{"paper_id":"19de6c8a-2447-4d0f-8e03-da964464ea3f","body_text":"The Hidden Epidemic: Post-Release Tuberculosis Risk in Formerly Incarcerated Populations | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The Hidden Epidemic: Post-Release Tuberculosis Risk in Formerly Incarcerated Populations Megan Murray, Chuan-Chin Huang, Meredith Brooks, Mercedes Becerra, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7707029/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted You are reading this latest preprint version Abstract 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. Health sciences/Diseases/Infectious diseases/Tuberculosis Health sciences/Risk factors Figures Figure 1 Figure 2 Introduction Prisons are high-risk environments for TB transmission due to overcrowding, poor ventilation, and inadequate healthcare. Prolonged close contact among persons deprived of liberty (PDLs) facilitates TB spread, while high rates of HIV infection, malnutrition, and substance use increase individual susceptibility.(1–5) Limited access to accurate diagnostic tools, inconsistent treatment protocols, and inadequate infection control measures further contribute to the spread of drug-resistant TB (DR-TB) and multidrug-resistant TB (MDR-TB).(2,6) Globally, PDLs face a more than tenfold higher risk of TB compared to the general population within the same communities. (2,7) The greatest disparity in TB incidence between PDLs and the general population is in Latin America, where the rapid expansion of the incarcerated population has driven an increase in national TB notifications.(8) In Peru, TB incidence rates among PDLs exceed those of the general population by more than 25-fold.(1,9) While incarceration is a well-established risk factor for Mycobacterium tuberculosis ( Mtb ) infection and TB disease,(10) its full impact on community transmission is likely underestimated.(3) High turnover in prisons, coupled with TB’s long and variable latency period, means that many individuals may acquire infection while incarcerated but develop active disease after release. Cross-sectional studies identify TB genomic clusters that include individuals with and without a history of incarceration, indicating spillover from prisons into the community.(3,11,12) However, the extent of this transmission remains unclear. While the elevated TB risk among PDLs is well documented, research on those who develop disease after release from prison is limited—despite their key role in understanding how incarceration contributes to broader TB transmission dynamics. In this study, we leveraged a prospective cohort of TB patients and their household contacts in Lima, Peru, to examine the relationship between incarceration history and TB outcomes after release. By integrating detailed epidemiological data and incarceration history, we aimed to provide insights into the interaction of TB transmission between prisons and the community. Results Index Patients Incarceration history and established risk factors for TB transmission Among 3,666 index patients aged 15–60, 188 (5.1%) reported a history of incarceration. Index patients with a history of incarceration were more likely to be male, smoke, drink alcohol, and have a positive sputum smear at the time of diagnosis (Table 1 ). Table 1 Characteristics of index TB patients aged 15–60, stratified by recent incarceration history. Total Without incarceration history With incarceration history P-values Sex (n = 3,658) < 0.001 Female 1,396 38% 1,392 40% 4 2% Male 2,262 62% 2,078 60% 184 98% Smoking status (n = 3,583) < 0.001 Non-smoker 3,485 97% 3,327 98% 158 89% Smoker 98 3% 78 2% 20 11% Drinking status (n = 3,495) < 0.001 Non-drinker 1,913 55% 1,877 57% 36 21% Drinker 1,582 45% 1,443 44% 139 79% Sputum smear status (n = 3,658) 0.045 Negative 1,011 28% 971 28% 40 21% Positive 2,647 72% 2,499 72% 148 79% Cavitary disease (n = 3,590) 0.276 No 2,605 73% 2,475 73% 130 69% Yes 985 27% 927 27% 58 31% Drug resistant profiles (n = 3,044) 0.503 Sensitive 1,875 62% 1,766 62% 109 63% Mono-resistance 487 16% 466 16% 21 12% Poly-resistance 235 8% 222 8% 13 8% Multidrug-resistance 447 15% 418 15% 29 17% TB severity scores and treatment outcomes Among 3,666 index patients aged 15–60, 513 (14%) had an unsuccessful treatment outcome. The mean TB severity score was 2.7 (standard deviation = 1.38). In the univariate analysis, those with a history of incarceration had higher TB severity scores at enrollment (mean difference [MD] = 0.30; 95% CI: 0.10–0.50) and experienced more unsuccessful treatment outcomes (risk ratio [RR] = 2.59; 95% CI: 1.99–3.38) compared to patients who had never been incarcerated. This association persisted after adjusting for age and sex (MD for severity score = 0.25; 95% CI: 0.05–0.47; RR for unsuccessful treatment outcomes = 2.17; 95% CI:1.63–2.90). Further adjustment for the DST profile of index patients had little impact on these associations (MD for severity score = 0.26; 95% CI: 0.06–0.47; RR for unsuccessful treatment outcomes = 2.10; 95% CI:1.59–2.76). Time interval between release and TB diagnosis Among 188 index patients with a history of incarceration within 60 months prior to their TB diagnosis, 138 (73%) reported their time of release. Of these, 100 (73%) were released ≤ 24 months before their TB diagnosis. TB diagnoses did not occur uniformly over time (p < 0.001) but instead clustered around the time of release (Fig. 1 ). This pattern remained when we restricted the analysis to the 45 