Articles

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, Yasmine Mabene, Sergio Camelo, Zulma Vanessa Rueda, Daniele Maria Pelissari, Fernanda Dockhorn Costa Johansen,
Moises A Huaman, Tatiana Avalos-Cruz, Valentina A Alarcón, Lawrence M Ladutke, Marcelo Bergman, Ted Cohen, Jeremy D Goldhaber-Fiebert,
Julio Croda, Jason R Andrews

Summary
Background Tuberculosis incidence is increasing in Latin America, where the incarcerated population has nearly Lancet Public Health 2024;
quadrupled since 1990. We aimed to quantify the impact of historical and future incarceration policies on the 9: e841–51

tuberculosis epidemic, accounting for effects in and beyond prisons. Published Online
October 14, 2024
https://doi.org/10.1016/
Methods In this modelling study, we calibrated dynamic compartmental transmission models to historical and S2468-2667(24)00192-0
contemporary data from Argentina, Brazil, Colombia, El Salvador, Mexico, and Peru, which comprise approximately See Comment page e832
80% of the region’s incarcerated population and tuberculosis burden. The model was fit independently for each Department of Epidemiology
country to incarceration and tuberculosis data from 1990 to 2023 (specific dates were country dependent). The model and Population Health
does not include HIV, drug resistance, gender or sex, or age structure. Using historical counterfactual scenarios, we (Y E Liu PhD), Division of
estimated the transmission population attributable fraction (tPAF) for incarceration and the excess population-level Infectious Diseases and
Geographic Medicine,
burden attributable to increasing incarceration prevalence since 1990. We additionally projected the effect of Department of Medicine
alternative incarceration policies on future population tuberculosis incidence. (Y E Liu, Y Mabene BSc,
Prof J R Andrews MD), Institute
Findings Population tuberculosis incidence in 2019 was 29·4% (95% uncertainty interval [UI] 23·9–36·8) higher than for Computational and
Mathematical Engineering
expected without the rise in incarceration since 1990, corresponding to 34 393 (28 295–42 579) excess incident cases (S Camelo MSc), Department of
across countries. The incarceration tPAF in 2019 was 27·2% (20·9–35·8), exceeding estimates for other risk factors Health Policy
like HIV, alcohol use disorder, and undernutrition. Compared with a scenario where incarceration rates remain stable (Prof J D Goldhaber-Fiebert PhD),
and Center for Health Policy,
at current levels, a gradual 50% reduction in prison admissions and duration of incarceration by 2034 would reduce
Freeman Spogli Institute
population tuberculosis incidence by over 10% in all countries except Mexico. (Prof J D Goldhaber-Fiebert),
Stanford University, Stanford,
Interpretation The historical rise in incarceration in Latin America has resulted in a large excess tuberculosis burden CA, USA; Department of
Medical Microbiology and
that has been under-recognised to date. International health agencies, ministries of justice, and national tuberculosis
Infectious Diseases, University
programmes should collaborate to address this health crisis with comprehensive strategies, including decarceration. of Manitoba, Winnipeg, MB,
Canada (Z V Rueda PhD); School
Funding National Institutes of Health. of Medicine, Universidad
Pontificia Bolivariana,
Medellin, Colombia (Z V Rueda);
Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND National Tuberculosis Program,
4.0 license. Ministry of Health, Brasília,
Brazil (D M Pelissari PhD,

Introduction Recognising the crisis of tuberculosis in prisons, the F Dockhorn Costa Johansen MD);
Division of Infectious Diseases,
Globally, 10·6 million people developed tuberculosis in Pan American Health Organization (PAHO) began Department of Internal
2022.1 Although the global tuberculosis incidence has requesting data from member states on case notifica- Medicine, University of
decreased by 8·7% since 2015, in Latin America the tuber- tions occurring among people deprived of liberty. Cincinnati College of Medicine,
Cincinnati, OH, USA
culosis incidence increased by 19% over the same period, Between 2014 and 2019, the percent of all notified (M A Huaman MD); Dirección de
highlighting the urgent need to address key tuberculosis tuberculosis cases in the region occurring among Prevención y Control de la
drivers in the region.1 In Latin America, the incarcerated people deprived of liberty increased from Tuberculosis, Ministerio de
population has nearly quadrupled over the last 30 years, 6·6% to 9·4%.2,4 While alarmingly high, this figure Salud, Lima, Perú
(T Avalos-Cruz MD,
the most rapid growth of any region in the world. People underestimates the tuberculosis burden attributable to V A Alarcón MD); New Jersey
deprived of liberty, who might already have elevated risk of incarceration, for several reasons. First, the case City University, Jersey City, NJ,
tuberculosis before incarceration, are further exposed to detection ratio is lower in prisons than in the general USA (L M Ladutke PhD); Center
prison conditions that foster transmission and disease population.4 Second, individuals who acquire infection for Latin American Studies on
Insecurity and Violence,
progression, including overcrowding, poor ventilation, in prison often do not progress to tuberculosis disease National University of Tres de
malnourishment, and limited access to health care.2 until after release. Indeed, previous studies showed Febrero, Buenos Aires,
Together these factors contribute to tuberculosis rates that formerly incarcerated individuals had elevated Argentina
that, in South America, are 26 times higher among people rates of tuberculosis for up to 7 years following release (Prof M Bergman PhD);
Department of Epidemiology
deprived of liberty than in the general population.3 from prison.5,6 As notifications databases do not record

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of Microbial Diseases, School of

