowding and physical space per person in the cell were associated with the tuberculosis-free disease time.

CONCLUSIONS

Interventions to reduce overcrowding or increase physical space are crucial to prevent tuberculosis in prisons.

Temporal-spatial risk assessment of COVID-19 under the influence of urban spatial environmental parameters: The case of Shenyang city

Respiratory infection is the main route for the transmission of coronavirus pneumonia, and the results have shown that the urban spatial environment significantly influences the risk of infection. Based on the Wells-Riley model of respiratory infection probability, the study determined the human respiratory-related parameters and the effective influence range; extracted urban morphological parameters, assessed the ventilation effects of different spatial environments, and, combined with population flow monitoring data, constructed a method for assessing the risk of Covid-19 respiratory infection in urban-scale grid cells. In the empirical study in Shenyang city, a severe cold region, urban morphological parameters, population size, background wind speed, and individual behavior patterns were used to calculate the distribution characteristics of temporal and spatial concomitant risks in urban areas grids under different scenarios. The results showed that the correlation between the risk of respiratory infection in urban public spaces and the above variables was significant. The exposure time had the greatest degree of influence on the probability of respiratory infection risk among the variables. At the same time, the change in human body spacing beyond 1 m had a minor influence on the risk of infection. Among the urban morphological parameters, building height had the highest correlation with the risk of infection, while building density had the lowest correlation. The actual point distribution of the epidemic in Shenyang from March to April 2022 was used to verify the evaluation results. The overlap rate between medium or higher risk areas and actual cases was 78.55%. The planning strategies for epidemic prevention and control were proposed for the spatial differentiation characteristics of different risk elements. The research results can accurately classify the risk level of urban space and provide a scientific basis for the planning response of epidemic prevention and control and the safety of public activities.

The role of prisons in disseminating tuberculosis in Brazil: A genomic epidemiology study

Background

Globally, prisons are high-incidence settings for tuberculosis. Yet the role of prisons as reservoirs of M. tuberculosis, propagating epidemics through spillover to surrounding communities, has been difficult to measure directly.

Methods

To quantify the role of prisons in driving wider community M. tuberculosis transmission, we conducted prospective genomic surveillance in Central West Brazil from 2014 to 2019. We whole genome sequenced 1152 M. tuberculosis isolates collected during active and passive surveillance inside and outside prisons and linked genomes to detailed incarceration histories. We applied multiple phylogenetic and genomic clustering approaches and inferred timed transmission trees.

Findings

M. tuberculosis sequences from incarcerated and non-incarcerated people were closely related in a maximum likelihood phylogeny. The majority (70.8%; 46/65) of genomic clusters including people with no incarceration history also included individuals with a recent history of incarceration. Among cases in individuals with no incarceration history, 50.6% (162/320) were in clusters that included individuals with recent incarceration history, suggesting that transmission chains often span prisons and communities. We identified a minimum of 18 highly probable spillover events, M. tuberculosis transmission from people with a recent incarceration history to people with no prior history of incarceration, occurring in the state’s four largest cities and across sampling years. We additionally found that frequent transfers of people between the state’s prisons creates a highly connected prison network that likely disseminates M. tuberculosis across the state.

Interpretation

We developed a framework for measuring spillover from high-incidence environments to surrounding communities by integrating genomic and spatial information. Our findings indicate that, in this setting, prisons serve not only as disease reservoirs, but also disseminate M. tuberculosis across highly connected prison networks, both amplifying and propagating M. tuberculosis risk in surrounding communities.

Funding

Brazil’s National Council for Scientific and Technological Development and US National Institutes of Health.

Assessing impact of ventilation on airborne transmission of SARS-CoV-2: a cross-sectional analysis of naturally ventilated healthcare settings in Bangladesh

OBJECTIVES

To evaluate the risk of exposure to SARS-CoV-2 in naturally ventilated hospital settings by measuring parameters of ventilation and comparing these findings with results of bioaerosol sampling.

STUDY DESIGN

Cross-sectional study.

STUDY SETTING AND STUDY SAMPLE

The study sample included nine hospitals in Dhaka, Bangladesh. Ventilation characteristics and air samples were collected from 86 healthcare spaces during October 2020 to February 2021.

PRIMARY OUTCOME

Risk of cumulative SARS-CoV-2 infection by type of healthcare area.

SECONDARY OUTCOMES

Ventilation rates by healthcare space; risk of airborne detection of SARS-CoV-2 across healthcare spaces; impact of room characteristics on absolute ventilation; SARS-CoV-2 detection by naturally ventilated versus mechanically ventilated spaces.

