ABSTRACT
The prevalence of pulmonary tuberculosis among prison in-mates at Aba Federal Prisons, in Abia State, South-Eastern Nigeria, was conducted between September-October, 2013. Out of a total number of 477 prison inmates present in the prison at the time of the study, 449 were screened for history of cough of 2 or more week’s duration. Fifty-two (10.42%) met the inclusion criterion. Eleven (21.15%) of the 52 tested for Acid Fast Bacilli (AFB) by sputum smear microscopy were positive for AFB. A total of 12 inmates of Aba prison were pulmonary tuberculosis cases giving a minimum point prevalence rate of 2, 405 cases per 100,000 inmates. Four of the 11 cells had at least one smear positive case with 7 of the 11 cases concentrated in two cells. The age group 25-34 had the highest number of sputum positive cases. The results of this study show that the prevalence of TB is very high (2,405 cases per 100,000 inmates) in Aba prison. This calls for urgent action to control TB in the prison.
TABLE OF CONTENTS
Dedication i
Acknowledgements ii
Table
of contents iii-iv
List
of Tables iv
Abstract v
CHAPTER ONE
1.0
INTRODUCTION AND LITERATURE REVIEW 1
1.1 BIOLOGY OF Mycobacterium tuberculosis 3
Transmission 4
Pathophysiology 5
Strain variation 6
Hyper-virulent strains 7
1.2
TUBERCULOSIS 7
1.2.1
Mode of transmission of
tuberculosis in prisons 9
1.2.2
Management of tuberculosis 11
1.2.3
Vaccines 11
1.2.4
Public health
importance 12
1.2.5
Antibiotics 12
1.3
CHALLENGES IN
IMPLEMENTING THE PREVENTION, 15
DIAGNOSIS AND TREATMENT OF TB IN
PRISONS
1.3.1
Programme
funding 15
1.3.2
Human resources 15
1.3.3 Infection
control 16
CHAPTER TWO
2.0 MATERIALS
AND METHODS 17
2.1 Study
setting 17
2.2 Selection
of study participant 17
2.3 Sputum
samples collection 18
2.4 Sample
processing 18
2.5 Statistical
analysis 19
CHAPTER THREE
3.0
RESULTS 20
CHAPTER FOUR
4.0 DISCUSSION 27
4.1
CONCLUSION 29
4.2 Recommendation
29
REFERENCES 30-35
LIST OF TABLES
Table Title Page
1. Demographic
characteristics of Prison in-mates in Aba Prison according 22
to age group, sex and A FB status
2. Age distribution of
smear positive cases among the prison inmates by prison 24 cells
3.
Distribution of sputum positive
cases by duration of stay in Prison 25
4.
Past history of incarceration, TB and
treatment of 8 Prison in-mates in Aba
26
Prison
CHAPTER ONE
1.0
INTRODUCTION AND
LITERATURE REVIEW
Tuberculosis (TB) is an infectious
disease caused by mainly Mycobacterium tuberculosis in humans.
Other mycobacteria such as Mycobacterium bovis, Mycobacterium africanum,
and Mycobacterium microti are significant cause of TB in some parts
of Africa (Van Gooken et al.,
1999). Tuberculosis is the most frequently
occurring infectious disease in the world and also stands out as a major cause
of morbidity, disability and death globally. It accounts for 2-3 million deaths
per annum, globally (Oxman et al., 1993).
In 2006, a total of 1.7 million people died of TB including 231,000 people with
HIV. One-third of the world's current population has been infected with Mycobacterium tuberculosis, and new infections occur at a rate of one per second.
Approximately 95% of new cases and 98% of deaths occur in developing nations (Oxman et al., 1993).
