The present study aimed to highlight the factors associated with TBDR in PDL in the state of Paraná, and it was identified, after conducting logistic regression, that schooling between 8 and 11 years of study (OR: 0.41, 95%CI: 0.16 - 0.93), having a negative sputum culture (OR: 0.29, 95%CI: 0.09–0.74) and not smoking (OR: 0.02, 95%CI: 0.01–0.74) are factors associated with a lower chance of developing TBDR, whereas pulmonary clinical form (OR: 9.87, 95%CI: 1.55 – 23.81) and positive bacilloscopy in the fourth month of follow-up (OR: 6.46, 95%CI: 1.04 – 53.79) were considered as factors associated with a higher chance of development of TBDR.
When the educational level has been evaluated, it was evidenced that the higher the level of education, the lower the chance for the development of TBDR. Since, the educational level directly implies self-care with health, and low education can make the individual more prone to risky behaviors and reduce their perception and self-care in relation to their clinical status, in addition to being associated with possible treatment failure, thus allowing the possibility of drug resistance, abandonment and death from TB17.
The educational level directly implies self-care with health, since low education can make the individual more prone to risky behaviors and thus reduce their perception of their clinical status, in addition to being associated with possible treatment failures, increasing possibility of drug resistance17.
In this perspective, a low level of education (less than eight years of schooling) has been associated with a higher risk of dropping out during TBDR treatment, and in turn this is associated with a set of precarious socioeconomic conditions18.
The population of the Brazilian prison system is considered, for the most part, young and with low access to education, since just over 10% of the PDL attend educational activities, whether for schooling, professional training, income generation, culture or sport19.
The literature highlights how factors that increase the risk of contracting TB are the unhealthy habits and lifestyle of this population, such as using illegal drugs, alcohol, tobacco, malnutrition and even other pathologies, which corroborates the findings of this study, since not using tobacco was characterized as a lower chance of developing TBDR20.
From this perspective, according to epidemiological data, the relationship between using illicit drugs and having TB is increasing, evidencing a public health problem. A research carried out in a university hospital in São Paulo showed that patients who drink alcohol, smokers and those who use illicit drugs fail to undergo TB treatment more often than those who did not have any of these risk factors21, increasing the likelihood of progressing to drug resistance for TB. The clinical pulmonary form was the most prevalent, which may hypothesize that it is the form that mostly causes drug resistance. However, if considered that in the cases included in this study, it was observed that 98.98% among the reported cases had this clinical form, it is expected that most cases of drug resistance present this form of TB.
As for the sputum culture, when a person is positive, it allows to state that this person supports the TB transmission chain, that is, he can infect about 10 to 15 people during a period of one year, which increases the concern when we are talking about those deprived of liberty living in overcrowded places, besides this person can directly transmit the resistant form of TB3.
It is known that sputum smear microscopy is a simple, safe method, used all over the world and has a low cost22. Given the above, it is expected that those who have a negative sputum culture have less chance of developing TBDR, whereas having a positive bacilloscopy in the 4th month of treatment represents a threat, as it indicates that the drugs used did not have the expected effect and thus, did not interrupt the chain of transmission and increases the chance of developing TBDR.
Furthermore, with regard to the PDL, it is worth noting that the Brazilian prison system was regulated in 1984 and since then it has brought debates about fundamental rights. In this perspective, the increase in the number of people deprived of liberty is a reality in Brazil, since in December 2017, the country had the third largest prison population in the world, with a predominance of black people with low education, with 88% not having completed high school19.
It is noteworthy that the structural conditions in prisons are crucial for the health-disease process of PDL. The environment is hostile and unhealthy, which enables the occurrence and spread of different diseases, including TB, as well as enhancing the possibility of the development of TBDR23.
This reality is also present in other countries, since TB in PDL is a global problem, especially in developing countries. Unhealthy conditions, inadequate treatment for TB, poor ventilation, overcrowding, lack of sun with consequent vitamin D deficiency, among other aspects, negatively contribute to the spread and permanence of the disease in this population10, 24.
The inadequate treatment of TB, carried out inside the prisons, exposes the other people who live with the PDL, be they the workers as well as the visitors themselves, increasing the transmission chain. Thus, in addition to enhancing the transmission of the disease, it increases the possibility of transmitting TB already in its resistant form, which ends up hindering the treatment and consequently the control of the disease, making it impossible to reach the third objective for sustainable development in its sub-item 3.3 of the 2030 agenda proposed by the United Nations, which is to end epidemics, including TB10, 25.
Since 2000, Brazil has had on average, an annual growth rate of its prison population of 7.14%, Paraná concentrates 6.88% of the country's prison population (Brasil, 2017). The occupancy rate, which is calculated by the ratio between the total numbers of people deprived of liberty and the number of spaces in the prison system. In June 2017 in Brazil, a rate of 171.62% was recorded and the crime of theft and drug trafficking represent the majority of reasons for deprivation of liberty19.
With the growth of this population, the implementation of the National Tuberculosis Program in prisons becomes increasingly important, since the actions proposed by the Ministry of Health are partially applied26.
TB is a disease that has treatment and cure, however, the patient must commit to the treatment until the end, as well as, that the State guarantees the effective treatment through directly observed treatment3,7–8,10,20. Thus, one of the reasons for the high mortality rate from TB would be the lack of patient adherence to treatment, which also increases the incidence and appearance of multidrug-resistant bacilli24, 27.
The delay in the diagnosis of the disease is generally related to the naturalization of the lack of assistance to PDL, the interpretation of the prison as a place of "death" and "suffering" and the deprivation of the right to health for the PDL due to its position before society, which highlights the inequity of access to health care for this population group28–29. Thus, this context points to another major challenge in disease control, which is the need for changes in the conceptions of the right to health within prison units20.
The invisibility of this population by the state, the low concern with re socializing, as they are a neglected population, mostly with low income and education, living in poverty, living in precarious conditions in overcrowded prisons, suffering prejudice and being absent of effective public policies is the reason that this and other diseases prevail within prison systems, being a national public health problem that ends up infringing the Federal Constitution itself23, 30.
Considering that the study showed positive microscopy in the fourth month of treatment as a factor associated with TBDR and the habit of not smoking and the presence of negative culture as protective factors, it is essential to develop public policies aimed at this population. It is suggested to invest in improving health conditions in the prison system, promoting healthy lifestyle/behavior and monitoring symptomatic respiratory diseases. For strategic monitoring in the admission of the deprived of liberty, active case finding for diseases, in addition to TB, should be intensified, treating this disease as a priority, bringing the State's responsibility and the importance of using strategies so that the PDL can be a priority. Building life projects, providing the reduction of social inequality is also important.
It is noteworthy that the study has limitations related to data collected from the SINAN of the State of Paraná, since the data may suffer from underreporting, mainly due to the diagnostic difficulty involved in TBDR, caused, for example,, due to the lack of indication of patients for sensitivity tests, as well as the difficulty in collecting blank information in the database and the impossibility of knowing and evaluating the history of previous treatment for TB.