RESULTS

The majority (78.7%) of naturally ventilated patient care rooms had ventilation rates that fell short of the recommended ventilation rate of 60 L/s/p. Using a modified Wells-Riley equation and local COVID-19 case numbers, we found that over a 40-hour exposure period, outpatient departments posed the highest median risk for infection (7.7%). SARS-CoV-2 RNA was most frequently detected in air samples from non-COVID wards (50.0%) followed by outpatient departments (42.9%). Naturally ventilated spaces (22.6%) had higher rates of SARS-CoV-2 detection compared with mechanically ventilated spaces (8.3%), though the difference was not statistically significant (p=0.128). In multivariable linear regression with calculated elasticity, open door area and cross-ventilation were found to have a significant impact on ventilation.

CONCLUSION

Our findings provide evidence that naturally ventilated healthcare settings may pose a high risk for exposure to SARS-CoV-2, particularly among non-COVID-designated spaces, but improving parameters of ventilation can mitigate this risk.

Incidence and Risk Factors Associated with Latent Tuberculosis Infection and Pulmonary Tuberculosis among People Deprived of Liberty in Colombian Prisons

People deprived of liberty (PDL) are at high risk of acquiring Mycobacterium tuberculosis infection (latent tuberculosis infection [LTBI]) and progressing to active tuberculosis (TB). We sought to determine the incidence rates and factors associated with LTBI and active TB in Colombian prisons. Using information of four cohort studies, we included 240 PDL with two-step tuberculin skin test (TST) negative and followed them to evaluate TST conversion, as well as, 2,134 PDL that were investigated to rule out active TB (1,305 among people with lower respiratory symptoms of any duration, and 829 among people without respiratory symptoms and screened for LTBI). Latent tuberculosis infection incidence rate was 2,402.88 cases per 100,000 person-months (95% CI 1,364.62-4,231.10) in PDL with short incarceration at baseline, and 419.66 cases per 100,000 person-months (95% CI 225.80-779.95) in individuals with long incarceration at baseline (who were enrolled for the follow after at least 1 year of incarceration). The TB incidence rate among PDL with lower respiratory symptoms was 146.53 cases/100,000 person-months, and among PDL without respiratory symptoms screened for LTBI the incidence rate was 19.49 cases/100,000 person-months. History of Bacillus Calmette-Guerin vaccination decreased the risk of acquiring LTBI among PDL who were recently incarcerated. Female sex, smoked drugs, and current cigarette smoking were associated with an increased risk of developing active TB. This study shows that PDL have high risk for LTBI and active TB. It is important to perform LTBI testing at admission to prison, as well as regular follow-up to control TB in prisons.

The escalating tuberculosis crisis in central and South American prisons

In the past decade, tuberculosis incidence has declined in much of the world, but has risen in central and South America. It is not yet clear what is driving this reversal of progress in tuberculosis control. Since 2000, the incarcerated population in central and South America has grown by 206%, the greatest increase in the world. Over the same period, notified tuberculosis cases among the incarcerated population (hereinafter termed persons deprived of their liberty [PDL], following the Inter-American Commission on Human Rights) have risen by 269%. In both central and South America, the rise of disease among PDL more than offsets tuberculosis control gains in the general population. Tuberculosis is increasingly concentrated among PDL; currently, 11% of all notified tuberculosis cases in central and South America occur among PDL who comprise less than 1% of the population. The extraordinarily high risk of acquiring tuberculosis within prisons creates a health and human rights crisis for PDL that also undermines wider tuberculosis control efforts. Controlling tuberculosis in this region will require countries to take urgent measures to prioritise the health of PDL.

