Training Inmate Peer Educators in Detecting Tuberculosis in Prisons

1. Background and justification

Although the global incidence of tuberculosis (TB) has fallen by an average rate of 1.5% per year between the years 2000 and 2013, TB remains a major global health problem and is the second leading cause of death from infectious diseases [1,2]. An estimated 9 million people had developed TB in the year 2013 of which one-quarter was from Africa, the continent that also has the highest rates of cases and deaths relative to its population [1,3]. In the same year, only 5.7 million cases were both detected and notified to the National TB programs (NTPs), meaning that about 3 million people were "missed" by TB control programs [1]. The TB case detection rate (calculated as notifications of new and relapse cases divided by the estimated incidence per year) was only 64% at the global level and is below the World Health Organization (WHO) target (70%) [1].

Tuberculosis disproportionately affects vulnerable populations such as prisoners. According to a review of studies from both high and low-income countries, the prevalence of TB in prisons was 3 to 200-fold higher than in the general population [4,5]. A number of factors such as overcrowding, inadequate ventilation, delayed case detection and the movement of prisoners from site to the site make prisons a high-risk environment for TB transmission [6]. The emergence of drug-resistant TB has also made TB control efforts very complicated in prisons. [7]. If untreated, prisoners with drug-resistant TB will be an additional health hazard for fellow prisoners and staff [8]. Furthermore, TB and resistant forms of TB can spill out into the community and create a public health hazard [9]. In sub-Saharan African prisons, the high burden of human immunodeficiency virus (HIV) infection and poverty make the problem much worse [10]. Health care services are also very limited and due to the lack of diagnostic facilities many TB patients remain undetected [11]. In a recent study from a South African prison, for example, the prevalence of undiagnosed TB was reported to be high at 3.5% [12].

Ethiopia, which ranks 8th of the 22 countries with a high burden of TB [13], has implemented the directly observed treatment short-course (DOTS) program since 1992 [14]. Currently, the country has achieved the Millennium Development Goals (MDGs) of halving TB incidence, prevalence, and mortality by 2015 [1]. However, the case detection rate (CDR) remains low as in many other developing countries.

The case detection rate of all forms of TB was reported to be 62% which is still below the WHO target [1]. Ethiopia is listed among the top ten countries that accounted for 74% (2.4% million) of missed TB cases [1]. Shortage of health workers, low service coverage, low health seeking behavior and lack of efficient TB diagnostics are some of the factors for the low case detection rate in the country [15].