1. Early TB case detection in pre-trial detention centers (SIZOs) and prison colonies in Ukraine 46 th Union World Conference on Lung Health Cape Town, South Africa December 4, 2015

2. 2000-2012: No defined TB control in the pre-trial detention system in Ukraine Pre-trial detention centers (SIZOs): fall between the prison and civil TB control systems, no improvements in TB case detection and management practices over the decades TB case detection in SIZOs: limited to fluorography screening upon entry Smear microscopy in SIZOs: indicated if fluorography or symptoms suggested active TB Follow-up algorithms for detainees with presumptive TB: poorly developed and followed TB treatment for detainees: might not become available until after sentencing, when the detainee was either transferred to a prison or civil TB hospital or released

3. May 2013: Project “Increasing TB Case Detection in the Ukrainian Detention System” Funding: Project Duration: 2013-2015 Project Geography: National Level Regional Level - Kherson, Mykolaiv and Lviv regions (intervention regions); Kirovograd and Poltava regions (control regions) Intervention Sites: 3 SIZOs and 5 prison colonies in three intervention regions

4. Project Goal: Improve the early TB diagnosis and increase the yield of bacteriologically confirmed TB cases among pre-trial detainees in SIZOs and prisoners in prison colonies in Kherson, Mykolaiv and Lviv regions, and ensure timely treatment start.

5. РАТН Project Partners  Ukrainian Center for Control of Socially Dangerous Diseases of the Ministry of Health of Ukraine  State Penitentiary Service of Ukraine  Regional Health Care Departments  Regional Civil TB Clinics  The All-Ukrainian Network of Organizations Working in the Penal System (PSN)  International Charitable Fund “Organization for Appropriate Technology in Health”

6. Intensified Case Finding: Develop and pretest among detainees and prisoners a verbal screening tool Implement systematic verbal screening for symptoms and risk factors of TB, followed by the sputum smear microscopy and further GeneXpert, culture/DST, if indicated Establish prompt referral to timely treatment. Arrest and Detention (upon entry at SIZO) X-ray screening Verbal screening for TB symptoms and risk factors by trained personnel TB symptoms (isolated) SIZO 1st level Lab: sputum microscopy, clinical examination; VCT for HIV No TB symptoms Prison or civil 3rd level Lab: GeneXpert MTB RIF examination, Bactec (liquid media) with the following DST for the 1st and 2nd line drugs Repeated TB screening in 3 months TB treatment at the civil or prison health system No TB TB

7. Year 1 Results (3 SIZOs) Across 12 months, 8,361 detainees were verbally screened upon entry ---> identification of 3,280 (39.2%) individuals with suspected TB ---> referred for further evaluation (smear microscopy, culture/DST) ---> 120 TB patients were diagnosed. This translates into a TB prevalence of 1,435 patients per 100,000 population, more than 10-fold higher than the national prevalence estimate. All TB patients were initiated on treatment in SIZO or in civil TB hospitals.

8. Year 2 Results (3 SIZOs and 5 Prison Colonies) Population 14,654 Screened 11,964 (82%) Diagnosed all forms of TB 309 осіб (7%) Confirmed TB SS+/B+ 68 cases TB symptoms 4,427 (37%)

9. Project Outcomes Early TB case detection algorithm among detainees based on the verbal screening tool with further lab diagnostic developed and implemented. Significant increase of the number of TB cases detected and referred for immediate treatment. Interruption of TB transmission inside and outside the detention and prison settings. Introduction of early TB case detection in all penitentiary institutions of Ukraine and institutionalization of the algorithm. Improved monitoring system of TB case detection in pre- trial detention centers.

10. Thank you! PATH www.path.org Kateryna Gamazina kgamazina@path.org Oleksiy Bogdanov abogdanov@path.org ICF “Organization for Appropriate Technology in Health”, Ukraine Svitlana Leontyeva sleontyeva@oath.org.ua All-Ukrainian Penitentiary Network Mykola Gagarkin p.i@mail.ru