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The burden of alcohol, tobacco and other drugs among the prison population diagnosed with tuberculosis: temporal trends and spatial determinants in southern Brazil | BMC Public Health

The use of tobacco and illegal drugs was widespread among the prison population diagnosed with tuberculosis, and an upward trend was verified for alcohol, tobacco and illegal drugs in penitentiary establishments. This study contributes to scientific technical improvement in the field, since most of the studies deal with tuberculosis among the prison population; thus, there is a knowledge gap when it comes to associating TB with users of alcohol, tobacco and other drugs.

The highest RR was found in prisons located in the eastern macro-region (Metropolitan region of Curitiba), showing that prisons contribute to the burden of tuberculosis and constitute a favorable environment for the disease, given a large number of alcohol and drug abusers [6, 8, 11, 22, 23].

It should be noted that the medical center for the care of detainees is located in the Eastern macro-region, which explains the high number of cases of tuberculosis in this area. The data suggests that the availability of medical services indicates that the prison population has access to health services, and the high rates of outpatient consultations and hospitalizations suggest the quality of the health status of these people. [24].

It should be noted that in 2003, the Ministry of Health, in collaboration with the Ministry of Justice, launched the National Health Plan for the Penitentiary System, and in 2014 established the National Integrated Health Care Policy for persons deprived of liberty in the Penitentiary System to promote health and prevent illnesses in the penitentiary system and guarantee that the prison population has access to comprehensive and quality health care provided by the Brazilian Unified Health System [25].

There are many factors that lead individuals to incarceration throughout their life, but it can be highlighted that conditions and social exclusion are an extremely relevant characteristic to trigger acts that lead to deprivation of liberty. [26].

However, it should be mentioned that the prison population is considered a population at high risk of disease and development of different comorbidities, including tuberculosis, due to their living conditions and exposure to adverse health behaviors such as consumption of alcohol, tobacco and other drugs [10xx].

Another characteristic that influences the development of TB among the prison population who use alcohol, tobacco and other drugs is the very lifestyle that contributes significantly to TB. A study points out that socio-economic, social and political conditions, as well as health service attendance and the distribution of social determinants are factors that directly influence the increase in the incidence of tuberculosis within a territory [27].

Thus, it is noted the fundamental importance that governments have in the face of two major social and public health problems, which is to invest in protective policies that keep young people away from delinquency and provide educational support and living conditions. as well as effective health services. for the control and elimination of tuberculosis worldwide.

Given this scenario, a high number of tuberculosis cases have been observed among the prison population, mainly pulmonary tuberculosis, which is of concern given that the bacillus is airborne and prison conditions, such as overcrowding and poor conditions. poor ventilation, promote the spread of tuberculosis [28]. Effective public policies therefore aim to provide health care to the prison population.

The prison population includes socially vulnerable people affected by different diseases, [25] among which stand out addiction to alcohol, tobacco and illicit drugs. Even though the consumption of alcohol and tobacco has decreased in the general population, there has been a significant increase in the number of smokers and drug users among the prison population [22]. Studies report that approximately 80% of the prison population in the United States has a history of illegal drug use [23]. A study was conducted in Norway to investigate drinking habits before imprisonment and reported that 55% of prisoners had alcohol problems of some severity; 18% of them may have been dependent on alcohol [29]. Few data are available in Brazil, and research in the field is still nascent given the difficulty of discussing this phenomenon in public security institutions. [30].

Thus, the consumption of legal or illegal psychoactive substances in prisons contributes to an increase in the number of diseases and, as this study shows, contributes to the development and maintenance of tuberculosis. [31, 32]. Furthermore, these substances not only contribute to the development of tuberculosis, but also lead to unfavorable treatment outcomes, since psychoactive substances are associated with higher rates of mental disorders, suicide, mortality, relapse after the Liberation [33]and violence in prisons.

PS consumption promotes the development of disease among the prison population and is associated with higher rates of physical violence and suicide attempts within prisons; suicide attempts in this population are estimated to be three to eight times higher than in the general population. Risk factors include mental disorders, substance use disorders, suicidal ideation, suicide attempts, self-harming behaviors, single cell accommodation, and conviction for violent crimes [34].

Social and spatial factors of prisons contribute directly to sustaining tuberculosis and other diseases, as many prisons are overcrowded, have high prison population turnover, are poorly ventilated and have limited access to health services [35].

The prison population lives in an unsanitary environment with poor hygienic conditions, which often fail to provide basic human needs to protect their physical and mental health, directly contributing to the spread of communicable diseases, violence-related injuries and mental disorders. [36]. These are characteristics observed in the eastern, northern and northwestern macro-regions, which are home to areas at risk for total tuberculosis and tuberculosis associated with alcohol, tobacco and illicit drugs. It should be noted that the western macro-region was not an area at risk of TB associated with psychoactive substances.

Identifying prisons at risk for the development of substance use-associated tuberculosis can support the implementation of preventive measures and quality health care, especially in prisons housing a large number of prisoners, that is, establishments exposed to a higher risk. However, there is usually a delay in the diagnosis of tuberculosis, with a high prevalence of resistant bacteria; inadequate treatment and abandonment of treatment; low level of education; malnutrition; mental disorders; previous illnesses; tuberculosis/HIV co-infection; and alcohol, tobacco and/or illicit drug use/dependence [6, 7, 37].

Therefore, prisons are a reservoir of various diseases, especially infectious-contagious diseases, such as tuberculosis. The community is also exposed to TB when it comes into contact with prison officers, released inmates or families visiting inmates. Consequently, the prison environment promotes the incidence and maintenance of tuberculosis, and health actions are necessary to break the cycle of transmission and reduce the number of new cases and deaths. [35].

Analysis of temporal trends showed that tuberculosis increased among the prison population consuming alcohol, tobacco or illegal drugs, which was similar in the general population. The fact that the consumption of these substances has increased worldwide is of concern, given that it is associated with worse treatment outcomes for TB [24, 28].

Therefore, a screening protocol should be implemented in the prison system to identify substance use and tuberculosis and invest and prioritize diagnosis and early interventions, providing appropriate treatment to avoid interruptions and relapses. [35].

Achieving the targets set by the TB strategy and eradicating TB by 2050 will only be possible by investing in preventive measures and appropriate treatment of TB. Therefore, one of the most difficult challenges is controlling disease progression among subpopulations with high incidence rates, such as the prison population. [38]. In this sense, the prison population is a social stratum at higher risk of TB, [8] and strategies are needed to reduce disease transmission and achieve global targets.

In this sense, the WHO recommends that measures be implemented in prisons to prevent new cases, including screening protocols applied to the admission and release of prisoners, in addition to periodic assessments of the population. prison or preventive treatment with isoniazid. [2]. Routine screening of inmates, isolation of confirmed cases, decreasing the number of inmates in a single cell, and prevention of crowding are effective ways to reduce transmission among inmates, prison officers, families and the community [8].

Programs for early diagnosis, reporting of new cases and initiation of appropriate treatment are essential. However, the prison population’s access to health services is restricted, leading to poor outcomes and high rates of tuberculosis.