ABSTRACT:

Objective:

This study aimed to investigate the factors associated with the outcomes of recovery and abandonment in the incarcerated population with tuberculosis.

Methods:

A quantitative and observational analytical study was performed with data from the Notification Disease Information System (Sinan), tuberculosis data from the incarcerated population in the state of Paraiba from 2007 to 2016; Notifications of individuals over the age of 18, reported as “new cases” and the outcome, “recovery” or “abandonment” status were included. Those people who until December 2016 had no outcome information were excluded. Analyses were performed using bivariate and multivariate statistics from the Poisson regression.

Results:

Of the 614 notifications, most were male (93.8%). In the bivariate analysis, there was a statistically relevant association of outcomes with Acquired Immunodeficiency Syndrome (p = 0.044), Human Immunodeficiency Virus (HIV) serology (p = 0.048) and lack of completion of follow-up bacilloscopy (p = 0.001). In the adjusted multivariate analysis, Acquired Immunodeficiency Syndrome (RR = 1.998; 95%CI 1.078 - 3.704; p = 0.028) and lack of completion of follow-up bacilloscopy (RR = 5.251; 95%CI 2.158 - 12.583; p <0.001*) remained significantly associated with the dropout outcome.

Conclusion:

Recovery and abandonment outcomes were mainly associated with whether the follow-up bacilloscopy was performed or not and Acquired Immunodeficiency Syndrome.

Keywords:
Tuberculosis; Prisoners; Therapeutics; Treatment; Risk factors

INTRODUCTION

Tuberculosis (TB) continues to be an important public health problem. The main goals discussed by the Ministry of Health (MoH) to affect its control are recovery and reducing patient treatment abandonment¹1. Sacramento DS, Gonçalves MJF. Situation of Tuberculosis in People Deprivedof Freedom in the Period 2007 To 2012. Rev Enferm UFPE2017; 11(1): 140-51. http://doi.org/10.5205/reuol.9978-88449-6-1101201717
https://doi.org/http://doi.org/10.5205/r... .

Studies carried out in Uganda and the Republic of Congo have emphasized that TB is a health problem in the prison system around the world and that many countries are facing a real outbreak of the disease in these places²2. Kayomo MK, Hasker E, Aloni M, Nkuku L, Kazadi M, Kabengele T, et al.Outbreak of Tuberculosis and Multidrug-Resistant Tuberculosis, Mbuji-Mayi Central Prison, Democratic Republic of the Congo. Emerg Infect Dis 2018; 24(11): 2029-35. http://doi.org/10.3201/eid2411.180769
https://doi.org/http://doi.org/10.3201/e... ^,33. Schwitters A, Kaggwa M, Omiel P, Nagadya G, Kisa N, Dalal S. Tuberculosis incidence and treatment completion among Ugandan prisoninmates. Int J Tuberc Lung Dis 2014; 18(7): 781-6. https://doi.org/10.5588/ijtld.13.0934
https://doi.org/https://doi.org/10.5588/... . In 2017, in Brazil, 10.5% of the new TB cases reported were in the incarcerated population (IP). The state of Paraíba had 1,031 new cases, with an incidence coefficient of 25.6 cases / 100 thousand inhabitants⁴4. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Especial tuberculose. Bol Epidemiol 2018; 49(11): 1-12..

Studies indicate that the higher incidence of TB in prisons is directly related to overcrowding conditions, poor ventilation, lighting and a high prevalence of other comorbidities at the site, factors that favor transmission⁵5. Seyedalinaghi S, Farhoudi B, Najafi Z, Jafari S, Shahbazi M. Comparing Tuberculosis incidence in a prison with the society, Tehran, Iran. Arch Clin Infect Dis 2018; E60247: 1-3. http://doi.org/10.5812/archcid.60247
https://doi.org/http://doi.org/10.5812/a... ^,66. Valença MS, Possuelo LG, Cezar-Vaz MR, Silva PEA da. Tuberculose em presídios brasileiros: uma revisão integrativa da literatura. Ciên Saúde Coletiva 2016; 21(7): 2147-60. http://dx.doi.org/10.1590/1413-81232015217.16172015
https://doi.org/http://dx.doi.org/10.159... .