This is probably due to limited resources availability and Higher Human
Immunodeficiency Virus (HIV) infections. Patients with active
pulmonary TB would broadcast the tubercle bacilli in droplet aerosols when they
cough, sneeze, or talks and thereby infecting others. A person with untreated
pulmonary TB is estimated, on average, to infect 10-15 persons annually (Mitsos
et al., 2003). A primary infection
due to Mycobacterium tuberculosis may actively develop into clinical TB,
pass as inapparent infection, or remain latent in the individual for months or
years depending on the various host and environmental factors. Overt TB, thus,
could result from a reactivated latent infection or from a recent primary
infection or (secondary) re-infection. It has been observed that the
transmission of M. tuberculosis is favoured by dusty environment and
overcrowding. Infections can be acquired by both close and casual contacts. The
risk of becoming infected depends on such factors as the relative virulence of
the strain, the intensity of exposure to an infectious TB case (closeness and duration),
and the susceptibility and immune status of the exposed individual (Lam et al., 2004). Mitsos et al.,
(2003) observed that only a small proportion of individuals infected with M.
tuberculosis develop clinical TB and a wide clinical spectrum of severity
of disease is observed in such individuals. A lifestyle, such as
tobacco/cigarette smoking, could increase the chances of developing clinical TB
four-fold due to the various effects of smoking on components of both innate
and adaptive immunity (Lam et al.,
2004). Exposure to indoor air pollution has been associated with TB among other
broncho-pulmonary diseases (Arcavia and Benowitz., 2004). Epidemiologic studies
have shown that risk of TB increases with close contacts of
sputum-smear-positive patients and that the prevalence of clinical disease
among intimate contacts of TB cases is high (Arcavia and Benowitz., 2004). HIV
infection has become an additional factor that has specifically threatened TB
programmes worldwide, and for the last two decades, the HIV Transmission of Mycobacterium
tuberculosis in Nigerian prisons (Chigbu and Iroegbu, 2010). TB has become
the most common cause of death among HIV-infected adults in less-developed
countries. In sub-Saharan Africa where 70% of HIV-infected patients live, the
annual rate of TB cases has increased since the mid-1980s, and over 2/3 of TB
patients in the region are dually infected with HIV (Gerdtham et al., 1996). It is estimated that
about 200,000 deaths due to TB occur among Africans concomitantly infected with
HIV (Arcavia and Benowitz., 2004). The Nigerian prisons seem most favourable
for the dissemination of M. tuberculosis and progression to AIDS given
the overcrowding in cells, poor feeding, and allegations of homosexual
practices and sexual abuse among the incarcerated (Arcavia and Benowitz, 2004).
Tobacco and cigarette smoking has
been observed to promote TB infection. Smoking more than 2 cigarettes a day
increases the chances of developing clinical TB double folds (Lehmann et al., 1991).
The rate of development of active TB
is noted to be similar in tuberculin positive and tuberculin negative HIV
patients. Montoya and colleagues documented 39 (75% 0f 80 HIV infected patients
having Mycobacterium infection (Oxman
et al., 1993).
Other mycobacterium species such as Mycobacterium africanum and Mycobacterium
bovis can also cause TB infection in
humans. Diagnosis is usually by observing the acid fast bacilli (AFB) in sputum
sample, or by culture, chest x-rays or by tuberculin skin test (Hirschtick et al., 1995).
In response to these problems, the
world health organization (WHO) and Red Cross joined forces to provided
guidelines for the control of TB in prisons and similar institutions world
over. One such guideline included screening of prisoners on entry into prisons
(Van Gooken et al., 1999).
AIMS AND OBJECTIVES
To determine the Prevalence of Tuberculosis in Aba Federal Prison.
LITERATURE REVIEW
1.1 BIOLOGY OF Mycobacterium tuberculosis
Mycobacterium
tuberculosis (MTB) is a pathogenic bacterial
species in the family Mycobacteriaceae
and the causative agent of most cases of tuberculosis
(TB) Cole and Barrell, 1998). First
discovered in 1882 by Robert Koch, M.
tuberculosis has an unusual, waxy coating on its cell surface (primarily mycolic
acid), which makes the cells impervious to Gram staining. Acid-fast
detection techniques are used instead. The physiology of M. tuberculosis
is highly aerobic
and requires high levels of oxygen. Primarily a pathogen of the mammalian respiratory
system, MTB infects the lungs. The most frequently
used diagnostic methods for TB are the tuberculin skin test, acid-fast stain,
and chest radiographs (Cole and Barrell, 1998).
