Prisons and TB in Europe Riga, 29 May 2008 Lars Moller Prison Health Manager WHO-EURO

Estimated TB burden; world, 2006 TB incidence stable in Europe, slow decline in other WHO regions 9.2 million new TB cases (>80% in Asia and Africa) 1.5 million TB deaths (195 000 due to TB/HIV) TB prevalence and mortality declining faster, but Europe and Africa will not reach the targets by 2015 489 000 MDR-TB cases 5% of MDR-TB cases are XDR-TB

Estimated TB incidence; EUR, 2006 TB cases (all) per 100,000 pop. < 10 11-20 21-50 51-100 > 100 433 000 new TB cases (49 sick persons every hour) 62 000 deaths due to TB (7 deaths every hour) Russian Fed. 11th among world TB high-burden countries 2  204 new TB cases per 100 000 (Monaco  Tajikistan)

TB challenges in EUR Economic recession, poverty and existence of socially vulnerable groups (homeless, unemployed, alcohol-dependent) Health systems poorly developed or under reform, leading to ineffective TB control (non-DOTS) High prevalence of MDR-TB Link with HIV epidemic through injecting drugs users Very large penitentiary system with poor TB services Migration (East to West, South to North, internal migration) Most cases occur in eastern Europe and in the former USSR where TB is increasing dramatically. Most countries in the former USSR have rates that are 10 times higher than those in western Europe.

New TB cases in prisons; EUR, 2004 37/52 (71%) countries reported to WHO-EURO on new TB cases by penal and civilian system

New TB cases in prisons; EEUR+, 2004

Main challenges for TB control in prisons Limited access to TB diagnosis and treatment Low political commitment (equivalence, equity) Lack of resources (financial, material, human) Frequent transfers between prisons Difficult TB treatment MDR-TB Concomitant pathologies (HIV, hepatitis, etc.) Poor treatment compliance (drug abuse, alcoholism) Prison dynamics (hierarchies, violence, etc.) Difficult follow-up after release from prison (no link with civilian system, social stigma, low education)  Prisons reservoirs of TB in the community

Estimated HIV prevalence in new TB cases; EUR, 2006. HIV in TB cases (%) no information <1 1-5 6-10 >10 HIV prevalence in TB cases with 3% regional average Lack of good, reliable and country-wide information Limited collaboration between HIV and TB programmes Different patterns and type of co-infection in W and E Lack of community and activists involvement

TB control in prisons: updating policies For National TB Programme managers (2000) For prison administrators (1998)

WHO Health in Prisons Project International Conference; Sinaia (Romania), 26 Oct 2006 In relation to the Collaborating Centre on Prison Health in London – WHO is responsible for the overall coordination of the project and WHO is responsible for the links with governmental and non-governmental bodies at national and international level.

Status paper on prisons and tuberculosis (a) Contents Introduction Background and epidemiology The Stop TB Strategy Challenges for prevention, diagnosis and treatment of TB in prisons (political commitment, infection control, case detection, standardized treatment, drug supply, monitoring and evaluation, TB/HIV, MDR-TB, community participation, advocacy-communication-social mobilization, research) TB control in prisons: minimum standards Also: foreword, acknowledgements, executive summary In relation to the Collaborating Centre on Prison Health in London – WHO is responsible for the overall coordination of the project and WHO is responsible for the links with governmental and non-governmental bodies at national and international level.

Status paper on prisons and tuberculosis (b) TB control in prisons: minimum standards The ideal TB control programme in a prison includes: Government structures in both prison and civil sector Written agreement between prison and civil sector Prevention of TB (early detection, no overcrowding, good nutrition, ventilation and light, infection control) Access to TB diagnosis and treatment for all prisoners Equal treatment, including for MDR-TB and TB-HIV Continued treatment following release from prison In relation to the Collaborating Centre on Prison Health in London – WHO is responsible for the overall coordination of the project and WHO is responsible for the links with governmental and non-governmental bodies at national and international level.

Status paper on prisons and tuberculosis (c) TB control in prisons: minimum standards The penitentiary system must have: Adequate number of staff with updated training Mechanism for timely investigation of TB suspects Quality-assured smear microscopy Quality drug susceptibility testing in reference laboratory Supply of quality second-line drugs Recording and reporting shared with the civil sector In relation to the Collaborating Centre on Prison Health in London – WHO is responsible for the overall coordination of the project and WHO is responsible for the links with governmental and non-governmental bodies at national and international level.

HIV prevalence (%) in selected countries

New cases of HIV 26% 12% 16% 32%

HIV prevalence in Spanish prisons