Tuberculosis in Persons Deprived of Liberty in Tete, Mozambique.

doi:10.21203/rs.3.rs-3025201/v1

Download PDF

Research Article

Tuberculosis in Persons Deprived of Liberty in Tete, Mozambique.

https://doi.org/10.21203/rs.3.rs-3025201/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Objective - To assess the prevalence and factors associated with tuberculosis in Persons Deprived of Liberty (PDL) in the Tete Provincial Prison Establishment (EPPT) in Mozambique.

Methods -This was a cross-sectional observational study conducted in 2020 at the EPPT in Mozambique. The study population included the 525 PDL in the male EPPT and the 53 PDL in the female penitentiary. Data from the tuberculosis screening campaigns conducted by the EPPT Sanitary Department were collected from 356 PDL contained in the registration book. Relative and absolute frequencies of the variables studied were calculated. Fisher's exact test or the χ2 test was used to verify the association between the outcome (tuberculosis) and the independent variables, and logistic regression, considering a 5% significance level.

Results - Among the 356 PDL, 322 (90.5%) were male and 34 (9.5%) were female. Approximately 65.0% of PDL were in the age group of 18 to 34 years and single, and half were from the city, with at least primary level schooling. Around 70.0% had no expected monthly income. The prevalence of TB in the EPPT was quite high, 24.1% (86/356), with 24.2% (78/322) among male PDL, and 23.5% (8/34) in female PDL. HIV prevalence was also high at 9.8% (35/356), and approximately 3.1% (11/356) of PDL presented TB-HIV co-infection. The main factor associated with TB in male PDL in the EPPT was time in prison, ORadj=9.0 (95%CI: (1.1 - 71.0).

Conclusions - The prevalence of tuberculosis, HIV, and TB-HIV observed in the EPPT was high, implying a high risk of infection, transmission, incidence, and prevalence in the community at large. Conditions in the prison environment were associated with the prevalence of tuberculosis in male PDL in the EPPT.

Epidemiology

Observational Study

Prevalence

Prisoners

Tuberculosis.

Tuberculosis – TB continues to be a major public health problem in many countries around the world, especially in prison settings. Global estimates indicate that, in 2020, 9.9 (95%CI: 8.9–11.0) million cases of TB were reported worldwide, representing an incidence rate of 127 cases/100,000 inhabitants-year (WHO, 2021). In Mozambique, the incidence of TB in the same period was 368 cases/100,000 inhabitants-year, which remains at a high level, despite having a stationary trend with a slight reduction (WORLD BANK, 2022). Mozambique is among the 10 countries with all forms of tuberculosis (TB, TB-HIV, and MDR/RR-TB) and is one of the 30 countries that has had a high burden of TB for many years, currently being responsible for 87% of all estimated cases in the world. TB is one of the 10 main causes of death in the world, as well as in Mozambique (WHO, 2022).

For many years, the World Health Organization (WHO) has recommended active case finding as a primary strategy for TB detection (CONDE et al., 2011). In 2008, the Stop TB strategy (2006–2015) was created and implemented, which paved the way for TB control beyond the long-term goal of eliminating the disease as a global health problem by 2050. One of the strategies outlined and taken into account, was “the management of high-risk groups” such as in “prisons”, (WHO, 2008). In addition to the Stop TB strategy (2006–2015), the WHO proposed guidelines for TB control in prisons and similar institutions, specifically for countries with a high prevalence of the disease (BAUSSANO, 2010). The WHO created the 2021–2025 global strategy for prioritizing countries with a high burden of TB and their overlaps using three rankings. Mozambique appears on the three lists (TB, drug-resistant TB, and TB-HIV), occupying the 5th position regarding the burden of disease (BRASIL, 2021 and WHO, 2021). In the prison context, estimates in 2021 indicate that a high prevalence of tuberculosis in PDL worldwide: Africa 1.61% (0.98–2.5%); North America 0.32 (0.13–0.65%); South America 1.68% (0.83–2.97%); Europe 1.0% (0.51–1.77%); South-East Asia Region 1.81% (0.67–4%); Western Pacific 0.72% (0.27–1.6%); and Eastern Mediterranean 1.16% (0.48–2.37%) (CORDS et al., 2021). In Southern Africa, including Mozambique, the prevalence of tuberculosis in PDL was 8.4% (0.4–16.6%) and for PDL with HIV was 18.6% (2.3–34.9%) (TELISINGHE et al., 2016)

In order to diagnose TB early in a population, it is suggested that investigations be performed; in people deprived of their liberty as soon as they enter a prison, and/or with diabetes, people living on the streets, people living with HIV, indigenous people, and people with needs arising from the use of alcohol and other drugs, with the presence of a cough for two weeks or more (BAUSSANO, 2010; RODRIGUES and CARDOSO, 2010).

Several studies have reported a high prevalence of tuberculosis in PDL, associated with factors such as substance abuse, low socioeconomic status, overcrowding, poorly ventilated cells with little sunlight, poor hygiene, inadequate nutrition, frequent exposure to Mycobacterium tuberculosis and HIV, high turnover within the prison system, and the lack of TB control measures which contribute to the presence and transmission of TB within penitentiaries (KALONJI et al., 2016; FUGE and AYANTO, 2016; JORDAN, 2019; PELISSARI and DIAZ-QUIJANO., 2020 and MACEDO, 2020).

Little is known about the prevalence of tuberculosis and its associated factors in penitentiary establishments in Mozambique, thus, this was the objective of the current study.

The identification of factors associated with tuberculosis in the EPPT in Mozambique is an important goal for drawing up effective control measures. Early detection of bacilliferous patients and rapid initiation of therapy are essential for TB control in this establishment. However, knowledge of possible specific intervention variables will collaborate to improve TB control not only in the prison context, but also for the public health of the surrounding community in general (LONGHIL, 2013).

Study design

A cross-sectional analytical observational study was carried out with the participation of people deprived of their liberty from the Provincial Penitentiary of Tete in Mozambique in 2020.

Study location

The study was carried out in Mozambique, in the Tete Province and the city of the same name, specifically in the Provincial Penitentiary of Tete. The province had a general population of 2,900,213 inhabitants, 1,423,794 men and 1,476,419 women, according to the projected population by area of residence and sex according to age for 2020, based on data from the 2017 census (MOÇAMBIQUE-INE, 2017).