Public Health, Yale University, Research in context
New Haven, CT, USA
(Prof T Cohen DPH, J Croda PhD); Evidence before this study prison turnover rates and mechanisms underlying historical
Universidade Federal de Mato We searched PubMed for studies on tuberculosis in prisons in incarceration growth. We estimate the true size of the
Grosso do Sul, Campo Grande, Latin America, using the search terms (“tuberculosis”) AND population ever exposed to incarceration via modelling, which
Brazil (J Croda); Fiocruz Mato
Grosso do Sul, Campo Grande,
(“prisons” OR “incarceration”) AND (“Latin America” OR across the six researched countries is over 11 times the size of
Brazil (J Croda) “Argentina” OR “Brazil” OR “Colombia” OR “El Salvador” OR the population in prison at any one time. We identify the
Correspondence to: “Mexico” OR “Peru”), published in any language. Previous settings in which excess cases occur and compare our results to
Dr Yiran E Liu, Department of studies have identified a high risk of tuberculosis in prisons in crude estimates based on notifications in prisons. We show,
Epidemiology and Population Latin America, finding that notifications in prisons are across six countries with diverse carceral contexts and
Health, Stanford University,
increasing and account for a growing proportion of all cases in tuberculosis epidemiology, that incarceration is a leading driver
Stanford, CA 94305, USA
yiranliu@stanford.edu the region. Other national or sub-national studies have found on par with or surpassing other major tuberculosis risk factors.
For more on incarceration data elevated tuberculosis risk among individuals who were formerly Finally, we demonstrate the potential effect of alternative
see https://www.prisonstudies. incarcerated and identified transmission chains spanning incarceration policies in reducing future tuberculosis burden in
org/ prisons and communities. However, the full contribution of carceral settings and the general population.
incarceration to the broader tuberculosis epidemic in Latin
Implications of all the available evidence
America—accounting for historical incarceration trends, under-
To date, the true impact of incarceration on the tuberculosis
detection in prisons, and spillover effects into communities—
epidemic across the region has been underestimated due to a
has never been quantified. Furthermore, previous studies have
narrow focus on cases occurring within prisons. Considering the
focused on biomedical interventions in prisons; the regional
substantial excess tuberculosis burden attributable to
effect of alternative incarceration policies on future population-
incarceration, interventions targeting incarceration can have
level tuberculosis incidence is unknown.
outsized effects on the broader tuberculosis epidemic in Latin
Added value of this study America—much greater than previously appreciated. These
In this study, we quantify the full contribution of incarceration interventions should include strategies to reduce tuberculosis
to the tuberculosis epidemic in Latin America. Our model risk among currently and formerly incarcerated individuals as
captures the dynamic nature of incarceration, incorporating well as efforts to end mass incarceration.
historical and contemporary data sources to account for varying

information on incarceration history, these cases are Methods

not currently attributed to incarceration.7 Finally, infec- Study design
tions acquired in prisons, including among people who In this modelling study, we selected countries in Latin
work in or visit prisons, can spread in the community. America, defined as Mexico, Central America, and South
Accordingly, genomic epidemiologic studies have iden- America, based on data availability and to represent
tified tuberculosis transmission chains that span regional heterogeneity in incarceration and tuberculosis
See Online for appendix prisons and communities.8–12 Therefore, existing studies trends (appendix p 28). Together, the six included
that focus on tuberculosis occurring in prisons overlook countries represent 82·4% of the region’s incarcerated
the role of incarceration as a population-level tuberculo- population, 79·7% of total tuberculosis notifications, and
sis driver. 80·1% of tuberculosis notifications in prisons in 2018.
Understanding the full contribution of incarceration We collected data on incarceration prevalence, prison
to the worsening tuberculosis epidemic in Latin entries or releases, and recidivism from each country’s
America is crucial to inform tuberculosis prevention penitentiary department or census agency via published
strategies and resource allocation. Furthermore, the reports and information requests for the years 1990–2023
effect of alternative incarceration policies on the tuber- (specific dates were country dependent; appendix p 13). We
culosis epidemic remains unknown, as previous studies also referenced reports and articles published by research-
have focused on biomedical interventions. In this study, ers, international agencies, and journalists. Population
we use mathematical modelling to quantify the popula- estimates and projections were obtained from World
tion-level burden of tuberculosis attributable to Population Prospects. Population-wide tuberculosis notifi-
incarceration in six countries: Argentina, Brazil, cations and incidence estimates were retrieved from the
Colombia, El Salvador, Mexico, and Peru. Specifically, WHO Global Tuberculosis Report.1 Notifications and
we hypothesise that the rise in incarceration since 1990 incidence estimates for people deprived of liberty were
has produced a growing excess tuberculosis burden sourced from PAHO and a 2023 study (appendix p 14).4
and hindered tuberculosis progress in the region. We
additionally simulate alternative incarceration policies Procedures
and project their effects on future population tubercu- We developed a deterministic, meta-population compart-
losis incidence. mental model to simulate incarceration and tuberculosis

