High Prevalence of Treponema pallidum Infection in Brazilian Prisoners

Prevalence of sexually transmitted infections and human papillomavirus in cervical samples from incarcerated women in São Paulo, Brazil: a retrospective single-center study

Introduction

Sexually transmitted infections (STIs) cause considerable morbidity worldwide and, depending on the specific pathogen, may lead to serious complications in the female reproductive tract. Incarcerated women are particularly vulnerable to health problems with a disproportionate high rate of STIs, including infections with human papillomavirus (HPV).

Methods

Here, cervical swab samples collected from 299 women (18 to 64 years) living in one of the women's prisons of São Paulo, Brazil were submitted for liquid-based cytology to determine the prevalence of precancerous lesions. Furthermore, direct detection of 30 genital HPV genotypes (18 high-risk and 12 low-risk types) and 11 additional STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, Herpes simplex virus 1 and 2, Haemophilus ducreyi, Mycoplasma genitalium and hominis, Treponema pallidum, Trichomonas vaginalis, Ureaplasma parvum and urealyticum) were performed by molecular typing using two PCR-based DNA microarray systems, i.e., EUROArray HPV and EUROArray STI (EUROIMMUN), respectively.

Results

The overall prevalence of cytological abnormalities was 5.8%, including five women with low-grade and five women with high-grade squamous intraepithelial lesions. The overall prevalence of HPV was 62.2, and 87.1% of the HPV-positive women were infected with oncogenic high-risk (HR) HPV types. HPV types 16 (24.1%), 33 and 52 (both 10.4%) were the most frequently detected. The prevalence of the other STIs was 72.8%. Up to four different pathogens were found in the infected women, the most frequent being Ureaplasma parvum (45.3%), Mycoplasma hominis (36.2%) and Trichomonas vaginalis (24.8%).

Conclusion

The high number of HR-HPV infections and other STIs described here highlights the fact that the Brazilian female prison population requires more attention in the country's health policies. The implementation of screening programs and treatment measures might contribute to a decrease in the incidence of STIs and cervical cancer in this vulnerable population. However, for such measures to be effective, further studies are needed to investigate the best practice to get more women to engage in in-prison prevention programs, e.g., through offering further sexual health education and self-sampling.

High prevalence of syphilis among recyclable waste collectors in Central Brazil

BACKGROUND

Syphilis is associated with social and behavioral factors.

METHODS

This cross-sectional study determined the prevalence of syphilis and its associated risk factors among recyclable waste collectors in Central Brazil.

RESULTS

A lifetime syphilis prevalence rate of 7.91% (95% confidence interval: 5.25-11.75) was found among 278 participants. Low educational level, history of sexually transmitted infection, and age ≥ 36 years were associated with a high prevalence of lifetime syphilis.

CONCLUSIONS

These findings emphasize the need for syphilis prevention, screening, and treatment among recyclable waste collectors, highlighting the potential for the spread of infection in vulnerable populations.

Syphilis and Co-Infections with HIV-1, HBV, and HCV among People Who Use Crack-Cocaine in Northern Brazil

The rates of syphilis and viral co-infections among people who use crack-cocaine (PWUCC) were assessed in this study. This cross-sectional study relied on biological and self-reported socio-behavioral data from a convenience sample of 990 PWUCC from twenty-six municipalities in the states of Amapá and Pará, northern Brazil. Blood samples were collected to assess the presence of Treponema pallidum using the Rapid Qualitative Test (RQT) and the Venereal Disease Research Laboratory (VDRL). Reactive samples by RQT were used to assess the presence of HBV, HCV, and HIV-1 using Enzyme Immunoassay (EIA) and Polymerase Chain Reaction (PCR). Logistic regression models were used to determine the association of variables assessed with syphilis. In total, 287 (29.0%) of the PWUCC sample had reactive results for syphilis. HBV (15.7%), HCV (5.9%), and HIV-1 (9.8%) were detected among PWUCC with syphilis. Young age, low monthly income and education level, long duration of crack-cocaine use, condomless sex, multiple sex partners, and exchange of sex for money/drugs were associated with syphilis. The present study provides unique insights on the epidemiological status of syphilis among PWUCC in northern Brazil, with multiple implications for improving urgent interventions for diagnosis, prevention, and treatment.