Tete Province is located in the extreme northwest of the central region of the country, with a total area of 100,724km², and in terms of surface area it is the 3rd largest province in the country after Niassa and Zambézia (MOÇAMBIQUE-INE, 2017).

Since its construction in colonial times, the Provincial Penitentiary of Tete has had a capacity of 90 inmates. The inmate populations at the facility in 2016 and 2018 were 525 and 465, five times over the anticipated capacity.

Study population

The target population of the present research was the 525 PDL from the male penitentiary establishment of Tete and 53 from the female penitentiary. After the PDL participated in the 2020 tuberculosis screening campaign carried out by the Penitentiary Health Care Department, all PDL were invited to participate in the research and only those who accepted the invitation and signed an informed consent form participated in the study. PDL who were transferred to other penitentiary establishments during the study period, who were released in light of presidential decree nº 11/2020 of March 30th of COVID-19 (MOZAMBIQUE, 2020), who died, and who had a history of TB were excluded.

Data collection

Data collection was carried out by three nursing technicians from the Health Sciences Institute of Tete (ICST), who were previously trained to apply the questionnaire and measure weight, height, and temperature. Supervision of data collection was carried out by the main researcher.

Primary data were collected through interviews, with a semi-structured questionnaire containing closed questions adapted from DARA et al., 2009 and WAISBORD, 2010. Anthropometric data were measured using a Multilaser Eastmart HC039 digital scale with an LCD Display to measure weight and a stadiometer to measure height. For secondary data, the record book of routine campaigns for tuberculosis screening of respiratory symptomatic PDL from the EPPT was used and data were extracted on sputum smear microscopy or the Genexpert test performed by the penitentiary health post, screening campaigns, and/or laboratory results at the Provincial Hospital of Tete.

Variables

The sputum test was performed only in PDL with respiratory symptoms (RS), that is, in people who had prolonged coughing with or without sputum for three weeks or more. A confirmed case of pulmonary TB was defined when a PDL presented clinical manifestations such as fever, weight loss, night sweats, cough, anorexia, fatigue, or chills, and whose direct sputum smear test (bacilloscopy or Genexpert) was positive for Koch's bacilli (+++, ++, +) (RODRIGUES and CARDOSO, 2010 and MOÇAMBIQUE-MISAU, 2013).

Sociodemographic variables were analyzed (sex, age group, marital status, level of schooling, origin, and income); clinical-epidemiological variables (nutritional status, family history of tuberculosis, presence of fever, weight loss, night sweats, presence of cough, anorexia, expectoration, smoking, drug use, previous illnesses, previous history of incarceration); variables related to knowledge of tuberculosis prevention and control measures (opportunity for diagnosis and treatment, release and/or transfer, access to health services, knowledge of the disease, types of TB prevention measures in the establishment); variables related to penitentiary conditions (cell capacity, number of PDL in the cell, presence of air conditioning, presence of windows, penetration of sunlight into the cell, presence of isolation rooms, presence of cleaning staff).

Data analysis

There was an association between the sociodemographic, clinical, and epidemiological variables, related to the knowledge of the PDL about tuberculosis and tuberculosis prevention and control measures, and related to the conditions of the penitentiary with the binary outcome variable of tuberculosis diagnosis.

Data were analyzed using the STATA program, version 14. In the descriptive analysis, measures of central tendency (means and medians) and dispersion (standard deviation and interquartile range) and relative and absolute frequencies for qualitative/categorical variables were calculated for quantitative variables.

In order to verify the existence of an association in the univariate analysis between tuberculosis and sociodemographic, clinical, and epidemiological factors, related to knowledge of tuberculosis prevention measures and related to penitentiary conditions, Fisher's exact test and the χ2-chi-square test were used, with a significance level of 5.0%.

The independent variables that presented a statistical significance level of p < 0.20 in the univariate analysis were considered in the multiple models of logistic regression. Only the variables that presented p < 0.05 remained in the multiple models. Age remained as an adjustment variable. At all stages of the design of the multiple logistic regression model, the Hosmer-Lemeshow test was applied to test the goodness of fit of the model. The strength of the associations was expressed in odds ratios (OR), with their respective 95% confidence intervals (95% CI).

Ethical considerations

The project was approved by the Ethics Committee for Research on Human Beings of the Faculty of Public Health of the University of São Paulo (Opinion 3,740,046.) and by the National Committee of Bioethics in Research of the Ministry of Health of Mozambique Ref. 503/CNBS/20 of September 14th, 2020, and administrative authorization from the Minister of Health of Mozambique Ref No. 1799/GMS/002/020 of October 27th, 2020. The PDL who were surveyed had prior information about their right to agree or not to participate through the informed consent form. The confidentiality of the data collected by the interviewers was guaranteed in all cases.

Among the total of 525 male PDL in the EPPT, those transferred to other penitentiary establishments during the study period (n = 17), those who refused to participate in the study (n = 11), those who were released under the presidential decree nº11/2020 of March 30th due to COVID-19 (n = 134), those who died (n = 3), and those with a history of TB (n = 38) were excluded, corresponding to 38.7% of the total. In the women's penitentiary, among the total of 53 PDL, those who had a history of TB (n = 5) and who were released under presidential decree nº 11/2020 of March 30th due to COVID-19 (n = 14) were excluded, corresponding to 35.8% of the total. Thus, the studied sample consisted of a total of 356 PDL of both sexes, (n = 322, 61.3%) from the male penitentiary and (n = 34, 64.2%) from the female penitentiary.

Table 1 presents the description of the sociodemographic, clinical, and epidemiological variables and the knowledge of the PDL about TB, according to sex. The predominant age group of the male PDL in the EPPT was 18 to 34 years (n = 213, 66.1%), with an average age of 27 years, the majority were single (n = 210, 65.2%), from the city of Tete (n = 162, 50.0%), with a primary level of schooling (n = 181, 56.0%) and with no expected monthly income. For females, half of the PDL were aged between 18 and 34 years (n = 19, 55.9%) with an average of 25 years, were single (n = 16, 47.0%), from the city of Tete (n = 16, 47.0%), and without any schooling (n = 17, 50.0%), in addition, most had no expected monthly income (n = 32, 94.0%).

