Alexandra Roma Sánchez

Tuberculosis in Rio de Janeiro prisons, Brazil: an urgent public health problem

The tuberculosis incidence rate in prisons in Rio de Janeiro State, Brazil, was 30 times higher in 2004 than in the general population and is probably underestimated, particularly given the difficult access to care in the prison setting. To obtain a better estimate, a survey used systematic X-ray screening and showed a prevalence rate of 4.6% in one such detention facility, A (n = 1,052). Two additional surveys, in facilities B (n = 590) and C (n = 1,372), showed even higher prevalence rates (6.3% and 8.6% respectively). A comparison of socio-demographic characteristics between A, B, and C showed a heterogeneous prison population. As compared to facility A, inmates in B and C come from poorer urban communities and have more frequent histories of incarceration and tuberculosis. These differences, consistent with the prevalence data, imply the necessary adaptation of tuberculosis control programs to each detention facilitys epidemiological and socio-demographic profile.Em 2004, a taxa de incidencia da tuberculose nas prisoes do Estado do Rio de Janeiro, Brasil, foi trinta vezes superior a da populacao geral do Estado. Essa taxa provavelmente e subestimada, especialmente pela dificuldade de acesso ao servico de saude nesse ambiente. Com o objetivo de melhor avaliar a situacao, um primeiro inquerito radiologico sistematico foi realizado e mostrou taxa de prevalencia de 4,6% (prisao A, n = 1.052). Dois inqueritos adicionais revelaram, nas unidades B (n = 590) e C (n = 1.372), taxas maiores (6,3% e 8,6%, respectivamente). A comparacao das caracteristicas socio-demograficas das prisoes A, B e C mostrou que a populacao encarcerada nao e homogenea. Em comparacao com prisao A, os individuos encarcerados nas prisoes B e C sao oriundos de comunidades mais desfavorecidas e tem mais frequentemente historia de encarceramento anterior e de tuberculose. Essas diferencas, coerentes com os dados de prevalencia, implicam a adaptacao das medidas de controle da tuberculose ao perfil epidemiologico e socio-demografico de cada unidade prisional.

Modeling the Impact of Tuberculosis Control Strategies in Highly Endemic Overcrowded Prisons

Background Tuberculosis (TB) in prisons is a major health problem in countries of high and intermediate TB endemicity such as Brazil. For operational reasons, TB control strategies in prisons cannot be compared through population based intervention studies. Methodology/Principal Findings A mathematical model is proposed to simulate the TB dynamics in prison and evaluate the potential impact on active TB prevalence of several intervention strategies. The TB dynamics with the ongoing program was simulated over a 10 year period in a Rio de Janeiro prison (TB prevalence 4.6 %). Then, a simulation of the DOTS strategy reaching the objective of 70 % of bacteriologically-positive cases detected and 85 % of detected cases cured was performed; this strategy reduced only to 2.8% the average predicted TB prevalence after 5 years. Adding TB detection at entry point to DOTS strategy had no major effect on the predicted active TB prevalence. But, adding further a yearly X-ray mass screening of inmates reduced the predicted active TB prevalence below 1%. Furthermore, according to this model, after applying this strategy during 2 years (three annual screenings), the TB burden would be reduced and the active TB prevalence could be kept at a low level by associating X-ray screening at entry point and DOTS. Conclusions/Significance We have shown that X-ray mass screenings should be considered to control TB in highly endemic prison. Prisons with different levels of TB prevalence could be examined thanks to this model which provides a rational tool for public health deciders.

Tuberculosis behind bars in developing countries: a hidden shame to public health

In developing countries, prisons do not have adequate healthcare systems. The problem is particularly acute for tuberculosis (TB) and is exacerbated by crowding and HIV infection. Improved passive TB detection is a priority for control, but in highly endemic prisons mass screening may be needed to obtain a more rapid decrease in incidence. The provision of health care in prisons is made more difficult by social conditions within prisons and the political climate in which they operate. International guidelines seem to be largely ignored.

Tuberculosis control in Brazilian prisons: new approaches to an old problem.

