Perguntas e respostas sobre tuberculose para educadores comunitários - Elaboração participativa de material educativo / Questions and answers about tuberculosis for community educators - Participatory development of educational material

Esta cartilha é resultado de um processo de construção participativa de material educativo entre educadores e lideranças comunitárias do Fórum TB/RJ e profissionais de saúde.

Costs and cost-effectiveness of a comprehensive tuberculosis case finding strategy in Zambia.

INTRODUCTION: Active-case finding (ACF) programs have an important role in addressing case detection gaps and halting tuberculosis (TB) transmission. Evidence is limited on the cost-effectiveness of ACF interventions, particularly on how their value is impacted by different operational, epidemiological and patient care-seeking patterns. METHODS: We evaluated the costs and cost-effectiveness of a combined facility and community-based ACF intervention in Zambia that utilized mobile chest X-ray with computer-aided reading/interpretation software and laboratory-based Xpert MTB/RIF testing. Programmatic costs (in 2018 US dollars) were assessed from the health system perspective using prospectively collected cost and operational data. Cost-effectiveness of the ACF intervention was assessed as the incremental cost per TB death averted over a five-year time horizon using a multi-stage Markov state-transition model reflecting patient symptom-associated care-seeking and TB care under ACF compared to passive care. RESULTS: Over 18 months of field operations, the ACF intervention costed $435 to diagnose and initiate treatment for one person with TB. After accounting for patient symptom-associated care-seeking patterns in Zambia, we estimate that this one-time ACF intervention would incrementally diagnose 407 (7,207 versus 6,800) TB patients and avert 502 (611 versus 1,113) TB-associated deaths compared to the status quo (passive case finding), at an incremental cost of $2,284 per death averted over the next five-year period. HIV/TB mortality rate, patient symptom-associated care-seeking probabilities in the absence of ACF, and the costs of ACF patient screening were key drivers of cost-effectiveness. CONCLUSIONS: A one-time comprehensive ACF intervention simultaneously operating in public health clinics and corresponding catchment communities can have important medium-term impact on case-finding and be cost-effective in Zambia. The value of such interventions increases if targeted to populations with high HIV/TB mortality, substantial barriers (both behavioral and physical) to care-seeking exist, and when ACF interventions can optimize screening by achieving operational efficiency.

Optima TB: A tool to help optimally allocate tuberculosis spending.

Approximately 85% of tuberculosis (TB) related deaths occur in low- and middle-income countries where health resources are scarce. Effective priority setting is required to maximise the impact of limited budgets. The Optima TB tool has been developed to support analytical capacity and inform evidence-based priority setting processes for TB health benefits package design. This paper outlines the Optima TB framework and how it was applied in Belarus, an upper-middle income country in Eastern Europe with a relatively high burden of TB. Optima TB is a population-based disease transmission model, with programmatic cost functions and an optimisation algorithm. Modelled populations include age-differentiated general populations and higher-risk populations such as people living with HIV. Populations and prospective interventions are defined in consultation with local stakeholders. In partnership with the latter, demographic, epidemiological, programmatic, as well as cost and spending data for these populations and interventions are then collated. An optimisation analysis of TB spending was conducted in Belarus, using program objectives and constraints defined in collaboration with local stakeholders, which included experts, decision makers, funders and organisations involved in service delivery, support and technical assistance. These analyses show that it is possible to improve health impact by redistributing current TB spending in Belarus. Specifically, shifting funding from inpatient- to outpatient-focused care models, and from mass screening to active case finding strategies, could reduce TB prevalence and mortality by up to 45% and 50%, respectively, by 2035. In addition, an optimised allocation of TB spending could lead to a reduction in drug-resistant TB infections by 40% over this period. This would support progress towards national TB targets without additional financial resources. The case study in Belarus demonstrates how reallocations of spending across existing and new interventions could have a substantial impact on TB outcomes. This highlights the potential for Optima TB and similar modelling tools to support evidence-based priority setting.

Assessment of delayed tuberculosis diagnosis preceding diagnostic confirmation among tuberculosis patients attending Isiolo County level four hospital, Kenya.