In addition to incarceration being a risk factor for TB infection, infection within prisons may be linked to that of the general population, since there is a large flow of people circulating between the two environments. Thus, programs and public policies for the control of TB must consider the importance of reducing the transmission of the disease in prisons, which, consequently, may reflect in the general population⁷7. Sacchi FPC, Praça RM, Tatara MB, Simonsen V, Ferrazoli L, Croda MG, et al. Prisons as Reservoir for Community Transmission of Tuberculosis, Brazil. Emerg Infect Dis 2015; 21(3): 452-5. http://doi.org/10.3201/eid2103.140896
https://doi.org/http://doi.org/10.3201/e... ^,88. Biadglegne F, Rodloff A, Sack U. Review of the prevalence and drug resistance of tuberculosis in prisons: A hidden epidemic. Epidemiol Infect 2015; 143(5): 887-900. https://doi.org/10.1017/S095026881400288X
https://doi.org/https://doi.org/10.1017/... .

As such, it is necessary to identify positive interventions in the early diagnosis and treatment of the patient until recovery is achieved⁹9. Valença MS, Cezar-Vaz MR, Brum CB, Silva PEA da. O processo de detecção e tratamento de casos de tuberculose em um presídio. Ciên Saúde Coletiva 2016; 21(7): 2111-22. http://dx.doi.org/10.1590/1413-81232015217.13822015
https://doi.org/http://dx.doi.org/10.159... . Additionally, it is necessary to discover strategies to improve treatment outcomes and avoid drug resistance caused by recurrent abandonment of treatment³3. Schwitters A, Kaggwa M, Omiel P, Nagadya G, Kisa N, Dalal S. Tuberculosis incidence and treatment completion among Ugandan prisoninmates. Int J Tuberc Lung Dis 2014; 18(7): 781-6. https://doi.org/10.5588/ijtld.13.0934
https://doi.org/https://doi.org/10.5588/... .

For management, the proportion indicators that show an end to TB cases such as recovery, abandonment, and death reflect on the effectiveness of programs and treatment. It must be reinforced that, in order to achieve the established goals, it is necessary to get to know the IP, in order to guarantee visibility for the planning of effective measures so that, finally, a positive impact can be obtained with the general indicators¹⁰10. Macedo LR, Maciel ELN, Struchiner CJ. Tuberculose na população privada de liberdade do Brasil, 2007-2013. Epidemiol Serv Saúde 2017; 26(4): 783-94. http://doi.org/10.5123/S1679-49742017000400010
https://doi.org/http://doi.org/10.5123/S... ^,1111. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de Controle da tuberculose. Manual de recomendações para o controle da tuberculose no Brasil. 2ª ed. Brasília: Ministério da Saúde; 2019..

As such, it is essential to carry out an investigation of the factors that can contribute to recovery and abandonment outcomes in order to contribute to the planning of actions that reduce unfavorable outcomes. Given the above, the present study aims to investigate the factors associated with the outcomes of recovery and abandonment in the IP affected by TB.

METHODS

This is a quantitative, observational and analytical study, carried out based on secondary data from the Notifiable Diseases Information System (Sistema de Informação de Agravos de Notificação - Sinan), provided by the Paraíba State Department of Health, regarding the cases of TB reported in the IP in Brazil in the years from 2007 to 2016.

For the composition of the sample, notifications were included from subjects over 18 years old who entered the system as a “new case” and whose case appears as closed from “recovery” or “abandonment”. Those whose cases had not been closed by December 2016 were excluded. “New cases” were considered to be any patient who had never undergone TB treatment or who had undergone it for up to 30 days. The “recovery” closure happened when the patient had completed TB treatment, and “abandonment” occurred in cases of active TB in patients, who had stopped taking the medication for 30 consecutive days or more.

For analysis purposes, the variable “follow-up bacilloscopy” was coded to cover the performance of a follow-up bacilloscopy that should have be performed during the treatment of the patient. Based on the recommendations of the Ministry of Health, it is recommended that the patient have at least two negative bacilloscopiess, if initially bacilloscopy-free, so that can be considered recovered¹¹11. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de Controle da tuberculose. Manual de recomendações para o controle da tuberculose no Brasil. 2ª ed. Brasília: Ministério da Saúde; 2019.. Therefore, it was established, in the present study, to consider notifications that consisted of at least two bacilloscopies as “performed” and those that did not, as “not performed”.