Cad. Saúde Pública, Rio de Janeiro, 26(5):850-851, mai, 2010 Numerous factors explain why tuberculosis (TB) is an urgent problem among persons deprived of liberty (PDL) in Brazil: severe overcrowding, increasing prision occupation rates (150% of planned capacity, and up to 300% in some prisons), poorly ventilated cells with no sunlight, high HIV prevalence... In some States of the country, the TB incidence rate among PDL is 35 times that of the general population! To fight this curse and to insure PDL their right to health, the number of health professionals working in the prison system is insufficient. They are underpaid, subject to precarious work contracts and have high turnover. TB and HIV/AIDS control programs, when they exist, are frequently vertical and prescriptive, to the detriment of a more comprehensive health approach. Further, these programs are poorly integrated to the extra mural health network which, in some places, set quotas for the prison system, thus limiting the access to AFB microscopy. Integration between health and justice at the various levels of government and their relationships with civil society organizations are still insufficient. Social control of prison health services is deficient. Nevertheless, some positive developments have appeared under the aegis of the Ministry of Health (MoH) – National TB Control Program, National AIDS Program, Technical Division for Health in the Prison System –, the Ministry of Justice (MoJ), and the Global Fund (GF). Structured TB control activities are being developed in prisons, including reinforcement for passive detection, implementation of active detection (especially among incoming PDL), better treatment supervision, and awareness-raising for PDL, their families and for prison staff. In various states, TB diagnostic capacity has been reinforced by creating intramural laboratories under the technical control of reference laboratories in order to respond to the high demand for AFB microscopy. The sustainability of these laboratories is being assured by State or municipal TB programs which, in some instances, provide technicians on a part time basis. For the first time, the MoH’s technical manual has dedicated a specific chapter to TB control in prisons. A course on health in the prison system is being prepared for health administrators and professionals to better adjust their practices to the specificities of the prison setting. Research projects are currently developed in order to provide scientific and technical basis for decision makers. Such initiatives include a program initiated by the GF in partnership with the Prison System Department of the MoJ and the National TB Program, seeking to establish guidelines for prison construction and renovation that take health needs into account. Finally, prison overcrowding is now considered as a problem that demands urgent solutions. As for TB and HIV/AIDS, recent regional meetings led by the MoH, MoJ, GF and UNODC should allow better organization for controlling these endemics in Brazilian prisons and including them in the public policy agenda. These activities are linked to the current revision of the National Health Plan for the Prison System. However, the minimum needs of PDL are still far from being met. Major human and financial investments are needed to insure access to health for Brazil’s 473,000 PDL, not as a privilege or charity, but as a Constitutional right. Tuberculosis control in Brazilian prisons: new approaches to an old problem EDITORIAL

Resistência a isoniazida e rifampicina e história de tratamento anterior para tuberculose

A case-control study in Rio de Janeiro in 1994 included 552 patients with a positive culture for Mycobacterium tuberculosis and reported a 1.8% resistance rate to rifampicin and isoniazid. Prior treatment for tuberculosis (the exposure factor) was associated with resistance. The binomial proportion was used to test the hypothesis of no dependence between the observed associations based on prior exposure to the drugs. This test showed a greater than expected dependence between resistances to rifampicin and isoniazid.

HIV behind Bars: Human Immunodeficiency Virus Cluster Analysis and Drug Resistance in a Reference Correctional Unit from Southern Brazil

People deprived of liberty in prisons are at higher risk of infection by the human immunodeficiency virus (HIV) due to their increased exposure through intravenous drug use, unprotected sexual activity, tattooing in prison and blood exposure in fights and rebellions. Yet, the contribution of intramural HIV transmission to the epidemic is scarcely known, especially in low- and middle-income settings. In this study, we surveyed 1,667 inmates incarcerated at Presídio Central de Porto Alegre, located in southern Brazil, for HIV infection and molecular characterization. The HIV seroprevalence was 6.6% (110/1,667). Further analyses were carried out on 40 HIV-seropositive inmates to assess HIV transmission clusters and drug resistance within the facility with the use of molecular and phylogenetic techniques. The molecular epidemiology of HIV-1 subtypes observed was similar to the one reported for the general population in southern Brazil, with the predominance of HIV-1 subtypes C, B, CRF31_BC and unique BC recombinants. In particular, the high rate (24%) of URF_BC found here may reflect multiple exposures of the population investigated to HIV infection. We failed to find HIV-infected inmates sharing transmission clusters with each other. Importantly, the analysis of HIV-1 pol genomic fragments evidenced high rates of HIV primary and secondary (acquired) drug resistance and an alarming proportion of virologic failure among patients under treatment, unveiling suboptimal access to antiretroviral therapy (ARV), low ARV adherence and dissemination of drug resistant HIV strains in primary infections. Our results call for immediate actions of public authority to implement preventive measures, serological screening and, for HIV-seropositive subjects, clinical and treatment follow-up in order to control HIV infection and limit the spread of drug resistance strains in Brazilian prisons.