Reliability of prisoners' survey responses: comparison of self-reported health and biomedical data from an australian prisoner cohort

OBJECTIVE

Prisoner health surveys primarily rely on self-report data. However, it is unclear whether prisoners are reliable health survey respondents. This paper aimed to determine the level of agreement between self-report and biomedical tests for a number of chronic health conditions.

METHOD

This study was a secondary analysis of existing data from three waves (1996, 2001, 2009) of the New South Wales (NSW) Inmate Health Survey. The health surveys were cross-sectional in nature and included a stratified random sample of men (n=2,114) from all NSW prisons. Self-reported histories of hepatitis, sexually transmissible infections, and diabetes were compared to objective biomedical measures of these conditions.

RESULTS

Overall, the sensitivity (i.e., the respondents who self-reported having the condition also had markers indicative of the condition using biomedical tests) was high for hepatitis C (96%) and hepatitis B (83%), but low for all other assessed conditions (ranging from 9.1% for syphilis using RPR to 64% for diabetes). However, Kappa scores indicated substantial agreement only for hepatitis C. That is, there were false positives and false negatives which occurred outside of chance leading to poor agreement for all other assessed conditions.

CONCLUSIONS

Prisoners may have been exposed to serious health conditions while failing to report a history of infection. It may be possible that prisoners do not get tested given the asymptomatic presentation of some conditions, were unaware of their health status, have limited health-service usage preventing the opportunity for detection, or are subject to forgetting or misunderstanding prior test results. These findings demonstrate the importance of the custodial environment in screening for health conditions and referral for treatment should this be needed. Testing on entry, periodically during incarceration, and prior to release is recommended.

Brazilian Protocol for Sexually Transmitted Infections 2020: acquired syphilis

The Clinical Protocol and Therapeutic Guidelines for Comprehensive Care of People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020, includes updates concerning acquired syphilis. The document comprises rapid test use, safety and efficacy of benzathine benzylpenicillin, case follow-up, neurosyphilis clinical and laboratory management, approaching sex partners, assistance and monitoring of diagnosed pregnant women, and syphilis and HIV co-infection specificities, as well as a case notification summary. Health managers and professionals must be continuously trained so as to integrate care and surveillance, to strengthen actions for efficient control of syphilis, to broaden the search for sex partners, and to expand access of most vulnerable populations to health services. Most people with syphilis are asymptomatic; this contributes to the maintenance of the transmission chain. Without adequate treatment of pregnant women with syphilis, severe consequences can occur, such as miscarriage, prematurity, low birth weight, natimortality, and congenital syphilis.

[Brazilian Protocol for Sexually Transmitted Infections 2020: acquired syphilis]

The Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Ministry of Health of Brazil in 2020, includes the update on acquired syphilis. The document comprises rapid tests use, safety and efficacy of the administration of benzathine benzylpenicillin, follow-up of cases, clinical and laboratory management of neurosyphilis, approach to sexual partnerships, assistance and monitoring of diagnosed pregnant women, and specificities of syphilis and HIV co-infection, as well as a summary of the notification of cases. It is necessary to train health managers and professionals on a continuous basis, with a view to integrating care and surveillance, strengthening effective syphilis control actions, increasing the search for sexual partnerships, and expanding the access of the most vulnerable populations to health services.

Lifetime Syphilis Prevalence and Associated Risk Factors Among Female Prisoners in Brazil

BACKGROUND

In 2016, approximately 42,000 women were incarcerated in Brazil. The objectives of this study were to measure the lifetime prevalence of syphilis and sociodemographic and behavior correlates of antibody positivity among female prisoners in Brazil.

METHODS

We conducted a cross-sectional survey of 1327 incarcerated women in 2014 to 2015 sampled through a multistage cluster design to represent the penitentiary system throughout Brazil. A rapid treponemal antibody test approved by the Ministry of Health (Rapid Test DPP Sífilis Bio-Manguinhos) was used to detect lifetime history of infection. Analyses were adjusted using weights based on the inverse of the product of the probabilities of the sampling units at each stage of the design. Variables significantly associated with syphilis infection at P < 0.05 in multivariate analyses were retained in the final model.