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transmission (appendix p 29). The model includes a relative and absolute difference in population tuberculo-
simple representation of the natural history of tuberculo- sis incidence between the observed and counterfactual
sis across five compartments: susceptible, early latent, scenarios. In this Article, we report model generated
late latent, infectious, and recovered. These compart- excess burden estimates for the years 2019 and 2022, but
ments are replicated across four population strata, which we use 2019 for the main estimates due to COVID-19-
individuals traverse via incarceration and release: never related uncertainty. We also analyse where excess
incarcerated, currently incarcerated, recent history of incident cases arose (ie, where individuals progressed or
incarceration, and distant history of incarceration. We relapsed to infectious tuberculosis disease) and where
distinguish between recent and distant incarceration cases were diagnosed and the required notification
history to account for the elevated risk of recidivism, made.
tuberculosis, and mortality in the early period after To estimate the transmission population attributable
release.5,6,13 The model does not include HIV, drug resist- fraction (tPAF) for incarceration among individuals aged
ance, gender or sex, or age structure and excludes 15 years and older, we simulated a scenario where incar-
children aged 14 years and younger who are assumed to ceration prevalence was gradually reduced to zero by
not be at risk of incarceration. We assume that higher 2009 (appendix p 9). After 10 years of no new exposure to
tuberculosis risk in prisons results from higher effective incarceration, we calculated the tPAF for incident cases
contact rates, higher disease progression rates, and lower in 2019 as follows:14
diagnosis rates compared with outside prison. We
include low levels of mixing between incarcerated and tPAF= Population tuberculosis incidenceobserved
non-incarcerated individuals to represent interactions –Population tuberculosis incidenceincarceration eliminated
with prison staff and visitors. Population tuberculosis incidenceobserved
The model was fit independently for each country to
incarceration and tuberculosis data from 1990 to 2023. We compared our estimates of the tPAF for incarcera-
Yearly calibration targets included incarceration preva- tion with WHO’s country-specific estimates of the
lence, prison entries (admissions), recidivism, and total fraction of all incident cases attributable to each of the
and within-prison tuberculosis incidence and notifica- five major tuberculosis risk factors in 2019. We note that
tion rates (appendix pp 13–14). We accounted for risk factors might be overlapping, and that WHO’s
uncertainty by sampling from distributions for calibra- estimates apply to varying age groups (undernutrition to
tion targets and for a subset of parameters that were fixed all ages; HIV to all ages; alcohol use disorders to those
during calibration (appendix pp 15–16). For each sample aged ≥15 years; smoking to those aged ≥15 years; and
of calibration targets and fixed parameters, optimisation diabetes to those aged ≥18 years). For diabetes, the popu-
algorithms were run to calibrate the remaining parame- lation attributable fraction (PAF) is reported as a fraction
ters, obtaining at least 1000 fitted parameter sets of all cases among individuals aged 15 years and older,
per country (appendix pp 6, 32). rather than a true PAF, and therefore might be
For time-varying parameters, we let the model reach overestimated.
equilibrium with baseline values and then applied rates Various incarceration scenarios were simulated over a
of change starting in the year 1990. Changes in incarcera- 10-year period (from the start of 2024 to the start of 2034)
tion prevalence over time were obtained through changes and their effects on future population tuberculosis
in prison entry and release rates; changes in tuberculosis incidence were estimated. Under the reference or stable
incidence and notification rates were obtained through scenario, prison entry rates and average duration of
changes in effective contact rates and diagnosis incarceration remain constant. Under the continue
rates (appendix pp 17, 33). COVID-19 pandemic-related trends scenario, entry rates and duration undergo the
changes were also accounted for (appendix p 18). same relative net change from 2024 to 2034 as over the
previous 10 years (ie, start of 2013 until start of 2023).
Statistical analysis The decarceration scenarios involved gradual 25% or
For each country, we quantified the excess population- 50% reductions in entry rates, duration, or both by the
level tuberculosis incidence attributable to the rise in beginning of 2034. We computed the percent difference
incarceration prevalence since 1990 by simulating a in projected population tuberculosis incidence in the
counterfactual scenario in which incarceration preva- year 2034 under each scenario compared with that
lence and dynamics remained stable at 1990 levels. To expected under the stable scenario.
operationalise this scenario, the model was rerun for In El Salvador, the prison population has nearly tripled
each set of fitted parameters from 1990, with time- since March, 2022, under a continued state of
dependent changes in prison entry and release rates emergency.15 We estimated the excess population tuber-
turned off. Time-dependent changes in the effective culosis incidence in 2024 attributable to the state of
contact rate within prison were also eliminated, as they emergency by simulating a counterfactual scenario
were assumed to be linked to growing prison popula- without the observed rise in incarceration prevalence
tions. The excess burden was then calculated as the since March, 2022. We additionally simulated the

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Argentina Brazil Colombia El Salvador Mexico Peru Source

Incarcerated population in 1990* 21 016 90 000 32 387 5 982 93 119 17 859 Data
Incarcerated population in 2019 109 405 755 274 123 078 38 114 200 936 95 548 Data
Prison occupancy in 2018 (%) 112 165 146 333 97 219 Data
Prevalence of incarceration per 321 452 316 825 216 399 Data
100 000 population in 2019
Percent increase in prevalence of 239 (229–249) 397 (393–400) 120 (107–134) 372 (331–404) 28 (19–38) 190 (171–197) Model
incarceration since 1990 (95% UI)
Incarceration growth driven by increasing Entry rates Entry rates Both Both Both Duration Model
entry rates or duration
Average duration of incarceration in 2019 2·6 (2.2–3·4) 1·3 (1·1–1·6) 3·2 (2·7–3·8) 6·0 (4·8–8·0) 1·9 (1·6–2·3) 4·7 (3·9–5·8) Model
(years [95% UI])
Within-prison prevalence of incarceration 30% (21–37) 52% (41–59) 21% (15–27) 18% (12–22) 25% (17–32) 25% (18–32) Model
history
Community prevalence of incarceration 1·3% (1·0–1·7) 2·8% (2·0–3·9) 4·2% (3·0–5·6) 2·9% (2·2–3·6) 6·0% (4·7–7·6) 3·5% (2·8–4·3) Model
history
Population-level tuberculosis 11 446 85 523 14 292 3009 23 702 31 764 Data
notifications in 2019
Population tuberculosis notification rate 25·7 40·5 28·7 47·9 19·0 97·6 Data
per 100 000 in 2019
Prison tuberculosis notification rate per 214 1303 784 3484 144 2945 Data
100 000 in 2019
Percent of all tuberculosis notifications 2·0 11·5 6·8 44·1 1·2 8·9 Data
occurring in prisons in 2019

Data are n or % (95% uncertainty interval), unless otherwise specified. For model outputs, medians are shown with 95% uncertainty intervals in parentheses. All population-wide prevalence estimates are for the
population aged 15 years and older. Data sources are detailed in the appendix (pp 13–14). UI=uncertainty interval. *Data are from 1992 for Argentina.