Transmission
When
people with active pulmonary TB cough, sneeze, speak, sing, or spit, they expel
infectious aerosol
droplets 0.5 to 5.0 µm in
diameter. A single sneeze can release up to 40,000 droplets. Each one of these
droplets may transmit the disease, since the infectious dose of tuberculosis is
very low (the inhalation of fewer than 10 bacteria may cause an infection)
(Nicas et al., 2005).
People
with prolonged, frequent, or close contact with people with TB are at
particularly high risk of becoming infected, with an estimated 22% infection
rate. A person with active but untreated tuberculosis may infect 10–15 (or
more) other people per year. Transmission usually occur from people with active
TB - those with latent infection are not thought to be contagious (Ahmed et al., 2011). The probability of
transmission from one person to another depends upon several factors, including
the number of infectious droplets expelled by the carrier, the effectiveness of
ventilation, the duration of exposure, the virulence of
the M. tuberculosis strain,
the level of immunity in the uninfected person, and others. The cascade of
person-to-person spread can be circumvented by effectively segregating those
with active ("overt") TB and putting them on anti-TB drug regimens.
After about two weeks of effective treatment, subjects with nonresistant
active infections generally do not remain contagious to others. If someone does
become infected, it typically takes three to four weeks before the newly
infected person becomes infectious enough to transmit the disease to others
(Nicas et al., 2005).
Pathophysiology
M. tuberculosis requires
oxygen to grow. It does not retain any
bacteriological stain due to high lipid content in its wall, hence Ziehl-Neelsen staining,
or acid-fast staining, is used. Mycobacteria do not seem to fit the
Gram-positive category from an empirical standpoint (i.e., they do not retain
the crystal violet
stain), they are classified as acid-fast
Gram-positive bacteria due to their lack of an outer cell membrane
(Camus et al., 2002).
M. tuberculosis
divides every 15–20 hours, which is extremely slow compared to other bacteria,
which tend to have division times measured in minutes (Escherichia coli
can divide roughly every 20 minutes). It is a small bacillus
that can withstand weak disinfectants
and can survive in a dry state for weeks. Its unusual cell wall, rich in lipids
(e.g., mycolic acid),
is likely responsible for this resistance and is a key virulence factor (Bell,
2005). When in the lungs, M.
tuberculosis is taken up by alveolar macrophages,
but they are unable to digest the bacterium. Its cell wall prevents the fusion
of the phagosome
with a lysosome.
Specifically, M. tuberculosis blocks the bridging molecule, early
endosomal autoantigen 1 (EEA1); however, this blockade does not prevent fusion
of vesicles filled with nutrients. Consequently, the bacteria multiply
unchecked within the macrophage. The bacteria also carries the UreC
gene, which prevents acidification of the phagosome (JoAnne and John, 2003).
The bacteria also evade macrophage-killing by neutralizing reactive nitrogen
intermediates. The ability to construct M.
tuberculosis mutants and test individual gene products for specific
functions has significantly advanced our understanding of the pathogenesis
and virulence factors of
M. tuberculosis. Many secreted and exported proteins are known to be
important in pathogenesis (Bell, 2005).
Strain variation
M.
tuberculosis comes from the genus Mycobacterium,
which is composed of approximately 100 recognized and proposed species. The
most familiar of the species are M. tuberculosis and M. leprae (causative
agent of leprosy) (Wooldridge, 2009).
M. tuberculosis is
genetically diverse, which results in significant phenotypic differences
between clinical isolates. Different strains of M. tuberculosis are
associated with different geographic regions. However, phenotypic studies
suggest that strain variation never has implications for the development of new
diagnostics and vaccines. Microevolutionary variation does affect the relative
fitness and transmission dynamics of antibiotic-resistant strains (JoAnne and
John, 2003).
Typing
of strains is useful in the investigation of tuberculosis outbreaks, because it
gives the investigator evidence for-or-against transmission from person to
person. Consider the situation where person A has tuberculosis and believes
that he acquired it from person B. If the bacteria isolated from each person
belong to different types, then transmission from B to A is definitively
disproved; on the other hand, if the bacteria are the same strain, then this
supports (but does not definitively prove) the theory that B infected A (Cole and Barrell, 1998).