INTRODUCTION: delayed diagnosis of Mycobacterium tuberculosis infection leads to accelerated individual to individual transmission. This study evaluated this aspect of delayed diagnosis among patients visiting Isiolo level four hospital in northern Kenya. METHODS: this was a cross-sectional cohort study conducted during January, 2018-January, 2019 with systematically sampled 172 tuberculosis (TB) patients. Epidemiological and clinical characteristics were abstracted from records to serve as independent variables. Outcome variable was delayed diagnosis dichotomised into < 21 or > 21 days and treated as a binary outcome. Pre-tested interviewer-administered questionnaires, focused group discussions, and key informant interview guides were used to collect relevant information. RESULTS: most (n=89, 57.8%) of the TB diagnosis fell in the category of > 21 day delay. Overall, among all patients, delay in days constituted a median of 27.6, a mean of 37.3 ± 57 days (range 0-414 days). Factors associated with delayed diagnosis (happening > 21 days) included (i) use of dispensary and private health facilities, (OR=4.3, 95% CI: 1.44,13.14; P=0.009) and (OR= 4.9, 95% CI: 1.64, 14.73; P=0.004), respectively (ii) Self-employed individuals (OR=21.7, 95% CI: 2.47,190.93; P=0.006) and employed individuals (OR=9.9, 95% CI: 1.14, 85.80; P=0.038) (iii) secondary-level education (OR=0.03, 95% CI: 0.01,0.21; P=0.000) and tertiary education (OR=0.033, 95% CI: 0.01, 0.23; P=0.001). CONCLUSION: delayed diagnosis of TB was found to be associated with health-seeking behaviour of TB patients, proxied by diagnosis facility, occupation, and education levels in our study area. Curtailment of local transmission of M. tuberculosis needs intensified health promotion and education in affected communities complemented with active case findings.

Commentary: Lessons from the COVID-19 global health response to inform TB case finding.

The coronavirus disease 2019 (COVID-19) has emerged as a serious threat to global public health, demanding urgent action and causing unprecedented worldwide change in a short space of time. This disease has devastated economies, infringed on individual freedoms, and taken an unprecedented toll on healthcare systems worldwide. As of 1 April 2020, over a million cases of COVID-19 have been reported in 204 countries and territories, resulting in more than 51,000 deaths. Yet, against the backdrop of the COVID-19 pandemic, lies an older, insidious disease with a much greater mortality. Tuberculosis (TB) is the leading cause of death by a single infectious agent and remains a potent threat to millions of people around the world. We discuss the differences between the two pandemics at present, consider the potential impact of COVID-19 on TB case management, and explore the opportunities that the COVID-19 response presents for advancing TB prevention and control now and in future.

Informing Balanced Investment in Services and Health Systems: A Case Study of Priority Setting for Tuberculosis Interventions in South Africa.

OBJECTIVES: Health systems face nonfinancial constraints that can influence the opportunity cost of interventions. Empirical methods to explore their impact, however, are underdeveloped. We develop a conceptual framework for defining health system constraints and empirical estimation methods that rely on routine data. We then present an empirical approach for incorporating nonfinancial constraints in cost-effectiveness models of health benefit packages for the health sector. METHODS: We illustrate the application of this approach through a case study of defining a package of services for tuberculosis case-finding in South Africa. An economic model combining transmission model outputs with unit costs was developed to examine the cost-effectiveness of alternative screening and diagnostic algorithms. Constraints were operationalized as restrictions on achievable coverage based on: (1) financial resources; (2) human resources; and (3) policy constraints around diagnostics purchasing. Cost-effectiveness of the interventions was assessed under one "unconstrained" and several "constrained" scenarios. For the unconstrained scenario, incremental cost-effectiveness ratios were estimated with and without the costs of "relaxing" constraints. RESULTS: We find substantial differences in incremental cost-effectiveness ratios across scenarios, leading to variations in the decision rules for prioritizing interventions. In constrained scenarios, the limiting factor for most interventions was not financial, but rather the availability of human resources. CONCLUSIONS: We find that optimal prioritization among different tuberculosis control strategies in South Africa is influenced by whether and how constraints are taken into consideration. We thus demonstrate both the importance and feasibility of considering nonfinancial constraints in health sector resource allocation models.

TB transmission is associated with prolonged stay in a low socio-economic, high burdened TB and HIV community in Cape Town, South Africa.