Tuberculosis cases in a prison in the extreme south of Brazil

Introduction. Tuberculosis (TB) control is a challenge, especially in vulnerable populations, such as prisoners.Hypothesis. In prison houses, the transmission of micro-organisms that cause infectious diseases can occur due to the susceptibility and immune compromise of prisoners, and due to the precarious physical conditions of the prison houses. However, strategies such as monitoring by health professionals, can mitigate the transmission of these micro-organisms, as well as, reduce the number of coinfections and antimicrobials resistance.Aim. This study attempted to analyse the dynamics of transmission and the antimicrobial resistance profile of Mycobacterium tuberculosis strains obtained from prisoners and to characterize the epidemiological, clinical and laboratory profiles of prisoners diagnosed with TB.Methodology. A cross-sectional and retrospective study was conducted with sputum samples collected from 228 distinct prisoners who were treated at the Health Unit located in the Regional Penitentiary of Rio Grande, Rio Grande do Sul, Brazil. The antimicrobial resistance profile of the strains was evaluated using the Resazurin Microtiter Assay and the transmission dynamics was investigated using 15-loci MIRU-VNTR.Results. Thirty-five patients (15.4 %) were diagnosed with TB, and when a TB/HIV coinfection was assessed, 8.6 % (3/35) of the patients were positive. In addition, all patients with results available for HBV, HCV, syphilis and diabetes mellitus were negative. Based on the genotypic profile, 55.9 % of the clinical isolates were grouped into five groups. One isolate with mono-resistance to isoniazid and two with mono-resistance to streptomycin were found.Conclusion. The presence of a Health Unit may have influenced the low numbers of TB/HIV, TB/HBV, TB/HCV, TB/syphilis coinfections and TB cases resistant to antimicrobials. Recent M. tuberculosis transmission can be inferred based on the high percentage of formatting of clusters. This situation stresses the need to improve active and passive detection, the screening of individuals for TB upon entrance into prison for early detection, and the implementation of prophylactic measures to reduce M. tuberculosis transmission.

Regional coordinators of Sao Paulo State prisons in tuberculosis and HIV coinfection care

OBJECTIVES

to analyze the care provided to individuals with Tuberculosis (TB)-HIV coinfection in prison units in the state of São Paulo, according to the regional coordination of prisons.

METHODS

cross-sectional study conducted between 2016 and 2018. A structured questionnaire was applied to 112 directors or health professionals from 168 prison units. Data were analyzed by frequency distribution and multiple correspondence analysis.

RESULTS

92.9% of participants reported active search for respiratory symptoms, 89.3% offer the directly observed treatment (DOT) for all TB cases, 95.5% anti-HIV testing for all inmates, 92.9% offer HIV follow-up in specialized care services and 59.8% antiretroviral drugs for cases of coinfection. An association was identified between the Northwest and Central regional coordinations and deficient human resources and low performance of actions for the diagnosis and follow-up of cases.

CONCLUSIONS

although most prison units perform planned actions for the care of coinfected persons, some places need support to guarantee access to these actions.

Primary Prophylaxis to Prevent Tuberculosis Infection in Prison Inmates: A Randomized, Double-Blind, Placebo-Controlled Trial

In many low- and middle-income countries, tuberculosis (TB) incidence in prisons is high, exposing incarcerated populations to an elevated risk of TB infection. We conducted a randomized, double-blind, placebo-controlled trial among HIV-negative male inmates of a high TB burden prison to determine whether isoniazid given twice weekly (900 mg) for 12 months prevents TB infection. The primary outcome was QuantiFERON-TB Gold in Plus (QFT) conversion to ≥ 0.35 international units per milliliter (IU/mL) at 6 months; secondary outcomes included alternative QFT thresholds (≥ 0.7, ≥ 2.0, and ≥ 4.0 IU/mL). In total, 467 participants were randomly assigned to intervention (N = 258) or control (N = 209). In an interim analysis of participants who had completed 6 months of follow-up (N = 170), QFT conversion occurred in 20.8% (19/91) and 21.5% (17/79) of participants in intervention and control arms (efficacy: 2.9%, P = 0.91), respectively. The trial was then stopped according to the trial protocol, and the remaining participants prematurely discontinued. In an analysis of secondary outcomes, the intervention arm had significantly lower rates of conversion at a cutoff of ≥ 2.0 IU/mL (efficacy: 82.6%, P < 0.01). In conclusion, 900 mg of isoniazid, administered twice a week, did not effectively prevent QFT conversion at a cutoff point ≥ 0.35 IU/mL in a trial of QFT-negative inmates. Higher QFT cutoffs are associated with sustained conversion and greater protection. Future clinical trials that evaluate protection for latent infection should use the highest cutoff than that recommended by the manufacturer.

Baseline Assessment of Risk Factors of Presumptive Tuberculosis among under Five Children Living with an Index Client under Treatment in Mbale District, Eastern Uganda

BACKGROUND AND AIMS

Children in contact with adults having pulmonary Tuberculosis (TB) are vulnerable to TB infection and hence contact tracing and screening is important for early detection of infection. However, there are few contacts traced and the prevalence and risk factors for transmission are not well studied. The objective of this study was to determine the prevalence of infection and risk factors associated with TB transmission among under five children in household contact with adult pulmonary TB patients.