There
are three generations of VNTR typing for M. tuberculosis. The first
scheme, called ETR (exact tandem repeat), used only five loci, (Gagneux, 2009)
but the resolution afforded by these five loci was not as good as PFGE. The
second scheme, called MIRU (mycobacterial interspersed repetitive unit) had
discrimination as good as PFGE. The third generation (MIRU2) added a further
nine loci to bring the total to 24. This provides a degree of resolution
greater than PFGE and is currently the standard for typing M. tuberculosis (Gagneux, 2009).
Hyper-virulent strains
Mycobacterium
outbreaks are often caused by hyper-virulent strains of M. tuberculosis.
In laboratory experiments, these clinical isolates elicit unusual
immunopathology, and may be either hyper-inflammatory or hypo-inflammatory.
Studies have shown the majority of hyper-virulent mutants have deletions in
their cell wall-modifying enzymes or regulators that respond to environmental
stimuli. Studies of these mutants have indicated the mechanisms that enable M.
tuberculosis to mask its full pathogenic potential, inducing a granuloma
that provides a protective niche, and enable the bacilli to sustain a
long-term, persistent infection (Zhang et
al., 1992).
1.2
TUBERCULOSIS
Tuberculosis, MTB,
or TB (short for tubercle bacilli ) is a common, and
in many cases lethal, infectious disease caused by various strains of mycobacteria, usually Mycobacterium
tuberculosis (Kumar et al., 2007).
Tuberculosis typically attacks the lungs, but can also affect other parts of the body. It is spread
through the air when people who have an active TB infection cough, sneeze, or
otherwise transmit respiratory fluids through the air (Konstantinos, 2010). Most infections are asymptomatic and
latent, but about one in ten latent infections eventually progresses to active
disease which, if left untreated, kills more than 50% of those so infected (Konstantinos, 2010).
The classic symptoms of active TB infection are
a chronic cough with blood-tinged sputum, fever, night sweats, and weight loss (the
latter giving rise to the formerly prevalent term "consumption").
Infection of other organs causes a wide range of symptoms. Diagnosis of active TB
relies on radiology (commonly chest X-rays), as well
as microscopic examination and microbiological
culture of body fluids. Diagnosis of
latent TB relies on the tuberculin skin test
(TST) and/or blood tests. Treatment is difficult and requires administration of multiple
antibiotics over a long period of time. Social contacts are also screened and
treated if necessary. Antibiotic resistance is a growing problem in multiple
drug-resistant tuberculosis (MDR-TB)
infections. Prevention relies on screening programs and vaccination with the bacillus
Calmette–Guérin vaccine (WHO, 2009).
One third of the world's population is thought
to have been infected with M. tuberculosis, with new infections
occurring in about 1% of the population each year. In 2007, there were an
estimated 13.7 million chronic active cases globally, while in 2010, there were
an estimated 8.8 million new cases and 1.5 million associated deaths,
mostly occurring in developing countries
(WHO, 2012). The absolute number of tuberculosis cases has been decreasing
since 2006, and new cases have decreased since 2002. The distribution of
tuberculosis is not uniform across the globe; about 80% of the population in
many Asian and African countries test positive in tuberculin tests, while only
5–10% of the United States population tests positive. More people in the
developing world contract tuberculosis because of compromised immunity, largely
due to high rates of HIV
infection and the corresponding development of AIDS (WHO, 2012).
1.2.1 MODE OF TRANSMISSION
OF TUBERCULOSIS IN PRISONS
Prisons are often
high-risk environments for TB transmission because of severe overcrowding, poor
nutrition, poor ventilation, and limited access to often insufficient health
care. Moreover, prisoners do not represent a mere cross-section of society in
general. Prisoners are overwhelmingly male, are typically aged 15–45 years, and
come predominantly from poorly educated and socioeconomically deprived sectors
of the population where TB infection and transmission are higher (Feldman, 2005). Offenders often belong to minority or migrant groups and live on
the margins of society. Prisoners are also more likely to suffer from other
debilitating diseases and have additional health problems such as drug
addiction, alcoholism and liver disease. Prison health services are often
minimal or nonexistent owing to a lack of funding. Prisoners are often admitted
to cells without being given a health check and are thereby mixed together in
settings ideal for the spread of disease (Ezzatti and Kammen,
2001). One infectious prisoner with
TB may infect the others very efficiently. The combination of overcrowding,
poor nutrition, poor ventilation and lack of screening for TB has turned prisons into breeding grounds and
incubators for TB. Various types of physical and psychological stress may
trigger the progression of TB infection to active disease. Malnutrition, abuse
of alcohol and other drugs, and infection with HIV promote this progression.
