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International Journal of Prisoner Health

The profile of prisoners with tuberculosis in Japan


Lisa Kawatsu, Kazuhiro Uchimura, Makoto Kobayashi, Nobukatsu Ishikawa,
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To cite this document:
Lisa Kawatsu, Kazuhiro Uchimura, Makoto Kobayashi, Nobukatsu Ishikawa, (2018) "The profile of prisoners with
tuberculosis in Japan", International Journal of Prisoner Health, Vol. 14 Issue: 3, pp.153-162, https://doi.org/10.1108/
IJPH-03-2017-0013
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The profile of prisoners with tuberculosis
in Japan

Lisa Kawatsu, Kazuhiro Uchimura, Makoto Kobayashi and Nobukatsu Ishikawa

Abstract Lisa Kawatsu is Senior


Purpose – Although globally, prisoners are considered one of the vulnerable groups to tuberculosis (TB), little Epidemiologist at The
is known about the situation of TB in prison setting in Japan. The purpose of this paper is to examine the Research Institute of
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characteristics of TB among prisoners in Japan. Tuberculosis, Japan


Design/methodology/approach – Records of TB patients from one medical prison were analyzed in terms Anti-Tuberculosis Association,
of general demographic characteristics, clinical manifestations, risk factors and delay in diagnosis and in Tokyo, Japan.
initiating treatment, and compared with data from the national TB surveillance and other published data on Kazuhiro Uchimura is based
health of inmates, where appropriate. Continuous variables were compared using student independent
at The Research Institute
samples t-test. Proportions were compared using χ2 or Fisher exact test as appropriate. Kaplan–Meier
of Tuberculosis, Japan
survival analysis was conducted to determine the time from entry to prison institution to diagnosis of TB.
Findings – A total of 49 patients were analyzed. The mean age was 49.5 (±14.3) and 69.4 percent were Anti-Tuberculosis Association,
males. Being unemployed and homeless prior to incarceration, and several co-morbidities were potential risk Tokyo, Japan.
factors for TB (p o0.01). Analysis of diagnosis and treatment delay showed that 16.1 percent of smear Makoto Kobayashi is based at
positive patients took more than a week to be placed on treatment after being diagnosed of TB. Tama Juvenile Training School,
Approximately 50 percent of the patients were diagnosed within four months of entering the prison institution. Tokyo, Japan.
Practical implications – Several potential risk factors identified suggest the need to strengthen screening Nobukatsu Ishikawa is based
for specific sub-groups within the prison population, such as those with poor socio-economic status and at The Research Institute
co-morbidities, as well as to consider the possible role of systematic screening for latent TB infection. of Tuberculosis, Japan
Originality/value – This study presents some important data to help understand the profile of TB patients in
Anti-Tuberculosis Association,
prisons in Japan, as well as showing that a detailed epidemiological analysis of existing records can provide
Tokyo, Japan.
useful insight.
Keywords Health in prison, Public health, Correctional health care, Prisoners, Infectious disease,
Tuberculosis
Paper type Research paper

Introduction
Tuberculosis (TB) is a serious health issue in prisons all over the world. Numerous reports have
indicated that the incidence of TB among prisoners can be several times higher than that of the
general population (Angie et al., 2000; Dara et al., 2009). In prisons of low and middle-income
countries, the incidence can be up to 100 times higher than that of the general population, and
TB is also often reported as one of the most common causes of death (Reyes and Coninx, 1997).
In high-income countries too, it has been reported that prisoners are at a higher risk of acquiring
TB infection and developing the disease (Baussano et al., 2010; European Center for Disease Received 6 March 2017
Revised 31 October 2017
Prevention and Control/WHO, 2012), as well as defaulting from both treatment for active TB Accepted 16 November 2017
(Fry et al., 2005) and preventive therapy for latent tuberculosis infection (Al-Darraji et al., 2012). This research was partially funded
by the Research Program on
TB in prisons may also spread to the community at large, through prison staff, visitors and Emerging and Re-emerging
released prisoners (Niveau, 2006). One study has indicated that the transmission dynamics Infectious Diseases from Japan
Agency for Medical Research and
between the prisoner and the general population may have substantial impact on the overall development, AMED (Ref No.
population-level of TB incidence, prevalence and mortality rates (Stuckler et al., 2008). Early case 16fk0108204h0002). The funder
detection via an effective screening policy of prisoners thus has implications not only for prisoners did not play any role in the study
design, implementation and
and prison staff, but also for the general population. submission to the journal.