MATERIALS AND METHODS

A cross sectional study was carried out in three health facilities with a high TB burden in Mbale District, Eastern Uganda involving all under five household contacts of adults with pulmonary tuberculosis recorded in the TB register from October 2018 to March 2019 and still on treatment. Structured questionnaires were administered to the index clients to obtain their demographic and clinical data about TB, HIV as well as information on the children. Children were screened using the intensive case finding forms to identify presumptive cases.

RESULTS

The total number of index TB Clients line listed were 70. Number of clients traced was 38, 21 (%) of whom had children under five years and a total of 33 children were identified. The number of presumptive cases was 9/33 (27.27%). 77.8% of the presumptive cases were living in poorly ventilated houses.

CONCLUSION

The study identified children with presumptive TB and various risk factors for TB transmission. Intensive contact tracing can therefore help reduce TB transmission within the communities. It is recommended to undertake studies aiming at improving contact tracing and strategies to eliminate the risk factors to TB transmission.

Epidemic Situation of Tuberculosis in Prisons in the Central Region of China

We aimed to investigate the epidemic situation of tuberculosis (TB) in prisons in the central region of China. Tuberculosis screening was carried out in two prisons in middle China. A sum of 3,459 prisoners accepted chest X-ray examination; 40 of them were diagnosed as active TB patients. The active TB prevalence (1,156/10⁵) was significantly higher than that of the province and China's general population (P < 0.01). As for gender, TB prevalence in men's prison (1,589/10⁵) was higher than that in the women's prison (946/10⁵). Nevertheless, the risk of having TB in women's prison was much higher than that in the men's prison when compared with the TB prevalence from the province (women: OR = 2.37, 95% CI: 1.34, 4.22; men: OR = 1.53, 95% CI: 0.90, 2.60) and the China's general population (women: OR = 3.30, 95% CI: 2.15, 5.09; men: OR = 2.06, 95% CI: 1.29, 3.30). In view of the severe epidemic situation of TB in prisons, integrating medical resources to establish a consummate and effective management system is necessary.

Treatment as prevention and other interventions to reduce transmission of multidrug-resistant tuberculosis

Drug-resistant tuberculosis (DR-TB) represents a major programmatic challenge at the national and global levels. Only ∼30% of patients with multidrug-resistant TB (MDR-TB) were diagnosed, and ∼25% were initiated on treatment for MDR-TB in 2016. Increasing evidence now points towards primary transmission of DR-TB, rather than inadequate treatment, as the main driver of the DR-TB epidemic. The cornerstone of DR-TB transmission prevention should be earlier diagnosis and prompt initiation of effective treatment for all patients with DR-TB. Despite the extensive scale-up of Xpert^® MTB/RIF testing, major implementation barriers continue to limit its impact. Although there is longstanding evidence in support of the rapid impact of treatment on patient infectiousness, delays in the initiation of effective DR-TB treatment persist, resulting in ongoing transmission. However, it is also imperative to address the burden of latent drug-resistant tuberculous infection because it is estimated that many DR-TB patients will become infectious before seeking care and encounter various diagnostic delays before treatment. Addressing latent DR-TB primarily consists of identifying, treating and following the contacts of patients with MDR-TB, typically through household contact evaluation. Adjunctive measures, such as improved ventilation and use of germicidal ultraviolet technology can further reduce TB transmission in high-risk congregate settings. Although many gaps remain in our biological understanding of TB transmission, implementation barriers to early diagnosis and rapid initiation of effective DR-TB treatment can and must be overcome if we are to impact DR-TB incidence in the short and long term.

Impact of incarceration on tuberculosis incidence and its interaction with income distribution inequality in Brazil

BACKGROUND

Deteriorated conditions in the non-prison population can lead to an approximation of its tuberculosis (TB) risk to that in the prison population. We evaluated the association between incarceration and TB incidence rate and its interaction with population income distribution inequality in Brazilian municipalities (2013-2015).

METHODS

We included 954 municipalities with at least one prison. Interaction between the Gini coefficient and prison exposure was analysed in a multiple regression model. We estimated the fraction of TB in the population attributable fraction (PAF) to exposure to prisons according the Gini coefficient.

RESULTS

Compared with the non-prison population, the prisoners had 22.07 times (95% confidence interval [CI] 20.38 to 23.89) the risk of TB in municipalities where the Gini coefficient was <0.60 and 14.96 times (95% CI 11.00 to 18.92) the risk where the Gini coefficient was ≥0.60. A negative interaction in the multiplicative scale was explained by a higher TB incidence in the non-prison population in municipalities with a Gini coefficient ≥0.60. The PAF ranged from 50.06% to 5.19% in municipalities with Gini coefficients <0.40 and ≥0.60, respectively.