Prevalence of HIV infection is much higher among prisoners than in the general
population (Odhiambo et al., 1999). Ongoing injecting drug use involving the sharing of injecting
materials, as well as unprotected sex among prisoners, makes prisons high-risk
places for the spread of HIV among inmates. An HIV-negative person infected
with M. tuberculosis has a 5–10% lifetime risk of developing active TB,
whereas an HIV-positive person has a lifetime risk of 50% or more. Since
prisoners have a high risk of having or developing TB, it is recommended that
prisoners are screened using methods such as symptomatic questionnaires, sputum
microscopy and chest X-ray on admission and at specified intervals.
Restrictions on access to health care may be compounded by health service staff
who are unmotivated owing to poor salaries, a lack of resources to practice
good medicine, or a lack of basic training about TB (Nunn and Getahum, 2004). Prisoners often do not adhere to prescribed treatments.
They may be taking “self-prescribed” erratic treatment or improper doses of
drugs. Worse still, prisoners sometimes prefer to resort to “self-medication”,
taking drugs brought in by family members or complacent guards. These
inadequately treated prisoners are at high risk of developing MDR-TB, which can
subsequently spread among their fellow inmates. Also, frequent movement of
infectious prisoners between prisons has increased transmission and led to
interruptions in treatment (Corbett et
al., 2003).
TB among prisoners may
spread to the population outside through infection of prison security and
health staff, infection of visiting family members, and prisoners released
while they are still infectious. The treatment of released prisoners needs to
be supervised at an outside facility, preferably under the national TB
programme (NTP), but this often does not happen (Williams and Dye, 2003).
The five facts of TB spread in
prisons are
1.
Prisons receive TB
2.
Prisons
concentrate TB
3.
Prisons
disseminate TB
4.
Prisons make
TB worse
5.
Prisons
export TB
In many countries, prison
TB services are not linked or well-coordinated with the NTP. It is often those
countries with a high TB burden that have the fewest means of ensuring
post-release follow-up. Also, prisoners released often give false names and
addresses, or have no registered home address (Bellete et al., 2002). Often they cannot afford transportation to go and receive
treatment or medical supervision. Released prisoners, therefore, often
“default” rather than “transfer out”. The importance of ensuring that a
prisoner completes the full course of TB treatment should lead to special
consideration being given to prisoners transferred between prisons (CDC, 1993).
TB control in prisons is less complicated when a TB patient starts and
completes treatment in the same prison. If this is not possible, the
authorities should ensure that a prisoner being treated for TB completes at
least the initial phase of treatment before being transferred. When a TB
patient in the second (continuation) phase of treatment is transferred to
another prison, completion of treatment in the other prison should be
guaranteed (CDC, 1993).
1.2.2
MANAGEMENT OF TUBERCULOSIS
1.2.3 Vaccines
The
only currently available vaccine as
of 2011 is bacillus Calmette–Guérin
(BCG) which, while it is effective against disseminated disease in childhood,
confers inconsistent protection against contracting pulmonary TB (Pai et al., 2008) Nevertheless, it is the
most widely used vaccine worldwide, with more than 90% of all children being vaccinated.
However, the immunity it induces decreases after about ten years. As
tuberculosis is uncommon in most of Canada, the United Kingdom, and the United
States, BCG is only administered to people at high risk. Part of the reasoning
arguing against the use of the vaccine is that it makes the tuberculin skin test
falsely positive, and therefore, of no use in screening. A number of new
vaccines are currently in development (Ahmed et al., 2011).
1.2.4
Public health importance
The
World Health Organization declared TB a "global health emergency" in
1993, and in 2006, the Stop TB Partnership developed a Global Plan to Stop
Tuberculosis that aims to save 14 million lives between
its launch and 2015 (Ahmed et al.,
2011). A number of targets they have set are not likely to be achieved by 2015,
mostly due to the increase in HIV-associated tuberculosis and the emergence of
multiple drug-resistant tuberculosis (MDR-TB). A tuberculosis classification
system developed by the American Thoracic Society is
used primarily in public health programs (Pai et al., 2008).