Table 1: Incarceration-related and tuberculosis-related characteristics by country

following future scenarios for 2024–34: continuation of Role of the funding source
current entry and release rates under the state of The funder of the study had no role in study design, data
emergency; passive abatement through entry and collection, data analysis, data interpretation, or writing of
release rates gradually returning to their pre-emergency the report.
levels by 2034; and active cessation of the state of
emergency by 2025 and reversion of incarceration preva- Results
lence to its approximate pre-emergency level in 10, 5, or Argentina, Brazil, Colombia, El Salvador, Mexico, and
2 years (ie, by the start of 2034, 2029, or 2026), with Peru exhibited wide variability in the population-wide
continued decarceration thereafter (appendix p 11). and within-prison burden of tuberculosis between 1990
Reversion of incarceration prevalence to pre-emergency and 2019 (table 1). In 2019, the tuberculosis notification
levels under the three different scenarios was done rate in prisons was a median 28·7 (IQR 13·1–31·6) times
through entry and release rates changing promptly by the population-wide notification rate (table 1).
2025. Rather than comparing with a reference scenario, Calibrated parameter values differed in prisons
the percent change in population tuberculosis incidence compared with the community: effective contact rates
was computed for 2034 under each scenario compared in prison were a median 6·8 (IQR 2·5–11·9) times
with 2021. those in the community, disease progression rates were
We calculated all estimates for each set of sampled cali- a median 2·3 (2·0–2·9) times those in the community,
bration targets, sampled parameters, and fitted and diagnosis rates were a median 0·55 (0·44–0·59)
parameters, yielding outcome distributions with more times those in the community (appendix p 19). Between
than 1000 values per country. For each outcome, we 1990 and 2019, the prevalence of incarceration among
report the median and 95% uncertainty interval (UI) the population aged 15 years and older more than
from these distributions, representing uncertainty in doubled in all countries except Mexico; across all
data and model parameters. studied countries the median reached 360 (IQR 317–439)
Five sensitivity analyses were done to vary key assump- per 100 000 population in 2019 (table 1). This historical
tions around natural history, differences across strata, rise was driven by an increase in prison entry rates
changes over time, and mixing (appendix pp 9–11). (Argentina and Brazil), an increase in average duration
Linear regression meta-modelling was also done using a of incarceration (Peru), or both (El Salvador, Colombia,
multi-level model to identify parameters associated with and Mexico; appendix p 20). By 2019, the average
variation in excess burden estimates.16 duration of incarceration ranged from 1·3 years

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A
Incarceration scenario
Observed No change since 1990
Argentina Brazil Colombia El Salvador Mexico Peru
Population tuberculosis

35 350
incidence per 100000

50 50
70 300
person-years

60 30
40 60 250
40
50 25 200
40
30 40 30 150
20 100
20 30 20

B
50
4 2·0 30
Excess tuberculosis
cases per 100000

15 9 40
person-years

3 1·5
6 30 20
2 10 1·0
20
1 5 3 0·5 10
10
0 0 0 0 0 0
1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010
Year Year Year Year Year Year

C
Status of person with tuberculosis
In prison, notified In prison, undetected Previously incarcerated Never incarcerated
15 6 40
1·5 20
Excess tuberculosis
cases per 100000

1·0
person-years

10 30 15
1·0 4
20 10
5 2 0·5
0·5
10 5
0 0 0 0 0 0
1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010 1990 2000 2010
Year Year Year Year Year Year

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.

(95% UI 1·1–1·6) in Brazil to 6·0 years (4·8–8·0) in El

Incidence rate Excess cases per Absolute excess cases Transmission
Salvador (table 1). The percent of the prison population ratio for observed 100 000 person-years relative to population
with previous incarceration history ranged from 18% vs counterfactual relative to counterfactual attributable
(12–22) in El Salvador to 52% (41–59) in Brazil. Such (95% UI) counterfactual (95% UI) (95% UI) fraction (95% UI)
differences in incarceration dynamics contribute to the Argentina 1·06 (1·04–1·16) 1·5 (1·0–3·9) 506 (344–1344) 8·4% (6·0–18·6)
heterogeneity in community prevalence of incarcera- Brazil 1·44 (1·32–1·59) 14·1 (10·9–18·4) 23 497 (18 160–30 739) 36·9% (29·5–45·1)
tion history among the population aged 15 years and Colombia 1·23 (1·13–1·42) 6·0 (3·4–10·6) 2337 (1338–4135) 21·8% (14·1–34·7)
older, which ranged from 1·3% (1·0–1·7) in Argentina El Salvador 2·34 (2·03–2·69) 32·2 (25·5–41·3) 1489 (1178–1907) 58·1% (51·6–64·1)
to 6·0% (4·7–7·6) in Mexico (table 1). Across all Mexico 1·06 (1·04–1·09) 1·3 (0·8–2·1) 1180 (740–1957) 7·5% (4·8–11·6)
six countries in 2019, 1·3 million people were incarcer- Peru 1·21 (1·13–1·34) 20·6 (12·6–33·0) 4922 (3028–7899) 23·3% (16·7–34·4)
ated at any given time and an estimated additional
All estimates are at the population level among individuals aged 15 years and older. Incidence rate ratios and excess
13·4 million (11·4–15·7 million) people had an incar- burden estimates were obtained from comparing incident tuberculosis cases in 2019 between the observed scenario of
ceration history. the historical rise in incarceration and the counterfactual scenario of no change in incarceration prevalence since 1990.
Compared with a counterfactual scenario in which The transmission population attributable fraction in 2019 was estimated using a scenario where incarceration
incarceration prevalence remained stable since 1990, the prevalence was reduced to zero by 2009. UI=uncertainty interval.

