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. 2024 Nov;9(11):e841-e851.
doi: 10.1016/S2468-2667(24)00192-0. Epub 2024 Oct 15.

Mass incarceration as a driver of the tuberculosis epidemic in Latin America and projected effects of policy alternatives: a mathematical modelling study

Yiran E Liu  1 , Yasmine Mabene  2 , Sergio Camelo  3 , Zulma Vanessa Rueda  4 , Daniele Maria Pelissari  5 , Fernanda Dockhorn Costa Johansen  5 , Moises A Huaman  6 , Tatiana Avalos-Cruz  7 , Valentina A Alarcón  7 , Lawrence M Ladutke  8 , Marcelo Bergman  9 , Ted Cohen  10 , Jeremy D Goldhaber-Fiebert  11 , Julio Croda  12 , Jason R Andrews  2
Affiliations

Mass incarceration as a driver of the tuberculosis epidemic in Latin America and projected effects of policy alternatives: a mathematical modelling study

Yiran E Liu et al. Lancet Public Health. 2024 Nov.

Abstract

Background: Tuberculosis incidence is increasing in Latin America, where the incarcerated population has nearly quadrupled since 1990. We aimed to quantify the impact of historical and future incarceration policies on the tuberculosis epidemic, accounting for effects in and beyond prisons.

Methods: In this modelling study, we calibrated dynamic compartmental transmission models to historical and contemporary data from Argentina, Brazil, Colombia, El Salvador, Mexico, and Peru, which comprise approximately 80% of the region's incarcerated population and tuberculosis burden. The model was fit independently for each country to incarceration and tuberculosis data from 1990 to 2023 (specific dates were country dependent). The model does not include HIV, drug resistance, gender or sex, or age structure. Using historical counterfactual scenarios, we estimated the transmission population attributable fraction (tPAF) for incarceration and the excess population-level burden attributable to increasing incarceration prevalence since 1990. We additionally projected the effect of alternative incarceration policies on future population tuberculosis incidence.

Findings: Population tuberculosis incidence in 2019 was 29·4% (95% uncertainty interval [UI] 23·9-36·8) higher than expected without the rise in incarceration since 1990, corresponding to 34 393 (28 295-42 579) excess incident cases across countries. The incarceration tPAF in 2019 was 27·2% (20·9-35·8), exceeding estimates for other risk factors like HIV, alcohol use disorder, and undernutrition. Compared with a scenario where incarceration rates remain stable at current levels, a gradual 50% reduction in prison admissions and duration of incarceration by 2034 would reduce population tuberculosis incidence by over 10% in all countries except Mexico.

Interpretation: The historical rise in incarceration in Latin America has resulted in a large excess tuberculosis burden that has been under-recognised to date. International health agencies, ministries of justice, and national tuberculosis programmes should collaborate to address this health crisis with comprehensive strategies, including decarceration.

Funding: National Institutes of Health.

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Conflict of interest statement

Declaration of interests YEL reports funding from the Stanford Knight Hennessy Scholars Program, the National Science Foundation Graduate Research Fellowship, and the Gerald J Lieberman Fellowship from the Stanford Office of the Vice Provost for Graduate Education; and a previous leadership role in the Stanford Jail and Prison Education Program. MAH reports grants or contracts paid to their institution from the National Institutes of Health (NIH), Gilead Sciences, Insmed, AN2 Therapeutics, and AstraZeneca; and participation on the AIDS Clinical Trials Group Tuberculosis Transformative Science Group Study Monitoring Committee. TC reports grants from the Centers for Disease Control and Prevention and NIH to their institution. JC reports grants or contracts from Valneva–Instituto Butantan, Merck & Co, Sanofi Pasteur, Coalition for Epidemic Preparedness Innovations–Sabin Vaccine Institute, and Takeda; speaking fees from Pfizer; and participation in Advisory Boards for the mRNA-1273 vaccine (for Moderna–Zodiac), RSV maternal vaccine (for Pfizer), Qdenga vaccine (for Takeda), Nirmatrelvir–Ritonavir (for Paxlovid and Pfizer), and the Global Dengue Steering Committee (for Takeda). JRA reports grants from Good Ventures–Open Philanthropy for an ethics evaluation of tuberculosis vaccine trials paid to their institution; payment for expert testimony involving tuberculosis in prisons in the USA; participation on safety monitoring boards and advisory boards for NIH-sponsored clinical studies and trials pertaining to tuberculosis; a leadership role in the TB in Prisons Working Group for the International Union Against Tuberculosis and Lung Disease; and a donation of materials from Cepheid for research use. All other authors declare no competing interests.

Figures

Figure 1:
Figure 1:. Excess population tuberculosis incidence attributable to the rise in incarceration prevalence since 1990
Solid lines represent medians and shaded bands represent 95% UI. (A) Population tuberculosis incidence per 100 000 person-years under the observed and counterfactual (no rise in incarceration since 1990) scenarios. Black points represent population tuberculosis incidence estimates from WHO, which are available from 2000. (B) Excess population-wide incident tuberculosis cases per 100 000 person-years. (C) Median estimates of excess cases, stratified by population subgroup in which they occurred, and for incident cases occurring in prison, additionally stratified by whether the disease was notified or undetected during incarceration. All model results are for the population aged 15 years and older. UI=uncertainty interval.
Figure 2:
Figure 2:. Population attributable fraction for incarceration and other tuberculosis risk factors
Median estimates and uncertainty intervals for the percent of population-level incident tuberculosis cases in 2019 that can be attributed to each risk factor. The crude estimate of the population attributable fraction for incarceration is based on the percent of all notified tuberculosis cases that occurred in prisons. Estimates for all other risk factors are from WHO. Risk factors are listed in descending order by PAF for each country. Estimates correspond to different age groups: incarceration for age ≥15 years; undernutrition for all ages; HIV for all ages; alcohol for age ≥15 years; smoking for age ≥15 years; and diabetes for age ≥18 years. PAF=population attributable fraction.
Figure 3:
Figure 3:. Projected impacts of incarceration-related interventions on future population tuberculosis incidence
(A) Median incarceration prevalence per 100 000 population aged ≥15 years under incarceration scenarios implemented between 2024 and 2034: stable entry and release rates (reference scenario), continuation of trends from previous 10 years, and 25% or 50% reduction in prison entry rates, duration of incarceration, or both by 2034. The dashed horizontal line represents incarceration prevalence in 1990. (B) Percent difference in population tuberculosis incidence in 2034 under each incarceration scenario, relative to the reference scenario of stable entry and release rates. Outliers are not shown. (C) Left: median incarceration prevalence under each incarceration scenario in El Salvador: continuation of entry and release rates under the state of emergency, passive abatement through gradual reversion of entry and release rates to pre-emergency levels by 2034, active cessation and approximate restoration of pre-emergency incarceration prevalence in 10 years, or restoration of pre-emergency prevalence in 5 years or 2 years with continued decarceration thereafter. The dashed horizontal line represents incarceration prevalence in 1990. Right: percent change in population tuberculosis incidence since 2021 under each scenario.
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