Peer education in prisons to improve tuberculosis case finding

Tuberculosis is the leading cause of death from a single infectious agent, and a third of the world population has it. In 2017, there were an estimated 10 million newly occurring tuberculosis cases; however, a third of these were unreached by health systems, missed, not diagnosed, or diagnosed and not notified in different settings.1WHOGlobal tuberculosis report 2018. World Health Organization, Geneva2018Google Scholar The Global Plan to End TB aims to detect 90% of estimated tuberculosis cases worldwide, including 90% of key populations at risk of acquiring tuberculosis because of their increased exposure and reduced access to quality tuberculosis services. Prisoners are key population groups with a high risk of acquiring and developing tuberculosis, and yet they are often missed or are not reached or served by health services.2Uplekar M Raviglione M WHO's End TB Strategy: from stopping to ending the global TB epidemic.Indian J Tuberc. 2015; 62: 196-199Crossref PubMed Scopus (27) Google Scholar Evidence has shown that in prison settings, the risk of developing tuberculosis is 6–30 times higher than in the general population but highest in sub-Saharan Africa, especially in overcrowded prisons.3Kawatsu L Uchimura K Izumi K Ohkado A A systematic review on the prevalence and incidence of latent tuberculosis infection among prison population.Kekkaku. 2016; 91 (in Japanese).: 457-464PubMed Google Scholar, 4Vinkeles Melchers NV van Elsland SL Lange JM Borgdorff MW van den Hombergh J State of affairs of tuberculosis in prison facilities: a systematic review of screening practices and recommendations for best TB control.PLoS One. 2013; 8: e53644Crossref PubMed Scopus (60) Google Scholar, 5Noeske J Kuaban C Amougou G Piubello A Pouillot R Pulmonary tuberculosis in the Central Prison of Douala, Cameroon.East Afr Med J. 2006; 83: 25-30Crossref PubMed Scopus (44) Google Scholar Inmates are more vulnerable to developing active tuberculosis after infection because of poor living conditions, poor nutrition, and stressful surroundings. The higher prevalence of HIV in such settings also contributes to the increased risk. However, access to health services has remained compromised by inadequate infrastructure and lack of awareness about tuberculosis in prisons, in the face of increasing prison populations affected by health inequalities in accessing diagnosis and treatment and multiple epidemics.6Trotter Ii, RT Camplain R Eaves ER Health disparities and converging epidemics in jail populations: protocol for a mixed-methods study.JMIR Res Protoc. 2018; 7: e10337Crossref PubMed Scopus (13) Google Scholar Thus, the quest for context-specific, sustainable, and cost-effective approaches that contribute to early tuberculosis case finding and ensure adherence to treatment continues. In The Lancet Global Health, Kelemework Adane and colleagues add to the pool of evidence for alternative peer education and tuberculosis case finding in prisons of Ethiopia.7Ali S Haileamlak A Wieser A Prevalence of pulmonary tuberculosis among prison inmates in Ethiopia, a cross-sectional study.PLoS One. 2015; 10: e0144040Crossref PubMed Scopus (24) Google Scholar, 8Melese A Demelash H The prevalence of tuberculosis among prisoners in Ethiopia: a systematic review and meta-analysis of published studies.Arch Public Health. 2017; 75: 37Crossref PubMed Scopus (14) Google Scholar In resource-constrained settings, there is little access to tuberculosis prevention and care, health-care facilities are few, and these facilities are understaffed. In such settings, studies that highlight alternatives to increase case finding and access to care are crucial. Adane and colleagues9Adane K Spigt M Winkens B Dinant G-J Tuberculosis case detection by trained inmate peer educators in a resource-limited prison setting in Ethiopia: a cluster-randomised trial.Lancet Glob Health. 2019; (published online Feb 26.)http://dx.doi.org/10.1016/S2214-109X(18)30477-7Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar investigated a public health intervention that gives prison inmates the opportunity to become peer educators, so that they provide health education to all other prison inmates about tuberculosis prevention and control every 2 weeks for 1 year. Such interventions help to create a community of well-informed inmates so that tuberculosis prevention and care could be sustained; very little financial support would be necessary to train the prisoners, with voluntary supervision done by prison health personnel. Peer educators also engaged in active tuberculosis case finding and encouraged prison inmates to adhere to the prescribed tuberculosis treatment, reducing pre-treatment symptom duration and increasing treatment adherence. 16 prisons were randomly assigned either to an intervention group or a control group; the intervention prisons involved trained peer educators in the tuberculosis control programme, and the control prisons followed the existing passive case finding system. During the 1-year study period, 75 new tuberculosis cases (1% of 8874 total inmates) were detected in the intervention prisons and 25 new cases (<1% of 9158 total inmates) were detected in the control prisons. The mean case detection rate was significantly higher in the intervention group than in the control group (mean difference 52·9 percentage points, 95% CI 17·5–88·3, p=0·010). Previous studies in prison settings have mainly been quantitative and assessed the prevalence and systematic screening of tuberculosis by health professionals. However, this study adds to best practice models in resource-constrained settings which was foreseen as a gap in research10Dara M Acosta CD Melchers NV Tuberculosis control in prisons: current situation and research gaps.Int J Infect Dis. 2015; 32: 111-117Summary Full Text Full Text PDF PubMed Scopus (84) Google Scholar and highlights the possibility of examining alternatives beyond generic case-finding activities in confined settings. Although such interventions appear to be feasible and cheaper to implement, a high attrition rate due to exit and transfer of trained peers would require frequent recruitment and training. Ensuring longer incentives for peer educators and the associated cost remains to be assessed. Additionally, aligning tuberculosis prevention and care in prisons with the End TB strategy is still required to effectively provide services to the prison community. In conclusion, engaging the prison community in tuberculosis prevention and control could be a very cost-effective alternative that reaches the inmates, improves knowledge, and ensures adherence to care. However, this requires acceptance from policy makers and prison administration, with commitment of human and financial resources. I declare no competing interests. Tuberculosis case detection by trained inmate peer educators in a resource-limited prison setting in Ethiopia: a cluster-randomised trialInvolving trained inmate peer educators in the tuberculosis control programme in Ethiopian prisons significantly improved the tuberculosis case detection rate. The findings have important implications for clinical and public health policy, particularly in prisons of low-income countries where tuberculosis burden is high and the recommended tuberculosis diagnostic and treatment algorithms have generally not been implemented. Full-Text PDF Open Access