RESULTS

Prevalence of syphilis antibody among female prisoners in Brazil was 11.6% (95% confidence interval [CI], 9.8%-13.8%). Higher syphilis prevalence was associated with black/Afro-Brazilian or mixed race/ethnicity (adjusted odds ratio [AOR], 1.78; 95% CI, 1.10-2.87), homelessness (AOR, 4.58; 95% CI, 2.78-7.56), abortion (AOR, 1.56; 95% CI, 1.02-2.38), and sexual violence (AOR, 1.59; 95% CI, 1.01-2.49). Syphilis prevalence was lower among women who had received condoms in school (AOR, 0.28; 95% CI, 0.08-1.00) as a marker for reproductive health education.

CONCLUSIONS

Women within the vast Brazilian prison system demonstrate a high lifetime cumulative incidence of syphilis. Our data advocate for increased screening and treatment of syphilis of incarcerated women and help identify women at higher risk within the prison system and within their communities of origin.

Knowledge of the prison population about sexually transmitted infections

OBJECTIVE

To verify the prison population's knowledge of sexually transmitted infections.

METHODS

An illustrated questionnaire was prepared based on the Ministry of Health's information booklet to provide information about sexually transmitted infections and applied to a sample of the prison population (PP) (n=158). This is a descriptive and cross-sectional research conducted in 2017 in one of the penitentiaries in the western region of the state of São Paulo.

RESULTS

The study sample presented both correct knowledge and misconceptions regarding the identification, prevention, treatment and ways of transmission of these infections. Among these aspects, the identification of these infections raised the most doubts, especially about those that produce penile lesions.

CONCLUSION

The data obtained in the study reinforces the need for greater investments in the knowledge of sexually transmitted infections in the prison setting. They should focus on educational activities contextualized to the profile of this population: young adults with low education and little access to information.

Prevalence, incidence and associated factors for HBV infection among male and female prisoners in Central Brazil: A multicenter study

BACKGROUND

Prison populations are at high risk for hepatitis B virus (HBV) infection. The aim of this study was to assess the prevalence, incidence, HBV associated factors and circulating genotypes/subtypes.

METHODS

A total of 3,368 prisoners from 12 closed prisons were randomly recruited for a cross-sectional study. In addition, a cohort study was conducted 12 months later and included 1,656 individuals. Participants underwent an interview and blood collection for the detection of HBV serological markers and HBV-DNA phylogenetic analysis.

RESULTS

HBV exposure (anti-HBc+) was 9.8% (95% CI: 8.8-10.8); 11.2% were female and 9.6% were male. HBsAg+ was 0.6%. Only 31.4% of the participants had HBV vaccination-like profile (anti-HBs+ alone; 30.4% male vs. 36.8% female; p=0.004). Most individuals were susceptible to HBV (60.2% female vs. 52.2% male, p=0.001). HBV isolates were classified as genotypes A (45.4%), D (27.3%) and F (27.3%). In males, HBV exposure was associated with increased age. Male prisoners had more evidence of HCV/HBV co-infection (10.7%) than females (3.4%) and the frequency of Treponema pallidum infection among prisoners who had been exposed to HBV was higher in female prisoners when compared with male (39.7% vs. 19.1%). The incidence of HBV was 0.18/100 person-years (95% CI: 0.12%-0.25%).

CONCLUSIONS

Our results indicate a high prevalence of HBV exposure in prisoners. Despite the low incidence of this infection, the occurrence of new cases indicates the need to implement preventive measures.

Screening for HBV, HCV, HIV and syphilis infections among bacteriologically confirmed tuberculosis prisoners: An urgent action required