Initially, a descriptive statistical analysis was performed, aiming to characterize the sample. Absolute and percentage frequencies were calculated for categorical variables, as well as measures of central tendency and variability for quantitative variables. Then, Pearson’s χ² test (or Fisher’s exact test, when appropriate) was used to determine the association between outcomes (recovery or abandonment) and independent variables (sex, age, education, tuberculin skin test, form, associated conditions, such as acquired immunodeficiency syndrome - AIDS - and diabetes, sputum culture, human immunodeficiency virus - HIV -, diagnostic bacilloscopy, follow-up bacilloscopy and supervised treatment). The level of significance was set at p < 0.05. Subsequently, Poisson regression analysis was performed to determine the magnitude of the associations observed in the bivariate analysis. The multivariate model was built based on the statistical significance of the variables in the bivariate analysis, as well as on the clinical and epidemiological relevance (confounding factors, such as sex, age and HIV). All analyzes were conducted with the aid of IBM SPSS Statistics software version 20.0, considering a 95% confidence interval.

The study was evaluated and approved by the Ethics and Research Committee of the Universidade Estadual da Paraíba, thus obtaining the approval report, under nº 52879215.4.0000.5187. In addition, the recommendations made in the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for observational studies were followed.

RESULTS

In the period corresponding to the study, from January 2007 to December 2016, 614 notifications of new cases from IP were made, with 93.8% (n = 576) referring to males. Sociodemographic data are shown in Table 1.

Table 2 shows the clinical profile of the subjects notified with TB during the study period, as well as the performance of tests for diagnosis and monitoring of the pathology.

According to Table 3, there was a statistically significant association between the outcomes (recovery or abandonment) and AIDS (p=0.044), HIV serology (p = 0.048) and the failure to perform follow-up bacilloscopy microscopy (p = 0.001). The abandonment rate was significantly higher among individuals with AIDS (33.3%) and those who did not undergo follow-up sputum bacilloscopy microscopy (21.2%).

According to Table 4, AIDS (relative risk - RR = 1.998; 95% confidence interval - 95%CI 1.078 - 3.704; p = 0.028) and no follow-up bacilloscopy microscopy (RR = 5.211; 95%CI) 2.158 - 12.583; p <0.001*) remained significantly associated with the abandonment outcome.

DISCUSSION

In the characterization of the study subjects, the IP proved to be formed predominantly of brown men, young adults, and individuals with eight years or less of schooling, which is in line with the national scenario of the prison system¹²12. Alves JP, Brazil JM, Nery AA, Vilela ABA, Martins Filho IE. Perfil epidemiológico das pessoas privadas de liberdade. Rev Enferm UFPE Online 2017; 11(Supl. 10): 4036-44. http://doi.org/10.5205/reuol.10712-95194-3-SM.1110sup201705
https://doi.org/http://doi.org/10.5205/r... ^,1313. Soares Filho MMS, Bueno PMMG. Demografia, vulnerabilidades e direito à saúde da população prisional brasileira. Ciên Saúde Coletiva2016; 21(7): 1999-2010. http://dx.doi.org/10.1590/1413-81232015217.24102015
https://doi.org/http://dx.doi.org/10.159... and with recent studies about TB in the IP¹1. Sacramento DS, Gonçalves MJF. Situation of Tuberculosis in People Deprivedof Freedom in the Period 2007 To 2012. Rev Enferm UFPE2017; 11(1): 140-51. http://doi.org/10.5205/reuol.9978-88449-6-1101201717
https://doi.org/http://doi.org/10.5205/r... ^,1414. Lima M da S, Martins-Melo FR, Heukelbach J, Alencar CH, Boigny RN, Ramos Júnior AN. Mortality related to tuberculosis-HIV/AIDS co-infection in Brazil, 2000-2011: epidemiological patterns and time trends. Cad Saúde Pública 2016; 32(10): 1-11. http://dx.doi.org/10.1590/0102-311X00026715
https://doi.org/http://dx.doi.org/10.159... ^,1515. Silva P da F, Moura GS, Caldas A de JM. Fatores associados ao abandono do tratamento da tuberculose pulmonar no Maranhão, Brasil, no período de 2001 a 2010. Cad Saúde Pública 2014; 30(8): 1745-54. http://dx.doi.org/10.1590/0102-311X00124513
https://doi.org/http://dx.doi.org/10.159... . The profile found draws attention to the social aggravation of the problem. The population considered is young, and affected by a disease historically laden with stigma and they are in seclusion in a phase of life where they are considered to be “economically active”.