patients with DR-TB, of whom 35 (78%) were diagnosed with TB ≤ 24 months post-release. In a sensitivity analysis restricted to 72 index patients who had been incarcerated for 12 months or less, 51 (71%) were diagnosed with TB within 24 months of their release. Household contacts Among 7,101 HHCs aged 15–60, 121 (1.7%) reported recent incarceration. In the univariate analysis, HHCs with a history of incarceration had a 1.34-fold higher prevalence risk of TB infection (95% CI: 1.20–1.49) at enrollment compared to those without such a history. This association remained nearly unchanged after adjusting for potential confounders (Prevalence Risk Ratio [PRR] = 1.33; 95% CI: 1.16–1.52). We did not observe a dose-response relationship between the duration of incarceration and TB infection risk. However, the risk of TB infection at enrollment was higher among those reporting any duration of incarceration (≤ 3 months vs. no history: PRR: 1.37; 95% CI: 1.06–1.78; 4–17 months vs. no history: PRR: 1.24; 95% CI: 0.96–1.59; >17 months vs. no history: PRR: 1.28; 95% CI: 1.03–1.59) (Fig. 2 ). Discussion Compared to those without a recent incarceration history, index TB patients with such a history were more likely to have well-established risk factors for transmission, present with advanced disease at diagnosis, and experience worse treatment outcomes. Notably, over 70% of index TB patients with a recent incarceration history were diagnosed within two years of release. Household contacts with a recent incarceration history were also more likely to be infected at enrollment, even after adjusting for potential risk factors for TB infection. This increased risk persisted even among HHCs who had served only short sentences. Our finding that a substantial proportion of TB patients with a recent incarceration history were diagnosed shortly after release aligns with the results of studies in Brazil, Paraguay, and France. Mabud et al. found that TB incidence among former PDLs in the Brazilian state of Mato Grosso do Sul between 2007 and 2013 was five times higher than baseline community incidence in the first year after release, declining over time.(11) Sequera et al. reported that among individuals incarcerated in Paraguay between 2010 and 2021, more than 40% of all TB cases were diagnosed after prison release. Within their cohort of former PDLs, TB notifications were highest in the first year following release and the elevated risk persisted for at least eight years. (3) Similarly, Niaux et al. reported that among 40 individuals who developed TB post-release in France from 2008 to 2020, 35% were diagnosed within two years after release.(18) This pattern of diagnosis suggests that many of these individuals acquired their TB infections while incarcerated. Additional evidence for the spillover of TB from prisons comes from genetic studies. Research from Brazil and Thailand has demonstrated that TB patients with a history of incarceration are more likely to belong to large Mtb genetic clusters. Miyahara et al. reported that formerly incarcerated TB patients in Chiang Rai, Thailand were 4.5 times more likely than never-incarcerated individuals to be included in large genetic clusters and that 28% of individuals in these clusters had an incarceration history​.(19) Similarly, Walter et al. found in Central West Brazil that 71% of genomic clusters involving never-incarcerated individuals also included people with a recent incarceration history. Moreover, over half (51%) of TB cases in non-incarcerated individuals were genetically clustered with those with incarceration history.(8) Using the Mtb WGS data of the index patients of our study, we previously showed that index patients with a history of incarceration were approximately 3 to 11 times more likely than others to transmit TB to another patient in our community-based cohort.(20) These findings support the hypothesis that prisons serve as reservoirs for TB and that former PDLs may be drivers of transmission. Despite strong evidence linking incarceration to TB infection, we are not aware of studies that have specifically examined its prevalence among former PDLs. However, many studies that have conducted large-scale TB infection screenings in prisons have consistently reporting higher TB infection prevalence than in the general population, with increases varying widely (ranging from 5- to 83-fold) across countries.(1,7) Several studies in Ethiopia and Brazil have assessed the association between incarceration duration and TB infection prevalence among PDLs, finding a stronger trend in Ethiopia than in Brazil. Chekesa et al. reported that in prisons in the East Wollega Zone, western Ethiopia, the prevalence of TB infection among PDLs incarcerated for more than 12 months was 16% higher than among those incarcerated for 12 months or less (61% vs. 45%).(21) Similarly, de Navarro et al. found that TB infection prevalence in Minas Gerais, Brazil was 3% higher among those incarcerated for at least 15 months compared to those with shorter stays (27% vs. 24%).(22) Notably, the reported 45% prevalence among PDLs with shorter prison stays in Ethiopia was considerably higher than the estimated TB infection prevalence in the general population (31%).