DOI 10.1108/IJPH-03-2017-0013 VOL. 14 NO. 3 2018, pp. 153-162, © Emerald Publishing Limited, ISSN 1744-9200 j INTERNATIONAL JOURNAL OF PRISONER HEALTH j PAGE 153
Japan is a TB middle-burden country with a notification rate of 15.4 per 100,000 population in
2014. TB is a notifiable disease under the Act on the Prevention of Infectious Diseases and
Medical Care for Patients with Infectious Diseases, and any physician who diagnoses TB is
required to report it to the local public health center. Public health centers, once they receive the
report, are requested to enter the patient data into the computerized national TB surveillance
system. The public health centers are also responsible for conducting various investigations,
including patient interviews and contact surveys. Previously, difficulties in coordinating with prison
institutions to control TB among prisoners have been pointed out – however, the situation has
gradually improved in recent years (Kawatsu and Ishikawa, 2014).
It has been estimated that notification of TB among prisoners was approximately 204.0 per
100,000 populations in 2014, 13 times higher than that of the general population in the
same year (Kawatsu et al., 2015). Reports of outbreaks in prison are not uncommon, with
“large-scale” outbreaks involving more than 20 infected cases being reported twice in 2011,
and once in 2012 ( Japan Anti-Tuberculosis Association, 2015). Health of prisoners is under
the jurisdiction of the Ministry of Justice, however, for TB control, prison institutions are now
“recommended” to cooperate and coordinate with the local public health centers in sharing the
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necessary information and conducting various investigations (Corrections Bureau, Ministry of


Justice, Japan, 2016). The aforementioned Act on infectious diseases requires prison
institutions to conduct health checks, including TB screening, once every year. However, TB
screening upon entry is not mandatory and not necessarily conducted in all prison
institutions. Several studies from other countries have indicated possible risk groups within the
incarcerated population, who may be prioritized for screening, including illegal immigrants,
alcohol and drug addicts, HIV-infected prisoners, those who have had contact with a TB patient
prior to incarceration and those with previous history of TB (Wong et al., 2008; Martin et al.,
2001; Solomon et al., 2015; Winetsky et al., 2014). However, characteristics of TB patients in
prison institutions in Japan are not well studied, and little evidence is available to guide
decision making.
This retrospective study was therefore conducted to examine the characteristics of prisoner TB
patients, who were treated for TB at one medical prison between 2009 and 2014, in Japan.
Comparison with newly notified TB patients in the general population was also made where data
were available. In assessing the potential risk factors for TB, the general incarcerated population
was used as a comparison.

Materials and method


Study setting
In 2015, there were in total 77 prisons and 111 detention centers in Japan, which together
interned approximately 60,000 prisoners. Of these, six were designated as medical prisons, nine
as sub-medical prisons and the rest as “standard” prisons with facilities for primary care only.
Thus, patients requiring treatment and care beyond the level of primary care, including TB
patients, are usually referred to either medical or sub-medical prisons, and less frequently, to
general non-prison hospitals.
Of the six medical prisons, two were for adolescents and four for adults. Two of the four medical
prisons for adults were specially designated for those with severe psychological disorders, with
the remaining two functioning as general hospitals. Two medical prisons accepted only men,
while two accepted both men and women. The study was conducted at Hachioji Medical Prison
(HMP), one of the two medical prisons serving as a general hospital. It accepts both men and
women, and being located in Tokyo, it usually, but not necessarily exclusively, receives TB
patients from prisons in central and northern parts of Japan. TB patients are usually confirmed
and diagnosed in their home institution, then transferred to HMP for treatment. There is no
standardized guideline on the conditions under which TB patients should be transferred to
medical prisons – thus, TB patients in HMP include those who are non-infectious and, in the
community, would be treated as outpatients, as well as those with advanced disease or those
with complications.

