The use of tobacco and illegal drugs was prevalent among PDL diagnosed with TB, and an ascending trend was verified for alcohol, tobacco, and illegal drugs in prison facilities. The highest RR was found in the prisons located in the east macro-region (metropolitan region of Curitiba), showing that prisons contribute to TB burden and are an environment that favors the disease, considering a large number of alcohol consumers and drug users [5, 7, 9, 19, 20].
Note that the medical center providing care to prisoners is located in the east macro-region, which explains the high number of TB cases in this area. Data suggest that the availability of medical services indicates PDL have access to healthcare services, and the high rates of outpatient care consultations and hospitalizations suggest the quality of these individuals’ health conditions [21].
It is worth noting that in 2003 the Ministry of Health, together with the Ministry of Justice, launched the National Health Plan for the Prison System and in 2014 established the National Policy for Integral Health Care for Persons Deprived of Liberty in the Prison System to promote health and prevent diseases in the prison system and ensure PDL access integral and quality health care provided by the Brazilian Unified Health System [22].
However, a high number of TB cases is observed among PDL, mainly pulmonary TB, which is of concern considering that the bacillus is airborne and the prisons’ conditions such as overcrowding and poor ventilation favor the dissemination of TB [23]. Therefore, efficient public policies intended to provide health care to PDL.
PDL include socially vulnerable people affected by different diseases,[22] among which dependency on alcohol, tobacco, and illegal drugs stand out. Even though alcohol and tobacco consumption decreased in the population in general, there was a significant increase in the number of smokers and drug users among PDL [19]. Studies report that approximately 80% of the PDL in the United States have a history of illegal drug use [20]. One study was conducted in Norway to investigate drinking habits before imprisonment, reporting that 55% of the prisoners presented alcohol problems of some severity, and 18% were possibly alcohol dependent [24]. Not much data are available in Brazil and research in the field is still incipient considering the difficulty in discussing this phenomenon in public security institutions [25].
Hence, the consumption of legal or illegal Psychoactive Substances (PS) within prisons contributes to an increase in the number of diseases, and as this study shows, contributes to the development and maintenance of TB [26, 27]. Furthermore, these substances not only contribute to the development of TB but lead to unfavorable treatment outcomes, considering that PS is associated with higher rates of mental disorders, suicide, mortality, relapse after release [28], and violence within prisons.
The consumption of PS favors the development of diseases among PDL 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 attempt, self-injury behaviors, accommodation in single-occupancy cells, and conviction due to violent crimes [29].
The prisons’ social, spatial factors directly contribute to the maintenance of TB and other diseases considering many prisons are overcrowded, present high turnover of PDL, are poorly ventilated, and access to health services is restricted [30].
PDL live in an unhealthy environment with poor hygiene conditions, which often fail to ensure basic human needs to protect one’s physical and mental health, directly contributing to disseminating transmissible diseases, violence-related injuries, and mental disorders [31]. These are characteristics observed in the east, north, and northwest macro-regions, which host risk areas for total TB and TB associated with alcohol, tobacco, and illegal drugs. Note that the west macro-region did not present any risk area for TB associated with PS.
The identification of risk prison facilities for the development of TB associated with PS consumption can support the implementation of preventive measures and quality health care, especially in those facilities with a large number of prisoners, that is, facilities exposed to a higher risk. However, there is usually a delay in the TB diagnosis, with a high prevalence of resistant bacteria, inadequate treatment and treatment abandonment, low educational level, malnutrition, mental disorders, previous diseases, TB-HIV co-infection, alcohol, tobacco, and/or illegal drugs consumption/dependency [5, 6, 32].
Therefore, prisons are a reservoir of various diseases, especially infectious-contagious diseases such as TB. The community is also exposed to TB when contacting prison officers, released prisoners, or families visiting prisoners. Hence, the prison environment promotes the incidence and maintenance of TB, and health actions are needed to break the transmission cycle and decrease the number of new cases and deaths [30].
Time trend analysis showed TB increased among PDL consuming alcohol, tobacco, or illegal drugs, which is similar in the general population. The fact that the consumption of these substances has increased worldwide is of concern, considering it is associated with worsened TB treatment outcomes [21, 23].
Therefore, a screening protocol should be implemented in the prison system to identify SP consumption and TB and invest and give priority to early diagnosis and interventions, providing appropriate treatment to avoid interruptions and relapses [30].
Achieving the goals established by the End TB Strategy and eradicating TB by 2050 will only be possible by investing in preventive measures and appropriate TB treatment. Therefore, one of the most difficult challenges is to control the progress of the disease among subpopulations presenting high incidence rates, such as PDL [33]. In this sense, PDL is a social stratum at a higher risk of TB, [7] and strategies are needed to decrease the transmission of the disease and achieve the global goals.
In this sense, the WHO recommends measures be implemented in prisons to prevent new cases, including screening protocols applied in the admission and discharge of inmates, in addition to periodical assessments of PDL or isoniazid preventive therapy [2]. Routinely screening prisoners, isolating confirmed cases, decreasing the number of inmates in a single cell, and avoiding agglomerations are efficient ways to decrease transmissions among prisoners, prison officers, families, and the community [7].
Programs intended to obtain early diagnoses, the report of new cases, and the implementation of proper treatment are vital. However, the access of PDL to health services is restricted, resulting in unfavorable outcomes and high rates of TB.