CONCLUSIONS

Interventions to reduce prison exposure would have an ostensible impact in population TB incidence rates mainly in settings with lower Gini coefficients. In those with extreme inequality in income distribution, strategies focused on mitigating the effects of socio-economic factors should also be prioritized.

Analysis of anti-tuberculosis drug resistance and sociodemographic and clinical aspects of patients admitted in a referral hospital

OBJECTIVE

To determine the occurrence of anti-tuberculosis drug resistance and its association with sociodemographic and clinical characteristics of patients in a referral hospital.

METHODS

This was a cross-sectional study based on data from patients who had mycobacterial culture identified and defined antimicrobials sensitivity profile (June 2014 to February 2016). The descriptive statistical analysis and Fisher's exact test were used to compare proportions.

RESULTS

The study included 104 patients who had positive results for Mycobacterium tuberculosis . Bacilloscopy had high positivity (93.3%). A total of 15 patients (14.4%) had resistant strains and six (5.6%) multidrug-resistant. The sociodemographic and clinical characteristics were not related with resistance.

CONCLUSION

This study contributed to further the understandings about the tuberculosis patients' profile, the study also served as a tool for development of specific public policies. Patients diagnosed with resistant tuberculosis must be under greater supervision.

Prison cell spatial density and infectious and communicable diseases: a systematic review

OBJECTIVE

To summarise the extent and quality of evidence on the association between prison cell spatial density (a measure of crowding) and infectious and communicable diseases transmission among prisoners.

DESIGN

Systematic review.

DATA SOURCES

Embase, PubMed, Medline, Scopus, Web of Science, PsycINFO, PsycExtra, ProQuest Databases, ProQuest Dissertations and Theses Global, Index to Legal Periodicals, InformitOnline, Cochrane Library, Criminal Justice Abstracts and ICONDA were searched to 31 December 2018.

ELIGIBILITY CRITERIA

Studies that reported on the association between prison cell spatial density (measured in square feet or square metres of cell floor area per person) and infectious and communicable diseases in juvenile and adult populations incarcerated in a correctional facility.

DATA EXTRACTION AND SYNTHESIS

A review protocol was developed in consultation with an advisory panel. Two reviewers independently extracted data and used the Australian National Health and Medical Research Council's (NHMRC) checklist to critically appraise individual studies. An assessment of the overall body of the evidence was conducted using the NHMRC's Evidence Scale and Statement Form.

RESULTS

A total of 5126 articles were initially identified with seven included in the review from Pakistan (2003), Chile (2016), Nigeria (2012, 2013) and the USA (1980s). Infectious and communicable disease outcomes included pneumococcal disease/acute pneumonia, Mycobacterium tuberculosis, latent tuberculosis infection, infectious skin conditions and contagious disease reporting to the prison clinic. Five articles reported statistically significant positive associations but were countered by associations possibly being explained by chance, bias or confounding factors. Heterogeneity prevented meta-analysis.

CONCLUSION

Overall, the body of evidence provides some support for an association between prison cell special density and infectious and communicable diseases, but care should be taken in the interpretation and transferability of the findings. Future research and policy responses should adequately consider prospective mediating factors implicated in associations between cell spatial density and health effects.

A systematic scoping review of environmental health conditions in penal institutions

Adequate environmental health conditions in penal institutions are necessary to protect and promote the health of prisoners and prison workers. We conducted a scoping systematic review to: describe the environmental health conditions in penal institutions and the associated exposures and health outcomes; identify effective approaches to prevent environmental health concerns; and identify evidence gaps on environmental health in penal institution populations. PubMed, Web of Science, EBSCOhost, Scopus, and ProQuest were searched. Peer-reviewed studies that reported original data and on environmental health conditions and/or exposures in penal institutions were included. Seventy-three studies met these criteria. The most common risk factor identified was contaminated food and/or beverages prepared or handled in the institution's kitchen. Overcrowding, inadequate ventilation, and a lack of, or sharing of, soap and other hygiene products increased the risk of adverse health outcomes. Common responses included isolating infectious patients, educating prisoners and prison staff on improved sanitation and hygiene practices, improving ventilation, and disinfecting contaminated surfaces and/or water sources. Inadequate environmental health conditions in penal institutions are common, and adversely impact the health of prisoners and prison staff, yet are preventable. Few studies have been conducted in low- and middle-income countries, biasing our results. The development and implementation of national guidelines for essential environmental health in prisons, monitoring of conditions, and greater accountability of facility managers are needed to secure the health, rights, and well-being of prisoners.

