Tuberculosis behind bars in Latin America and Caribbean: A growing public health crisis

To the Editor—Despite advances in recent years to end the tuberculosis (TB) epidemic and global efforts to reduce its prevalence, the disease remains a burden on public health in several countries. In Latin America and the Caribbean, the situation is no different. With incidence rates of 61.2 per 100,000 population in the Caribbean, 46.2 in South America, and 25.9 in Mexico and Central America, the region is at risk of falling short of the “End TB Strategy” goals. ¹

TB transmission correlates with susceptible populations, which include the socioeconomically disadvantaged, migrants, ethnic minorities, individuals with comorbidities (eg, human immunodeficiency virus [HIV]), and persons deprived of their liberty (PDL). According to the World Health Organization (WHO), the incidence rate of TB is 100 times greater among inmates compared to the general population, and TB in PDL continues to increase because of gross neglect. ¹

The disparity between prison and civilian TB control measures and the lack of policies to safeguard prison healthcare are the primary concerns. Overcrowding in prisons of Central and South America contributed to a 206% average increase in TB since 2000, higher than in any region. PDL TB in this region increased from 5% of the total reported cases in 2011 to 11.1% in 2017. ² El Salvador, for example, had the greatest increase of 411% among TB PDL, with a corresponding increase in TB of 51.5%, in 2017. ³ In Brazil, the increase in the incarceration rate has led to more PDL than capacity in detention centers, with average occupancy at 161% of availability. A similar trend has been noted in other American countries. ⁴

Both the prison environment and host factors are responsible for TB surges. Globally, prisons have limited access to healthcare and medical facilities, lack of well-trained medical staff, an insufficient supply of newly updated quality medicine regimen, poor ventilation and sanitation, deficient new and upgraded diagnostic approach and laboratories, and malnutrition. These factors tend to be more conspicuous in Latin America. ^5,6 Additionally, PDL are highly associated with low socioeconomic backgrounds, limited access to health care before incarceration, underprivileged ethnic groups, high tendency of substance misuse, smoking, and sexual abuse once imprisoned, all of which combine to create a nidus for TB and its transmission. ^4,7

Higher evidence of drug trafficking and a small fraction of Directly Observed Treatment Short-Course (DOTS) implementation and completion among PDL in Latin America caused a surge in TB transmission. A recent study showed a lower prevalence of latent TB infection than active infection in Brazil at the time of entry, likely due to high risk thereafter in the prison setting. ⁸ Long duration and previous history of incarceration have been identified as risk factors for latent TB infection. Furthermore, incarcerated people are deprived of their human rights—they are socially, emotionally, and psychologically isolated. Access to social welfare organizations, human rights activists, community representatives, and rehabilitation services to support this vulnerable populations is lacking. ⁸

Another matter of concern is the increase in multidrug-resistant (MDR)-TB cases. TB screening systems before incarceration are highly neglected, and screening is impeded by logistic obstacles and very short periods of stay for many inmates. ⁷ Late diagnoses only following symptoms, inadequate observation of treatment, and monitoring of the disease condition led to the development of MDR-TB. This factor is particularly worrying in the region because 70% of global RR/MDR-TB cases are concentrated in Central and South America. ¹ In Central and South America, where 77.5% of TB patients can be treated successfully, mortality among PDL is high and preventable. Among the reasons for these excess deaths among PDL is the nonadherence rate, which is high due to negligence regarding patient education and/or counseling to improve drug adherence.

Additionally, the HIV coinfection rate is high in Central America and Caribbean countries, and TB is the leading infectious cause of death for HIV patients. HIV coinfection also increases MDR-TB. The high rate of prison turnover, reincarceration, and movement in prisons are less-prioritized factors of TB expansion. Overlapping periods of stay between infected and healthy PDL as well as inevitable contact with guards and prison employees have raised the risk of transmission. Treatment discontinuity is also high due to the circulation of inmates, which has further exacerbated TB spread. ^7,9 Reduced physical activity also makes PDL vulnerable to diseases.

Escalating infectious diseases, use of immunosuppressives, and increases in comorbidities have also made the PDL more susceptible to TB. ^10,11 A cross-sectional study of Brazilian PDL demonstrated that coinfection with viral hepatitis had a higher risk of hepatotoxicity related to the cessation of first-line antituberculosis drugs. ¹⁰ Notably, depending upon the facility type for incarceration, the rate of TB varies. It is estimated to be higher in local jails than in state and federal prisons because of the high population, movement, and turnover in local jails. ⁶

The implications of an increase in TB in prisons in Central and South America include spread of TB to visitors, family members, and prison workers. Moreover, admitting PDL to community hospitals and releasing PDL with a history of TB without proper liaison between the prison health system and local health authorities are also contributing to TB circulation to the general public. These factors create a favorable situation for TB spread outside of prisons, potentially to those at high risk, particularly HIV patients.

PDL are not easily accessible to visiting authorities due to legal concerns. Research gaps, lack of funding, and outdated policies to ameliorate prison health services plague most of South and Central America. Increased violence and crime are also major concerns in the TB crisis behind bars. ⁵ With the lack of data from these jails, proper implementation cannot take place to prevent TB spread. This situation presents challenges for healthcare systems and frontline workers, for those of low socioeconomic background who cannot afford medical treatment for TB, and for legal systems that need to take precautions to decrease incarceration rates. Implementable actions include, but are not limited to, health and sex education to reduce HIV prevalence and consequently TB, provision of basic healthcare services to local and federal jails, active routine testing of TB in jails, legal interventions to decrease incarceration rates, lower mobility of inmates, educational resources on drug adherence, and routine updates on the development of TB in jails. ^3,6

The increasing incidence of tuberculosis among the PDL of Latin America and the Caribbean can be attributed to several preventable causes: overcrowding in prisons, lack of basic healthcare in prisons, and increased susceptibility to TB due to underlying medical conditions (eg, AIDS). If inmates are not already carriers of TB when incarcerated, overcrowding of prisons increases the chances of acquiring TB while incarcerated. The disproportionate incarceration of poor people and minority groups who may have been marginalized by healthcare systems before incarceration comprises a major risk factor. ¹²

A notable limitation of our study was the lack of routinely updated data on the development of TB in jails of Central and South America. Although some viable research articles have been published regarding the TB crisis among PDL of Central and South America, not enough attention has been given to this grave yet preventable crisis. Urgent measures are needed to deal with this growing public health crisis.