The Hidden Epidemic: Post-Release Tuberculosis Risk in Formerly Incarcerated Populations

Incarcerated populations face an extremely high risk of tuberculosis (TB), yet little is known about whether this elevated risk persists after release into the community. Among 3,666 TB patients aged ≤ 60 years enrolled in a prospective cohort study in Lima, Peru, 188 (5%) reported a history of incarceration. These individuals presented with more severe disease (mean score difference = 0.25) and had a higher risk of a poor treatment outcome compared to those who had not been incarcerated (risk ratio [RR] = 2.17). Among 138 with known incarceration dates, nearly three-quarters (73%) were diagnosed within two years of release, suggesting that infections were acquired while in prison. Among 7,101 household contacts aged 15-60 years, 121 (1.7%) had a history of incarceration and these had a higher prevalence of TB infection (prevalence risk ratio [PRR] = 1.33). The prevalence risk was similarly elevated in the subset who were incarcerated for only ≤ 3 months (PRR = 1.37). Incarceration leaves a lasting imprint on TB dynamics, driving more severe disease, poorer outcomes, and elevated household infection risk after release. Prisons act as reservoirs that amplify TB epidemics, underscoring the urgent need for control strategies that bridge prison and community health systems.