Dynamic Models of Infectious Disease Transmission in Prisons and the General Population

Incarcerated populations experience elevated burdens of infectious diseases, which are exacerbated by limited access to prevention measures. Dynamic models are used to assess the spread and control of diseases within correctional facilities and repercussions on the general population. Our systematic review of dynamic models of infectious diseases within correctional settings identified 34 studies published between 1996 and 2017. Of these, 23 focused on disease dynamics and intervention in prison without accounting for subsequent spread to the community. The main diseases modeled in these studies were human immunodeficiency virus (HIV; n = 14, 41%), tuberculosis (TB; n = 10, 29%), and hepatitis C virus (HCV; n = 7, 21%). Models were fitted to epidemiologic data in 14 studies; uncertainty and sensitivity analyses were conducted in 8, and validation of model projection against empirical data was done in 1 study. According to the models, prison-based screening and treatment may be highly effective strategies for reducing the burden of HIV, TB, HCV, and other sexually transmissible infections among prisoners and the general community. Decreasing incarceration rates were projected to reduce HIV and HCV infections among people who inject drugs and TB infections among all prisoners. Limitations of the modeling studies and opportunities for using dynamic models to develop quantitative evidence for informing prison infection control measures are discussed.

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.

Modelling the Impact of Different Tuberculosis Control Interventions on the Prevalence of Tuberculosis in an Overcrowded Prison

The aim of this study was to simulate the effects of tuberculosis (TB) treatment strategies interventions in an overcrowded and poorly ventilated prison with both high (5 months) and low (3 years) turnover of inmates against improved environmental conditions. We used a deterministic transmission model to simulate the effects of treatment of latent TB infection and active TB, or the combination of both treatment strategies. Without any intervention, the TB prevalence is estimated to increase to 8.8% for a prison with low turnover of inmates but modestly stabilize at 5.8% for high-turnover prisons in a 10-year period. Reducing overcrowding from 6 to 4 inmates per housing cell and increasing the ventilation rate from 2 to 12 air changes per hour combined with any treatment strategy would further reduce the TB prevalence to as low as 0.98% for a prison with low inmate turnover.

Increase in Tuberculosis Cases among Prisoners, Brazil, 2009-20141

During 2009-2014, incarceration rates in Brazil rose 34%, and tuberculosis (TB) cases among prisoners rose 28.8%. The proportion of national TB cases that occurred among prisoners increased from 6.2% to 8.4% overall and from 19.3% to 25.6% among men 20-29 years of age.

Serum vitamin D levels and risk of prevalent tuberculosis, incident tuberculosis and tuberculin skin test conversion among prisoners

Poor vitamin D status has been associated with tuberculosis (TB); whether poor status is cause or consequence of disease is uncertain. We conducted a case-control study and two nested case-control studies to determine whether vitamin D levels were associated with active TB, tuberculin skin test (TST) conversion, and risk of progression to the active TB in prisoners in Brazil. In multivariable conditional logistic regression, subnormal vitamin D levels (OR, 3.77; 95% CI, 1.04–13.64) were more likely in prisoners with active TB. In contrast, vitamin D was not found to be a risk factor for either TST conversion (OR, 2.49; 95% CI, 0.64–9.66) or progression to active disease (OR, 0.59; 95% CI, 0.13–2.62). Black race (OR, 11.52; 95% CI, 2.01–63.36), less than 4 years of schooling (OR, 2.70; 95% CI, 0.90–8.16), cigarette smoking (OR, 0.23; 95% CI, 0.06–0.79) were identified as risk factors for TST conversion. Risk of progression to active TB was found to be associated with cigarette smoking (OR, 7.42; 95% CI, 1.23–44.70). Our findings in the prison population show that poor vitamin D status is more common in individuals with active TB, but is not a risk factor for acquisition of latent TB or progression to active TB.