BACKGROUND: While several studies have assessed the associations between biological factors and tuberculosis (TB) transmission, our understanding of the associations between TB transmission and social and economic factors remains incomplete. We aimed to explore associations between community TB transmission and socio-economic factors within a high TB-HIV burdened setting. METHODS: We conducted a cross-sectional molecular epidemiology study among adult patients attending a routine TB clinic. Demographic and clinical data were extracted from TB registers and clinical folders; social and economic data were collected using interviewer-administered questionnaires; Mycobacterium tuberculosis isolates were genotyped and classified as clustered/non-clustered using IS6110-based Restriction Fragment Length Polymorphism. Composite "social" and "economic" scores were generated from social and economic data. Data were analyzed using StataCorp version 15.0 software. Stratified, bivariable analyses were performed using chi-squared. Wilcoxon signed rank tests; univariable and multivariable logistic regression models were developed to explore associations in the social, economic, traditional and composite TB risk factors with TB transmission. RESULTS: Of the 505 patient Mtb  strains, 348(69%) cases were classified as clustered and 157(31%) were non-clustered. Clustered cases were more likely to have lived longer in the study community, (odds ratio [OR] = 1.05, 95% Confidence interval [C.I]:1.02-1.09, p = 0.006); in the same house (OR = 1.04, C.I: 0.99-1.08, p = 0.06); and had increased household crowding conditions (i.e fewer rooms used for sleeping, OR = 0.45, C.I:0.21-0.95, p = 0.04). Although a higher proportion of clustered cases had a low economic score, no statistically significant association was found between clustering and either the economic score (p = 0.13) or social score (p = 0.26). CONCLUSIONS: We report a novel association between Mtb transmission and prolonged stay within a high burdened community. Transmission was also associated with fewer rooms for sleeping in a household. Increased social interaction and prolonged residence in a high burdened community are important factors linked to Mtb transmission, possibly due to increased probability of higher effective contact rates. The possible importance of degrees of poverty within low socio-economic setting warrants further study.

[Tuberculosis and healthcare workers: Risk reduction and disease prevention in health care settings]. / Tuberculose et personnel soignant : prévention du risque en milieu de soins.

Tuberculosis is a human disease caused by Mycobacteriumtuberculosis, and transmitted by airborne pathway. Documented cases of tuberculosis infection in healthcare workers have been reported in both developed and developing countries. Early recognition of potentially infectious cases, immediate implementation of airborne precautions and prompt medical treatment of cases, are required to lower the risk of disease transmission. Molecular biology techniques allow earlier diagnosis. In the event of non-compliance with airborne precautions, the investigation will further have to establish exhaustive lists of potentially exposed healthcare workers and patients, looking for cases of latent tuberculosis infections whose treatment should help avoid active tuberculosis disease.

The age-specific burden and household and school-based predictors of child and adolescent tuberculosis infection in rural Uganda.

BACKGROUND: The age-specific epidemiology of child and adolescent tuberculosis (TB) is poorly understood, especially in rural areas of East Africa. We sought to characterize the age-specific prevalence and predictors of TB infection among children and adolescents living in rural Uganda, and to explore the contribution of household TB exposure on TB infection. METHODS: From 2015-2016 we placed and read 3,121 tuberculin skin tests (TST) in children (5-11 years old) and adolescents (12-19 years old) participating in a nested household survey in 9 rural Eastern Ugandan communities. TB infection was defined as a positive TST (induration ≥10mm or ≥5mm if living with HIV). Age-specific prevalence was estimated using inverse probability weighting to adjust for incomplete measurement. Generalized estimating equations were used to assess the association between TB infection and multi-level predictors. RESULTS: The adjusted prevalence of TB infection was 8.5% (95%CI: 6.9-10.4) in children and 16.7% (95% CI:14.0-19.7) in adolescents. Nine percent of children and adolescents with a prevalent TB infection had a household TB contact. Among children, having a household TB contact was strongly associated with TB infection (aOR 5.5, 95% CI: 1.7-16.9), but the strength of this association declined among adolescents and did not meet significance (aOR 2.3, 95% CI: 0.8-7.0). The population attributable faction of TB infection due to a household TB contact was 8% for children and 4% among adolescents. Mobile children and adolescents who travel outside of their community for school had a 1.7 (95% CI 1.0-2.9) fold higher odds of TB infection than those who attended school in the community. CONCLUSION: Children and adolescents in this area of rural eastern Uganda suffer a significant burden of TB. The majority of TB infections are not explained by a known household TB contact. Our findings underscore the need for community-based TB prevention interventions, especially among mobile youth.

Opportunities from a new disease for an old threat: Extending COVID-19 efforts to address tuberculosis in South Africa.

