Tuberculose ativa e latente na população privada de liberdade : prevalência, perfil epidemiológico e avaliação de tecnologias diagnósticas.

Abstract

Introduction: Tuberculosis (TB) remains a major public health problem, especially in prisons, where incidence is more than 22 times higher than in the general population (GP). Active case finding has shown high effectiveness in increasing detection and reducing incidence. Overall objective: To estimate the prevalence of active and latent tuberculosis among people deprived of liberty (PDL), to characterize their sociodemographic and epidemiological profile, and to evaluate diagnostic technologies used in the prison context. Manuscript 1: Objective: To assess the occurrence of active tuberculosis and latent infection, as well as associated factors, in a male prison in southern Brazil using a systematic screening strategy. Methods: A cross-sectional study with mass screening was conducted, including symptom assessment, digital chest X-ray with automated interpretation using artificial intelligence (LunitTB), and molecular testing with GeneXpert MTB/RIF. Latent TB infection was evaluated using the interferon-gamma release assay (IGRA). Sociodemographic, clinical, and behavioral variables were analyzed. Results: Of the 677 eligible individuals, 652 (96.3%) completed screening, and 120 underwent IGRA testing. The prevalence of active TB was 4.7%, and 62% of those tested had latent infection. TB occurrence was associated with contact with a TB case within the same cell, problematic alcohol use, and symptoms such as weight loss, chest pain, and night sweats. Chest X-ray combined with artificial intelligence showed good performance in case identification. Conclusion: Findings reveal a high burden of TB and latent infection in the prison setting, reinforcing the importance of active screening. The integration of chest X-ray, artificial intelligence, and molecular testing proved effective in increasing case detection, including cases that would likely not be identified by symptom-based strategies alone. Manuscript 2 Objective: To evaluate the performance of diagnostic tests for TB in the general population (GP) and people deprived of liberty (PDL) across four Brazilian states. Methods: An ecological study was conducted using data from the Brazilian Notifiable Diseases Information System (SINAN), including new pulmonary TB cases reported between 2017 and 2023 in the states of São Paulo, Rio Grande do Sul, Espírito Santo, and Goiás. Variables included sociodemographic characteristics and the use of sputum smear microscopy, sputum culture, rapid molecular testing (RMT), and chest X-ray. Descriptive and inferential analyses were performed using Pearson’s chi-square test, with post-hoc analysis based on adjusted standardized residuals. Results: A total of 103,956 cases were analyzed, of which 82.1% were in the GP and 17.9% in the PDL. The PDL group had a higher proportion of young men, individuals of mixed race (brown), and lower educational levels. The GP showed higher use of sputum smear microscopy and chest X-ray, while the PDL had proportionally greater use of RMT and sputum culture. Despite the high TB incidence in the PDL, access to diagnostic technologies was similar to that of the GP. The mean time between diagnosis and treatment initiation was also similar between groups. Conclusion: Sociodemographic and territorial inequalities in TB diagnosis persist. Differences in the use of diagnostic tests between GP and PDL are small when considering the disproportionate disease burden in prisons, highlighting inequities in the organization of care and reinforcing the need for equity-oriented strategies in TB control. Overall conclusion: The adoption of an integrated screening strategy combining computer-aided digital chest X-ray and rapid molecular testing revealed a high hidden burden of TB in the prison system. These findings demonstrate that reactive, symptom-based models are insufficient, that structural inequalities affect access to diagnosis, and that systematic, equitable, and targeted expansion of diagnostic technologies is essential to interrupt transmission within prisons and reduce its impact on the broader community.