CARGA DA TUBERCULOSE NAS COMUNIDADES ATRIBUÍVEL ÀS PRISÕES POR MEIO DE NOVOS MODELOS DE ANÁLISE DA TRANSMISSÃO DO CONTÁGIO, COM INFORMAÇÕES QUE INCORPORAM DADOS GENÔMICOS E EPIDEMIOLÓGICOS CLÍNICOS DE CASOS DE TUBERCULOSE NO PARAGUAI

Abstract

The recent increase in tuberculosis cases in Paraguay and their concentration in prisons highlight the urgency of targeting strategies to interrupt transmission and prevent new infections in these settings. However, the role of prison populations and institutions in transmission is still unknown. Objective: To estimate the burden of tuberculosis in communities attributable to prisons in Paraguay, using new models for analysing transmission and directionality of infection, with information incorporating genomic, clinical epidemiological and demographic data for each case. Methodology: Specific methodological approaches were applied in each published manuscript. Regarding the first article, this is an observational and descriptive study that included all tuberculosis cases notified to the National tuberculosis Control Programme in Paraguay between 2009 and 2018, in addition to records of tuberculosis cases in prisoners from the Ministry of Justice. The population attributable fraction of tuberculosis in the community due to incarcerated cases was estimated using the Levin formula. The characteristics of tuberculosis cases inside and outside prison were compared, looking at the evolution of tuberculosis in prisons over time. The second article is a review of tuberculosis data for Central and South America, from 2011 to 2017, in persons deprived of liberty, using publicly available data from 19 Latin American countries. Finally, regarding the third article, genomic surveillance was conducted in the Central, Capital District and Alto Paraná departments, which represent half of the country's population. Sputum samples were collected and sent to the reference laboratory of the National Tuberculosis Control Programme for diagnosis and sequencing. Results: Regarding the first article of the 28,534 tuberculosis cases reported in Paraguay during 2009-2018, 2764 (9.7%) occurred in prisons. The number of prisoners increased from 6258 in 2009 to 14,627 in 2018, while tuberculosis cases in prisoners increased by 250%. The tuberculosis notification rate among male prisoners ranged from 3218 to 3459 per 100,000 prisoners in 2009 and 2018. The relative risk of tuberculosis in prisons compared to the community was 70.3 (95% CI, 67.7-73.1). Regarding the second article, in both Central and South America, the increase in disease among incarcered population more than offsets the gains in tuberculosis control in the general population. tuberculosis is increasingly concentrated among incarcered population; currently, 11% of all tuberculosis cases reported in Central and South America are among incarcered population, who represent less than 1% of the population. Finally, in the third article, we sequenced 471 M. tuberculosis genomes from incarcered population and urban areas, finding evidence of frequent and recent transmission within prisons and between prisons and neighbouring communities. Conclusions: Our findings show that the tuberculosis epidemic in prisons represents one of the most important challenges for tuberculosis control in Paraguay, especially in the country's largest cities. It highlights the urgency of strengthening tuberculosis control programmes to reduce the risk of transmission inside prisons in Paraguay, where incidence was 70 times higher than outside prisons in 2021.