PAGE 154 j INTERNATIONAL JOURNAL OF PRISONER HEALTH j VOL. 14 NO. 3 2018


Data collection
Medical records of patients who were sent to HMP for treatment of TB between 2009 and 2014
were examined. A structured data collection form was used to extract basic demographic data,
medical history, clinical, radiographic and bacteriological findings, drug susceptibilities and risk
factors such as co-morbidities. Dates when TB was suspected for the first time, when TB was
diagnosed and when treatment was started, were also collected to calculate various potential
delays. For the purpose of our study, time between initial suspicion of TB and diagnosis was
defined as “diagnostic delay”, and between diagnosis and start of treatment as “treatment delay”.
Time between suspicion and start of treatment was defined as “total delay”. The term “suspicion”
was defined as referring to suspicion by either a nurse or a physician in the prison institution.
Data regarding newly notified TB patients in the general population was retrieved from national TB
surveillance data, and data relating to the general prison population was obtained from the
“Annual Reports on Correctional Statistics” (Ministry of Justice, Japan) and “Disease Surveys”
(Mochizuki et al., 2010). The latter had been conducted as a point prevalence survey to assess
the health status of prisoners of all prison institutions in Japan until 2008. The data from the 2008
survey was used for analysis in our report.
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Data analysis
Data were entered into Excel 2013 (Microsoft, Redmond, WA, USA) and statistical analysis was
performed using the R 3.1.3 (R Foundation for Statistical Computing, Vienna, Austria,
www.r-project.org/). Continuous variables were compared using student’s t-test for independent
samples. Proportions were compared using χ2 or Fisher exact test as appropriate. Kaplan–Meier
survival analysis was conducted to determine the time from entry to prison institution to diagnosis
of TB. Differences were considered significant at p o 0.01.

Ethics approval
As the research used pre-existing data and did not involve collection of new information, informed
consent from prisoners was not deemed necessary, according to the Ethical Guidelines for
Medical and Health Research Involving Human Subjects established by the Japanese Ministry of
Health, Labor and Welfare, and the Ministry of Education, Culture, Sports, Science and
Technology. The study protocol was reviewed and approved by the Research Ethics Committee
of the Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Japan, and the
Research Ethics Committee of HMP (ref no. IRB 25-13).

Results
A total of 49 TB patients received treatment at HMP during the study period. The mean age
of the patients was 49.5 (±14.3) and 69.4 percent were males. The basic demographic profile of
the patients is summarized and compared with that of the newly notified TB patients in the
general population between 2009 and 2014 in Table I. While the proportion of males and
foreign born were similar (69.4 vs 61.6 percent, 4.1 vs 4.7 percent), the mean age of the TB
patients from the HMP was significantly younger (49.5±14.3 vs 66.1±20.4, po 0.01), and the
proportion of those aged 70 and above lower (6.1 vs 54.2 percent), compared with patients from
the general population.
Of the 49 TB patients, 43 had pulmonary TB (PTB), four had extra-pulmonary TB (EPTB) and two
had concomitant PTB and EPTB. Table II compares the clinical and microbiological characteristics
of the 45 PTB patients from the HMP, and of the newly notified PTB from the general population
between 2009 and 2014. Among the former, 71.1 percent (n ¼ 32) and 68.9 percent (n ¼ 31) were
confirmed by smear and culture respectively. 62.2 percent presented with respiratory symptoms,
the proportion of which was slightly higher than the general population (57.6 percent), but no
statistical significance was observed (p ¼ 0.16). 20.0 and 11.1 percent presented with cavity and
extensive lung involvement, respectively – the proportions which were slightly lower than the
general population (33.6 and 15.1 percent). Again, no statistical significance was observed

