CHU de Bordeaux

Prevalence of pulmonary tuberculosis among prison inmates in Côte d’Ivoire: a cross-sectional study conducted in “Maison d’Arrêt et de Correction d’Abidjan” (“MACA”, Correctional and Detention Facility of Abidjan) MC Receveur, CHU de Bordeaux, Expertise France-Côte d’Ivoire

Côte d’Ivoire 19,26 million people Tuberculosis (TB) incidence in 2014 : 165/100 000 MDR TB : 2.5% HIV estimation 2015 : 3.2% among 15-49 years old people 12300 inmates 34 prisons

Cross-sectional study In « MACA » prison which has a capacity of 1,500 places and where there were 4,600 inmates during our study period From March to September 2015 concerned woman inmates, long-term male inmates and infirmary inmates

Study implementation Information and awareness meetings before starting the study, then : in the infirmary court : by 25 people groups and 3 days a week : 1st stage : consent signature, questionnaire administration 2nd stage : first sputum sample, chest X-ray 3rd stage : 2nd sputum, HIV serology test (Determine HIV-1/2®)

943 inmates participated in the study. 871 from the men’s buildings 62 women 10 from the infirmary

And also for the 2nd sputum sample for all presomptive TB* Culture was performed on the 1st sputum sample of all participants, in Lowenstein-Jensen medium and Bactec MGIT 960 liquid culture system And also for the 2nd sputum sample for all presomptive TB* When positive culture, 4 antibiotics were tested : HRES * : cough lasting more than 2 weeks within the month preceding the study and/or abnormal chest X-ray, and/or positive HIV serology and/or positive microscopy on the first sputum samples after Ziehl-Nelson staining.

Cases classification Confirmed tuberculosis: positive culture for Mt Probable tuberculosis: positive microscopy with at least one acid-fast bacilli (AFB) per field and/or chest X-ray findings compatible with TB  Possible tuberculosis, in case of uninterpretable chest X-ray, if : Positive HIV serology and at least 3 compatible clinical signs suggestive of tuberculosis; or positive microscopy with less than 1 AFB per field and at least 3 compatible clinical signs suggestive of tuberculosis; or Negative HIV serology and negative or unavailable microscopy but with at least 4 compatible clinical signs suggestive of tuberculosis.

Resistance classification Primary or initial resistance was defined as the presence of bacilli resistant to one or more TB drugs in previously untreated patients or those treated for less than one month. Secondary or acquired resistance was defined as the presence of bacilli resistant to one or more TB drugs in patients treated for TB for one month or more.

Results 35 cells were involved in the study 26 from the men building (1.3 m2/inmate) 9 from the women building (5.2m2/inmate) Current imprisonment = 1st one for 83% of people Medium term of current imprisonment : = 23 months in the men’s building = 5 months in the women’s building

Among the 943 inmates who participated in the study Medium age : 31 years 79% were of Ivorian nationality 55% were active smokers 804 (85%) were managed by the 3 complementery tests : 765 (88%) male 31 (50%) female 8 (80%) from the infirmary

Clinical characteristics Radiography performing 247 (26%) had chest pains 207 (22%) had been coughing > 2 weeks 107 (11%) had a BMI < 18.5 46 (5%) had a prior history of TB Chest X-rays was performed among 930 participants (99%). 46 (5%) were not interpretable, all of them from the men’s building chest X-rays interpretation was performed by 2 independent readers Radiography performing

Radiography results 43 abnormal chest X-ray (but 13 with prior TB history) 37 men from the long pain building 1 woman 5 people from the infirmary 2 with excavation 11 alveolor opacities in the apex 25 alveolor opacities outside the apex 5 pleural effusions

Virology HIV serology testing was performed among 876 inmates (93%) 21 (2.6%) men 6 (11.1%) women had a positive result

Bacteriology results (1) Mycobacteriological examinations of sputum were performed among 904 inmates (96%). Microscopy and culture were performed on all sputum samples. 368 inmates (39%) had 2 sputum samples tested. 8 people were AFB + 11 more had a sputum culture +

