Mass incarceration as a driver of the tuberculosis epidemic in Latin America and projected impacts of policy alternatives: A mathematical modeling study

Background Tuberculosis incidence is increasing in Latin America, where the incarcerated population has nearly quadrupled since 1990. The full impact of incarceration on the tuberculosis epidemic, accounting for effects beyond prisons, has never been quantified. Methods We calibrated dynamic compartmental transmission models to historical and contemporary data on incarceration and tuberculosis in Argentina, Brazil, Colombia, El Salvador, Mexico, and Peru. Together these countries comprise approximately 80% of the region's incarcerated population and tuberculosis burden. 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 impact of various incarceration scenarios on future population tuberculosis incidence. Findings The rise in incarceration prevalence since 1990 has resulted in an estimated 30,241 (95% UI, 24,333 - 39,303) excess incident tuberculosis cases in 2019 across the six countries. The tPAF for incarceration in 2019 was 23.5% (95% UI, 17.7-32.0), exceeding estimates for other key risk factors like HIV, alcohol use disorders, and undernutrition. Compared to a base-case scenario where current incarceration policies persist, decarceration interventions could reduce future population tuberculosis incidence in all countries, notably by over 10% in Brazil, Colombia, El Salvador, and Peru. Interpretation The historical rise in incarceration in Latin America has resulted in a large excess burden of tuberculosis that has been under-recognized to-date. International health agencies, ministries of justice, and national tuberculosis programs should collaborate to address this health crisis with comprehensive strategies, including decarceration. Funding National Institutes of Health ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by the National Institutes of Health (grant numbers 5R01AI130058 and 5R01AI149620). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors and will be made available upon publication