VOL. 14 NO. 3 2018 j INTERNATIONAL JOURNAL OF PRISONER HEALTH j PAGE 155


Table I Demographic characteristics of TB patients in the incarcerated and the general population

TB patients at Hachioji medical prison n ¼ 49 Newly notified TB in general population 2009–2014, n ¼ 130,645
Characteristics n Proportion in % n Proportion in % p-value

Sex 0.33
Male 34 69.4 80,531 61.6
Female 15 30.6 50,114 38.4
Mean age 49.5 (±14.3) 66.1 (±20.4) o0.01
Age groups
20–69 46 93.9 58,336 44.7
70 and above 3 6.1 70,787 54.2
Nationality 1.00
Japanese 47 95.9 121,405 92.9
Foreigner 2 4.1 6,087a 4.7

Note: aExclude those whose nationality is unknown


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Table II Clinical and microbiological characteristic of pulmonary TB patients among the incarcerated and general
population (2014)
PTB patients at Hachioji Medical Prison Newly notified PTB in general population 2009–2014,
n ¼ 45 n ¼ 101,841
n Proportion in % n Proportion in % p-value

Smear o0.05
Positive 32 71.1 53,196 53.0
Negative 13 28.9 47,149 47.0
Culture 0.55b
Positive 31 68.9 70,165 68.9
Negative 6 13.3 19,347 19.0
Unknown 8 17.8 12,323a 12.1
Symptoms 0.16b
Respiratory 28 62.2 58,655 57.6
Others 3 6.7 17,323 17.0
No symptoms 8 17.8 25,189 24.7
Unknown 6 13.3 674 0.7
Cavity
Positive 9 20.0 32,961 33.6 0.48b
Negative 25 55.6 64,965 66.3
Unknown 11 24.4 89 0.1
Lung involvement
Extensive 5 11.1 14,824 15.1 1.00b
Non-extensive 29 64.4 82,144 83.8
Unknown 11 24.4 1,047 1.1
DST results n ¼ 31 n ¼ 59,982 0.98b
Susceptible 22 71.0 51,168 85.3
INH resistance 1 3.2 2,337 3.9
RFP resistance 0 0.0 171 0.3
INH/RFP resistance 0 0.0 419 0.7
Other resistance 2 6.5 3,563 5.9
DST unknown/not done 6 19.4 2,324 3.9

Notes: PCR, polymerase chain reaction; DST, drug sensitivity test; INH, isoniazid; RFP, rifampicin. aInclude under examination, examination
discontinued, not examined and unknown. bExcludes unknown

( p ¼ 0.48, p ¼ 1.00). There were no statistically significant differences in terms of the proportion
of those with drug susceptibility between the patients from the HMP and the general population
(71.0 vs 85.3 percent, p ¼ 0.98). Among the former, there were no multi-drug-resistant cases,
however, of the 31 culture confirmed cases, 6 were without DST results.

PAGE 156 j INTERNATIONAL JOURNAL OF PRISONER HEALTH j VOL. 14 NO. 3 2018


Table III compares the socio-economic background of the 49 TB patients and the newly incoming
prisoners between 2009 and 2014, and also the underlying co-morbidities with the study
population of the Disease Survey conducted in 2008. The proportions of those unemployed and
without a permanent address prior to incarceration among the prisoner TB patients were
significantly higher than that of the newly incoming prisoners. Similarly, the proportions of those
with diabetes mellitus, malignancy, drug addiction and psychological disorders, (depression and
mood disorder) were significantly higher among the prisoner TB patients.
Information on delay was available for 48 of the 49 TB patients. Table IV summarizes the different
types of delay by the result of smear examination. The median duration of diagnostic delay,
treatment delay and total delay was higher among smear positive than smear negative patients.
Diagnostic delay mainly contributed to the total delay. However, even among the smear positive
patients, treatment delay ranged from 0 to 24 days, with 16.1 percent of the patients taking more
than a week to be placed on treatment after being diagnosed of TB.
Finally, Figure 1 shows the results of the Kaplan–Meier survival analysis of all 49 patients.
Approximately 50 percent of the patients were diagnosed within four months, and 90 percent
within 1.8 years of entering the prison institution.
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Discussion
General profile of prisoner TB patients
To our knowledge, only three studies have been published in the past on the profile of TB patients
in prison institutions in Japan, two of which were conference abstracts and one a full report, but