Table 1

Sociodemographic and clinical-epidemiological characteristics of PDL in the EPPT according to sex, Mozambique – 2020.
Variable - Scale	Total	Male	Female	p-value
Variable - Scale	n = 356 (100.0%)	n = 322 (90.5%)	n = 34 (9.5%)	p-value
Age range				0.261
18–34 years	232 (65.0)	213 (66.1)	19 (55.9)
35–59 years	117 (33.0)	102 (31.7)	15 (44.1)
60 - + years	7 (2.0)	7 (2.2)	0 (0.0)
Marital status				< 0.001
Married	119 (33.4)	105 (32.6)	14 (41.0)
Single	226 (63.5)	210 (65.2)	16 (47.0)
Divorced	6 (1.7)	6 (1.9)	0 (0.0)
Widowed	5 (1.4)	1 (0.3)	4 (12.0)
Origin				0.037
Tete city	178 (50.0)	162 (50.0)	16 (47.1)
Tete province	150 (42.0)	135 (42.0)	15 (44.1)
Another province	24 (7.0)	23 (7.0)	1 (2.9)
Foreigner	4 (1.0)	2 (1.0)	2 (5.9)
Academic level				< 0.001
Primary level	191 (54.0)	181 (56.0)	10 (29.4)
Secondary level	100 (28.0)	95 (30.0)	5 (14.7)
Pre-university	25 (7.0)	23 (7.0)	2 (5.9)
University	11 (3.0)	11 (3.0)	0 (0.0)
No schooling	29 (8.0)	12 (4.0)	17 (50.0)
Economic income				0.024
≤ 1 minimum wage	52 (14.6)	51 (15.8)	1 (3.0)
1 to 2 minimum wages	22 (6.2)	21 (6.5)	1 (3.0)
> 2 minimum wages	26 (7.3)	26 (8.1)	0 (0.0)
No expected monthly income	256 (71.9)	224 (69.6)	32 (94.0)
Nutritional status of PDL				< 0.001
Eutrophic (BMI − 18.5 to 24.5)	283 (79.5)	262 (81.4)	21 (61.8)
Malnutrition (BMI < 16 to 18.49)	38 (10.7)	37 (11.5)	1 (2.9)
Obese (BMI 25 to > 40)	35 (9.8)	23 (7.1)	12 (35.3)
Fever				0.006
Yes	4 (1.1)	2 (0.6)	2 (5.9)
No	352 (98.9)	320 (99.4)	32 (94.1)
Weight loss				< 0.001
Yes	148 (41.6)	125 (38.8)	23 (68.0)
No	208 (58.4)	197 (61.2)	11 (32.0)
Night sweats				< 0.001
Yes	145 (40.7)	116 (36.0)	29 (85.3)
No	211 (59.3)	206 (64.0)	5 (14.7)
Anorexia				0.111
Yes	93 (26.1)	88 (27.3)	5 (14.7)
No	263 (73.9)	234 (72.7)	29 (85.3)
Family history of TB				0.622
Yes	52 (14.6)	48 (14.9)	4 (11.8)
No	304 (85.4)	274 (85.1)	30 (88.2)
Cough				0.198
Yes	108 (27.0)	108 (100.0)	10 (100.0)
No	248 (73.0)	0 (0.0)	0 (0.0)
Sputum				0.382
Yes	61 (17.1)	57 (17.7)	4 (11.8)
No	295 (82.9)	265 (82.3)	30 (88.2)
Smoking habit				< 0.001
Yes	140 (39.3)	139 (43.2)	1 (2.9)
No	216 (60.7)	183 (56.8)	33 (97.1)
Use of drugs				0.032
Yes	39 (11.0)	39 (12.1)	0 (0.0)
No	317 (89.0)	283 (87.9)	34 (100.0)
Previous history of incarceration				0.032
Yes	39 (11.0)	39 (12.1)	0 (0.0)
No	317 (89.0)	283 (87.9)	34 (100.0)
TB-Diabetes co-infection				0.745
Yes	1 (0.3)	1 (0.3)	0 (0.0)
No	355 (99.7)	321 (99.7)	34 (100.0)
TB – HIV/AIDS co-infection				< 0.001
Yes	35 (9.8)	25 (7.8)	10 (29.4)
No	321 (90.2)	297 (92.2)	24 (70.6)
TB – Cardiovascular D. co-infection
Yes	43 (12.1)	34 (10.6)	9 (73.5)	0.007
No	313 (87.9)	288 (89.4)	25 (26.5)
TB - Depression co-infection
Yes	7 (2.0)	7 (2.2)	0 (0.0)	0.385
No	349 (98.0)	315 (97.8)	34 (100.0)

The following variables presented different distributions between sexes: marital status (p < 0.001), origin (p = 0.037), academic level (p < 0.001), economic income (p = 0.024), fever (p = 0.006), weight loss (p < 0.001), night sweats (p < 0.001), smoking (p < 0.001), drug use (p = 0.032), prison history (p = 0.032), TB-HIV co-infection (p < 0.001), TB-cardiovascular diseases co-infection (p = 0.007), and TB-other diseases co-infection (p = 0.034), (Table 1).

In the studied sample, 86 PDL tested positive for TB. The average prevalence of TB considering both penitentiaries was 24.1% (86/356), being 24.2% (78/322) in the male EPPT and 23.5% (8/34) in the female EPPT. Meanwhile, the prevalence of HIV in both penitentiaries was 9.8% (35/356), being 7.8% in males and 29.4% in females. The prevalence of TB-HIV co-infection was 12.8%, of which 11.5% corresponded to the male penitentiary and 25.0% to the female penitentiary.

The analysis of factors associated with TB was performed only for the male PDL, since in the female EPPT only 8 cases were identified. No sociodemographic characteristics or those related to knowledge of tuberculosis prevention measures were associated with tuberculosis (Tables 2 and 3).

