INT J TUBERC LUNG DIS 11(11):1216–1220 © 2007 The Union Tuberculosis and multidrug resistance in Zambian prisons, 2000–2001 C. Habeenzu,* S. Mitarai,* †‡ D. Lubasi,* V. Mudenda,* T. Kantenga,* J. Mwansa,* J. N. Maslow § * Department of Pathology and Microbiology and Department of Medicine, University Teaching Hospital, Lusaka, Zambia; † Japan International Cooperation Agency, Tokyo, Japan; ‡ TB Laboratory of the University Teaching Hospital, Center for Infectious Diseases, Lusaka, Zambia; § Section of Infectious Diseases, Veterans Affairs Medical Center and SUMMARY the Division of Infectious Diseases University of Pennsylvania, Philadelphia, Pennsylvania, USA BACKGROUND: Data on prevalence of tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB) in Zam- bian prisons are lacking. METHODS: Between January 2000 and July 2001, a case- finding study was performed in 13 Zambian prisons for pulmonary TB. Prisoners were administered a question- naire to obtain demographic information. Information re- garding housing density and diet was also collected. Three consecutive first morning sputum specimens were cultured for Mycobacterium tuberculosis. Antimicrobial resistance testing was performed by the resistance ratio method. RESULTS: A total of 1080 prisoners were recruited: 1055 were males and 25 females. Sputum from 245 (22.7%) prisoners yielded M. tuberculosis, including 168 (15.6%) with smear-positive disease. Based on a total prison pop- ulation of 6118, the minimal prevalence of TB was 4.0%. There was a linear relationship between the proportion of prisoners evaluated and the prevalence of TB (R 2  0.9366) across facilities, suggesting that the true preva- lence of TB may approach 15–20%. Resistance to at least one anti-tuberculosis drug was detected for 40 (23.8%) isolates, while MDR-TB was identified for 16 (9.5%) isolates. CONCLUSION: There is a high rate of pulmonary TB in Zambian prisons, with significant rates of drug resis- tance and MDR-TB, highlighting the need for active sur- veillance and treatment programs. KEY WORDS: prisons; tuberculosis; surveillance; Zambia OVER THE PAST DECADES increasing global at- tention has been paid to the problem of tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB, defined as resistance to both isoniazid [INH] and ri- fampicin [RMP]). In the developing world, especially in African nations, the challenges associated with ade- quate diagnosis and treatment have resulted in burgeon- ing case rates as well as increasing rates of MDR-TB. TB case rates have increased in many sub-Saharan countries despite directly observed treatment and sur- veillance (DOTS) programs. 1,2 Over the past 20 years, case rates in Kenya, Malawi, Mozambique and Tan- zania have doubled or tripled, while rates in Zambia and Zimbabwe have increased by respectively 5- and 8-fold. 1,3,4 With a baseline prevalence two to three times that of other sub-Saharan nations, TB poses an espe- cial problem for Zambia. 3 High rates of TB are observed among those re- manded to the penal system in large part due to home- lessness, poverty and drug use. 5 The added problems of overcrowding, malnutrition and non-ideal medical care increase the risk of reactivation, spread of infection to other inmates and rapid progression of disease. 5,6 Exacerbating the risk for disseminated infection and transmission are high rates of human immunodefi- ciency virus (HIV) co-infection and low treatment completion rates. 5,6 The prevalence of TB among prisons in sub-Saharan countries is largely unknown. Malawi and Cote d’Ivoire have developed tracking and treatment programs for their prisons, with a prevalence of infection reported at 4–5% for Malawi’s 22 prisons 7,8 and 5.8% among prisoners in a single prison in Cote-d’Ivoire. 9 Data are, however, lacking for other countries. In the present study, the prevalence of undiagnosed TB was determined for 13 Zambian prisons. A risk factor analysis was performed to determine whether different prisons had different rates of detection, and the role of longer incarceration periods and socio- economic status, sex and age. Isolates were tested to determine rates of resistance to anti-tuberculosis drugs. METHODS Study population Thirteen of Zambia’s 53 prisons participated in this study; of these, 10 had onsite medical clinics. Recruited subjects were interviewed to complete a structured Correspondence to: Joel Maslow, Veteran Affairs Medical Center, University and Woodland Aves, Philadelphia, PA 19104, USA. Tel: (+1) 215 823 4307. Fax: (+1) 215 823 5171. e-mail: joel.maslow@va.gov Article submitted 24 April 2007. Final version accepted 25 July 2007.