observed rise in incarceration prevalence since 1990 Table 2: Estimates of population tuberculosis incidence attributable to incarceration in 2019
resulted in an estimated 34 393 (95% UI 28 295–42 579)
excess incident cases in 2019 across the six countries or
29·4% (95% UI 23·9–36·8) more than expected under 134% or 32·2 (25·5–41·3) cases per 100 000 person-years
the counterfactual scenario (figure 1A, B, table 2). The in El Salvador (table 2). Estimates for the year 2022 were
excess population tuberculosis incidence in 2019 varied similar to 2019 (appendix p 21). Sensitivity analyses
widely across countries, ranging from 6% or 1·3 (95% UI varying several assumptions did not substantively change
0·8–2·1) cases per 100 000 person-years in Mexico to our results (appendix p 37).

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WHO estimates Crude estimates based on notifications in prisons Modelled estimates for incarceration
Argentina Brazil Colombia

Alcohol Incarceration Incarceration

Smoking HIV Alcohol

Undernourishment Alcohol HIV

Incarceration Smoking Undernourishment

HIV Undernourishment Smoking

Diabetes Diabetes Diabetes

0 10 20 30 100 0 10 20 30 40 100 0 10 20 30 100

El Salvador Mexico Peru

Incarceration HIV Incarceration

Undernourishment Incarceration Undernourishment

Alcohol Undernourishment Alcohol

HIV Smoking HIV

Smoking Diabetes Smoking

Diabetes Alcohol Diabetes

0 20 40 60 100 0 5 10 15 100 0 10 20 30 100

Incident cases (%) Incident cases (%) Incident cases (%)

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.

The burden of excess incident cases that arose (ie, pro- than or commensurate with PAFs for other major risk
gression to disease or relapse) in prisons in 2019 exceeded factors (figure 2). Moreover, the median tPAF estimate
that of excess cases diagnosed within prisons by a median was 1·3 to 6·3 times the percent of all tuberculosis notifi-
of 81% across studied countries, ranging from 10% in cations occurring in prisons in 2019 (figure 2).
El Salvador to 102% in Colombia (figure 1C). Furthermore, We projected the impact of future incarceration
a considerable fraction of the excess burden in 2019 was policies, implemented from 2024 to 2034, on population
comprised of incident cases arising among individuals tuberculosis incidence in 2034 (figure 3A; appendix
who had been formerly incarcerated, particularly in p 25). If recent incarceration trends continue, the
countries with a shorter average duration of incarcera- projected population tuberculosis incidence in 2034
tion (figure 1C). For instance, the percent of excess cases would be slightly (<3%) higher in Peru, Argentina, and
arising in the community among individuals who had Mexico, and slightly lower in Colombia and Brazil
been formerly incarcerated was 34% (95% UI 24–45) in (figure 3B). More active decarceration interventions—for
Argentina, 34% (26–42) in Brazil, and 26% (16–36) instance, a 50% decrease in prison entry rates and
Mexico (appendix p 23). In all countries, the estimated duration of incarceration—could reduce population
tuberculosis incidence rates among individuals with tuberculosis incidence in 2034 by an estimated 28·9%
recent or incarceration history were much higher than (95% UI 22·0–36·7) in Brazil, 16·4% (11·4–23·3) in
population-wide incidence rates (appendix pp 24, 38). Peru, 13·7% (8·9–21·3) in Colombia, 10·3% (7·1–16·9)
Collectively across countries, incarceration was the in Argentina, and 3·0% (1·3–5·7) in Mexico.
leading determinant compared with other key tuberculo- In El Salvador, the projected tuberculosis incidence in
sis risk factors, accounting for an estimated 27·2% 2024 was estimated to be 2·1 (95% UI 1·8–2·4) times as
(95% UI 20·9–35·8) of incident cases in 2019 among the high as expected without the recent state of emergency,
population aged 15 years and older. The country-specific corresponding to 2444 (95% UI 1562–3245) excess
tPAF of incarceration in 2019 was 58·1% (51·6–64·1) in incident cases in 2024 (appendix p 23). Maintaining the
El Salvador, 36·9% (29·5–45·1) in Brazil, 23·3% state of emergency for 10 years is projected to increase
(16·7–34·4) in Peru, 21·8% (14·1–34·7) in Colombia, population tuberculosis incidence in 2034 by 112%
8·4% (6·0–18·6) in Argentina, and 7·5% (4·8–11·6) in (63–176) compared with pre-emergency in 2021
Mexico (table 2). Despite this variability, the country- (figure 3C). A gradual, passive abatement of the state of
specific tPAF for incarceration was consistently greater emergency would still increase population tuberculosis

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A
Stable Continue trends Reduce entries 25% Reduce entries 50% Reduce duration 25% Reduce duration 50% Both 25% Both 50%
Argentina Brazil Colombia Mexico Peru
500
Incarceration prevalence per 100 000

400

300

200

100

0
2015 2020 2025 2030 2015 2020 2025 2030 2015 2020 2025 2030 2015 2020 2025 2030 2015 2020 2025 2030
Year Year Year Year Year