(23) In our study, we also observed that HHCs with short prison stays already faced an increased risk of TB infection. These findings indicate that the extremely high TB burden in prisons contributes to substantial transmission risk, even for individuals incarcerated for short durations. Some countries, including Brazil and Peru, have implemented active case-finding (ACF) programs incorporating TB symptom screening and chest radiography (CXR) to reduce TB transmission within prisons and prevent spillover into the community.(24–26) However, the timing of diagnosis in our cohort and in similar studies indicates that many TB-infected PDLs only develop active disease after release. This is especially likely for PDLs incarcerated for a short period, who make up a substantial proportion of the prison population in Latin America. For example, in a prison in Lima, housing approximately 8,500 PDLs, more than 50% were incarcerated for less than one year.(27) This included many individuals held in pre-trial detention, who may be imprisoned for months without a conviction due to overburdened court systems.(28,29) Thus, for a substantial proportion of PDLs, prisons may function as a revolving door of short detention, TB infection, and release, with the resulting transmission risk ultimately borne by the community. Consequently, an ACF program alone is unlikely to be sufficient to curb the TB spillover effect from prisons into the community. Our study has several limitations. First, index TB patients enrolled in our prospective cohort study were likely to have better treatment outcomes than those in routine practice settings. Also, all HHCs were exposed to TB at home, so the prevalence of TB infection at enrollment among HHCs without a history of incarceration was higher than that in the general population of the same age group. Therefore, the effect sizes of the associations between individuals’ incarceration history and TB outcomes were likely underestimated compared to the true relative risks that would be observed in the general population. Second, recall bias regarding incarceration history may have introduced non-differential misclassification of exposure, which likely biased our results toward the null. Conclusion Our study highlights the important role of incarceration in shaping TB transmission dynamics beyond prison walls, underscoring the need for interventions that bridge both prison and community settings. Implementing TB infection screening at prison entry or prior to release—paired with appropriate interventions such as TPT—may help mitigate spillover and reduce transmission in high-burden communities. Methods Study Setting and Data Collection We conducted a prospective cohort study of TB patients and their household contacts in Lima, Peru. We identified individuals over 15 years of age with newly diagnosed pulmonary tuberculosis and invited them to participate as index patients. We confirmed TB diagnoses by sputum smear microscopy or mycobacterial culture. At enrollment, we collected detailed information on index patients’ sociodemographic characteristics, history of previous tuberculosis, tobacco and alcohol use, incarceration history, duration of symptoms before diagnosis, presence of cavitary lesions, and comorbidities including diabetes mellitus and HIV infection. The detailed study design and data collection process have been previously described. (13) Informed consent was obtained from all participants, and this study protocol was approved by the Harvard University Institutional Review Board and by the Research Ethics Committee of the National Institute of Health of Peru. Household contacts (HHCs) of consenting index patients were enrolled within two weeks of the index patient’s recruitment. We referred those with signs or symptoms suggestive of TB disease to their local health center for further evaluation, including chest radiography and sputum smear testing. At enrollment, HHCs without a prior positive tuberculin skin test (TST) or history of tuberculosis disease had a TST to determine TB infection status. Those with an induration size ≥ 10 mm or a known positive TST were classified as TB-infected at enrollment. We also collected sociodemographic data from HHCs, including age, sex, incarceration history, comorbidities (e.g., diabetes mellitus and HIV status), Bacillus Calmette-Guérin (BCG) vaccination status, and use of isoniazid preventive therapy. TB severity score and TB treatment outcomes of index patients We assessed TB severity in index patients using a modified Bantim TB Severity Score, incorporating the presence of cough, hemoptysis, night sweats, dyspnea, fever (> 37°C), and BMI (< 18 kg/m²).(14) Each of these factors contributed one point to the score, with an additional point assigned for BMI < 16 kg/m², resulting in a maximum total score of seven. We followed index patients until they achieved TB cure, were lost to follow-up, died, or reached a maximum of five years, whichever occurred first. We classified treatment outcomes following World Health Organization (WHO) guidelines which define TB treatment outcomes as either successful (cure or treatment completion) or unsuccessful (treatment failure, loss to follow-up, or death).(15) Incarceration History We asked index TB patients and HHCs whether they had been incarcerated for more than one day during the 60 months preceding enrollment. For those who reported incarceration, we collected the start and end dates (month and year) and calculated the time from release to disease diagnosis for index patients and the duration of incarceration of HHCs. Statistical Analysis Index patients We excluded index patients older than 60 years at enrollment from the analyses, as none of these patients reported a history of incarceration. We considered that TB patients with known risk factors for transmission may be more likely to contribute to community-level TB transmission. Therefore, we evaluated the association between incarceration history and well-established TB transmission risk factors using Fisher’s exact test. These factors included sex, tobacco use, alcohol use, sputum smear status at enrollment, and the presence of cavitary disease.