Table 2

Association between sociodemographic and clinical-epidemiological characteristics of male PDL with respiratory symptoms and tuberculosis in EPPT, Mozambique − 2020.
Variable-Scale	Male	Respiratory Symptoms	BK/Genexpert +	BK/Genexpert-	Odds Ratio (95%CI)
Variable-Scale	n = 322	n = 108	n = 78 (72.2%)	n = 30 (27.8%)	Odds Ratio (95%CI)
Age range
18–34 years	213 (66.0)	63 (58.3)	45 (71.4)	18 (28.6)	1.0
35–59 years	102 (32.0)	43 (39.8)	32 (74.4)	11 (25.6)	1.2 (0.5–2.8)
60 - + years	7 (2.0)	2 (1.9)	1 (50.0)	1 (50.0)	0.4 (0.0–6.8)
Marital status
Married	105 (32.6)	33 (30.6)	22 (66.7)	11 (33.3)	1.0
Single	210 (65.2)	75 (69.4)	56 (74.7)	19 (25.3)	1.5 (0.6–3.6)
Divorced	6 (1.9)	---------	---------		---------
Widowed	1 (0.3)	---------	---------	---------	---------
Origin
Tete city	162 (50.0)	54 (50.0)	40 (74.1)	14 (25.9)	1.0
Tete province	135 (42.0)	47 (43.5)	33 (70.2)	14 (29.8)	0.8 (0.4-2.0)
Another province	23 (7.0)	6 (5.6)	5 (83.3)	1 (16.7)	0.8 (0.1–11.3)
Foreigner	2 (1.0)	1 (0.9)	0 (0.0)	1 (100.0)	---------
Academic level
Primary level	181 (56.0)	74 (68.5)	51 (68.9)	23 (31.1)	1.0
Secondary level	95 (30.0)	25 (23.0)	19 (76.0)	6 (24.0)	1.4 (0.5–4.1)
Pre-university	23 (7.0)	3 (2.8)	3 (100.0)	0 (0.0)	---------
University	11 (3.0)	2 (2.0)	2 (100.0)	0 (0.0)	---------
No schooling	12 (4.0)	4 (3.7)	3 (75.0)	1 (25.0)	1.4 (0.1–13.7)
Economic income
≤ 1 minimum wage	26 (8.1)	13 (12.1)	8 (61.5)	5 (38.5)	1.0
1 to 2 minimum wages	21 (6.5)	5 (4.6)	4 (80.0)	1 (20.0)	2.5 (0.2–29.3)
> 2 minimum wages	51 (15.8)	5 (4.6)	3 (60.0)	2 (40.0)	0.9 (0.1–7.7)
No expected monthly income	224 (69.6)	85 (78.7)	63 (74.1)	22 (25.9)	1.8 (0.5–6.1)
Nutritional status of PDL
Eutrophic	262 (81.4)	90 (83.3)	62 (68.9)	28 (31.1)	1.0
Malnutrition	37 (11.5)	10 (9.3)	9 (90.0)	1 (10.0)	4.1 (0.5–33.6)
Obesity	23 (7.1)	8 (7.4)	7 (87.5)	1 (12.5)	3.2 (0.4–26.9)
Smoking habit
No	183 (56.8)	62 (57.4)	47 (75.8)	15 (24.2)	1.0
Yes	139 (43.2)	46 (42.6)	31 (67.4)	15 (32.6)	0.7 (0.3–1.5)
Use of drugs
No	283 (87.9)	94 (87.0)	67 (71.3)	27 (28.7)	1.0
Yes	39 (12.1)	14 (13.0)	11 (78.6)	3 (21.4)	1.5 (0.4–5.7)
Previous history of incarceration
No	283 (87.9)	96 (88.9)	70 (72.9)	26 (27.1)	1.0
Yes	39 (12.1)	12 (11.1)	8 (66.7)	4 (33.3)	0.7 (0.2–2.7)
TB-Diabetes co-infection
No	321 (99.7)	108 (100.0)	78 (72.2)	30 (27.8)	1.0
Yes	1 (0.3)	0 (0.0)			------------
TB – HIV/AIDS co-infection
No	297 (92.2)	96 (88.9)	69 (71.9)	27 28.1)	1.0
Yes	25 (7.8)	12 (11.1)	9 (75.0)	3 (25.0)	1.2 (0.3–4.7)

Table 3

Association between knowledge of tuberculosis prevention measures of male PDL with respiratory symptoms and tuberculosis in EPPT, Mozambique − 2020.
Variable-Scale	Male	Respiratory Symptoms	BK/Genexpert+	BK/Genexpert-	Odds Ratio (95%CI)
Variable-Scale	n = 322	n = 108	n = 78 (72.2%)	n = 30 (27.8%)	Odds Ratio (95%CI)
Knowledge of tuberculosis
No	26 (8.0)	5 (4.6)	3 (60.0)	2 (40.0)	1.0
Yes	296 (91.9	103 (95.4)	75 (72.8)	28 (27.2)	1.8 (0.3–11. 3)
Presence of Health Center
No	2 (0.6)				1.0
Yes	320 (99.4)	108 (100.0)	78 (72.2)	30 (27.8)	------------
Presence of care for sick PDL
No	18 (5.6)	3 (2.8)	1 (33.3)	2 (66.7)	1.0
Yes	304 (94.4)	105 (97.2)	77 (73.3)	28 (26.7)	5.5 (0.5–63.1)
Availability of medication at the Health Center
No	24 (7.5)	5 (4.6)	2 (40.0)	3 (60.0)	1.0
Yes	298 (92.5)	103 (95.4)	76 (73.8)	27 (26.2)	4.2 (0.7–26.7)
Use of TB control measures in the establishment
No	23 (7.1)	2 (2.0)	1 (50.0)	1 (50.0)	1.0
Yes	299 (92.9)	106 (98.0)	77 (72.6)	29 (27.4)	2.7 (0.2–43.9)
Early diagnosis and treatment
No	322 (100.0)	108 (100.0)	78 (72.2)	30 (27.8)	1.0
Yes					------------
Isolation
No	122 (37.9)	50 (46.3)	38 (76.0)	12 (24.0)	1.0
Yes	200 (62.1)	58 (53.7)	40 (69.0)	18 (31.0)	0.7 (0.3–1.7)
Use of a mask
No	298 (92.5)	96 (88.9)	68 (70.8)	28 (29.2)	1.0
Yes	24 (7.5)	12 (11.1)	10 (83.3)	2 (16.7)	2.1 (0.4–10.0)
Screening
No	214 (66.5)	0 (0.0)	0 (0.0)	0 (0.0)	1.0
Yes	108 (33.5)	108 (100.0)	78 (72.2)	30 (27.8)	------------

The factor related to the conditions of the penitentiary environment associated with TB was the first 12 months of prison time, with OR = 9.9 (95%CI: 1.3–78.2) (Table 4).

