Incarceration and TB: the epidemic beyond prison walls

Correspondence to Dr Alberto L Garcia-Basteiro; alberto.garcia-basteiro@manhica.net Globally, incarceration is a well-documented risk factor for Mycobacterium tuberculosis infection and tuberculosis (TB) disease.1 Persons deprived of liberty (PDLs) in Latin America (LA) experience incidence rates of TB that are 26 times higher (95% CI 17.1 to 40.1) than those in the general population, and this disparity is the largest in the world.2 Over the last decade, the prison population in LA has more than doubled, which now has some of the highest incarceration rates in the world, has not been accompanied by concomitant improvements in physical or healthcare infrastructure, creating conditions for intensified TB transmission.3 4 The heightened risk of TB has long been a part of the sentence received by PDLs.5 Every year that a PDL spends in prison increases their risk of developing TB.6 The cumulative risk of TB, although decreasing once a person is released from prison, consistently remains higher than the general population rates for years afterward.6 7 Studies indicate that prisons are an important driver of TB epidemics, whereby rising incarceration and high transmission rates in prisons are amplifying TB at the population level, undermining the progress of TB programmes in the general population.6 8 Most national TB programmes (NTPs) in the LA region define PDLs as one of the high-risk populations (such as indigenous population, drug users, immigrants, among others). History of incarceration is typically not an element of notification databases, so cases occurring in the community among individuals with prior incarceration are not currently recognised by the NTPs as being related to prisons. [...]there is evidence from molecular epidemiology studies indicating that genomic clusters of TB occurring in the community are shared among individuals with and without incarceration history, suggesting onward community transmission of prison-related cases.9 10 A straightforward but crucial surveillance change is that NTP notification forms must include incarceration history, specifying facility, duration and dates. [...]appropriate questions should be developed with relevant stakeholders and focus groups. Table 1 The features of prisons in 14 Latin American countries are compared in terms of incarceration rates, the ratio of TB notification rates between prisons and the community, surveillance of prison history in community TB cases by national TB programmes and the ins