1. CHU de Bordeaux

2. 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

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

4. 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

5. 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®)

6. 943 inmates participated in the study.
871 from the men’s buildings
62 women
10 from the infirmary

7. 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.

8. 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.

9. 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.

10. 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

11. 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

12. 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

13. 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

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

15. 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 +

16. 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)

17. 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)

18. 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%)

19. 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)

20. 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

21. 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.

22. 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