Environmental factors associated with the time to tuberculosis diagnosis in prisoners in São Paulo, Brazil


      • This study provides a complete picture of how fast active tuberculosis emerge in prison population.
      • The speed of becoming ill from tuberculosis increases when inmates are exposed to higher overcrowded settings.
      • Higher physical space per person in the cell increases the tuberculosis-free survival time.
      • This study supports the need for a drastic reduction in overcrowding and an increase in physical space to control tuberculosis in prison population.



      Environmental conditions play an important role in the high incidence of tuberculosis in prisons. We estimated the effect of environmental factors, including measurements based on cell dimensions, over time to tuberculosis diagnosis in prison population of Brazil.


      This is a retrospective cohort of 2,257 prisoners diagnosed with tuberculosis in 2014 and 2015. We collected environmental data from 105 prisons and linked with routine tuberculosis surveillance and prison data. We estimated tuberculosis-free survival time with Cox risk models, guided by a validated directed acyclic graph.


      The median disease-free time was 1.71 years (95% confidence interval [95%CI] 1.64-1.78). Each 50% increase in occupancy-rate, increased the tuberculosis speed incidence by 16% (95%CI 8%-25%) in the first two years, and 9% (95%CI 3%-16%) up to five years. An increase in the cell area per person reduced the hazard of tuberculosis by 13% (95%CI 3%-23%) for up to two, and 12% (95%CI 3%-21%) for up to five years.


      Most tuberculosis cases were diagnosed within two years of incarceration. Prison overcrowding and physical space per person in the cell were associated with the tuberculosis-free disease time.


      Interventions to reduce overcrowding or increase physical space are crucial to prevent tuberculosis in prisons.


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