Table III Possible risk factors for tuberculosis in the incarcerated population
TB patients (n ¼ 49) Newly incoming prisoners 2009–2014 (n ¼ 150,272)
Risk factors n Proportion in % n Proportion in % p-value
Employment status prior to incarceration o0.05a
Employed 7 14.3 47,056 31.3
Unemployed 41 83.7 103,176 68.7
Unknown 1 2.0 61 0.0
Housing status prior to incarceration o0.01
No permanent address 21 42.9 31,953 21.3
Own/family house 22 44.5 n/a n/a
Hotels, saunas, etc. 1 2.0 n/a n/a
Others 5 10.2 n/a n/a
History of incarceration 0.98
Yes 24 49.0 74,858 49.8
No 25 51.0 74,320 49.5
Smoking prior to incarceration
Yes 29 64.4 n/a n/a n/a
No 5 10.2 n/a n/a n/a
Unknown 15 30.6 n/a n/a n/a
Excessive drinking prior to incarceration
Yes 10 20.4 n/a n/a n/a
No 24 49.0 n/a n/a n/a
Unknown 15 30.6 n/a n/a n/a
Previous history of TB n/a n/a n/a
Yes 8 16.3 n/a n/a n/a
No 40 81.2 n/a n/a n/a
Unknown 1 2.0 n/a n/a n/a
TB patients (n ¼ 49) Disease survey 2008 (n ¼ 80,070) p-value
Underlying co-morbidities n Proportion in % n Proportion in %
Diabetes mellitus 8 16.3 2166 2.6 o0.01
Malignancy 2 4.1 269 0.3 o0.01
Drug addiction 16 32.7 2075 2.9 o0.01
Psychological disorders 8 16.3 1138 1.3 o0.01

Notes: n/a: data not available. aExcludes unknown

VOL. 14 NO. 3 2018 j INTERNATIONAL JOURNAL OF PRISONER HEALTH j PAGE 157


Table IV Different types of delay, by smear examination result

Smear positive n ¼ 31 Smear negative n ¼ 17 Total

Diagnostic delay, d
Median (IQR) 6 (1.3–23.5) 28 (8.5–72.0) 9 (3.0–35.0)
Range 0–182 0–538 0–538
Treatment delay, d
Median (IQR) 4 (2.0–7.8) 8 (6.3–10.5) 5 (2.0–8.3)
Range 0–24 0–20 0–24
Total delay, d
Median (IQR) 11 (6.0–26.0) 34 (14.5–74.0) 15 (7.8–43.3)
Range 0–187 6–545 0–545

Notes: d, day; IQR, interquartile range


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Figure 1 Time taken between entry to prison institution to diagnosis of TB, CI: confidence
interval

1.0 Survival curve


95% CI

0.8

0.6

0.4

0.2

0.0

0 2 4 6 8 11 14 17 20 23 26 29 32 35 38 41 44 47 50 53 56 59
Entry to Diagnosis[months]

all written in Japanese (Nishimori et al., 1997; Yamashita et al., 1998; Koda et al., 2001).
Compared with the TB patients in the general population, prisoner TB patients were much
younger. The mean age of our study population was 49.5, which was similar to those reported by
the abovementioned three studies, at 50.5, 46.9 and 47.0, respectively. On the other hand, the
proportion of patients aged 70 and above was higher in our study compared to the study by
Koda and colleagues back in 2001 (6.1 vs 2.0 percent) (Koda et al., 2001). This may partially be
explained by the aging trend in the general incarcerated population, which has accelerated
especially in the past decade or so. Between 2005 and 2014, the proportion of those aged 70
and above among the general prison population has increased by 2.9 times, from 1.8 to
5.2 percent (Ministry of Justice, Japan).
Information relating to the proportion of foreign born among TB patients is not reported in
previous studies; however, considering that approximately 5 percent of newly incoming prisoners
are foreign born, it is reasonable to assume that our result was within the expected range. Among
the general population, the proportion of foreign-born patients can be quite high especially in the
younger age groups – in 2014, as many as 44.1 percent of newly notified TB patients aged 20–29
were foreign born (Tuberculosis Surveillance Center (1), 2016a, b) – and it would not be surprising
to find a similar trend among the incarcerated population. However, as we only observed two
foreign-born patients among our study population, it was not possible to discuss the proportion
of foreign-born patients by age groups.

