Pitfalls of TB management in prisons, revisited

Almost 10 years ago, attention was drawn to the many pitfalls involved in the treatment of tuberculosis (TB) in prison settings, based on field experience from the ICRC (International Committee of the Red Cross) (Coninx et al., 1995). Since that time, the ICRC has continued working in the field of TB in prisons, either directly or by supporting the local programmes in different countries. Further experience gained since then has, if anything, confirmed and reinforced the worries caused by the specific problems posed both by the prison environment and by "prisoner-patients" for the treatment of TB. Medical staff working in prisons need to be familiar with these issues if tuberculosis is to be managed and treated successfully. With the menace of drug-resistant TB no longer merely a marginal problem but arguably becoming a direct menace to public health, it becomes all the more important to be aware of these pitfalls. This paper addresses the following: why prison settings are especially difficult for TB detection and management; why prisoners can be particularly difficult patients; how different resistant strains of TB are produced or enhanced in prisons; added difficulties in treating MDR-TB in prisoners; and how and why the association of TB and HIV complicate TB, and MDR-TB, treatment in prisons even further. The photographs and additional illustrations are from the author's collection. Permission was obtained from all persons photographed for reproduction.