Healthcare resources are inadequate to address the burden of illness among HIV-infected male prisoners in Malaysia

Purpose Criminalization of drug use in Malaysia has concentrated people who inject drugs (PWID) and people living with HIV into prisons where health services are minimal and HIV-related mortality is high. Few studies have comprehensively assessed the complex health needs of this population. The paper aims to discuss these issues. Design/methodology/approach From October 2012 through March 2013, 221 sequentially selected HIV-infected male prisoners underwent a comprehensive health assessment that included a structured history, physical examination, and clinically indicated diagnostic studies. Findings Participants were mostly PWID (83.7 percent) and diagnosed with HIV while incarcerated (66.9 percent). Prevalence of hepatitis C virus (90.4 percent), untreated syphilis (8.1 percent), active (13.1 percent), and latent (81.2 percent) tuberculosis infection was several fold higher than non-prisoner Malaysian adults, as was tobacco use (71.9 percent) and heavy drinking (30.8 percent). Most (89.5 percent) were aware of their HIV status before the current incarceration, yet few had been engaged previously in HIV care, including pre-incarceration CD4 monitoring (24.7 percent) or prescribed antiretroviral therapy (ART) (16.7 percent). Despite most (73.7 percent) meeting Malaysia's criteria for ART (CD4 <350 cells/ μL), less than half (48.4 percent) ultimately received it. Nearly one-quarter (22.8 percent) of those with AIDS (<200 cells/ μL) did not receive ART. Originality/value Drug addiction and communicable disease comorbidity, which interact negatively and synergistically with HIV and pose serious public health threats, are highly prevalent in HIV-infected prisoners. Interventions to address the critical shortage of healthcare providers and large gaps in treatment for HIV and other co-morbid conditions are urgently needed to meet the health needs of HIV-infected Malaysian prisoners, most of whom will soon transition to the community.

The prevalence of tuberculosis among prisoners in Ethiopia: a systematic review and meta-analysis of published studies

Background

Except individual studies with varying prevalence rates, there are no national prevalence studies conducted in prison settings in Ethiopia. Appropriate estimates of the disease is essential to formulate health service plans most fitted for prisoners. Therefore, this systematic review and meta-analysis was designed to pool the results of individual studies and estimate the prevalence of tuberculosis among prisoners in Ethiopia.

Methods

MEDLINE/PubMed, Cochran library, and Google scholar databases were searched for potential studies on the prevalence of tuberculosis among prisoners in Ethiopia. A total of 177 titles were identified and 10 studies met the inclusion criteria. Descriptive and quantitative data of the included studies were presented in tables and forest plots. Potential sources of heterogeneity across studies were assessed using the Cochrane’s Q and I² tests. The MetaXL (version 5.3) was employed to compute the pooled prevalence of TB using the random effect model and 95% confidence interval.

Result

Based on the ten studies included in the meta-analysis, about 4086 prisoners were infected with tuberculosis (TB). The pooled prevalence of TB among prisoners was therefore 8.33% (95% CI; 6.28%–10.63%) and the pooled point prevalence was estimated at 888 per 100,000 prison population (95% CI; 531–1333). The prevalence of TB using microscopy alone was 6.59% (95% CI: 3.96–9.50%) whereas the prevalence of TB when microscopy is combined with either culture or molecular tests was 8.57% (95% CI: 4.94–12.6%).

Conclusion

The pooled prevalence of tuberculosis among prisoners in Ethiopia is expectedly high. This high prevalence could explain the spread of TB within prisons and between prisoners and varies communities. Thus; attention should be given to prison settings to prevent the transmission and emergence of drug resistance TB both in inmates and general population. Further studies covering large scale prison population are needed to design effective diagnostic, treatment and preventive methods.

Electronic supplementary material

The online version of this article (doi:10.1186/s13690-017-0204-x) contains supplementary material, which is available to authorized users.

Tuberculosis transmission in public locations in Tanzania: A novel approach to studying airborne disease transmission

OBJECTIVES

For tuberculosis (TB) transmission to occur, an uninfected individual must inhale the previously infected breath. Our objective was to identify potential TB transmission hotspots in metropolitan city of Dar es Salaam, Tanzania and to model the annual risk of TB transmission in different locations of public importance.

METHODS

We collected indoor carbon dioxide (CO₂) data from markets, prisons, night clubs, public transportation, religious and social halls, and from schools. Study volunteers recorded social contacts at each of the locations. We then estimated the annual risks of TB transmission using a modified Wells-Riley equation for different locations.

RESULTS

The annual risks of TB transmission were highest among prison inmates (41.6%) and drivers (20.3%) in public transport. Lower transmission risks were found in central markets (4.8% for traders, but 0.5% for their customers), passengers on public transport (2.4%), public schools (4.0%), nightclubs (1.7%), religious (0.13%), and social halls (0.12%).

CONCLUSION

For the first time in a country representative of sub-Saharan Africa, we modelled the risk of TB transmission in important public locations by using a novel approach of studying airborne transmission. This approach can guide identification of TB transmission hotspots and targeted interventions to reach WHO's ambitious End TB targets.