Table 4

Association between penitentiary conditions and tuberculosis in respiratory symptomatic male PDL in EPPT, Mozambique − 2020.
Variable-Scale	Male	Respiratory Symptoms	BK/Genexpert +	BK/Genexpert-	Odds Ratio (95%CI)
Variable-Scale	n = 322	n = 108	n = 78 (72.2%)	n = 30 (27.8%)	Odds Ratio (95%CI)
Number of PDL in the cell
≤ 10 PDL	2 (0.6)	1 (0.9)	1 (100.0)	0 (0.0)	1.0
> 10 PDL	320 (99.4)	107 (99.1)	77 (72.0)	30 (28.0)	--------
Absence of window in the cell
No	15 (4.7)	7 (6.5)	3 (42.9)	4 (57.1)	1.0
Yes	307 (95.3)	101 (93.5)	75 (74.3)	26 (25.7)	3.9 (0.8–18.3)
Sunlight penetration into the cell
No	160 (49.7)	52 (48.1)	40 (76.9)	12 (23.1)	1.0
Yes	162 (50.3)	56 (51.9)	38 (67.9)	18 (32.1)	0.6 (0.3–1.5)
Presence of isolation rooms
Yes	316 (98.1)	107 (99.1)	78 (72.9)	29 (27.1)	1.0
No	6 (1.9)	1 (0.9)	0 (0.0)	1 (100.0)	--------
Prison time of the PDL
> 12 months	139 (43.2)	87 (80.6)	58 (66.7)	29 (33.3)	1.0
≤ 12 months	183 (56.8)	21 (15.7)	20 (95.2)	1 (4.8)	9.9 (1.3–78.2)
Existence of Cleaning Staff in the Cells
No	169 (52.5)	61 (56.5)	46 75.4)	15 (24.6)	1.0
Yes	153 (47.5)	47 (43.5)	32 (68.1)	15 (31.9)	0.7 (0.3–1.6)
PDL who clean the cell themselves
No	30 (9.3)	17 (15.7)	14 (82.0)	3 (18.0)	1.0
Yes	292 (90.7)	91 (84.3)	64 (70.3)	27 (29.7)	0.5 (0.1–1.9)

Table 5 presents the association between the bacilloscopy/Genexpert result and the variables prison time and presence of windows, adjusted for age of respiratory symptomatic PDL in the male EPPT. In the multiple regression model, the only factor that was associated with tuberculosis was prison time OR = 9.0; (95%CI: 1.1–71.0). Thus, the time in prison in the EPPT in the first 12 months showed a statistically significant association (p < 0.037) as a risk factor associated with the development of tuberculosis in male PDL.

Table 5

Crude and adjusted association measures of variables with p < 0.20 and sputum smear/Genexpert result of respiratory symptomatic male PDL in EPPT, Mozambique − 2020.
	Factors associated with Tuberculosis
	Univariate analysis		Multiple regression model
Variable	Crude Odds Ratio (95%CI)	p-value	Adjusted Odds Ratio (95%CI)	p-value
Age	1.0 (0.5–2.2)	0.982	1.1 (0.5–2.6)	0.800
Prison time	9.9 (1.3–78.2)	0.028	9.0 (1.1–71.0)	0.037
Absence of windows	3.8 (0.8–18.3)	0.091	3.1 (0.6–15.7)	0.173

The prevalence of TB found in PDL in the EPPT of around 24.1% is quite high. Likewise, high prevalence of HIV (9.8%) and proportions of TB cases co-infected with HIV (12.8%) were found, which were higher among female PDL (29.4% and 25.0%, respectively). Prison time equal to or less than 12 months was positively associated with TB in the male EPPT.

The TB prevalence in PDL in the EPPT is approximately 60.3 times higher than the national average (368/100,000 = 0.4%) in the general population, as was the HIV prevalence, which was almost 24.5 times higher than the national average (35/100 = 0.4%) in the general population. The same scenario of high rates was also observed in TB-HIV co-infection, where the prevalence in PDL was approximately 15.5 times higher than the national average (18.5/100 = 0.2%) in the general population (UNAIDS, 2021).

These results are consistent with other studies. High prevalence of TB in PDL was found in Mbuji Mayi prisons in the Democratic Republic of Congo (KALONJI et al., 2016). Two studies carried out in Brazil, in Minas Gerais in Brazil and in Mato Grosso do Sul, reported a high prevalence of TB in PDL (NAVARRO et al., 2016 and CARBONE et al., 2017). In an Iranian prison, the prevalence of tuberculosis in PDL was 3 times more than the prevalence of the present study (MAMANI et al., 2016). This was also reported by an Ethiopian study that showed a 5-fold higher prevalence of tuberculosis in PDL when compared to the general population (SAHLE et al., 2019). In Tianjin, China, the prevalence of tuberculosis in PDL was 2 times higher than the prevalence found in the current research (ZHANG et al., 2020).

The high prevalence of TB in PDL implies maintenance of the transmission cycle, incidence, and prevalence of the disease in the general population and vice versa. Some studies consider penitentiaries as a reservoir of tuberculosis that facilitates the transmission of Koch's bacillus within cells and to the community in general (SACCHI et al.; 2015). Transmission occurs through PDL, visitors, and released prisoners, leading one to believe that in Mozambique both populations are far from the goal established by the WHO for TB control, which is why the PDL should not be seen as people isolated from the community, without health care priorities.

A study carried out in Brazil clarifies that incarcerated individuals who enter prison with a low risk of TB, present a rapid increase in the risk over 5 years, reaching a peak 30 times higher than that of the general population (SACCHI et al., 2015). After release, former PDL have an almost 5.5 times greater risk of active TB than the general population - a risk that remains elevated for 7 years and is likely to be underestimated due to emigration (GEBRECHERKOS et al., 2016). The concentration of TB control health interventions in prisons can therefore have potent effects in reducing TB rates in the general population (MABUD et al., 2019).

