Scaling up screening, detection and management of tuberculosis in Bangladeshi prisons

Research Overview

TRAction is currently funding a research study in Bangladesh exploring the effectiveness of an active screening strategy in prevention of tuberculosis transmission among prisoners incarcerated across 68 penal institutions in Bangladesh.

Tuberculosis (TB) kills an estimated 75,000 people per year in Bangladesh. The country is ranked 6^th among the 22 high-burden countries for TB in the world, and 10^th among 27 high priority multidrug resistant (MDR) and extensively drug resistant (XDR) TB countries.

Prisons in Bangladesh are notorious in facilitating the spread of tuberculosis. Overcrowded environments, prevalent drug users, and high population turnover are contributing factors that increase prisoner vulnerability to infection. Unsurprisingly, TB rates in prisons are 5 to 10 times higher than national rates. A high turnover of prisoners in every institution due to judicial transfer and release back to the community poses a significant public health threat to the general population as well.

Data on the prevalence of TB in prisons in Bangladesh is limited. Although all prisons are officially covered under directly observed treatment short course (DOTS), gaps in coverage exist. Currently, case finding is passive; i.e. patients who actively seek treatment for cough and other respiratory ailments undergo sputum smear microscopy. Drug resistance patterns of these cases remain unknown.

Since 2005, icddr,b in collaboration with the National Tuberculosis Program have been conducting an active screening program inside the prison cells to determine the prevalence of pulmonary TB, its drug resistance, and to prevent transmission in the Dhaka Central Jail (DCJ), the largest prison in Bangladesh. Based on the recommendations from this study, an active screening program of all inmates has been established at the entry point of the DCJ in 2009.  Consequently, a significant number of cases have been detected, isolated and brought under treatment. Active screening was judged to be an effective strategy in controlling TB inside the prison. Accordingly, the next step was to investigate the effectiveness of scaling up this intervention in the other prisons of Bangladesh and testing its effectiveness in prevention of TB infection. 

Study Location

Bangladesh: Dhaka

Research Objectives

Primary Objectives:

1. To determine the prevalence of pulmonary TB in two divisional and one district level jails.
2. To establish an active screening system at the entry point of prisons and inside the prison cells in order to prevent transmission of TB by early case detection.
3. To ensure proper management, follow up and referral of the TB cases detected.
4. To introduce a lung health awareness campaign in the prison health system.

Secondary Objectives:

1. To see the feasibility of active screening strategy in different prison settings in terms of prison population and prison structure.
2. To investigate the use X-ray and Gene X-pert in detecting smear negative pulmonary TB cases in Dhaka Central Jail.
3. To estimate the additional costs of introducing the proposed screening system and related activities at the selected study settings.

Study Approach

A symptomatic verbal screening system was established both at the entry point and inside the prison cells in four different prisons of Bangladesh to identify presumptive pulmonary TB cases.  One large, two medium, and one small prison--Dhaka Central Jail (DCJ), Chittagong Central Jail (CCJ), Rajshahi Central Jail (RCJ), and Gazipur District Jail (GDJ)--were selected based on their capacity. Sputum samples were sent for microscopy in nearby DOTS Centre and also for culture at icddr,b laboratory. Additionally, a subset of microscopy-negative suspects from DCJ was tested with GeneXpert. All identified cases were closely followed to ensure treatment registration, proper referral upon release or during judicial transfer, and treatment completion. An awareness campaign was organized involving the convicted prisoners. Small group lectures were given utilizing the IEC materials of NTP. Cost of these additional activities was calculated using the ingredient costing approach.

Key Findings

In all four prisons, 124,697 prisoners were screened; 4,101 presumptive cases were identified; sputum was collected from 3,715 (90.6%) of them and tested. In total, 274 (7.4%) TB patients were identified. In DCJ, 24 (4.0%) of the 594 tested smear-negative patients were identified by GeneXpert MTB/RIF assay. Of the 274 patients identified, 84.3% were registered for treatment, 4% refused treatment, another 0.7% died before treatment registration, and 10.9% were lost to follow-up. Of the 231 registered patients, 75.8% had already completed treatment, another 0.9% were still on treatment, 1.3% died while on treatment, 4.8% refused to continue their treatment after being released from prison, 13% were lost to follow-up, and the rest 4.3% of the patients could not be followed up as study period was over. In the baseline survey, it was found that 91% knew about cough as a symptom of TB, 90% knew about sputum test for detection of TB, and 95% knew that TB treatment is available free of charge. After the awareness campaign, knowledge regarding causative agent of TB increased from 11% to 45%, knowledge regarding the source of free treatment for TB increased from 37% to 74%, knowledge regarding treatment duration for TB increased from 47% to 72%.

Lessons Learned

Several recommendations were developed as a result of this study. These include:

• Screening at entry and periodic follow-up of prisoners inside prison cells in all jails are necessary. 
• Culture and/or GXP of smear-negative suspected cases should be done.
• Proper referral to DOTS Centre after release/transfer should be ensured.
• Periodic campaign on lung health awareness among prisoners and prison staff should be launched. 
• Access of the prisoners to mass media (TV/radio/newspaper) should be improved.

Research into Action 

The commission of this study was directly supported and lobbied by the highest level stakeholders, including officials from the Ministry of Health of Bangladesh, other relevant policymakers and non-government collaborators of the National TB Program. The findings of this study will be of strategic importance in informing long-term policy regarding the management of TB in prisons of Bangladesh.

Implemented by

International Centre for Diarrheal Disease Research (icddr,b)

Principle Investigator: Dr. Sayera Banu

Project Status