Introduction
Reliable data on tuberculosis (TB) incidence in the Soviet Union are lacking.
There is, however, strong reason to believe that the incidence has increased
considerably since 1991. According to official national figures, the
incidence was 34/100 000 in 1991 and 90/100 000 in 2000 [1]. The TB problem
has received much attention both in Russia and western countries [2,
3]. The high incidence of TB in Russian prisons is of particular concern
[4-6]: a search of the databases MEDLINE and CAplus yielded 45 publications
since 1980 on TB in Russian prisons. However, 25 of these were published
in Russian only. There have been several initiatives from international
organisations to assist national authorities in their control efforts
among prisoners [7]. TB in prison is not an isolated problem - especially
not in a remand prison - since incompletely treated patients may well
spread the disease in the general population after release [8-10].
All suspected criminals are held in remand prisons (SIZOs) while awaiting
trial. According to Russian legislation, prisoners on remand should be
held in a SIZO for no more than 12 months. In 2002 this time period was
cut to 6 months. However, before 2002, delays in bringing cases to trial
led to overcrowding of SIZOs [1] with suspects being held for several years.
If convicted, prisoners are transferred to regular prisons in the countryside
known as 'colonies'.
St Petersburg is one of the largest cities in Russia, with an population
of approximately 5 million. According to official data, TB incidence in
the city was 44/100 000 in 2002 and 40/100 000 in 2003 [11], about half
the average national incidence. These figures include all TB cases registered
in St Petersburg: city residents, homeless people, prisoners and migrants.
The ‘incidence’ of TB in a Russian prison is defined as the
number of diagnosed cases during a year, divided by the average number
of prisoners during the year (sum of the monthly average, divided by 12),
expressed as cases per 100 000 prisoners per year. It should be noted that
these figures include cases diagnosed at entry into prison, as well as
those diagnosed during incarceration.
Several articles about the TB situation in the Russian prison system only
present data from the prison colonies [12,13], although it is acknowledged
that the SIZO is the first place where prisoners are at high risk for contamination
[8]. We have found only a few published articles that try to analyse the
TB situation in pre-trial SIZO facilities in detail [14,15]. This study
aims to describe the epidemiology of pulmonary TB in two SIZOs in St Petersburg.
Material and Methods
The city has six SIZOs - four in the city and two in the district (Leningrad
oblast). One of them houses female prisoners and one teenagers in addition
to adults. At entry into a SIZO each detainee undergoes a health examination
including blood tests and fluorographic screening. This method helps
to rapidly separate people with pulmonary changes from those without.
For the latter, chest x ray is repeated every 6 months during their
stay in the SIZO. Patients with pulmonary changes and clinical symptoms
indicative of pneumonia are given a test therapy of about two weeks
with broad-spectrum antibiotics. If positive changes in x ray and symptoms
persist, then the case is diagnosed as TB. Diagnosis is not based only
on radiographic examination and absence of response to broad spectrum
antibiotics but also, if possible, on microbiological confirmation
by smear sputum microscopy and culture of sputum. Laboratory results,
including susceptibility testing, assist the diagnosis and choice of
proper treatment. Both previously treated and previously untreated
patients receive therapy with four antituberculosis drugs in the SIZO.
We analysed TB rates for two SIZOs in St Petersburg: SIZO-1, which is
the largest and well-known remand prison in St Petersburg, commonly known
as ‘Kresty’ because of its two cross-shaped buildings, and
SIZO-4. This choice was made because SIZO-1 has the largest medical division
for prisoners with TB, and SIZO-4 admits prisoners aged under 18 years.
Both SIZOs take only male prisoners. Before summer 2002, SIZO-1 and SIZO-4
held three to four times their official capacity. The number of people
in the SIZOs declined considerably after this, because of a general amnesty
and the change of legislation for remand prisoners in mid-2002.
We searched the registers of the TB divisions of the two SIZOs for all
cases (876) diagnosed during the three-year period from 1 January 2000
to 31 December 2002 and ascertained all TB cases who were considered
free from TB on admission, but who were later diagnosed with TB (444).
Of the 735 cases in SIZO-1, 360 were diagnosed at entry into prison,
and 375 during their prison stay (for 109 of these latter cases we have
only limited information, since the prison ledger was destroyed in May
2000). Among the 141 cases in SIZO-4, 72 came into prison with TB and
69 developed TB during incarceration. Each TB case was diagnosed and
classified as described above. This was in accordance with standard diagnostic
procedures accepted in the Russian Federation.
The data collected for each TB case were: date of entry into the SIZO,
date of birth, dates of initial and subsequent chest x rays, date of
confirmed TB diagnosis, and TB type. The type was defined from the x
ray picture as focal, infiltrative, disseminated, lympho-nodal, or pleural.
Results
The officially reported rate of TB in SIZO-4 remained almost constant
for the three years (P value >0.10). For SIZO-1 the incidence dropped
significantly (P<0.006) from 2000 to 2001, but then rose significantly
(P<0.006) again in 2002 [TABLE 1].
Among those who were deemed free from TB at entry but later developed
TB, only 6 out of 266 (2%) in SIZO-1 and 2 out of 69 (3%) in SIZO-4
were diagnosed during their first 2 months in prison. The peak time
for being diagnosed was at the end of the first year and the beginning
of the second year of imprisonment. Almost half of these cases were
diagnosed within one year of arrival in the SIZOs, and two thirds within
18 months [FIGURE ]. However, these figures do not represent the true
risk for prisoners over time, since the denominator of still-detained
prisoners is decreasing all the time. The proportion of people who
developed tuberculosis during their stay in both SIZOs is almost 50%
of all registered cases.