TB cases in the EPPT are detected during TB screening campaigns, which depend largely on non-governmental organizations, and during health consultations at the penitentiary health post. Screening of prisoners on entry to the penitentiary could play an important role in the early detection of cases and prevent the spread of TB in the penitentiary. A three-phase screening program; on entry, periodically during incarceration, and on exit has been successfully used in Malawi and may serve as a model for Mozambique (SINGANO et al., 2020). Identification of respiratory symptoms, and diagnosis of tuberculosis cases, mainly bacilliferous, is the first point to interrupt the transmission cycle, incidence, and prevalence of exposure (BAUSSANO, 2010; TELISINGHE et al., 2016; and MABUD et al., 2019).

The results of the present study demonstrated a high prevalence of TB-HIV co-infection in PDL in the EPPT. A systematic review showed that the prevalence of TB-HIV co-infection in PDL worldwide is also high: Africa − 14% (CI: 8–24%); North/South America − 37% (CI: 31–44%); Asia − 35% (CI: 12–68%), and Europe − 25% (CI: 12–45%). The review study also described that in countries of the WHO African region, specifically Southern Africa, the proportion of cases of TB-HIV co-infection is higher, being over 50% (DIANATINASAB et al., 2018). A survey carried out in Gondar prison in Ethiopia revealed that the prevalence of positive TB-HIV co-infection was high, more than twice as high when compared to the general population (GEBRECHERKOS et al., 2016). Another study on TB in a penitentiary in New York in 2016 estimated a prevalence of TB-HIV co-infection three times higher than that found in the current study (EDGE, et al., 2016).

The risk of tuberculosis is higher in people living with HIV. People with HIV infection are 20 to 30 times more likely to develop active TB than HIV negative people. Researchers cite several reasons to substantiate the TB-HIV co-infection: immunosuppression of HIV infection predisposes individuals to TB reactivation and increases the risk of progression from infection to disease; the two infections share a number of sociodemographic and behavioral risk factors with each other and with the likelihood of incarceration, such as intravenous drug use; conditions in prisons, such as poor ventilation and overcrowding, which increase the risk of TB transmission; racial and ethnic groups tend to experience proportionately higher TB rates, such as black and Hispanic populations in the US, who are often overrepresented, as much as 30 to 40 times, in EPPT (EDGE, et al., 2016).

The sociodemographic characteristics of PDL with TB were similar to those described in previous studies. It was observed that TB especially affected male PDL, young people between 18 and 34 years of age, single, with an urban origin, a low level of schooling, and without an expected monthly income due to unemployment. According to the WHO, the male/female ratio is not relevant for the disease, since women are often outnumbered by men in the prison population (WHO, 2009; SINGANO et al., 2020, ZHANG et al., 2020; SAHLE et al., 2019 and MERID et al., 2018).

Previous studies point out previous TB, a history of contact with TB, low body mass index, lack of sanitary conditions of incarceration, lack of adequate and timely health care, lack of detection of cases of active TB in prisons through frequent screening, and the use of inhaled drugs as factors associated with the high prevalence of TB in PDL (KALONJI et al., 2016; NAVARRO et al., 2016; MAMANI et al., 2016; CARBONE et al., 2017; SAHLE et al., 2019; and ZHANG et al., 2020).

The results of the present study demonstrated that prison time is associated with tuberculosis in the male EPPT. Studies indicate that penitentiaries with weak disease control measures may increase the risk of tuberculosis in PDL with ≤ 12 months of prison time, and the opposite may occur in penitentiaries where measures are stricter and screening for TB in PDL begins as soon as they enter. Therefore, it is assumed that in the EPPT the occurrence of the disease in PDL is early, that is, in the first ≤ 12 months of incarceration, which may be associated with the lack of compliance with some measures, such as screening for TB in PDL as soon as they enter the penitentiary and isolation of suspected TB cases in dedicated cells. Studies conducted in Ethiopian prisons and Tianjin Prison in China found that PDL with ≤ 12 months in prison had higher sputum smear positivity than PDL incarcerated for more than > 12 months in prison (MERID et al., 2018; CHEKESA et al., 2020 and ZHANG et al., 2020). In the Central prison of Suratthani in Thailand, a study carried out on the prevalence and risk factors associated with tuberculosis, reported the opposite finding, a fact that may be associated with poor health care for PDL in the Thai penitentiary (MORASERT et al., 2018).

A study that evaluated the association between environmental factors and the time of diagnosis of tuberculosis in prisons in São Paulo concluded that the majority of cases of tuberculosis were diagnosed within the first 2 years of incarceration (PELISSARI et al., 2022). Research in Tianjin prison in China revealed that PDL with a length of stay ≤ 12 months had a 20% greater chance of developing tuberculosis compared to PDL with > 12 months of prison stay, as found in the current study (ZHANG et al., 2020). Another study carried out in Ethiopia showed that PDL with ≤ 12 months of prison stay had a 5% greater occurrence of tuberculosis, when compared to PDL with > 12 months in prison (BIADGLEGNE et al., 2014).

Research carried out in Mato Grosso, Brazil, showed that the penitentiary's environmental conditions promote a high risk of infection in a short period of time (CARBONE, 2017). The exposure time required for successful infection was calculated to be between 100h and 200h, depending on the characteristics of the transmitting focus and the contact, as well as their relation (CONDE et al., 2011). A longer time of coexistence and proximity between the focus and the contact favors transmission. Restricted environments and constant exposure to the bacillus, such as penitentiaries, and health care environments, present greater risks of contagion. (URREGO, et al., 2015).

The main limitations of this investigation were the lack of establishment of the temporality of the facts, which would allow identification of the nature of the relation between exposures and tuberculosis, the difficulty in separating new cases of the disease from cases that had been present for some time, the PDL who had a mandate for release or who died, or who gained freedom in accordance with presidential decrees in light of Covid-19, are not part of the casuistry of cases, and the focus on a single penitentiary in Mozambique. Despite the limitations, the study showed that the prevalence of TB, HIV, and TB-HIV in the EPPT is high, as well as in the general population, which indicates a high risk of infection and transmission within the penitentiary and in the surrounding community.