The predominant form of TB was pulmonary, followed by extrapulmonary, which was similar to a study conducted in 2017 that evaluated the incidence of TB in IP in the country¹⁰10. Macedo LR, Maciel ELN, Struchiner CJ. Tuberculose na população privada de liberdade do Brasil, 2007-2013. Epidemiol Serv Saúde 2017; 26(4): 783-94. http://doi.org/10.5123/S1679-49742017000400010
https://doi.org/http://doi.org/10.5123/S... . The predominance of pulmonary TB in IP is concerning, since the bacillus is transmitted through the air, and overcrowding conditions, poor ventilation and lighting in prison units favor the spread of the disease.

In relation to clinical data and the management of patients during treatment, some findings stand out, such as the case of performing the directly observed treatment (DOT). In addition to the low DOT performance in prison units, flaws were found in the notifications, as many of them did not contain this information. When compared to the national literature, this data alerts to the fact that the literature refers to DOT as an important tool for reducing treatment abandonment, directly contributing to the control of the disease¹¹11. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de Controle da tuberculose. Manual de recomendações para o controle da tuberculose no Brasil. 2ª ed. Brasília: Ministério da Saúde; 2019.^,11. Sacramento DS, Gonçalves MJF. Situation of Tuberculosis in People Deprivedof Freedom in the Period 2007 To 2012. Rev Enferm UFPE2017; 11(1): 140-51. http://doi.org/10.5205/reuol.9978-88449-6-1101201717
https://doi.org/http://doi.org/10.5205/r... ^,1717. Shuhama BV, Silva LMC, Andrade RLP, Palha PF, Hino P, Souza KMJ. Evaluation of the directly observed therapy for treating tuberculosis according to the dimensions of policy transfer. Rev Esc Enferm USP 2017; 51. http://dx.doi.org/10.1590/s1980-220x2016050703275
https://doi.org/http://dx.doi.org/10.159... ^,1818. Silva CCAV, Andrade MS, Cardoso MD. Fatores associados ao abandono do tratamento de tuberculose em indivíduos acompanhados em unidades de saúde de referência na cidade do Recife, Estado de Pernambuco, Brasil, entre 2005 e 2010. Epidemiol Serv Saúde 2013; 22(1): 77-85. http://dx.doi.org/10.5123/S1679-49742013000100008
https://doi.org/http://dx.doi.org/10.512... .

When considering the existence of the prison health team (PHT) to assist the IP, a greater accomplishment of DOT was expected. However, it did not occur, raising questions about the assistance provided by the teams to enable adherence to the treatment and obtain recovery. The MoH emphasizes in its 2019 manual that DOT is an important tool for therapeutic adherence, especially in vulnerable populations¹¹11. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de Controle da tuberculose. Manual de recomendações para o controle da tuberculose no Brasil. 2ª ed. Brasília: Ministério da Saúde; 2019..

The data also point to a low coverage of tests for the diagnosis and monitoring of TB, which are recommended by the Ministry of Health, especially the tuberculin skin test. It is recommended for the detection of latent TB infection, especially in the population with HIV. Furthermore, it is considered to be a relevant tool to help in decision making for the treatment of latent TB¹¹11. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de Controle da tuberculose. Manual de recomendações para o controle da tuberculose no Brasil. 2ª ed. Brasília: Ministério da Saúde; 2019..