The COVID-19 pandemic and phased nationwide lockdown have impacted negatively on individuals with tuberculosis (TB) and routine TB services. Through a literature review and the perspective of members of a national TB Think Tank task team, we describe the impact of the pandemic and lockdown on TB patients and services as well as the potential long-term setback to TB control in South Africa (SA). Strategies to mitigate risk and impact are explored, together with opportunities to leverage synergies from both diseases to the benefit of the National TB Programme (NTP). With the emergence of COVID-19, activities to address this new pandemic have been prioritised across all sectors. Within the health system, the health workforce and resources have been redirected away from routine services towards the new disease priority. The social determinants of health have deteriorated during the lockdown, potentially increasing progression to TB disease and impacting negatively on people with TB and their households, resulting in additional barriers to accessing TB care, with early reports of a decline in TB testing rates. Fewer TB diagnoses, less attention to adherence and support during TB treatment, poorer treatment outcomes and consequent increased transmission will increase the TB burden and TB-related mortality. People with TB or a history of TB are likely to be vulnerable to COVID-19. Modifications to current treatment practices are suggested to reduce visits to health facilities and minimise the risks of COVID-19 exposure. The COVID-19 pandemic has the potential to negatively impact on TB control in TB-endemic settings such as SA. However, there are COVID-19-related health systems-strengthening developments that may help the NTP mitigate the impact of the pandemic on TB control. By integrating TB case finding into the advanced screening, testing, tracing and monitoring systems established for COVID-19, TB case finding and linkage to care could increase, with many more TB patients starting treatment. Similarly, integrating knowledge and awareness of TB into the increased healthcare worker and community education on infectious respiratory diseases, behavioural practices around infection prevention and control, and cough etiquette, including destigmatisation of mask use, may contribute to reducing TB transmission. However, these potential gains could be overwhelmed by the impact of increasing poverty and other social determinants of health on the burden of TB.

Contextualizing tuberculosis risk in time and space: comparing time-restricted genotypic case clusters and geospatial clusters to evaluate the relative contribution of recent transmission to incidence of TB using nine years of case data from Michigan, USA.

PURPOSE: Novel approaches must address the underlying factors sustaining the tuberculosis (TB) epidemic in the United States, specifically what maintains new Mycobacterium tuberculosis (Mtb) transmission. METHODS: Culture-confirmed TB cases reported to the Michigan Department of Health and Human Services (2004-2012) were analyzed for time-restricted genotypic and/or geospatial clustering. Cases with both types of clustering were used as a proxy for recent, local transmission. Modified, multivariate Poisson regression models were fit to estimate this prevalence in relation to various individual- and neighborhood-level demographic and socio-economic variables. RESULTS: Those individuals that were spatially clustered were 1.7 times as likely to also be time-restricted genotypically clustered. The prevalence of recent, local transmission was higher among U.S.-born cases, males, and non-Hispanic blacks. Moreover, people living in neighborhoods in the highest poverty quartile had 13.8 times the prevalence of recent, local transmission compared with those in the lowest poverty neighborhoods. CONCLUSIONS: Our results suggest geographic areas with high concentration of TB cases are likely driven by ongoing transmission, rather than enclaves of individuals who have reactivated a case of latent TB. Furthermore, efforts to continue reducing Mtb transmission in the United States, and other low-incidence settings, must better identify community-level sources of risk, manifested through the complex social interactions among people and their environments.

Hot and Cold Spot Areas of Household Tuberculosis Transmission in Southern China: Effects of Socio-Economic Status and Mycobacterium tuberculosis Genotypes.