Viral hepatitis, syphilis, HIV, and tuberculosis infections in prisons have been identified globally as a public health problem. Tuberculosis (TB) and viral hepatitis co-infection may increase the risk of anti-tuberculosis treatment-induced hepatotoxicity, leading to the frequent cause of discontinuation of the first-line anti-tuberculosis drugs. Therefore, the aim of this cross-sectional study was to investigate the epidemiological features of HCV, HBV, syphilis and HIV infections among bacteriologically confirmed tuberculosis prisoners in Campo Grande (MS), Central Brazil. The participants who agreed to participate (n = 279) were interviewed and tested for the presence of active or current HCV, HBV, syphilis and HIV infections. The prevalence of HCV exposure was 4.7% (13/279; 95% CI 2.2-7.1). HCV RNA was detected in 84.6% (11/13) of anti-HCV positive samples. Out of 279 participants, 19 (6.8%; 95% CI 4.4-10.4) were HIV co-infected, 1.4% (4/279, 95% CI 0.5-3.8) had chronic hepatitis B virus (HBsAg positive) and 9.3% (26/279, 95% CI 6.4-13.4) had serological marker of exposure to hepatitis B virus (total anti-HBc positive). The prevalence of lifetime syphilis infection (anti-T. pallidum positive) was 10% (28/279, 95% CI 7.0-14.2) and active syphilis (VDRL ≥ 1/8 titre) was 5% (14/279, 95% CI 2.9-8.3). The prevalence of TB/HCV co-infection among prisoners with HIV (15.8%) was higher than among HIV-non-infected prisoners (3.8%; P<0.05). These results highlight the importance of hepatitis testing among prisoners with bacteriologically confirmed case of TB who can be more effectively and safely treated in order to reduce the side effects of hepatotoxic anti-TB drugs.

Health morbidity in Brazilian prisons: a time trends study from national databases

OBJECTIVE

The goal of this study was to explore the surveillance data about mandatory reporting diseases, included in the official information systems, and evaluate the historical trend analysis in prisoners in Brazil.

DESIGN

A time trends study was performed using secondary data from prisons' health units.

SETTING

Nationwide representative data of Brazilian prisoners obtained from 2007 to 2014 health and prison information systems database were analysed. These data are carried out by units identified as prison health facilities.

PRIMARY OUTCOME MEASURES

Diseases diagnosis and individual data were available at the National System of Disease Notification (in Portuguese SINAN), Mortality Information System (in Portuguese SIM) and Prison Registration Systems (in Portuguese INFOPEN and GEO prisons). Analyses of the notification data performed in the SINAN at the national level. SINAN was consolidated with SIM, INFOPEN and GEO prison data.

RESULTS

A total of 23 235 cases of compulsory disease notification causing morbidity were reported in prison units in Brazil; of these cases, 20 003 (85.6%) were men and 3362 (14.4%) were women. Over time, the proportion of prisoners increased from 1.92 per 1000 inhabitants in 2007 to 2.77 per 1000 inhabitants in 2014 (rising trend). From a total of 27 states, 12 of them presented a growth in disease notifications, 14 were stable and in only one state was there a decrease in notifications. There was an increase in notifications in the country as a whole. Tuberculosis (64.4%), dengue (9.1%), AIDS (9.0%) and viral hepatitis (5.9%) were among the most frequently reported diseases during the study period.

CONCLUSION

Despite showing stable tendencies, our results show high rates of diseases in Brazilian prisons. Prison health services should not be isolated but integrated into regional and national health and justice systems.

Treatment Outcomes of Brazilian Inmates with Treponema pallidum and Human Immunodeficiency Virus Infection: A Prospective Cohort Study

A prospective cohort study was conducted to evaluate the incidence and treatment outcomes of syphilis and human immunodeficiency virus (HIV) in inmates from Central Brazil. In 2013, 3,363 inmates from 12 prisons in the state of Mato Grosso do Sul were recruited, and 1,614 remained incarcerated after 1 year. The inmates were interviewed, and blood samples were collected for serological testing for Treponema pallidum and HIV infections. Inmates infected with T. pallidum or HIV within the first year were assessed for treatment using prison medical record data, based on Venereal Disease Research Laboratory test results, HIV-1 viral load, and CD4 counts. Acquired syphilis was identified in 5.8% (N = 95) of the inmates and 74% (N = 70) of them demonstrated poor treatment outcomes after 1 year. Multivariate analysis revealed that not reporting a stable partner was a risk factor for failure of syphilis treatment. Twenty-five patients had HIV (1.5%) and among those, 13 (52%) had an HIV-1 viral load > 200 copies/mL after 1 year. The incidence of T. pallidum and HIV infections was 0.5% (N = 9). The poor treatment outcomes of syphilis and HIV within Brazilian prisons demonstrate the inadequacy of public health programs. Although the incidence of these infections within the prison population is low, new cases still occur. Our results reinforce the significance of screening programs during prison admission for early detection and treatment of sexually transmitted infections.