Elsevier

The Lancet

Volume 353, Issue 9157, 20 March 1999, Pages 969-973
The Lancet

Articles
First-line tuberculosis therapy and drug-resistant Mycobacterium tuberculosis in prisons

https://doi.org/10.1016/S0140-6736(98)08341-XGet rights and content

Summary

Background

We assessed a programme of tuberculosis control in a prison setting in Baku, Azerbaijan. The programme used first-line therapy and DOTS (directly observed treatment, short course).

Methods

467 patients had sputum-positive tuberculosis. Their treatment regimens followed WHO guidelines, and they had regular clinical examinations and dietary supplements. Isolates were tested by standard methods for resistance to isoniazid, rifampicin, ethambutol, and streptomycin in three laboratories. Treatment success was defined as three consecutive negative sputum smears at end of treatment. Factors independently associated with treatment failure were estimated by logistic regression.

Findings

Drug-resistance data on admission were available for 131 patients. 55% of patients had strains of Mycobacterium tuberculosisresistant to two or more antibiotics. Mortality during treatment was 11%, and 13% of patients defaulted. Overall, treatment was successful in 54% of patients, and in 71% of those completing treatment. 104 patients completed a full treatment regimen and remained sputum-positive. Resistance to two or more antibiotics, a positive sputum result at the end of initial treatment, cavitary disease, and poor compliance were independently associated with treatment failure.

Interpretation

The effectiveness of a DOTS programme with first-line therapy fell short of the 85% target set by WHO. First-line therapy may not be sufficient in settings with a high degree of resistance to antibiotics.

Introduction

Tuberculosis is more common within prison populations than in the general population, because of overcrowding, insufficient ventilation, poor hygiene, and generally low socioeconomic status, poor nutrition, and poor general health of inmates.1, 2 Late diagnosis and inappropriate case management may compound the problem. Despite these concerns, tuberculosis in prisons has been labelled as a “forgotten plague”.3 Since 1991, there has been an increase in notification of tuberculosis cases and an increase in mortality rates from tuberculosis in the republics of the former Soviet Union.4 In Azerbaijan, data from prisons are not included in Ministry of Health statistics: 1429 tuberculosis cases were reported to WHO in 1995 (18·8 per 100 000),5 but an estimated 700 tuberculosis patients were held in Azerbaijani prisons at that time.6

The International Committee of the Red Cross (ICRC) visits prisoners in countries that are or have been in situations of armed conflict. Medical personnel of the ICRC work to ensure that conditions of detention, including health care, are adequate. In Azerbaijan, the ICRC found that tuberculosis was the most common cause of death among prisoners.6 Accordingly, a pilot tuberculosis-treatment programme was started there in June, 1995, with the collaboration of the prison authorities and the Ministry of Justice.

The pilot programme used the direct observation of treatment, short course strategy (DOTS),7, 8 and was designed to convince prison authorities that such a programme would merit widespread application within the prison system. We report here the main outcomes of the programme, which was restricted to first-line therapy in a setting with high resistance to antibiotics.

Section snippets

Patients

The pilot programme took place in the Central Penitentiary Hospital in Baku, Azerbaijan. This hospital is the referral hospital for the Azerbaijan prison system, and has 450 beds for tuberculosis patients. The ICRC programme was limited to two wards with 160 beds in total. Patients with suspected tuberculosis in prisons throughout the Azerbaijan prison system are sent to the Central Penitentiary Hospital, and may then be referred to the ICRC programme if a bed is available. Admission criteria

Results

467 men (mean age 29·7 years [SD 8·3]) presented with poor nutritional status and advanced pulmonary disease. Mean body-mass index was 18·0 (SD 2·2), and 38% of the patients had cavitary disease. By use of the WHO classsification,9 235 (50·3%) patients were classified as new cases, 30 (6·4%) as relapse cases, and 202 (43·3%) as failure cases. Of the new cases, 64 men reported no previous treatment for tuberculosis. We analysed results separately for 64 true-new cases, and 171 pseudo-new cases.

Discussion

In a population with a high degree of resistance to antibiotics, a DOTS programme with first-line therapy resulted in an overall cure of 54%, despite excellent compliance. This figure falls short of the programme objective of 85% recommended by WHO for national tuberculosis programmes.9 This result should help to open the debate on the most appropriate response or responses to the limited effectiveness of first-line therapy in such settings.

There were several limitations of our study. Our study

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