In view of the high prevalence of HIV in the IP¹⁹19. Sousa KAA de, Araújo TME de, Teles SA, Rangel EML, Nery IS. Fatores associados à prevalência do vírus da imunodeficiência humana em população privada de liberdade. Rev Esc Enferm USP 2017; 51: 1-9. http://dx.doi.org/10.1590/s1980-220x2016040903274
https://doi.org/http://dx.doi.org/10.159... , it was expected that greater HIV testing would be carried out, in order to assist in the early diagnosis of co-infection. Understanding the airborne transmission of the bacillus and the high occupancy rates of Brazilian prisons, which could favor a false positive in the tuberculin skin test, a study carried out in 2016 showed that the health team that works in the prison units use the chest x-rays, sputum cultures and rapid molecular tests instead⁶6. Valença MS, Possuelo LG, Cezar-Vaz MR, Silva PEA da. Tuberculose em presídios brasileiros: uma revisão integrativa da literatura. Ciên Saúde Coletiva 2016; 21(7): 2147-60. http://dx.doi.org/10.1590/1413-81232015217.16172015
https://doi.org/http://dx.doi.org/10.159... .

HIV testing was a variable included in the notification form only starting in 2014. For this reason, there is no way to know precisely, over the study period, how the exam coverage was provided. However, since this information started, low performance was observed, since testing is recommended for all patients. In a Brazilian multicenter study and in an international study, the need for greater emphasis on early diagnosis and monitoring of TB/HIV co-infection¹⁹19. Sousa KAA de, Araújo TME de, Teles SA, Rangel EML, Nery IS. Fatores associados à prevalência do vírus da imunodeficiência humana em população privada de liberdade. Rev Esc Enferm USP 2017; 51: 1-9. http://dx.doi.org/10.1590/s1980-220x2016040903274
https://doi.org/http://dx.doi.org/10.159... ^,2020. Mbu ET, Sauter F, Zoufaly A, De C Bronsvoort BM, Morgan KL, Noeske J, et al. Tuberculosis in people newly diagnosed with HIV at a large HIV care and treatment center in Northwest Cameroon: Burden, comparative screening and diagnostic yields, and patient outcomes. PLoS One 2018; 13(6): 86-96. https://doi.org/10.1371/journal.pone.0199634
https://doi.org/https://doi.org/10.1371/... ^,2121. Carbone ASS, Sgarbi RVE, Lemos EF, Paião DAG, Simionatto S, Castro ARCM, et al. Estudo multicêntrico da prevalência de tuberculose e HIV na população carcerária do Estado do Mato Grosso do Sul. Com Ciências Saúde 2017; 28(1): 53-7.is highlighted.

Another important examination is the sputum culture, which is part of the national plan to end TB. Its broad achievement was established as one of the strategies for disease control²²22. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Coordenação Geral do Programa Nacional de Controle da Tuberculose. Brasil livre da tuberculose: plano nacional pelo fim da tuberculose como problema de saúde pública [Internet]. Brasília: Ministério da Saúde ; 2017 [acessado em 26 jan. 2019]. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/brasil_livre_tuberculose_plano_nacional.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... . The studied IP did not have wide access to this test, which is worrying, since it provides bacteriological confirmation and has become a relevant tool in decision making in the treatment of the disease and in the detection of bacterial resistance²³23. Lalli M, Hamilton M, Pretorius C, Pedrazzoli D, White RG, Houben RMGJ. Investigating the impact of TB case-detection strategies and the consequences of false positive diagnosis through mathematical modelling. BMC Infect Dis 2018; 18: 1-10. https://doi.org/10.1186/s12879-018-3239-x
https://doi.org/https://doi.org/10.1186/... .

The low performance of chest X-rays is also questioned, as they have been shown to be relevant in the diagnosis of pulmonary TB in the penitentiary environment⁶6. Valença MS, Possuelo LG, Cezar-Vaz MR, Silva PEA da. Tuberculose em presídios brasileiros: uma revisão integrativa da literatura. Ciên Saúde Coletiva 2016; 21(7): 2147-60. http://dx.doi.org/10.1590/1413-81232015217.16172015
https://doi.org/http://dx.doi.org/10.159... ^,2424. Sánchez A, Larouzé B. Brasil Tuberculosis control in prisons , from research to action : the Rio de Janeiro, Brazil, experience. Ciênc Saúde Coletiva 2016; 21(7): 2071-80. http://dx.doi.org/10.1590/1413-81232015217.08182016
https://doi.org/http://dx.doi.org/10.159... . Therefore, access should be widely offered²⁵25. Navarro PD, Almeida IN, Kritski AL, Ceccato MD, Maciel MM, Carvalho WD, et al. Prevalence of latent Mycobacterium tuberculosisinfection in prisoners. J Bras Pneumol 2016; 42(5): 348-55. http://dx.doi.org/10.1590/S1806-37562016000000001
https://doi.org/http://dx.doi.org/10.159... as a screening for incoming prisoners and for the diagnosis of those who are already inmates²⁴24. Sánchez A, Larouzé B. Brasil Tuberculosis control in prisons , from research to action : the Rio de Janeiro, Brazil, experience. Ciênc Saúde Coletiva 2016; 21(7): 2071-80. http://dx.doi.org/10.1590/1413-81232015217.08182016
https://doi.org/http://dx.doi.org/10.159... .