1.2.5
Antibiotics
Treatment
of TB using antibiotics
kills the bacteria. Effective TB treatment is difficult, due to the unusual
structure and chemical composition of the mycobacterial cell wall, which
hinders the entry of drugs and makes many antibiotics ineffective (Odhiambo et al., 1999).
The two antibiotics most commonly used are isoniazid
and rifampicin,
and treatments can be prolonged, taking several months. Latent TB treatment
usually employs a single antibiotic, while active TB disease is best treated
with combinations of several antibiotics to reduce the risk of the bacteria
developing antibiotic resistance (WHO, 2009). People with latent
infections are also treated to prevent them from progressing to active TB
disease later in life. Directly observed therapy,
i.e. having a health care provider watch the person take their medications, is
recommended by the WHO in an effort to reduce the number of people not
appropriately taking antibiotics. The evidence to support this practice over
people simply taking their medications independently is poor. Methods to remind
people of the importance of treatment do, however, appear effective (WHO, 2009).
Table 1: Current tuberculosis treatment and guidelines
Regimen 1: New adults tuberculosis treatment
Two months
initial phase Patient
under 50kg Patient over 50 kg
Combination Tablet-Rifampicin-four 4
Tablets 5 Tablets
Four months continuation phase
Combination
tablets 3 Tablets 2
Tablets
Regimen 2:
Retreatment adult cases
Two months
initial phase
Rifampicin-four
4 Tablets 5
Tablets
Streptomycin 750 mg 1000mg
Third month (5
times a week)
Rifampicin - 120 mg 1 Tablet 2
Tablets
Isomazide -
60 mg 3 Tablets 4
Tablets
Pyrazinamide
- 250 mg 250 mg 500 mg
Ethambutol -
200 mg 200 mg 400 mg
Source: Current tuberculosis
treatment (Ahmed et al.,
2011).
1.3
CHALLENGES IN IMPLEMENTING THE PREVENTION,
DIAGNOSIS AND TREATMENT OF TB IN PRISONS
1.3.1 Programme funding
Many
countries provide only a limited budget for health care and TB control in
prisons, and implementation of even the most cost-effective DOTS strategy is
often seriously lacking in resources. In some settings, TB is seen as a
chronic, incurable disease and therefore not worthy of funding. This is why TB
control in prisons is an essential component of TB control in each Status Paper
on Prisons and Tuberculosis country. With increasing access to MDR-TB treatment
during recent years, greater levels of funding for TB control are justified and
even an ethical obligation. External funding is provided by The Global Fund (TGF),
the World Bank, bilateral donors, nongovernmental organizations and others.
Experience has clearly shown that support to TB programmes should promote and
ensure coordination and integration between the civil and prison sectors (Ezzatti and Kammen,
2001).
1.3.2 Human
resources
In
most prisons, there is a lack of staff qualified to work with TB. Effective
plans for human resource development need to be implemented and should cover
the entire process, including basic education (in-service and pre-service),
retraining, on-the-job-training, supervision, career development, salary
scales, job descriptions and infection control measures. Low salaries and fear
of infection are among the reasons that health staff may not want to work in
prisons. The need to adequately train and motivate medical staff on the
difficulties of treating resistant forms of TB over long periods of time, with
medicines that have side-effects, should be a high priority for TB control
programmes (Odhiambo et al., 1999).
1.3.3 Infection
control
To
reduce the risk of TB transmission to prisoners, prison staff and visitors, it
is important to make sure that infection control measures are in place. From a
TB infection control perspective, early diagnosis and separation of patients
according to their type and category of disease is highly recommended. In
general, there are three main elements in infection control:
1. Administrative
measures (separating infectious cases, and rapid detection of cases with immediate
initiation of treatment to interrupt transmission and prevent emergence of drug resistance);
2. Engineering
measures (for example negative ventilation);
3. Personal protection (respirators for staff and
disposable masks for patients) (Nunn and Getahum, 2004).
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