Thus, the results of the current research contribute to public health, recommending the elaboration or reformulation of some normative documents of the Ministry of Justice and Religious Affairs of Mozambique, of the National Health System (SNS) of the Ministry of Health (MISAU) of the same country, with regard to the development of a National Tuberculosis Control Policy and Program including PDL in the prison system, in compliance with the norms and respecting the health status of the PDL, thus, reducing the double penalty, improving the conditions of the prison environment, reducing the number of cases of tuberculosis in PDL of the various penitentiary establishments in the country and in the community in general, and allowing the application of preventive measures and control of tuberculosis before the phenomenon occurs. A better TB control system in penitentiaries could protect PDL and staff from the spread of TB within the penitentiary and would significantly reduce the national TB burden (BAUSSANO, et al., 2010).

From another perspective, this article contributed with additional data in the scientific literature, given the scarcity of studies that measure the prevalence and factors associated with tuberculosis in penitentiaries in Mozambique. Further prospective studies on tuberculosis in this population are needed.

The prevalence of tuberculosis observed in EPPT is high among PDL, which indicates a high risk of infection and transmission within the Penitentiary. Prison time was the main factor of EPPT conditions associated with tuberculosis prevalence in male PDL.

The majority of the PDL were male, in the 18–34 age range with a mean age of 26 years (27 years male and 25 years female), single, from the city, had primary level of education, no predicted income, eutrophic. Widowed marital status, foreign provenance, having no schooling, having no expected monthly income, febrile status, weight loss, having night sweats, having a smoking habit, drug use, being previously incarcerated, having TB- HIV confection, presenting TB- cardiovascular disease confection or to other diseases, unawareness of isolation, mask use as well as other tuberculosis prevention measures were more frequent in male PDL of EPPT.

CNBS: National Committee of Bioethics in Research

EPPT: Tete Provincial Prison Establishment

HIV: Human Immunodeficiency Virus

ICST: Health Sciences Institute of Tete

MDR/RR-TB: Multi-drug Resistant Rifampicin Tuberculosis

MISAU: Ministry of Health

PDL: Persons Deprived of Liberty

RS: Respiratory Symptoms

SNS: National Health System

TB: tuberculosis

WHO: World Health Organization

ORIGIN OF THE ARTICLE

Article derived from the doctoral thesis entitled “Factors associated with tuberculosis in persons deprived of their liberty in the provincial penitentiary of Tete – Mozambique”, presented to the Graduate Program in Epidemiology at the Faculty of Public Health of the University of São Paulo, in 2022.

Ethical approval: The project of study was approved by the Ethics Committee for Research on Human Beings of the Faculty of Public Health of the University of São Paulo (Opinion 3,740,046.) and by the National Committee of Bioethics in Research of the Ministry of Health of Mozambique Ref. 503/CNBS/20 of September 14th, 2020.

Consent to participate and publication: Informed consent was obtained from all individual Persons Deprived of Liberty included in the study.

Data availability: The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Conflict of interest: There is no conflict of interest to declare.

Funding: Work financed by the Coordination of Higher Education Personnel (CAPES): Process nº 88881.284198/2018-01.

Author contributions: MAN, and APSS contributed from research project design, writing, analysis, and conceptualization of the article.

Acknowledgments: We thank the National Penitentiary Service of Tete, the Directorate of the Provincial Penitentiary Establishment of Tete and especially Lucas Raiva, who authorized that the Persons Deprived of Liberty were contacted and invited to participate in this study, as well as all participating Persons Deprived of Liberty who were kindly willing to contribute their time to the study and share their experiences.

