Enhanced tuberculosis case finding through advocacy and sensitisation meetings in prisons of Central India

Abstract

Tuberculosis (TB) in prisons is a major problem. The prisons in Chhattisgarh, India, are overcrowded, and there are no formal efforts to engage them in TB control. In 2014, the International Union Against Tuberculosis and Lung Disease and the state TB programme advocated with state prison authorities to implement an enhanced case-finding strategy in the prisons. Sensitisation meetings (one/quarter/prison) to improve awareness among prisoners about TB symptoms and services were coupled with improved access to diagnosis. Patients with presumptive TB who were examined by sputum microscopy increased by 39% per 100 000 prisoners, and TB case notification rates increased by 38%, in 2014 relative to 2013.

An estimated three million tuberculosis (TB) cases were missed worldwide in 2013, and this number increased to 4.3 million in 2015.^1,2 To detect missed cases, and to strengthen the existing infrastructure of national TB programmes (NTPs), a number of recommendations are made in the End TB strategy, including an improved notification system, involvement of the private sector through public-private partnership models, and enhanced and active case finding using new rapid point-of-care diagnostic tests among vulnerable and marginalised populations at high risk for TB.^1,3 Enhanced case finding is defined as providing information on the appropriate type of health-seeking behaviour, often combined with improving access to diagnostic services, for people experiencing TB symptoms.⁴

TB in prisons is a major public health problem in many settings,⁵ particularly in India, which has a high incidence of TB of 217 per 100 000 population.² There are several reasons why TB propagates in prisons, including concomitant conditions—particularly human immunodeficiency virus (HIV) infection—injecting drug use, poor nutritional status, smoking, overcrowding and inadequate or inaccessible medical care.⁵ TB incidence in prisons is 23 times higher than in the general population.⁶ This situation is worsened by the emergence and spread of multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB.^2,7

Chhattisgarh, located in central India, is a vulnerable state, affected by the Naxalite conflict. As of August 2016, 28 of the 30 high-security prisons in the state (two prisons were non-functional) housed 19 473 inmates; the capacity is for 9267 inmates. In this paper, we describe the advocacy and sensitisation activities that we undertook in these prisons and the effect on TB case notification.

ASPECT OF INTEREST

Prison intervention is a flagship activity under India's Revised National Tuberculosis Control Programme (RNTCP). Prior to 2014, however, TB control activities in prisons in Chhattisgarh were neither systematically implemented nor reported. As a result, along with overcrowding in the different prisons in the state, the technical consultant of the International Union Against Tuberculosis and Lung Disease (The Union), in collaboration with Chhattisgarh State TB programme officials, informed state-level policy makers and administrators of the State Department of Prisons about the need for regular education of prison inmates on TB. Instructions were issued by state prison authorities to all the prisons, and by the State TB cell to staff at the district and sub-district levels, to coordinate regular sensitisation meetings (at least one session every 3 months per prison) and to provide reports in the sub-district and district level quarterly reports.

Sensitisation meetings were conducted in all 28 functional prisons in Chhattisgarh state in 2014, using various tools such as videos and flipcharts and contests such as question-and-answer games. Inmates who identified their own TB symptoms and sought care during the sensitisation meetings, or after the meetings during routine health check-ups, underwent sputum smear microscopy. In prisons without a designated microscopy centre (DMC) (n = 25), the district health system and prison authorities made arrangements for sputum smear testing either through accompanied patient referral or through sputum collection and transport to the nearest DMC. In districts where The Union's Project Axshya was involved (10/27 districts), community volunteers were involved in sputum collection and transport. Project Axshya is a flagship programme of The Union being implemented in 300 districts across 21 states of India to enhance the visibility and reach of the RNTCP programme.⁸

In 2014, 92 sensitisation meetings were conducted for 16 199 prisoners and 735 prison staff (Table 1). Sputum examination was performed for 1348 patients with presumptive TB, resulting in the diagnosis of 124 patients with TB, of whom 96 had smear-positive pulmonary TB and 28 had smear-negative pulmonary TB. Three patients were diagnosed with MDR-TB. All diagnosed patients were initiated on treatment per national guidelines. These prisons contributed 1% of the state's 154 868 patients with presumptive TB who were examined and 0.5% of the state's 28 832 notified TB cases in 2014.

TABLE 1.

Enhanced case finding conducted across the prisons ^* of Chhattisgarh State, India, 2014 (n = 30) ^†

Compared to 2013, the number of patients with presumptive TB who were examined by sputum microscopy per 100 000 prisoners increased by 39% and the TB case notification rate increased by 38% in 2014 (Table 2). The sources of data were the RNTCP quarterly reports and the prison records.

TABLE 2.

Presumptive TB examination rate and TB case detection rate among prison inmates before and during enhanced case finding in prisons ^* (n = 30) in Chhattisgarh State, India

DISCUSSION

Prison inmates are at high risk for TB and require management. This paper shows that the implementation of an enhanced case-finding strategy with improved access to diagnostic services (via accompanied patient referral or sputum collection and transport) was associated with increased presumptive TB examination and TB case detection rates. We believe that the involvement of relevant stakeholders from the prisons and from TB control at the highest level was critical to success.

To the best of our knowledge, there is no published literature on prison interventions documenting improvement in the detection of TB in India. A situational analysis of TB control activities in a large prison in New Delhi, India, has been published.⁹ While a before-after study with a control arm would have been the ideal design to be able to attribute the increase in case detection to the enhanced case-finding strategy, this was not possible, given the implementation in all the prisons.

Enhanced case finding might also have led to early diagnosis, resulting in reduced transmission of TB within the prisons. Operational research focusing on these issues and integrating prison and national TB control activities will be helpful to enhance TB control in the prisons. Future research should also focus on assessing the perceptions of prison inmates and prison officials on the challenges in implementing these interventions. Given the high rates of TB, including MDR-TB, in prisons,⁷ we recommend systematic active screening of all prisoners¹⁰ every 3 months and linking presumed cases to diagnosis using rapid diagnostics such as Xpert MTB/RIF^® (Cepheid, Sunnyvale, CA, USA).

In conclusion, sustained enhanced case finding with improved access to diagnostic services in prisons has value in improving TB case detection. This should be coupled with systematic screening using rapid diagnostics if we are to reduce TB in line with the World Health Organization End TB strategy.³