Abstract
BackgroundGlobally, 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.MethodsWe 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.ResultsAmong 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 smearpositive 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 upConclusionsMass 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.
Highlights
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
1,422 remained incarcerated in the same prison after 1 year (Fig. 1); this subset comprises the prospective cohort in whom TST conversions and TB incidence were assessed
Previous incarceration was reported among 61 % of participants, and 45 % had less than 4 years of schooling
Summary
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. Incarcerated populations have among the highest tuberculosis (TB) notification rates, frequently in excess of 20 times the rates of their corresponding non-incarcerated communities [1]. While TB incidence is declining in community settings across Brazil, it has risen by nearly 40 % among incarcerated population over the past seven years, representing 8 % of approximately 70,000 TB cases reported annually to the Ministry of Health [2]. Prisons are optimal environments for TB transmission since they bring together individuals with high rates of tobacco, alcohol, and drug use, and limited access to healthcare and TB diagnostics, into crowded, poorly ventilated cells for 16–20 h a day [7, 8]. Determining which interventions would be most effective and efficient in reducing the burden of TB in such settings is difficult due to the lack of data
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