The aims of the study were: (1) compare sociodemographic characteristics among active tuberculosis (TB) cases and their household contacts in cold and hot spot transmission areas, and (2) quantify the influence of locality, genotype and potential determinants on the rates of latent tuberculosis infection (LTBI) among household contacts of index TB cases. Parallel case-contact studies were conducted in two geographic areas classified as "cold" and "hot" spots based on TB notification and spatial clustering between January and June 2018 in Guangxi, China, using data from field contact investigations, whole genome sequencing, tuberculin skin tests (TSTs), and chest radiographs. Beijing family strains accounted for 64.6% of Mycobacterium tuberculosis (Mtb) strains transmitted in hot spots, and 50.7% in cold spots (p-value = 0.02). The positive TST rate in hot spot areas was significantly higher than that observed in cold spot areas (p-value < 0.01). Living in hot spots (adjusted odds ratio (aOR) = 1.75, 95%, confidence interval (CI): 1.22, 2.50), Beijing family genotype (aOR = 1.83, 95% CI: 1.19, 2.81), living in the same room with an index case (aOR = 2.29, 95% CI: 1.5, 3.49), travelling time from home to a medical facility (aOR = 4.78, 95% CI: 2.96, 7.72), history of Bacillus Calmette-Guérin vaccination (aOR = 2.02, 95% CI: 1.13 3.62), and delay in diagnosis (aOR = 2.56, 95% CI: 1.13, 5.80) were significantly associated with positive TST results among household contacts of TB cases. The findings of this study confirmed the strong transmissibility of the Beijing genotype family strains and this genotype's important role in household transmission. We found that an extended traveling time from home to the medical facility was an important socioeconomic factor for Mtb transmission in the family. It is still necessary to improve the medical facility infrastructure and management, especially in areas with a high TB prevalence.

Operationalization of bi-directional screening for tuberculosis and diabetes in private sector healthcare clinics in Karachi, Pakistan.

BACKGROUND: Many countries are facing overlapping epidemics of tuberculosis (TB) and diabetes mellitus (DM). Diabetes increases the overall risk of developing Tuberculosis (TB) and contributes to adverse treatment outcomes. Active screening for both diseases can reduce TB transmission and prevent the development of complications of DM. We investigated bi-directional TB-DM screening in Karachi, Pakistan, a country that ranks fifth among high TB burden countries, and has the seventh highest country burden for DM. METHODS: Between February to November 2014, community-based screeners identified presumptive TB and DM through verbal screening at private health clinics. Individuals with presumptive TB were referred for a chest X-ray and Xpert MTB/RIF. Presumptive DM cases had random blood glucose (RBS) tested. All individuals with bacteriologically positive TB were referred for diabetes testing (RBS). All pre-diabetics and diabetics were referred for a chest X-ray and Xpert MTB/RIF test. The primary outcomes of this study were uptake of TB and DM testing. RESULTS: A total of 450,385 individuals were screened, of whom 18,109 had presumptive DM and 90,137 had presumptive TB. 14,550 of these individuals were presumptive for both DM and TB. The uptake of DM testing among those with presumptive diabetes was 26.1% while the uptake of TB testing among presumptive TB cases was 5.9%. Despite efforts to promote bi-directional screening of TB and DM, the uptake of TB testing among pre-diabetes and diabetes cases was only 4.7%, while the uptake of DM testing among MTB positive cases was 21.8%. CONCLUSION: While a high yield for TB was identified among pre-diabetics and diabetics along with a high yield of DM among individuals diagnosed with TB, there was a low uptake of TB testing amongst presumptive TB patients who were recorded as pre-diabetic or diabetic. Bi-directional screening for TB and DM which includes the integration of TB diagnostics, DM screening and TB-DM treatment within existing health care programs will need to address the operational challenges identified before implementing this as a strategy in public health programs.

Those Who Don't Return: Improving Efforts to Address Tuberculosis Among Former Miners in Southern Africa.

Despite increasing awareness regarding the role of oscillating migration in the mining industry as a major driving force in the spread of tuberculosis (TB) throughout southern Africa, very little work has focused on the historical and contextual factors which may contribute to former migrant miners' present-day risk of TB. Most research regarding migration-related and occupational influences on TB has been done on current miners still employed by the mining industry. Through both a historical and contemporary lens, this paper explores and elucidates the need to address the TB epidemic among former migrant mine workers and provides considerations to improve current interventions among this critical population.

[Evaluation of tuberculosis control actions in a large Brazilian municipality]. / Avaliação de ações de controle da tuberculose em um município brasileiro de grande porte.

OBJECTIVE: To evaluate tuberculosis control actions in one large Brazilian municipality. MATERIALS AND METHODS: Quantitative, cross-sectional study, with a population (N=137) of patients with tuberculosis notified in the Sistema de Informação de Agravos e Notificação (Brazilian Case Registry Database). The final sample (n = 75) was obtained based on inclusion and exclusion criteria. The studied variables were: "health center in charge of diagnosing tuberculosis", "time elapsed since the onset of signs and symptoms until diagnosis of tuberculosis", "health center in charge of providing treatment of tuberculosis" and "type of tuberculosis treatment". Data were collected between March and July of 2015, and were obtained from structured interviews and analyzed through descriptive and analytic statistics by Chi square test method, using the R software. CONCLUSION: The study identified that tuberculosis control actions are focused on specialized services and the private network, which contributes to a late diagnosis, and hinder the interruption of disease transmission. Self-administered treatment was also observed, modality that favors the antagonistic outcome of the treatment.