PAGE 158 j INTERNATIONAL JOURNAL OF PRISONER HEALTH j VOL. 14 NO. 3 2018


Sex ratio is not reported in previous studies; however, the annual reports show that the proportion
of female TB patients have constantly been less than 10.0 percent. The relatively higher proportion
of females in our study is most likely due to female TB patients being concentrated at HMP, as it is
the only institution which can receive female patients in central Japan.
No previous studies reported on the results of microbiological testing, however, Koda and
colleagues have concluded that among the 50 PTB patients in their study, as only 26 percent
presented with cavity and 2 percent with extensive lung involvement, the majority of TB among
the prisoners was at a non-severe stage (Koda et al., 2001). They argue that this may be
attributable to opportunities for early detection at entry and annual health checks. However, as
mentioned earlier, a chest X-ray is only routinely conducted at all prison institutions in annual
health checks, but not upon entry. Comparison with the general population indicated no
significant difference, and thus evidence suggesting that prisoner TB patients are detected at a
less severe stage than the TB patients in the general population is weak.
A recent systematic review has reported high levels of drug-resistant TB, including
MDR-TB and XDR-TB, worldwide (Biadglegne et al., 2014), and also among the countries of
the European region (Aerts et al., 2006). In the UK, for example, isoniazid resistance and MDR
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among prisoners between 2004 and 2007 was reported to be 35 and 1 percent respectively,
the former being approximately five times higher than that of the general population
(Aerts et al., 2006). On the other hand, the rate of drug resistance was relatively low among
prisoner patients in our study, at 3.2 percent for isoniazid resistance and 6.5 percent for
resistance to drugs other than isoniazid and/or rifampicin, and not significantly different from
that of the general population. The difference may partially be explained by the fact
that in the UK, like many other industrialized countries, almost half of the prison population are
non-natives and come from countries with a high burden of TB and drug-resistant TB.
However, as mentioned above, the proportion of foreign born among prisoners in Japan
is still comparatively small, and the burden of drug-resistant TB among patients born in
Japan is not high (Tuberculosis Surveillance Center, 2016b).

Risk factors for TB among the incarcerated population


Several studies have examined prisoners’ socio-economic background including factors such as
employment status and homelessness, as risk factors for TB infection. However, the results were
variable with some indicating association (Hanau-Berçot et al., 2000) and others not (Adib et al.,
1999). Other studies have reported on the socio-economic background of prisoner TB patients
(Porsa et al., 2006; Al-Darraji et al., 2014) but none from Japan, and none have examined
potential risk factors for TB disease. Our results have suggested that those among the prison
population who were unemployed or were without a permanent address prior to incarceration,
may be at a higher risk of TB. Our results are more or less in line with a previous ecological study,
which indicated that the proportion of those homeless and those unemployed prior to
incarceration among newly incoming prisoners was positively associated with TB incidence in
prisons (Kawatsu et al., 2015). We have also identified certain co-morbidities as being potential
risk factors – these findings could be used to identify high-risk groups within the prison population
for effective screening.