BAUSSANO I., et al. Tuberculosis Incidence in Prisons: A Systematic Review. PLoS Med 7(12): e1000381; 2010; https://dx.doi.org/10.1371/journal.pmed.1000381.
BIADGLEGNE F. et al.; A first insight into high prevalence of undiagnosed smear-negative pulmonary tuberculosis in Northern Ethiopian prisons: implications for greater investment and quality control. PLoS One. 2014 Sep 9;9(9): e106869. doi: 10.1371/journal.pone.0106869. PMID: 25203007; PMCID: PMC4159260.
BRASIL, Livre da Tuberculose: Plano Nacional pelo Fim da Tuberculose como Problema de Saúde Pública: estratégias para 2021-2025; Brasília: Ministério da Saúde, 2021. 68 p.: il. ISBN: 978-65-5993-080-7.
CARBONE S. S.; Estudo multicêntrico da prevalência de tuberculose e HIV na população carcerária do Estado do Mato Grosso do Sul; Com. Ciências Saúde. 2017; 28(1):53 57.
CHEKESA B.; et al.; Prevalence of latent tuberculosis infection and associated risk factors in prison in East Wollega Zone of western Ethiopia; PLoS ONE 15(5): e0233314. 2020; http://dx.doi.org/10.1371/; journal. pone.0233314.
CONDE M. et al., Tuberculose; Rio de Janeiro; A. Araújo Silva Farmacêutica; 2011.
CORDS O., Incidence, and prevalence of tuberculosis in incarcerated populations: a systematic review and meta-analysis; 2021; Published by Elsevier Ltd; www.thelancet.com/public-health; Vol 6.
DARA M. et al.; Guidelines for control of tuberculosis in prisons; Tuberculosis Coalition for Technical Assistance and International Committee of the Red Cross; India; 2009.
DIANATINASAB M., et al; Prevalence of Tuberculosis in HIV-positive Prisoners: A Systematic Review and Meta-analysis; AIDS Rev. 2018 Apr-Jun; 20(2):114-124; doi: 10.24875/AIDSRev.M18000023.
EDGE, C. L. et al., Prisoners co-infected with tuberculosis and HIV: a systematic review; Journal of the International AIDS Society 2016, 19:20960; in http://www.jiasociety.org/index.php/jias/article/view/20960.
FUGE T. G. e AYANTO S. Y. Prevalence of smear positive pulmonary tuberculosis and associated risk factors among prisoners in Hadiya Zone prison, Southern Ethiopia; (2016) 9:201;http://doi.org/10.1186/s13104-016-2005-7.
GEBRECHERKOS T. et al., Smear positive pulmonary tuberculosis and HIV co-infection in prison settings of North Gondar Zone, Northwest Ethiopia; 2016; DOI 10.1186/s12889-016-3761-y.
JORDAN A. M.; Prevalence and risk factors of tuberculosis disease in South African correctional facilities in 2015; 2019; http://dx.doi.org/10.5588/ijtld.18.0782.
KALONJI G. M. P. et al.,Prevalence of tuberculosis and associated risk factors in the Central Prison of Mbuji Mayi, Democratic Republic of Congo; Tropical Medicine and Health; 2016; http://doi.org/10.1186/s41182-016-0030-9.
LONGHIL, R. M. P, Fatores de risco associados ao desenvolvimento de tuberculose na população urbana do município de Dourados – MS, Rio de Janeiro, 2013.
MABUD T. S. et al., Evaluating strategies for control of tuberculosis in prisons and prevention of spillover into communities: An observational and modeling study from Brazil; 2019; doi: 10.1371/journal.pmed.1002737.
MACEDO,L. R, Fatores associados à tuberculose na população privada de liberdade no Espírito Santo; 2020; http://doi.org/10.11606/s1518-8787.2020054001818.
MAMANI, M. et al.; Prevalence and incidence rates of latent tuberculous infection in a large prison in Iran; 2016; http://dx.doi.org/10.5588/ijtld.15.0857.
MERID Y. et al.;High utility of active tuberculosis case finding in an Ethiopian prison; 2018; http://dx.doi.org/10.5588/ijtld.17.0635.
MOÇAMBIQUE, boletim da república, Decreto presidencial nº11/2020 de 30 de março da COVID-19; 2020.
MOÇAMBIQUE. MISAU. Programa Nacional de Controle da Tuberculose; Plano estratégico e operacional 2014-2018. Maputo, 2013.
MOÇAMBIQUE. INE; Resultado Definitivo do Censo Populacional; INE. GOV. MZ; 2017.
MORASERT T. et al.; Prevalence and risk factors associated with tuberculosis disease in Suratthani Central Prison, Thailand; 2018; http://dx.doi.org/10.5588/ijtld.17.0654.
NAVARRO, P. D.; Prevalência da infecção latente por Mycobacterium tuberculosis em pessoas privadas de liberdade; Universidade de Minas Gerais, Belo Horizonte (MG) Brasil; 2016.
PELISSARI D. M. e DIAZ-QUIJANO F. A.; Impact of incarceration on tuberculosis incidence and its interaction with income distribution inequality in Brazil; 2020; https://doi.org/10.1093/trstmh/trz088.
PELISSARI, D. M. et al., Environmental factors associated with the time to tuberculosis diagnosis in prisoners in São Paulo, Brazil; 2022;doi: 10.1016/j.ajic.2022.05.015.
RODRIGUES I. L. A. e CARDOSO N. C. Detecção de sintomáticos respiratórios em serviços de saúde da rede pública de Belém, Pará, Brasil; Rev Pan-Amaz Saude 2010; 1(1):67-71.
SACCHI F. P. C. et al.; Prisons as Reservoir for Community Transmission of Tuberculosis, Brazil. Emerging Infectious Diseases. 2015; 21(3):452-455. doi:10.3201/eid2103.140896.
SAHLE E. T.;Bacteriologically confirmed pulmonary tuberculosis in an Ethiopian prison: Prevalence from screening of entrant and resident prisoners; PLoS ONE 14(12): e0226160; 2019; https://doi.org/10.1371/journal.pone.0226160.
SINGANO V., et al., Tuberculosis treatment outcomes among prisoners and general population in Zomba, Malawi; (2020); https://doi.org/10.1186/s12889-020-08841-z.
TELISINGHE L. et al. HIV and tuberculosis in prisons in sub-Saharan Africa; Lancet. 2016; https://dx.doi.org/10.1016/S0140-6736.
UNAIDS; Global and Regional Data; Programme on Hiv/Aids; 2021; 20 Avenue Appia; 1211 Geneva 27; Switzerland.
URREGO J. et al. The impact of ventilation and early diagnosis on tuberculosis transmission in brazilian prisons; 2015; Am. J. Trop. Med. Hyg., 93(4); https://dx.doi.org/10.4269/ajtmh.15-0166.
WAISBORD, S.; Participatory communication for tuberculosis control in prisons in Bolivia; Ecuador, and Paraguay. Rev. Panam. Salud Publica, v. 27, n. 3, p. 168-173, 2010.
WHO; Global tuberculosis report. Geneva; 2021; ISBN 978-92-4-003702-1 (electronic version) and ISBN 978-92-4-003703-8 (print version).
WHO; Global tuberculosis report. Geneva; 2022; ISBN 978-92-4-006172-9 (electronic version) and ISBN 978-92-4-006173-6 (print version).
WHO; La santé des femmes en milieu carcéral; Éliminer les disparités entre les sexes en matière de santé dans les prisons; Copenhague. Bureau régional de l’Europe; 2009; Avaliable: www.unodc.org/documents/hiv-aids/WHO_EURO_UNODC_2009_Womens_health_in_prison_correcting_gender_inequity-FR.pdf.WHO; Implementing the WHO Stop TB Strategy: a handbook for national tuberculosis control programmers; Geneva; 2008; (WHO/HTM/TB/2008.401).
WORLD BANK GROUP; Incidence of tuberculosis (per 100,000 people) – Mozambique; access in 28/08/2022; in https://data.worldbank.org/indicator/SH.TBS.INCD?locations=MZ.
ZHANG G. et al., High Prevalence of and Risk Factors for Latent Tuberculosis Infection among Prisoners, Vol. 26, No. 3, March 2020; DOI: https://doi.org/10.3201/eid2603.190891.

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Tuberculosis in Persons Deprived of Liberty in Tete, Mozambique.

Status:

Version 1

Abstract

INTRODUCTION

METHODS

Study design

Study location

Study population

Data collection

Variables

Data analysis

Ethical considerations

RESULTS

DISCUSSION

CONCLUSIONS

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1