A tuberculose nas prisões: uma fatalidade?

There are currently some 350000 individuals incarcerated in Brazil. Although the countrys incarceration rate (191/100000 inhabitants in 2005) is far short of the worlds highest rates (USA 738/100000 Russia 600/100000) it has increased by 44% since 2001 increasing the prisons occupancy rate to 143%. Considering this prison overpopulation and the precarious conditions (confinement in poorly ventilated cells) it is no surprise that tuberculosis (TB) a disease characterized by airborne transmission poses a major problem for inmates the majority of whom come from communities where TB is highly endemic and who are repeatedly exposed to the risk of re-infection as repeat incarcerations are frequent. In prisons of the State of Rio de Janeiro the TB incidence rate in prisons (3532/100000) was 30 times that of the overall State in 2005 and chest X-ray screening studies in 2002 (n = 6500 inmates) showed prevalence rates ranging from 4.6% to 8.2% varying from one prison to another. Some 3% of inmates already have TB upon entering penitentiaries which may be related to the high endemicity in their original communities but also to conditions of confinement in police remand jails. (excerpt)

Nascer na prisão: gestação e parto atrás das grades no Brasil

The high vulnerability of incarcerated women is worsened when they are pregnant and give birth during imprisonment. This article traces the profile of incarcerated women living with their children in female prison units of the capitals and metropolitan regions of Brazil and describes pregnancy and childbirth conditions and healthcare practices while in incarceration. This study is an analysis of a series of cases resultant from a national census conducted between August 2012 and January 2014. This analysis included 241 mothers. Of these, 45% were younger than 25 years old, 57% were dark skinned, 53% had studied less than eight years and 83% were multiparous. At the time of incarceration, 89% were already pregnant and two thirds did not want the current pregnancy. Access to prenatal care was inadequate for 36% of the women. During their hospital stay, 15% referred to having suffered some type of violence (verbal, psychological, or physical). Only 15% of the mothers rated the care received during their hospital stay as excellent. They had low social/familial support and more than one third reported the use of handcuffs during their hospital stay. Incarcerated mothers received poorer healthcare during pregnancy and birth when compared with non-incarcerated users of the public sector. This study also found violations of human rights, especially during birth.

Tuberculose nos presídios brasileiros: entre a responsabilização estatal e a dupla penalização dos detentos

, inclusive para aqueles que ainda aguardam julgamento (40% do total), frequentemente encarcerados nas mesmas con-dicoes que os condenados. A incidencia de TB ativa nas prisoes e cerca de vinte vezes superior a da populacao geral (Ministerio da Saude. Sis-tema de Informacao de Agravos de Notificacao. http://dtr2004.saude.gov.br/sinanweb/tabnet/dh?sinannet/tuberculose/bases/tubercbrnet.def, acessado em 27/Fev/2015) e rastreamentos de massa realizados em prisoes das regioes Sul e Sudeste, onde as caracteristicas de encarcera-mento sao semelhantes as da maioria das prisoes do pais, mostraram que 5 a 10% dos detentos apresentam uma TB ativa, including those still awaiting trial (40% of the total), who are often kept in the same conditions as those already convicted. The incidence of active TB in the prison population is about twenty times higher than in the overall population (Brazilian Ministry of Health. Siste-ma de Informacao de Agravos de Notificacao. http://dtr2004.saude.gov.br/sinanweb/tabnet/dh?sinannet/tuberculose/bases/tubercbrnet.def, accessed on 27/Feb/2015), and mass screen -ing carried out in prisons of Southern and South -eastern regions of Brazil, where the characteris-tics of incarceration are similar to most prisons in the country, has shown that 5 to 10% of the inmates present an active TB

Realidade e desafios da saúde nas prisões

The promotion of health in prison is based on an inherent paradox: the prison universe as a place of deprivation of liberty is in contradiction with the very principle of health education: the principle of autonomy of the patient.