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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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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
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
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.
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
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
Figure 1 Time taken between entry to prison institution to diagnosis of TB, CI: confidence
interval
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.
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).
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.
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Corresponding author
Lisa Kawatsu can be contacted at: kawatsu@jata.or.jp
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