Bi and multivariate analyzes indicate an association of AIDS with the outcomes, with greater proportions of abandonment in individuals with the disease. This relationship may be even more serious, according to a study published in 2017, which showed that a TB/AIDS co-infection can lead to death due to the health conditions of AIDS patients²⁶26. Magno E da S, Saraceni V, Souza AB de, Magno R da S, Saraiva M das GG, Bührer-Sékula S. Fatores associados à coinfecção tuberculose e HIV: o que apontam os dados de notificação do Estado do Amazonas, Brasil, 2001-2012. Cad Saúde Pública 2017; 33(5): 1-11. http://dx.doi.org/10.1590/0102-311x00019315
https://doi.org/http://dx.doi.org/10.159... .

Another association found was HIV, corroborating other studies that affirm that a ­TB/­HIV co-infection makes adherence to treatment difficult, which can cause abandonment¹⁸18. Silva CCAV, Andrade MS, Cardoso MD. Fatores associados ao abandono do tratamento de tuberculose em indivíduos acompanhados em unidades de saúde de referência na cidade do Recife, Estado de Pernambuco, Brasil, entre 2005 e 2010. Epidemiol Serv Saúde 2013; 22(1): 77-85. http://dx.doi.org/10.5123/S1679-49742013000100008
https://doi.org/http://dx.doi.org/10.512... ^,2727. Belchior ADS, Arcêncio RA, Mainbourg EMT. Diferenças no perfil clínico-epidemiológico entre casos novos de tuberculose e casos em retratamento após abandono. Rev da Esc Enferm da USP 2016; 50(4): 622-7. http://dx.doi.org/10.1590/S0080-623420160000500012
https://doi.org/http://dx.doi.org/10.159... .

Sputum bacilloscopy microscopy for diagnosis did not show a statistically significant association for the outcomes, but the exam is extremely important, as it allows for the diagnosis of bacilliferous patients, the main sources of disease transmission¹¹11. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de Controle da tuberculose. Manual de recomendações para o controle da tuberculose no Brasil. 2ª ed. Brasília: Ministério da Saúde; 2019..

Follow-up sputum bacilloscopy showed a significant association in the bi and multivariate analyzes, especially when it was observed that the proportion of abandonment was higher in patients who did not undergo the exam. The MoH recommends a monthly examination to monitor the patient’s bacillus load during treatment and points out that, in the incarceration environment, the exam is even more relevant, as it assesses the presence of bacilli and, consequently, the risk to patient contacts¹¹11. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de Controle da tuberculose. Manual de recomendações para o controle da tuberculose no Brasil. 2ª ed. Brasília: Ministério da Saúde; 2019..

In addition to the disagreement with what is recommended by the Ministry of Health, this data may raise another important issue, that periodic examination is only possible when there is monitoring and a consequent bond with the patient, which should be performed by the PHT. The bond with patients provides the professional with signs presented by patients in relation to the possibility of abandoning treatment²⁸28. Couto DS de, Carvalho RN, Azevedo EB de, Moraes MN de, Pinheiro PGOD, Faustino EB. Fatores determinantes para o abandono do tratamento da tuberculose: representações dos usuários de um hospital público. Saúde Debate 2014; 38(102): 572-81. http://dx.doi.org/10.5935/0103-1104.20140053
https://doi.org/http://dx.doi.org/10.593... .