B
Argentina Brazil Colombia Mexico Peru

Continue trends
Reduce entries 25%
Reduce entries 50%
Reduce duration 25%
Reduce duration 50%
Both 25%
Both 50%

–15 –10 –5 0 5 –40 –30 –20 –10 0 10 –25 –20 –15 –10 –5 0 –7·5 –5·0 –2·5 0 2·5 –25 –20 –10 0 10
Difference in population Difference in population Difference in population Difference in population Difference in population
tuberculosis incidence (%) tuberculosis incidence (%) tuberculosis incidence (%) tuberculosis incidence (%) tuberculosis incidence (%)

C
El Salvador El Salvador
3000 Continue state of emergency
Incarceration prevalence per 100 000

Gradual passive abatement Continue state of emergency

Active 10-year reversion
Active 5-year reversion
Active 2-year reversion Gradual passive abatement
2000

Active 10-year reversion

1000 Active 5-year reversion

Active 2-year reversion

0
2015 2020 2025 2030 –50 0 50 100 150 200
Year Change in population tuberculosis incidence since 2021 (%)

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.

incidence in 2034 by a projected 39% (13–72). By contrast, population tuberculosis incidence in 2034 by as much as
prompt and active cessation of the state of emergency 34% (25–42) compared with 2021.
and reversion of incarceration prevalence to approximate
pre-emergency levels by 2034 could restore the popula- Discussion
tion tuberculosis incidence in 2034 to its approximate Across six Latin American countries, more than
rate in 2021. More decisive actions to revert to pre-emer- 34 000 incident cases in 2019 can be attributed to the rise
gency incarceration prevalence in 2 years or 5 years and in incarceration since 1990. Collectively in these
continue further decarceration thereafter could reduce countries, incarceration accounts for an estimated 27·2%

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(95% UI 20·9–35·8) of incident cases in 2019 among incarceration as a tuberculosis driver and social determi-
individuals aged 15 years and older, a far greater fraction nant with effects that transcend prison walls.
than any other determinant.1 Against the backdrop of the We also show the potential effect of alternative incar-
region’s alarming increase in tuberculosis incidence over ceration policies on the tuberculosis epidemic in the
the last decade, we project that policies to reduce incar- region. For instance, policies that decrease prison admis-
ceration prevalence might considerably reduce future sions and duration by 50% could reduce future
population tuberculosis incidence. Together, the results population tuberculosis incidence by more than 10% in
of this study implicate incarceration as a leading popula- Brazil, Peru, Colombia, and Argentina, countries which
tion-level driver of the tuberculosis epidemic in Latin encompass the majority of Latin America’s tuberculosis
America. In addition to improving prison conditions and burden. In El Salvador, which already had an exorbitant
implementing biomedical interventions in prisons, tPAF for incarceration before 2022, the current state of
criminal legal reforms and development of non-carceral emergency is projected to have catastrophic conse-
alternatives will be crucial to re-ignite progress towards quences for tuberculosis. We predict that swift, resolute
tuberculosis elimination. termination of the state of emergency could enable a
Our results elucidate the harmful impacts of decades return to pre-emergency incidence by 2034, and that
of punitive policies on the tuberculosis epidemic in the further decarceration can recover, at least in part, a
region. Beginning in the 1990s, amidst rising crime and decade of lost opportunity for tuberculosis progress.
public support for tough-on-crime initiatives, govern- Such measures have precedent in Kazakhstan, where the
ments in Latin America expanded police and Royal Netherlands Tuberculosis Foundation and Penal
prosecutorial activity, criminalised new acts, and imposed Reform International co-led comprehensive efforts to
harsher sentences, including for minor offences.17,18 address tuberculosis in prisons, integrating biomedical
Consequently, prison populations surged, largely interventions with decriminalisation reforms, imple-
comprised of individuals detained for property-related mentation of alternatives to incarceration, and
and drug-related offences.17,19 Meanwhile, inadequate improvements in prison conditions.25 Following
investments in the penitentiary system led to severe expansion of the programme in 2000, incarceration
overcrowding, inhumane living conditions, deficient prevalence decreased by 70% and, with it, the rate of
health care, corruption among staff, uprisings, and self- tuberculosis in prisons by 90%.26 Therefore, decarcera-
governance.17,20 Today, the incarceration rate in Latin tion interventions, especially if coupled with biomedical
America is twice the global rate and higher than all other interventions and efforts to improve prison conditions,
regions except North America. Criminologists argue that have substantial potential to accelerate progress towards
prisons have been ineffective and even counterproduc- the 2035 End TB Strategy targets.
tive in curbing crime in the region.17,20 Instead, they have Our estimates of the tuberculosis burden attributable
created new challenges, including a worsening crisis of to incarceration vary greatly across the six countries
tuberculosis in prisons. included, correlating with incarceration prevalence and
In this study, we show that the scope and magnitude of country-specific disparities in tuberculosis risk between
this crisis is even larger than previously recognised. To prisons and the general population. Between-country
date, research and policy guidance has focused on tuber- variation in where excess cases arise can also be attrib-
culosis occurring within prisons.3,21–24 However, unlike uted to distinct carceral dynamics across countries. For
other tuberculosis risk factors, incarceration is highly instance, in countries with a longer average duration of
dynamic. The constant flow of people who are newly incarceration, such as El Salvador and Peru, our model
incarcerated and released yields a much larger popula- predicts that the majority of excess incident cases occur
tion ever exposed to the high-risk carceral environment, within prisons.4 Conversely, in countries with a shorter
which we estimate for six countries is over 11 times the average duration of incarceration, such as Brazil and
size of the population in prison at any given time. By Mexico, a greater proportion of excess incident cases
accounting for this phenomenon and its interplay with occur in the community after prison release. Therefore,
the variable latent period of tuberculosis, we obtained it is crucial to consider incarceration dynamics and
attributable burden estimates that far exceeded crude, changing carceral policies in identifying optimal inter-
static estimates based on notifications in prisons.2 Of vention strategies. These insights might generalise to
note, most of the difference was due to under-detection other countries and regions. Specifically, in most other
in prisons and progression to disease following release, settings with lower incarceration rates and less disparity
rather than onward transmission. Therefore, although in tuberculosis rates between prisons and the general
traditional PAF estimates for other tuberculosis determi- population, incarceration might have a reduced role in
nants might also be underestimated due to not the tuberculosis epidemic. Nonetheless, in all settings,
accounting for onward transmission, incarceration is the true incarceration-attributable tuberculosis burden
particularly subject to under-recognition by conventional probably exceeds crude estimates based on tuberculosis
approaches that do not account for its dynamic nature. occurring within prisons, especially where prison
Policy guidance and future research should recognise turnover rates are high.