Improving TB case notification in northern Uganda: evidence of a quality improvement-guided active case finding intervention.

BACKGROUND: Strategies to identify and treat undiagnosed prevalent cases that have not sought diagnostic services on their own, are necessary to treat TB in patients earlier and interrupt transmission. Late presentation for medical services of symptomatic patients require special efforts to detect early and notify TB in high risk populations. An intervention that combined quality improvement with facility-led active case finding (QI-ACF) was implemented in 10 districts of Northern Uganda with the highest TB burden to improve case notification among populations at highest risk of TB. METHODS: Using QI-ACF intervention approach in 48 facilities, we; 1) targeted key vulnerable populations, 2) engaged district and facility teams in TB systems strengthening, 3) conducted systematic screening and diagnosis in vulnerable groups (people living with HIV, fishing communities, and prisoners), and 4) trained health workers on national x-ray diagnosis guidelines for smear-negative patients. Facility-led QI-ACF meant that health care providers identified the target population, mobilized and massively screened suspects, and addressed gaps in documentation. Chest X-ray diagnosis was promoted for smear-negative TB among those suspects whose sputum examination was negative. The effect of the intervention on case notification was then assessed separately over the post intervention period. RESULTS: Over all TB case notification in the intervention districts increased from 171 to 223 per 100,000 population between the baseline months of October-December 2016 and end line month of April-June 2017. TB patient contacts had the majority of TB positive cases identified during active case finding (40, 6.1%). Fishing communities had the highest TB positivity rate at 6.8%. Prisoners accounted for the lowest number of TB positive cases at 34 (2.3%). CONCLUSION: Targeting should be applied at all levels of TB intervention to improve yield: targeting districts and facilities with the lowest rates of case notification and targeting index patient contacts, HIV clients, and fishing communities. Screening tools are useful to guide health workers to identify presumptive cases. Efforts to improve availability of x-ray for TB diagnosis contributed to almost half of the new cases identified. Having all HIV patients who were eligible for viral load provide sputum for TB screening proved easy to implement.

Contemporary women prisoners health experiences, unique prison health care needs and health care outcomes in sub Saharan Africa: a scoping review of extant literature.

BACKGROUND: Sub Saharan African (SSA) prisons have seen a substantial increase in women prisoners in recent years. Despite this increase, women prisoners constitute a minority in male dominated prison environments, and their special health needs are often neglected. Research activity on prison health remains scant in SSA, with gathering of strategic information generally restricted to infectious diseases (human immunodeficiency virus infection HIV/tuberculosis TB), and particularly focused on male prisoners. Health care provisions for women (and pregnant women) in SSA prisons are anecdotally reported to fall far short of the equivalence care standards mandated by human rights and international recommendations, and the recent agreements set out in the Southern African Development Community (SADC) Minimum Standards for HIV in Prisons. METHODS: A scoping review mapped what is currently known about women prisoners' health experiences, unique prison health care needs and health care outcomes in SSA. A systematic search collected and reviewed all available and relevant published and grey literature (2000-2017). Following removal of duplicates and application of exclusion measures, 46 records remained, which represented 18 of the 49 SSA countries. These records were subsequently charted and thematically analysed. RESULTS: Three themes were generated; 'The Prison Regime'; 'Navigating inside the Prison Health Infrastructure' and 'Accessing the outside Community and Primary Care Health Services'. Women in SSA prisons experience the same substandard nutrition, overcrowding and unhygienic conditions which exacerbate poor health and infectious disease transmission as males. Human rights abuses, substandard prison conditions and poor access to prison based and community clinical care, along with the invisible nature of women and that of their unique health needs are deplorable. CONCLUSIONS: The review has highlighted the dearth of gender specific strategic information on women prisoners in the region, appalling environmental conditions and prison health care provision, and violation of human rights for those incarcerated. Enhanced donor support, resource allocation, prison health and population health policy reform, health systems surveillance and gender sensitive prison health service provision is warranted. This will help address women prisoners' conditions and their specific health needs in SSA prisons, and ultimately bridge the gap between prison and population health in the region.