It is also necessary to reflect on whether there are enough health and safety professionals to offer a service that provides for the creation of bonds and monthly monitoring of the patient in the prison system. It is understood that the dynamics in prisons value the security of the incarcerated and health professionals, and therefore, they rely on the support of the penitentiary agents to move in the prison environment and to guide the incarcerated individuals to the prison units. In the case of IP, care and bonding become even more important, due to the patient’s condition of vulnerability²⁹29. Santos MN de A, Sá AMM. Viver com tuberculose em prisões: O desafio de curar-se. Texto Contexto Enferm 2014; 23(4): 854-61. http://dx.doi.org/10.1590/0104-07072014000840013
https://doi.org/http://dx.doi.org/10.159... .

Monitoring during treatment needs to be carried out holistically by PHT, which, according to the National Policy for Comprehensive Health Care for Persons Deprived of Liberty in the Prison System (Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional - PNAISP), must include multiple professionals that are trained to offer prevention and treatment actions for health problems²⁸28. Couto DS de, Carvalho RN, Azevedo EB de, Moraes MN de, Pinheiro PGOD, Faustino EB. Fatores determinantes para o abandono do tratamento da tuberculose: representações dos usuários de um hospital público. Saúde Debate 2014; 38(102): 572-81. http://dx.doi.org/10.5935/0103-1104.20140053
https://doi.org/http://dx.doi.org/10.593... . PNAISP also clarifies that the subject is in a situation of deprivation of liberty and not deprevation of the right to comprehensive health care³⁰30. Brasil. Ministério da Saúde. Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional (PNAISP) [Internet] 2014 [acessado em 29 jan. 2019]. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2014/pri0001_02_01_2014.html
http://bvsms.saude.gov.br/bvs/saudelegis... ^,3131. Lermen HS, Gil BL, Cúnico SD, Jesus LO. Saúde no cárcere: análise das políticas sociais de saúde voltadas à população prisional brasileira. Physis 2015; 25(3): 905-24. http://dx.doi.org/10.1590/S0103-73312015000300012
https://doi.org/http://dx.doi.org/10.159... .

Thus, it is necessary to build effective strategies that are capable of offering an integrated, humanized and quality form of care, prioritizing actions recommended in the fight against TB, and ensuring patients’ rights and care for their health.

It is important to envision the condition of imprisonment for incarcerated individuals as a unique opportunity to intervene in the diagnosis and treatment of TB, mainly because TB is an infectious disease, so the idea is to reduce the burden of the disease inside and outside the prison units⁹9. Valença MS, Cezar-Vaz MR, Brum CB, Silva PEA da. O processo de detecção e tratamento de casos de tuberculose em um presídio. Ciên Saúde Coletiva 2016; 21(7): 2111-22. http://dx.doi.org/10.1590/1413-81232015217.13822015
https://doi.org/http://dx.doi.org/10.159... .

The main limitation of this study was the use of secondary data. However, this type of data source becomes important, especially when working on a topic as complex as TB in the IP. Secondary data, if well analyzed, has advantages, mainly due to its high coverage and low cost¹⁰10. Macedo LR, Maciel ELN, Struchiner CJ. Tuberculose na população privada de liberdade do Brasil, 2007-2013. Epidemiol Serv Saúde 2017; 26(4): 783-94. http://doi.org/10.5123/S1679-49742017000400010
https://doi.org/http://doi.org/10.5123/S... .

In addition, the definition of “follow-up bacilloscopy” adopted in the study may have influenced the results found, since there is the possibility that the subject may have abandoned treatment at any time, and it was not possible to perform at least two bacilloscopies.

The findings show that TB patients who are deprived of their liberty do not receive recommended interventions for early diagnosis, and, during the treatment of the disease, the bond between the team and the patient is superficial. The actions recommended by the Ministry of Health must be carried out by the PHT, which has professionals that are qualified for the management of the disease, such as doctors, nurses and nursing technicians.

The study contributes to the field by raising the discussion on the importance of follow-up bacilloscopy microscopy in prison units, in addition to demonstrating that monitoring and bonding during treatment are essential for achieving recovery. In this way, it contributes to the improvement of public health, with the reduction of the dissemination of the bacillus, and the control and fight against the disease in the prison system.

ACKNOWLEDGMENTS

We thank the Paraíba State Department of Health for making the data available, the Coordination for the Improvement of Higher Education Personnel (CAPES) for granting the scholarship to the author and Taise Ribeiro de Morais, in memoriam, who was part of the research project that resulted in this work.

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