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In response to this public health crisis, bold and socioeconomic inequities that affect mixing and tuber-
decisive investments and actions are needed. First, inter- culosis risk might result in lower estimates for
national health agencies and national tuberculosis incarceration.23 Moreover, we had little to no data to
programmes must improve reporting of incarceration as inform mixing assumptions or stratum-specific param-
a structural determinant of tuberculosis; they must eters for individuals with incarceration history. In these
collect information on incarceration history in case noti- cases of insufficient data, we used wide parameter
fications databases and current and past incarceration uncertainty distributions and varied our assumptions in
must be included as a key risk factor in WHO’s Global sensitivity analyses, with our findings generally
Tuberculosis Report.7 Given the stigma and discrimina- remaining robust. However, the dearth of reliable,
tion faced by individuals with incarceration history, publicly accessible data on incarceration and tuberculo-
procedures for collecting this information in a sensitive sis must be urgently addressed. Finally, our future
manner should be developed alongside stakeholders projections are subject to great uncertainty, including
with lived experience of incarceration.27 Second, effective uncertainty around how the COVID-19 pandemic has
strategies to prevent, detect, and treat tuberculosis in affected and will continue to affect tuberculosis and
individuals who are incarcerated or formerly incarcer- incarceration. We were unable to model specific policies
ated must be identified, incorporated in national or reforms (ie, decriminalisation of drug use) due to
guidelines, and implemented at scale.28,29 Although insufficient data. Our future simulations also do not
existing research has focused on prison-based interven- include changes in any other dimension aside from
tions, future work should expand to include formerly prison entry and release rates, such as improvements in
incarcerated individuals and their community contacts. prison conditions or scale-up of biomedical interven-
Finally, and equally as important, governments must tions. Generally, our historical counterfactual and future
implement structural reforms to reduce the prison popu- policy simulations are simplistic, modifying incarcera-
lation. Although our study focused on tuberculosis, tion in isolation from what is inevitably an intricate web
incarceration exposure has been linked to other adverse of upstream and downstream social, economic, political,
health outcomes.13,30,31 Therefore, decarceration strategies, and institutional forces that themselves also affect
especially in conjunction with efforts to transform condi- population health and tuberculosis. Nonetheless, our
tions of confinement, have the potential to both accelerate findings underscore the substantial potential for
tuberculosis progress and improve population health at criminal legal reforms to reduce tuberculosis burden
large. Currently, political will and public support for such in Latin America, impacts which could be enhanced
measures remain low. However, calls are growing for by additional prison-based and community-based
governments to improve prison conditions, decriminal- interventions.
ise minor offences, reduce pre-trial detention, and Mass incarceration policies have undermined tubercu-
develop restorative justice-based alternatives to incarcera- losis control in Latin America to a greater extent than
tion, with several initiatives underway across Latin previously recognised. Our estimates of the outsized
America.17,19,20,32–35 tuberculosis burden attributable to incarceration eclipse
This study has several limitations. First, for four of those of other determinants that currently receive far
six countries (ie, Argentina, El Salvador, Mexico, and greater attention. However, this exceptional excess
Peru) empirical prison-based active case-finding studies burden must not be regarded as inevitable. Health
were unavailable, so prison incidence estimates for agencies, national tuberculosis programmes, ministries
model calibration were based on a regional case of justice, and other key stakeholders should undertake
detection ratio. For these countries, findings should be bold commitments and actions to elevate the promi-
viewed as estimates within a plausible range of uncer- nence of incarceration in national and international
tainty. Second, deterministic compartmental models are strategies for tuberculosis control and elimination,
unable to capture the full range of complexity in real- accounting for effects beyond prison walls. These strate-
world phenomena. The extent to which we were able to gies should take an integrated health and human rights
incorporate complexity in our model was constrained by approach, combining biomedical interventions and
inadequate data to inform model parameters and improvements in prison conditions with actions to
assumptions. For instance, our model did not account enable decarceration. Such measures will be crucial to
for age, gender or sex, socioeconomic status, HIV advancing towards regional and global tuberculosis
status, heterogeneity in duration of incarceration, het- elimination targets.
erogeneity in infectiousness, or multi-drug resistant Contributors
tuberculosis, which is less common in prisons in the YEL and JRA conceived and designed the study. YEL and YM collected
WHO region of the Americas than in other regions.36 data with assistance from LML. YEL and YM developed and calibrated
the incarceration sub-model. YEL developed and calibrated the primary
Accounting for HIV or multi-drug resistant tuberculo- tuberculosis model, performed analyses, and made tables and figures.
sis, which might be exacerbated in prisons, might SC, JDG-F, and JRA assisted with model development and calibration.
increase estimates of the incarceration-attributable JRA, JC, JDG-F, and TC provided guidance on analyses. YEL wrote the
burden.11 Accounting for other factors such as age or first draft of the manuscript. YM and MB contributed to writing of

