Latent tuberculosis infection in a Malaysian prison: implications for a comprehensive integrated control program in prisons

Abstract

BackgroundPrisons continue to fuel tuberculosis (TB) epidemics particularly in settings where access to TB screening and prevention services is limited. Malaysia is a middle-income country with a relatively high incarceration rate of 138 per 100,000 population. Despite national TB incidence rate remaining unchanged over the past ten years, data about TB in prisons and its contribution to the overall national rates does not exist. This survey was conducted to address the prevalence of latent TB infection (LTBI) in Malaysia’s largest prison.MethodsFrom July to December 2010, all HIV-infected and a comparative group of HIV-uninfected prisoners housed separately in Kajang prison were asked to participate in the survey after explaining the study protocol. Subjects providing informed consent were interviewed using a structured questionnaire followed by the placement of tuberculin skin test (TST) with 2 TU of PPD RT-23 to subjects not being treated for active TB. TST was read after 48-72 hours and indurations of ≥ 5 mm and ≥ 10 mm were considered positive among HIV-infected and HIV-uninfected subjects, respectively. Additionally, HIV-infected inmates underwent phlebotomy for CD4 lymphocyte count assessment. A logistic regression model was explored to determine factors associated with TST positivity.ResultsOverall, 286 subjects (138 HIV-infected and 148 HIV-uninfected) had complete data and TST results. The majority were men (95.1%), less than 40 years old (median age 36.0, SD 7.87), and Malaysians (93.3%). Most (82.5%) had been previously incarcerated and more than half (53.1%) reported sharing needles just prior to their incarceration. TST was positive in 88.8% (84.7% among HIV-infected and 92.5% among HIV-uninfected subjects) and was independently associated with being HIV-uninfected (AOR = 2.97, p = 0.01) and with frequent previous incarcerations (AOR = 1.22 for every one previous incarceration, p = 0.01) after adjusting for other potential confounding factors.ConclusionsThe prevalence of LTBI was extraordinary high in this sample of Malaysian prisoners, regardless of their age or HIV status. This warrants further examination of the size of the problem of TB in other congregate settings and the establishment of an evidence-based TB control program in Malaysian prisons with integrated TB, HIV and substance abuse components.

Prevalence and correlates of latent tuberculosis infection among employees of a high security prison in Malaysia

“…Important to these findings is that the TST positivity among prison personnel parallels recent reports of TST positivity among prisoners within this prison21 and also from a remote prison in North-eastern Malaysia 2223 but also among HCWs (52.1%) within the same state in Malaysia 24.…”

“…The majority of participants were vaccinated with BCG as part of the Malaysian vaccination policy and though BCG vaccination may impair the specificity of TST, its effect is minimal after adolescence 42. No association was found between BCG vaccination and TST positivity from previous TST surveys in Malaysia,21 22 and there was no association with younger age and TST, making BCG contribution to TST reactivity unlikely. Interferon Gamma Release Assays (IGRAs) offer a suitable alternative to TST in countries where repeated BCG vaccination is still implemented, but its advantage over TST differs with the TB burden of the country, being of less superiority in high-burden settings 43.…”

“…This was largely attributed to the missed diagnosis of active TB cases among prisoners and hence the facilitation of on-going TB transmission 25 31. Our recent study of an intensified TB case finding revealed a very high (12.0%) prevalence of undiagnosed active TB among HIV-infected inmates in the same Malaysian prison,11 which may have contributed to the extraordinarily high reported prevalence of TST positivity among prisoners (88.8%) and prison officers (81.0%) in this prison 21…”

Correlates and Experiences of HIV Stigma in Prisoners Living With HIV in Indonesia: A Mixed-Method Analysis

“…Criminalization of drug use has concentrated PWID in prisons where unsafe drug injection, needle sharing, and limited access to harm reduction services may contribute to ongoing HIV transmission (Culbert et al, 2015). Prison overcrowding and poor sanitation increase exposure to tuberculosis and other opportunistic infections (Al-Darraji, Kamarulzaman, & Altice, 2014). Socio-cultural barriers to ART utilization, especially HIV stigma and fear of discrimination (Wasti et al, 2012), may be intensified in prison settings, thereby restricting ART expansion and contributing to high mortality in incarcerated PLWH.…”

Infecção latente por tuberculose entre pessoas com HIV/AIDS, fatores associados e progressão para doença ativa em município no Sul do Brasil

“…É conhecida a vulnerabilidade de desenvolvimento da TB nas pessoas privadas de liberdade, explicado por razões tais como o ambiente superlotado e contato íntimo constante, que favorece a transmissão do bacilo 37,38 . Estudos com essas pessoas apresentaram percentuais elevados de ILTB, 40% 39 e 46,9% 40 quando submetidas à PT.…”