Recent transmission of drug-resistant Mycobacterium tuberculosis in a prison population in southern Brazil

We conducted a cross-sectional, retrospective study, characterized by classical and molecular epidemiology, involving M. tuberculosis isolates from a regional prison in southern Brazil. Between January of 2011 and August of 2014, 379 prisoners underwent sputum smear microscopy and culture; 53 (13.9%) were diagnosed with active tuberculosis. Of those, 8 (22.9%) presented with isoniazid-resistant tuberculosis. Strain genotyping was carried out by 15-locus mycobacterial interspersed repetitive unit-variable-number tandem-repeat analysis; 68.6% of the patients were distributed into five clusters, and 87.5% of the resistant cases were in the same cluster. The frequency of drug-resistant tuberculosis cases and the rate of recent transmission were high. Our data suggest the need to implement an effective tuberculosis control program within the prison system.

Tuberculosis in congregate settings: Policies and practices in various facilities in Mumbai, India

Congregate settings and correctional facilities have high risk of transmission of tuberculosis. They should have capacity to identify and diagnose cases early and initiate prompt treatment to prevent spread to inmates and staff. Appropriate interventions should ensure completion of treatment, documentation and reporting, and prevention of reactivation of successfully treated cases. This requires support from local health authorities. Although international policies and guidelines for infection control in congregate settings are available, there is very little information on how these are practiced in such settings. Our investigation highlights the policies and practices of various congregate facilities in the city of Mumbai.

Impact of mass-screening on tuberculosis incidence in a prospective cohort of Brazilian prisoners

BACKGROUND

Globally, prison inmates are a high-risk population for tuberculosis (TB), but the specific drivers of disease and impact of mass screening interventions are poorly understood.

METHODS

We performed a prospective cohort study to characterize the incidence and risk factors for tuberculosis infection and disease in 12 Brazilian prisons, and to investigate the effect of mass screening on subsequent disease risk. After recruiting a stratified random sample of inmates, we administered a questionnaire to ascertain symptoms and potential risk factors for tuberculosis; performed tuberculin skin testing (TST); collected sera for HIV testing; and obtained two sputum samples for smear microscopy and culture, from participants reporting a cough of any duration. We repeated the questionnaire and all tests for inmates who remained incarcerated after 1 year. TST conversion was defined as TST ≥10 mm and an induration increase of at least 6 mm in an individual with a baseline TST <10 mm. Cox proportional hazard models were performed to identify risk factors associated with active TB. To evaluate the impact of screening on subsequent risk of disease, we compared TB notifications over one year among individuals randomized to screening for active TB with those not randomized to screening.

RESULTS

Among 3,771 inmates recruited, 3,380 (89.6 %) were enrolled in the study, and 1,422 remained incarcerated after one year. Among 1,350 inmates (94.9 %) with paired TSTs at baseline and one-year follow-up, 25.7 % (272/1060) converted to positive. Among those incarcerated for the year, 10 (0.7 %) had TB at baseline and 25 (1.8 %) were diagnosed with TB over the subsequent year. Cases identified through active screening were less likely to be smear-positive than passively detected cases (10.0 % vs 50.9 %; p < 0.01), suggesting early case detection. However, there was no reduction in subsequent disease among individuals actively screened versus those not screened (1.3 % vs 1.7 %; p = 0.88). Drug use during the year (AHR 3.22; 95 % CI 1.05-9.89) and knows somebody with TB were (AHR 2.86; 95 % CI 1.01-8.10) associated with active TB during one year of follow up CONCLUSIONS: Mass screening in twelve Brazilian prisons did not reduce risk of subsequent disease in twelve Brazilian prisons, likely due to an extremely high force of infection. New approaches are needed to control TB in this high-transmission setting.

Prevention of transmission of HIV, hepatitis B virus, hepatitis C virus, and tuberculosis in prisoners

The prevalence of HIV, hepatitis B virus, hepatitis C virus, and tuberculosis are higher in prisons than in the general population in most countries worldwide. Prisons have emerged as a risk environment for these infections to be further concentrated, amplified, and then transmitted to the community after prisoners are released. In the absence of alternatives to incarceration, prisons and detention facilities could be leveraged to promote primary and secondary prevention strategies for these infections to improve prisoners health and reduce risk throughout incarceration and on release. Effective treatment of opioid use disorders with opioid agonist therapies (eg, methadone and buprenorphine) prevents blood-borne infections via reductions in injection in prison and after release. However, large gaps exist in the implementation of these strategies across all regions. Collaboration between the criminal justice and public health systems will be required for successful implementation of these strategies.