Tuberculosis diagnosis per building Case, n (%) Total (N=943) Men’s building(1) (n=871) Women’s building (n=62) Infirmary (n=10) No tuberculosis 855 (90.7) 793 (91.0) 59 (95.2) 3 (30) Possible tuberculosis 29 (3.1)) 26 (3.0) 2 (3.2) 1 (10) Probable tuberculosis 40 (4.2) 34 (3.9) 1 (1.6) 5 (50) Confirmed tuberculosis 19 (2.0) 18 (2.1) - Antibiogram performed 19 (100) 18 (100) 1 (100) Pan-susceptible 9 (47.4) 8 (44.4) Monodrug-resistance 1 (5.3) ) 1 (5.6) Multidrug-resistance 7 (36.8) 7 (38.9) Polydrug-resistance 2 (10.5) 2 (11.1)

Tuberculosis diagnosis per building Case, n (%) Total (N=943) Men’s building(1) (n=871) Women’s building (n=62) Infirmary (n=10) No tuberculosis 855 (90.7) 793 (91.0) 59 (95.2) 3 (30) Possible tuberculosis 29 (3.1)) 26 (3.0) 2 (3.2) 1 (10) Probable tuberculosis 40 (4.2) 34 (3.9) 1 (1.6) 5 (50) Confirmed tuberculosis 19 (2.0) 18 (2.1) - Antibiogram performed 19 (100) 18 (100) 1 (100) Pan-susceptible 9 (47.4) 8 (44.4) Monodrug-resistance 1 (5.3) ) 1 (5.6) Multidrug-resistance 7 (36.8) 7 (38.9) Polydrug-resistance 2 (10.5) 2 (11.1)

Tuberculosis diagnosis per building Case, n (%) Total (N=943) Men’s building(1) (n=871) Women’s building (n=62) Infirmary (n=10) No tuberculosis 855 (90.7) 793 (91.0) 59 (95.2) 3 (30) Possible tuberculosis 29 (3.1)) 26 (3.0) 2 (3.2) 1 (10) Probable tuberculosis 40 (4.2) 34 (3.9) 1 (1.6) 5 (50) Confirmed tuberculosis 19 (2.0) 18 (2.1) - Antibiogram performed 19 (100) 18 (100) 1 (100) Pan-susceptible 9 (47.4) 8 (44.4) Monodrug-resistance 1 (5.3) ) 1 (5.6) Multidrug-resistance 7 (36.8) 7 (38.9) Polydrug-resistance 2 (10.5) 2 (11.1) Total possible + probable + confirmed cases = 88 (ie; prevalence 9%)

Bacteriology results So, 19 TB cases were bacteriologicaly confirmed among 943 participants → ie confirmed TB prevalence of 2% Among those 19 cases, 3 (16%) didn’t have any clinical symptom suggestive of TB The 18 active TB in the men’s building mainly found in the 11 most overcrowded cells (average of 49 people/cell)

Discussion Social deprivation Overcrowding Living in enclosed environments are well known TB risk factors which are all presents in prisons especially in resource-limited countries …including probable and possible cases in our study would give a prevalence of 9% when national prevalence was 0,21% in 2014

When somebody gets into prison, one day he will mostly get out. The concentration of the 18 active TB cases in the high-density cells probably increased transmission of TB including drug-resistant forms The men’s building available individual surface area of 1.3 m2 was largely below WHO recommendation (4m2) . The considerable proportion of TB drug resistance should bring our attention to the fact that prisons are a reservoir for cluster transmission of TB, especially for these problematic cases. When somebody gets into prison, one day he will mostly get out. Detecting and treating TB in prison is not simply a matter of human rights, it is a public health imperative.

TB MACA team MACA infirmary : Marcel Angora Abidjan University Hospital Treichville, Programme PACCI : Benjamin Séry, Christine Danel, Xavier Anglaret, Timothée Ouassa, Ange Koffi, Serge Domoua Expertise France, Abidjan, Paris : Jeanne d’Arc Assémien, Jean-Marie Masumbuko, Arnaud Laurent, Nathalie Cartier, Christophe Michon CHU de Bordeaux : Marie-Catherine Receveur Many thanks to : ANRS (Agence Nationale de Recherche contre le Sida) for financial support Ivorian Ministry of Justice for « opening the door » of prison to our team