TB: control failure and prison effects.
Article Type: Report
Subject: Prisons (Health aspects)
Tuberculosis (Risk factors)
Tuberculosis (Care and treatment)
Tuberculosis (Research)
Disease transmission (Research)
Pub Date: 02/01/2011
Publication: Name: South African Medical Journal Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 South African Medical Association ISSN: 0256-9574
Issue: Date: Feb, 2011 Source Volume: 101 Source Issue: 2
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: South Africa Geographic Code: 6SOUT South Africa
Accession Number: 262037414
Full Text: Control failure. South Africa's tuberculosis control has failed. Wood and colleagues explain the problem and explore ways of dealing with this. (3)

The TB programme has primarily focused on effective case management of passively presenting TB cases, and progress has been recorded towards international treatment targets. But while outcomes for notified cases of TB have improved, this strategy has failed to contain the TB epidemic. In South Africa (SA) TB notifications have increased fivefold over the past 20 years, and SA now has the third-highest TB burden after India and China. SA was responsible for approximately 25% of the global burden of HIV-associated TB cases in 2007. The 2009 Cape Town (population 3.4 million) notification of 31 095 cases represents double the number of TB cases reported in the USA (population >300 million). South Africa has the highest per capita annual risk of TB disease of comparably sized countries globally, and its communities have extremely high TB transmission rates. The TB rates of children and adolescents are now similar to those 100 years ago in Europe before the advent of chemotherapy.

High rates of HIV testing of HIV patients and use of other data allow analysis of TB notifications and a better idea of TB epidemiology. Improved understanding of the major drivers of the TB epidemic allows reasons for failure and new control strategies to be identified.

TB and the prison time bomb. Most citizens are unaware of the appalling circumstances that many prisoners in our prisons have to endure. While the ideal is to rehabilitate prisoners, they are often recruited into criminal gangs. O'Grady and colleagues, in their editorial on TB in sub-Saharan prisons, (4) provide a stark reminder that prisons are also potentially a health time bomb.

The incidence of TB in sub-Saharan Africa (SSA) is very high at over 300 new cases of TB per 100 000 population in 2007. The incidence of multi- and extensively drug-resistant tuberculosis (MDR-TB and XDR-TB) is also increasing. The prevalence of TB in SSA prisons is estimated to be 6-30 times higher than in the general population. Restricted and confined conditions for prisoners and prison staff, poor nutrition, poor ventilation, stress and inadequate prison health services are conducive to the emergence and transmission of drug-resistant TB, which can then spread in the community. Prisons in SSA have no proper isolation facilities to treat MDR/XDR-TB. Other serious infectious diseases are also rapidly transmitted in prisons, including HIV, respiratory and skin infections, and STDs.

To achieve TB control SSA governments must focus and take action on all aspects of the TB problem, including TB in confined institutions such as prisons.
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