Delay among prisoner TB patients


It has generally been recognized that delay can be a serious issue in prison settings
(Vinkeles Melchers et al., 2013). However, to our knowledge, no study has been published which
has actually specifically investigated delay among the prison population. According to our results,
diagnostic delay was the main contributor to total delay, which was longer among the sputum
smear negative patients. Considering the time generally taken to diagnose sputum smear
negative patients, these results are understandable. Looking at the median values, however, even
among sputum smear negative patients, it took 28 days to diagnose a case, which is a very
reasonable performance.
What may be of more concern is the treatment delay, which ideally should be non-existent.
However, our results have indicated a median delay of 4 and 8 days for sputum smear positive

VOL. 14 NO. 3 2018 j INTERNATIONAL JOURNAL OF PRISONER HEALTH j PAGE 159


and negative patients respectively, with some taking almost 3 weeks to start their treatment.
A detailed case study, which was beyond the scope of this study, may be necessary to identify
possible causes of such treatment delay.

Time taken between entry to prison institution to diagnosis of TB


The results of the Kaplan–Meier survival analysis indicated that a considerable proportion of
prisoner TB patients may have been infected prior to being incarcerated, and points to the
possible role of screening for latent TB infection (LTBI) upon entry. A systematic review on
the prevalence of LTBI among the incarcerated population has shown that average prevalence
of LTBI among middle and high-burden countries was 73.0 percent, and among low-burden
countries, 40.3 percent (Kawatsu et al., 2016). One study has also reported the results of an
experimental entry screening program, which was conducted in one prison institution in Japan
for newly incoming prisoners using QuantiFERON-TB Gold, with a positive rate of 20 percent
(Ushiyama et al., 2012). Although systematic screening for LTBI is not routinely conducted
in Japan, serious discussions ought to start on the possible yield and cost-effectiveness of
LTBI screening upon entry, and on the treatment guidelines for LTBI among the
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incarcerated population.

Study limitations
Our study was limited by the relatively small number of the study population, and
thus the results may not be entirely generalizable to the entire prison population. On the
other hand, considering that the study results were comparable with previous studies, and also
the fact that the study population included both severe and less severe cases, it seems
reasonable to conclude that our study results provide a general insight into the profile
of TB patients in prison institutions in Japan. Furthermore, the study was retrospective in design
and thus was prone to limitations typical of such studies, including lack of some key
statistics, inferior level of evidence, recall and misclassification bias and inability to establish a
causal relationship.
HIV/AIDS was not discussed in our study, which is one of the major health issues
among the incarcerated population globally (WHO, 2014). In Japan, HIV testing is not a
mandatory component of either the entry or annual health check, and no data regarding HIV
infection rate and AIDS among prisoners is made public. No guidelines exist regarding
HIV testing and counseling among prisoners, however, one study has suggested that
opportunities for such support are likely to be limited among the prison population in
Japan, and recommended HIV screening for those at high risk, such as injecting drug users
(Fujikawa et al., 2014).
It was also not possible to discuss the treatment outcome of the patients included in our study.
This is due to two factors: first, prison institutions in Japan, including HMP, are not required, and
in general do not, follow up on those prisoners released while still on TB treatment, and thus
treatment outcomes are not recorded in the patient medical record. Second, history of
imprisonment is not collected under the current TB surveillance system – thus, cohort analysis of
TB among prisoners in Japan is not possible.

Conclusion
A detailed epidemiological analysis of patient records can provide fruitful insight as well as
identify possible issues. Our results showed that prisoner TB patients tended to be younger
compared to the newly notified TB patients in the general population in Japan. Clinical and
radiographic characteristics were similar and we did not find evidence to indicate that prisoner
TB patients were at a more progressed stage upon diagnosis, or otherwise. Being
unemployed, and being homeless prior to incarceration, as well as several co-morbidities, were
potential risk factors for TB and indicated strengthening screening for specific sub-groups
within the prison population. A possible treatment delay was indicated, which may be further
investigated through case studies.

PAGE 160 j INTERNATIONAL JOURNAL OF PRISONER HEALTH j VOL. 14 NO. 3 2018


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toukei/toukei_ichiran_kousei.html (accessed December 5, 2016).

Corresponding author
Lisa Kawatsu can be contacted at: kawatsu@jata.or.jp

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