Prisons as Hotspots of Tuberculosis: A Silent Threat in Ecuador

Tuberculosis (TB) has become established as a critical public health crisis within Ecuador's penitentiary system, with incidence and prevalence rates that drastically exceed those of the general population. This narrative review aims to synthesize the available evidence regarding the epidemiological burden, structural determinants, and transmission dynamics of TB in Ecuadorian prisons. We conducted a structured literature search in PubMed, Scopus, and Web of Science, using keywords related to tuberculosis, prisons, and Ecuador. Within the literature review, a severe epidemiological burden was found when evaluating 2015-2016 TB control and treatment risks at CPL Guayas No. 1 (Ecuador's largest prison), which reported an incidence of 3947 per 100,000 inmates, approximately 68 times the national average. Structural determinants, especially extreme overcrowding exceeding 140% in some facilities, poor ventilation, and limited access to rapid diagnostics such as Xpert MTB/RIF, enable prisons to act as amplifiers of pathogen transmission. Furthermore, the review highlights the circulation of rifampicin-resistant strains and the predominance of lineage 4 (LAM sublineage), which is strongly associated with drug resistance in the Ecuadorian context. Because the infection transcends prison walls through released inmates, staff, and visitors, the disease spreads into the general community, increasing state costs and control challenges. In conclusion, evidence demonstrates that structural deficiencies and extreme overcrowding drive this health crisis. Based on these findings, urgent structural interventions are recommended to reduce overcrowding and strengthen healthcare infrastructure, integrating criminal justice policies with public health strategies.