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subsequent drafts. All authors contributed to data interpretation and 10 Sanabria GE, Sequera G, Aguirre S, et al. Phylogeography and
critical revision of the manuscript. YEL and YM accessed and verified transmission of Mycobacterium tuberculosis spanning prisons and
the underlying data. All authors approved the final version of the surrounding communities in Paraguay. Nat Commun 2023; 14: 303.
manuscript and agreed to submission. 11 Utpatel C, Zavaleta M, Rojas-Bolivar D, et al. Prison as a driver of
recent transmissions of multidrug-resistant tuberculosis in Callao,
Declaration of interests Peru: a cross-sectional study. Lancet Reg Health Am 2024; 31: 100674.
YEL reports funding from the Stanford Knight Hennessy Scholars 12 Trevisi L, Brooks MB, Becerra MC, et al. Who transmits
Program, the National Science Foundation Graduate Research tuberculosis to whom: a cross-sectional analysis of a cohort study in
Fellowship, and the Gerald J Lieberman Fellowship from the Stanford Lima, Peru. Am J Respir Crit Care Med 2024; 210: 222–33.
Office of the Vice Provost for Graduate Education; and a previous 13 Liu YE, Lemos EF, Gonçalves CCM, et al. All-cause and cause-
leadership role in the Stanford Jail and Prison Education Program. specific mortality during and following incarceration in Brazil:
MAH reports grants or contracts paid to their institution from the a retrospective cohort study. PLoS Med 2021; 18: e1003789.
National Institutes of Health (NIH), Gilead Sciences, Insmed, 14 Mishra S, Baral SD. Rethinking the population attributable fraction
AN2 Therapeutics, and AstraZeneca; and participation on the AIDS for infectious diseases. Lancet Infect Dis 2020; 20: 155–57.
Clinical Trials Group Tuberculosis Transformative Science Group Study 15 Asamblea Legislativa. Régimen de excepción. 2024. https://www.
Monitoring Committee. TC reports grants from the Centers for Disease asamblea.gob.sv/taxonomy/term/1922 (accessed Feb 12, 2024).
Control and Prevention and NIH to their institution. JC reports grants or 16 Jalal H, Dowd B, Sainfort F, Kuntz KM. Linear regression
contracts from Valneva–Instituto Butantan, Merck & Co, Sanofi Pasteur, metamodeling as a tool to summarize and present simulation
Coalition for Epidemic Preparedness Innovations–Sabin Vaccine model results. Med Decis Making 2013; 33: 880–90.
Institute, and Takeda; speaking fees from Pfizer; and participation in 17 Bergman M, Fondevila G. Prisons and crime in Latin America.
Advisory Boards for the mRNA-1273 vaccine (for Moderna–Zodiac), Cambridge: Cambridge University Press, 2021.
RSV maternal vaccine (for Pfizer), Qdenga vaccine (for Takeda), 18 Hathazy P, Müller M-M. The rebirth of the prison in Latin America:
Nirmatrelvir–Ritonavir (for Paxlovid and Pfizer), and the Global Dengue determinants, regimes and social effects. Crime Law Soc Change
Steering Committee (for Takeda). JRA reports grants from Good 2016; 65: 113–35.
Ventures–Open Philanthropy for an ethics evaluation of tuberculosis 19 Chaparro Hernández SPC. Catalina. Sobredosis carcelaria y política
vaccine trials paid to their institution; payment for expert testimony de drogas en América Latina. 2017. https://www.dejusticia.org/
involving tuberculosis in prisons in the USA; participation on safety publication/sobredosis-carcelaria-y-politica-de-drogas-en-america-
monitoring boards and advisory boards for NIH-sponsored clinical latina/ (accessed June 28, 2024).
studies and trials pertaining to tuberculosis; a leadership role in the TB in 20 InSight Crime. The prison dilemma: Latin America’s incubators of
Prisons Working Group for the International Union Against Tuberculosis organized crime. 2017. https://insightcrime.org/investigations/
prison-dilemma-latin-america-incubators-organized-crime/
and Lung Disease; and a donation of materials from Cepheid for research
(accessed June 28, 2024).
use. All other authors declare no competing interests.
21 World Health Organization. WHO consolidated guidelines on
Data sharing tuberculosis. Module 2: screening—systematic screening for
No individual participant data were collected in this study. Data and code tuberculosis disease, 2021. Geneva: World Health Organization,
used for modelling are available at https://www.github.com/yemloo/tb_ 2021.
incarc_mod. 22 World Health Organization. Tuberculosis in prisons. 2023.
https://www.who.int/teams/global-tuberculosis-programme/tb-
Acknowledgments reports/global-tuberculosis-report-2023/featured-topics/tb-in-
This study was funded by the National Institutes of Health (grant prisons (accessed Feb 2, 2024).
numbers 5R01AI130058 and 5R01AI149620). We thank Edwin Segura, 23 Pelissari DM, Diaz-Quijano FA. Impact of incarceration on
Hernán Olaeta, Victor Peña Garcia, Noah Bullock, and the National tuberculosis incidence and its interaction with income distribution
Penitentiary and Prison Institute of Colombia for providing data and inequality in Brazil. Trans R Soc Trop Med Hyg 2020; 114: 23–30.
useful insights. 24 Li Y, de Macedo Couto R, Pelissari DM, et al. Excess tuberculosis
cases and deaths following an economic recession in Brazil:
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