Systematic review on the diagnosis, treatment, care and prevention of tuberculosis in prison settings

Systematic review
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European Centre for Disease Prevention and Control. Systematic review on the diagnosis, treatment, care and prevention of tuberculosis in prison settings. Stockholm: ECDC; 2017.

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People in prisons have a higher prevalence of several communicable diseases than the general population, a fact which affects both the prison and the general population. The objective of this report is to systematically review data on the diagnosis, treatment, care and prevention of tuberculosis in prison settings, with a focus on the countries of the European Union and the European Economic Area.

Executive summary

A systematic literature review was performed in PubMed and Embase (1990 and newer) and in the Cochrane Library (publications from 1980 and newer). No language or geographical limits were applied. In addition, the following sources were searched through a predefined website list search and a call for papers: conference abstracts (2010 or newer), unpublished research reports, protocols and guidelines (2005 and newer).

From the peer-reviewed literature, 34 primary articles were included: four articles on TB diagnosis, 18 articles on TB care/treatment, and 12 articles on TB prevention. Furthermore, a total of eight conference abstracts/unpublished research reports and 15 guidelines were included. 

Diagnosis: No studies were found about active TB diagnosis. Four studies (two from EU/EEA countries, two from the USA) reported on the diagnosis of latent tuberculosis infection (LTBI); all studies compared the tuberculin skin test (TST) with the interferon gamma release assay (IGRA). As no gold standard for the diagnosis of LTBI exists, no conclusions could be drawn from these studies. 

Treatment and care: Five studies and six grey literature documents investigated active TB treatment and care. Two studies (one from an EU/EEA country, one from the USA) compared directly observed therapy (DOT) with selfadministered treatment. Both studies concluded that the use of DOT resulted in higher active TB treatment completion rates. One EU/EEA study looking at the effect of the place of treatment concluded that being treated entirely during prison stay increased the chance of active TB treatment completion. When comparing the results of the individual studies, no clear trends were seen regarding treatment duration or adherence intervention. 

Two studies from EU/EEA countries and eleven studies from the USA reported on LTBI treatment in correctional facilities. Within-study comparisons revealed that: 1) the use of DOT increased LTBI treatment completion compared to self-administered treatment (one study from the EU/EEA, one from the USA); 2) interventions such as education, incentives, or active referral after release increased LTBI treatment completion compared to usual care (two studies from the USA); 3) short-course LTBI therapies resulted in higher completion rates compared to longcourse therapies (one study from the EU/EEA, one from the USA). However, in the latter US study this difference was no longer found when only looking at those incarcerated during the entire treatment. Another US study found no difference in completion rates between both LTBI treatment durations; and 4) those treated in jails were less likely to complete LTBI treatment than those in prisons2 (one study from the USA). When comparing the results of individual studies, DOT and adherence interventions showed a generally similar effect. The most frequently reported reasons for non-completion of active TB treatment were death, transfer, and loss to follow-up.

The most frequently reported reasons for non-completion of LTBI treatment were adverse events, being transferred/released, refusal of treatment continuation, or loss to follow-up.

Prevention: Twelve studies and two grey literature documents reported on contact tracing during a TB outbreak in a correctional facility (one from the EU/EEA, the remainder from the US). Different strategies were used and different populations were tested. All studies showed that contact tracing led to the identification of new LTBI and/or active TB cases, a large part of which received treatment. 

No (major) cost-effectiveness studies were found on the diagnosis, treatment, care, or prevention of TB.

Both peer-reviewed and grey literature studies show a high level of heterogeneity in the evidence they present, which makes comparisons difficult. A large portion of the studies were conducted in US prison settings, which raises concerns whether these results can be applied to the situation in the EU/EEA. Overall, the level of evidence derived from the included studies is quite low; most studies had a descriptive and observational design, were conducted in single institutions and with relatively small sample sizes, and study characteristics, interventions and outcomes were often poorly described.

The evidence for TB control interventions in correctional facilities is limited, especially with regard to diagnosis and, to a lesser extent, prevention. Results in peer-reviewed and grey literature studies were heterogeneous, making it difficult to arrive at meaningful conclusions. More comparative studies are needed on the effectiveness and impact of different TB strategies in correctional facilities in the EU/EEA. Nevertheless, as part of the effort to eliminate TB, especially in low and intermediate-incidence countries, it is important to identify and treat TB and LTBI in selected at-risk groups, including people in prisons.