The majority of TB patients were under 30 years old (SIZO-1: 62-68% and
SIZO-4: 70-83%). SIZO-4 holds more young people, but during the study
period there was not a single case of TB in a prisoner under 18 years
of age.
Among prisoners who were diagnosed during incarceration in SIZO-1, infiltrative
TB was most common in 2000, but in 2001 focal TB accounted for 50% of
cases. Disseminated TB, which requires more intense and prolonged therapy,
remained common accounting for 11%-22% of cases. In SIZO-4 about 60%
of all the cases that developed during imprisonment were infiltrative
tuberculosis [TABLE 2].
Discussion
The present situation with TB in prison in St Petersburg city and region
is still serious, and the annual rate for 2000 (3199/100 000) was higher
than the average for the entire Russian penal system ( 2828/100 000)
[1].
As shown in Table 1, overall TB incidence in SIZO-1 and SIZO-4 remains
high. The highest reported TB rate in the period was seen in 2000; the
apparent increase in 2002 was probably due to the amnesty in the middle
of this year, which will have affected the denominators used for calculation
of the statistics.
Official Russian calculation of TB incidence in SIZOs includes cases
diagnosed at entry as well as during incarceration. When evaluating prevention,
it might be advantageous to differentiate between these two, since with
the present way of reporting incidence figures would be high whether
or not a single case of TB developed during incarceration.
One could argue that some of the patients in our study probably spent
a large part of their life in prison, with only short periods of freedom
in between, and that it would thus make little difference if they happened
to be diagnosed at entry or later. However, all prisoners have a final
x-ray before release from pre-trial detentions. For re-apprehended persons
with TB, the result of that x-ray test is used to determine whether the
case is developed in SIZO or is brought from outside.
Successful case finding, rapid isolation and adequate treatment of TB
cases in remand prison will reduce TB transmission within prison. This
in turn will decrease occurrence of disease in recidivist prisoners and
reduce in some way prevalence of disease at entry to prison. Persons
re-apprehended in the remand prison several times during the one-year
period must be counted only once. Furthermore, incidence figures would
be considerably more reliable if person-years in prison could be used
as the denominator instead of the average number of prisoners during
a year. This would probably require a more automated system of record-keeping,
since the present manual ledger system would make such calculations difficult.
Another problem for descriptive epidemiology is double registration of
cases. In the SIZO there is usually only a weak attempt to retrieve information
from the civil tuberculosis dispensary on previously diagnosed TB. A
number of cases are thus probably registered both in the SIZO and in
the city due to the lack of a shared public health surveillance system.
The proportion of the number of TB cases in St Petersburg SIZOs that
developed during incarceration increased [14], for example, in SIZO-1
it increased from 30% to 44% for the period 1998-1999, and for SIZO-4
- from 29% to 42% for the same time period . In both SIZOs the proportion
of cases that developed during incarceration was close to half of the
total reported cases by the end of the study period. In comparison, this
percentage in the Voronezh region of Russia was estimated to be between
6% and 10% in 1995-1999 [15]. The proportion of newly detected cases
during the stay in a SIZO is rarely presented in the literature: for
example, 26% of all TB cases in the penitentiary system of Arkhangelsk
region of Russia were detected in one of the SIZOs in 1996-1997, but
the percentage of people who developed TB while detained in these SIZOs
was not stated [17].
Undoubtedly, the situation with many prisoners awaiting trial in overcrowded
cells will contribute to spread of infection. In order to prevent violence
and conflicts within the SIZO, prisoners are also frequently moved between
cells, which will further increase the mixing of susceptible and infectious
prisoners.
Co-infection with HIV may well be another problem. The number of HIV-infected
people in the prison system has increased. In 1995 the first patient
with HIV was registered in St Petersburg. At the end of 2002 in the prison
system of the city, 113 patients were registered with HIV and TB [16].
WHO guidelines recommend sputum smear microscopy as the standard method
for TB diagnosis [18]. For economical and practical reasons, these guidelines
are not yet implemented in the Russian penitentiary system. At present,
fluorographic screening at entry to the SIZO, repeated at six-month intervals
and combined with a short-course test treatment with antibiotics is the
main method for early tuberculosis detection in this setting, especially
as the prison system in St Petersburg does not have its own TB laboratory.
Combining smear sputum microscopy with x ray would probably be the optimal
diagnostic method for screening in SIZOs. The absence of information
on previous treatment, as well as the low number of sputum cultures with
resistance testing performed, increases the risk for development of multi-drug
resistant TB during the prison stay. Of all TB cases registered in the
penitentiary system of the Russian Federation, 16-19% have positive sputum
smear, and 23% of them were multi-drug resistant in 2001 [1].
Even if tuberculosis in remand prisons in Russia constitutes a big problem,
one should realize that these institutions are often the first to offer
socially maladapted people good diagnostic facilities and adequate treatment
with antituberculosis drugs. One of us has compared the prison system
to a sieve, in which socially disadvantaged persons at high risk for
TB are found and diagnosed [Victor Sazhin, personal communication, 2002].
This study was approved by the Department of the Penal System of the
Ministry of Justice of the Russian Federation in St Petersburg and Leningrad
region. It was supported by the Swedish Committee for Eastern Europe
(ÖEK), grant N 2204.
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