Mass incarceration can explain population increases in TB and multidrug-resistant TB in European and central Asian countries

Abstract

Several microlevel studies have pinpointed prisons as an important site for tuberculosis (TB) and multidrug-resistant TB in European and central Asian countries. To date, no comparative analyses have examined whether rises in incarceration rates can account for puzzling differences in TB trends among overall populations. Using longitudinal TB and cross-sectional multidrug-resistant TB data for 26 eastern European and central Asian countries, we examined whether and to what degree increases in incarceration account for differences in population TB and multidrug-resistant TB burdens. We find that each percentage point increase in incarceration rates relates to an increased TB incidence of 0.34% (population attributable risk, 95% C.I.: 0.10 -0.58%, P < 0.01), after controlling for TB infrastructure; HIV prevalence; and several surveillance, economic, demographic, and political indicators. Net increases in incarceration account for a 20.5% increase in TB incidence or nearly threefifths of the average total increase in TB incidence in the countries studied from 1991 to 2002. Although the number of prisoners is a significant determinant of differences in TB incidence and multidrug-resistant TB prevalence among countries, the rate of prison growth is a larger determinant of these outcomes, and its effect is exacerbated but not confounded by HIV. Differences in incarceration rates are a major determinant of differences in population TB outcomes among eastern European and central Asian countries, and treatment expansion alone does not appear to resolve the effect of mass incarceration on TB incidence. drug resistance ͉ prison

Government Health Care Spending and Child Mortality

“…This methodology has been widely used in health-economic studies and is regarded as a statistically robust approach. 7,21 Our basic linear fixed-effects statistical model uses the following equation:…”

Tuberculosis in prisons: anatomy of global neglect

“…In addition, poor prison living conditions and mass incarceration [12] with inadequate ventilation, in such congregate settings, promote the transmission of Mycobacterium tuberculosis between prisoners. Such host and environmental risk factors facilitate new M. tuberculosis infections to progress to active disease, or may cause re-activation of latent TB in prisoners, the risk of which is at least an order of magnitude higher in prisons than in the general community [3].…”

“…TB in prisons poses a particularly challenging public health, economic and social problem in SSA countries [8,9,14,15,19] and countries of the former Soviet Union [7,11,12,25,26]. It is estimated that the total prison population in Europe is .2 million, with .10.5 million prisoners passing through the prison system each year [17].…”

“…Such host and environmental risk factors facilitate new M. tuberculosis infections to progress to active disease, or may cause re-activation of latent TB in prisoners, the risk of which is at least an order of magnitude higher in prisons than in the general community [3]. Prisons serve as reservoirs of drugresistant TB [10][11][12] which is increasingly being reported from Eastern European [6,7,10,11,13] and SSA prisons [8,9,12,[14][15][16], where TB in prisons remains a neglected public health and human rights issue [15,[17][18][19]. However, the problem of TB in prisons is not only confined to Eastern European and SSA countries.…”

TB Control in Prisons

“…The way TB in prison influences TB and TB control in general populations has been explored by recent research. Stuckler et al (2008) established a clear relationship between rises in incarceration rates and increased TB incidence and multi-drug resistant TB prevalence rates in Eastern European and Central Asian countries. Increases in the size of prison populations accounted for a 20.5% increase in TB incidence in the countries studied from 1991 to 2002.…”