By : F N’guni, N Kabelenga National Health Research Authority
Citation Style For This Article: N’guni F, Kabelenga N , . “MIND THE GAP” Improving Tuberculosis Care and Treatment in Correctional Facilities in Zambia. Health Press Zambia Bull. 2020; 4(3); pp 3-5
Key Messages
• Zambia ranks 13th among countries with the highest TB burden in the world.
• 6.3% of TB cases in Zambia are attributable to TB transmission within correctional facilities
• However, the National Tuberculosis and Leprosy Program (NTLP) currently does not have a robust recording and reporting mechanism on TB case detection and treatment outcomes from correctional facilities.
• There is need for a clear policy that includes guidance on data collection and reporting to NTLP from correctional facilities, without compromising human rights of inmates diagnosed with TB.
Problem Statement
In 2016, there were: -10.4 million people who fell ill with tuberculosis (TB); -1.4 million people who died from TB; -4.3 million cases missed by health systems across the globe.1 Many deaths and people missed with TB by the public health system each year are likely to be disproportionally concentrated among high risk population groups such as detainees (prisoners).2 In correctional facilities, TB incidence can be as high as 70 times that in the general population.3 Conditions in correctional facilities can fuel the spread of the disease through;
-Overcrowding
-Poor ventilation
-Week nutrition -Inaccessible or inadequate medical care Some of the consequences of high TB burden in correctional facilities may include:
-Transmitting the disease into the community through staff, visitors and inadequately treated former inmates;
-Developing of multi-drug resistant TB which has become a major public health problem in most developing countries.
In recognition of the importance in curbing the global TB epidemic, two of the three WHO Global Plan to End TB (2016- 2020)4 identify key populations as a group that needs special attention. Zambia is ranked 13th among the countries with high TB burden in the world.1 Correctional facilities are an important contributor to TB burden in Zambia. In 2015 there were 18,560 inmates crowded into 88 correctional facilities in Zambia, representing a 229% occupancy rate.5 An estimated 6.3% of TB in the general population is attributable to TB transmission within correctional facilities 6. End TB Strategy 2016 – 20204
Routine screening for TB is conducted in selected Zambian correctional facilities with support from cooperating partners. However, the NTLP has not yet established routine TB recording and reporting for TB cases diagnosed and their treatment outcomes in correctional services. This is attributed to the lack of a clear policy on how to address TB issues while ensuring confidentiality and observing human rights in correctional facilities. Comprehensive and updated data are key to informing the NTLP on the magnitude of TB in the correctional facilities and the various outcomes related to TB treatment. However, comprehensive data on national estimates for TB in Zambian correctional facilities do not exist.
A review of data from the Zambia Correctional Services Annual Report (2017) showed that 696 out of 21000 inmates (3.3%) were screened for TB, of which 171 (24.5%) were diagnosed with TB.7 This is far short of the second target of the WHO Global Plan to End TB. This target requires that TB testing and treatment reach at least 90% of key population.
Another Zambian study involving six correctional facilities demonstrated that of the 345 individuals initiated on TB treatment, the treatment success rate was only 66%,8 again below the 90% target.
Policy Option
This data highlights the need for ensuring a robust monitoring and evaluation system for TB control in correctional facilities in line with WHO recommendations. This will require:
What: Addressing the human rights concerns surrounding capturing TB data in TB treatment registers and cards from correctional facilities, which may include an electronic system. In addition, a robust support system for TB patients needs to be strengthened in all prisons.
Why: This will allow monitoring the level of TB detection and quality of TB treatment services in correctional facilities in line with the desired Global End TB Targets and improve public health in general.
Feasibility: High – It builds on the Ministry of Health’s strong commitment to eliminating TB in Zambia by 2030 as outlined in the National TB Strategic Plan 2017 – 2021.
Recommendations and next steps
Capturing TB data in treatment registers and cards in correctional facilities is an effective strategy to improve monitoring, reporting and assessing the performance of the TB control in correctional facilities. This reflects the need for a policy that: -Has clear guidance on data collection and reporting that covers data confidentiality and data protection. -Addresses human rights issues of concern to inmates and other stakeholders. -Has a requirement that data collected by cooperating partners should be submitted to NTP.
To develop such a policy, the following steps should be considered: -A policy dialogue forum to bring together stakeholders, Ministry of Home Affairs, Ministry of Health, relevant United Nations Agencies, Human Rights Commission and Civil Society Organizations. The expected outcome of this dialogue is to map out issues of human rights concern, learn from best practices in other countries and propose the road map to develop a TB in Prisons Policy for Zambia.
-An action plan for country wide scale up of the policy
LIST OF REFERENCES
1. World Health Organisation (2017). Global Tuberculosis Report (2017).
2. STOP TB Partnership – Working Document (September 2017). Data for Action for Tuberculosis Key, Vulnerable and Underserved Populations – https://www.health-e.org.za/wp content/uploads/2015/10/Global-TB-Report-2015-FINAL-2.pdf
3. USAID TB – Brochure. Tuberculosis In Prisons: A Growing Public Health Challenge (https://www.usaid.gov/sites/default/files/ documents/1864/USAID-TB-Brochure).
4. Stop TB Partnership (2015). “The Paradigm Shift: the Global Plan to End TB 2016 2020” (http://www.stoptb.org/assets/documents/global/plan/GlobalPlanToEndTB_TheParadigmShift_2016-2020_StopTBPartnership.pdf).
5. Telisinghe L, Charalambous S, Topp, SM, Herce ME, Hoffmann CJ, Barron P, & Beyrer C. (2016). HIV and tuberculosis in prisons in sub-Saharan Africa. The Lancet, 388(10050), 1215-1227.
6. Baussano, I, Williams BG, Nunn, P, Beggiato, M, Fedeli U, & Scano F. (2010). Tuberculosis incidence in correctional facilities: a systematic review. PLoS Medicine,7(12), 1470.
7. Zambia Correctional Services Annual Report (2017).
8. S. Hatwiinda, S. M. Topp, M. Siyambango, J. B. Harris, K. R. Maggard, C. Chileshe, N. Kapata, S. E. Reid, G. Henostroza, (December 2017). Article in Tropical Medicine & International Health – Poor continuity of care for TB diagnosis and treatment in Zambian Prisons: a situation analysis (DOI: 10.1111/tmi.13024)