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PLoS Med. 2019 Jan 24;16(1):e1002737. doi: 10.1371/journal.pmed.1002737. eCollection 2019 Jan.

Evaluating strategies for control of tuberculosis in prisons and prevention of spillover into communities: An observational and modeling study from Brazil.

Author information

1
Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America.
2
Agência Estadual de Administração do Sistema Penitenciário, Campo Grande, Brazil.
3
Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America.
4
Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, United States of America.
5
Department of Mathematics, Imperial College London, London, United Kingdom.
6
Department of Mathematics, Simon Fraser University, Burnaby, Canada.
7
School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, Brazil.
8
Oswaldo Cruz Foundation, Campo Grande, Brazil.

Abstract

BACKGROUND:

It has been hypothesized that prisons serve as amplifiers of general tuberculosis (TB) epidemics, but there is a paucity of data on this phenomenon and the potential population-level effects of prison-focused interventions. This study (1) quantifies the TB risk for prisoners as they traverse incarceration and release, (2) mathematically models the impact of prison-based interventions on TB burden in the general population, and (3) generalizes this model to a wide range of epidemiological contexts.

METHODS AND FINDINGS:

We obtained individual-level incarceration data for all inmates (n = 42,925) and all reported TB cases (n = 5,643) in the Brazilian state of Mato Grosso do Sul from 2007 through 2013. We matched individuals between prisoner and TB databases and estimated the incidence of TB from the time of incarceration and the time of prison release using Cox proportional hazards models. We identified 130 new TB cases diagnosed during incarceration and 170 among individuals released from prison. During imprisonment, TB rates increased from 111 cases per 100,000 person-years at entry to a maximum of 1,303 per 100,000 person-years at 5.2 years. At release, TB incidence was 229 per 100,000 person-years, which declined to 42 per 100,000 person-years (the average TB incidence in Brazil) after 7 years. We used these data to populate a compartmental model of TB transmission and incarceration to evaluate the effects of various prison-based interventions on the incidence of TB among prisoners and the general population. Annual mass TB screening within Brazilian prisons would reduce TB incidence in prisons by 47.4% (95% Bayesian credible interval [BCI], 44.4%-52.5%) and in the general population by 19.4% (95% BCI 17.9%-24.2%). A generalized model demonstrates that prison-based interventions would have maximum effectiveness in reducing community incidence in populations with a high concentration of TB in prisons and greater degrees of mixing between ex-prisoners and community members. Study limitations include our focus on a single Brazilian state and our retrospective use of administrative databases.

CONCLUSIONS:

Our findings suggest that the prison environment, more so than the prison population itself, drives TB incidence, and targeted interventions within prisons could have a substantial effect on the broader TB epidemic.

Conflict of interest statement

I have read the journal’s policy and the authors of this manuscript have the following competing interests: SB receives a stipend as a specialty consulting editor for PLOS Medicine and serves on the journal’s editorial board.

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