(13) We used linear and modified Poisson regression to assess associations between the incarceration history of index TB patients and (1) TB severity scores at enrollment and (2) treatment outcomes. We built univariate analyses and multivariate models adjusted for age and sex. Because previous studies have reported a high prevalence of drug-resistant TB (DR-TB) in prisons,(2) we performed a sensitivity analysis that adjusted for the drug susceptibility testing (DST) profiles of the index TB patients. We did not disaggregate these results by sex due to the very small number of female participants reporting an incarceration history. We used the time interval from the patient’s reported date of release from prison until their disease diagnosis to evaluate whether TB disease in patients with an incarceration history was linked to infections that were acquired in prison. Since TB progression risk is highest in the first 24 months after infection,(16) we expected that if incarceration was driving TB risk, disease onset times in this group would be clustered near the time of prison release and incident disease would be less common as time since release increased. If incarceration had no impact, the time interval between release and disease onset would follow a uniform distribution. We tested this hypothesis using the Kolmogorov-Smirnov (K-S) test.(17) We also considered that some patients incarcerated for extended periods may have been infected early in their prison stay and therefore have a relatively constant risk of TB progression by the time they are released. To account for this, we conducted a sensitivity analysis restricting the sample to individuals incarcerated for 12 months or less. Household contacts We excluded HHCs younger than 15 years or older than 60 years at enrollment from the analyses, as very few reported a history of incarceration. We used modified Poisson regression to evaluate the association between HHC incarceration history and their TB infection risk at enrollment. We constructed a univariate and multivariate model adjusting for index-patient and HHC characteristics identified a priori as potential modifiers of TB infection risk at enrollment. These included the index patient's age, sex, smoking and drinking status, sputum smear grade, duration of cough symptoms, and presence of cavitary disease, as well as the HHC's age, sex, BCG vaccination history, and socioeconomic status. We examined the impact of the duration of incarceration on TB infection risk among HHCs at enrollment, categorizing the duration of incarceration into tertiles: ≤3 months, 4–17 months, and > 17 months. Declarations Role of funding source The sponsor had no role in the study design, data collection, data analysis, data interpretation, manuscript writing, or the decision to submit the manuscript for publication. Funding This work was supported by the National Institutes of Health grants U01AI057786, U19AI076217, U19AI109755, U19AI111224., U19AI142793, to MBM; K01AI151083 to M.B.B. and Burke Fellowship to C.-C.H.. The views expressed in this article are our own and not an official position of these funders. Author Contributions: M.B.B., M.B.M. and C.-C.H. conceptualized the study and designed the methodology. J.J. and J.T.G. were responsible for project administration, C.C.C. and R.M.Y. led the study implementation and data collection, and L.W.L. provided supervision. R.I.C. oversaw the clinical laboratory input. Z.Z. oversaw the data management and data quality assurance. C.-C.H. performed the analysis; M.B.M, C.-C.H., and A.E.M wrote the first draft of the manuscript. C.-C.H. and Z.Z. accessed and verified all the data. All authors revised critically for interpretation and content. All authors had final responsibility for the decision to submit for publication. Acknowledgements: We thank the patients and their families who gave their time and energy to contribute to this study, the National Strategy for Tuberculosis Control at the Peruvian Ministry of Health, and the healthcare personnel at the participating health centers in Lima. This work was also supported by Kathy and Bob Burke through the Burke Global Health Fellowship Program at The Harvard Global Health Institute. The authors gratefully acknowledge their support, which made this research possible. 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Available from: https://www.state.gov/reports/2019-country-reports-on-human-rights-practices/brazil/ Criminal Policy and Incarceration for Drug-Related Offenses in Costa Rica - Dejusticia [Internet]. [cited 2025 May 14]. Available from: https://www.dejusticia.org/publication/politica-criminal-y-encarcelamiento-por-delitos-relacionados-con-drogas-en-costa-rica/ Additional Declarations There is NO Competing Interest. Cite Share Download PDF Status: Under Review Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7707029\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Article\",\"associatedPublications\":[],\"authors\":[{\"id\":524012577,\"identity\":\"77ba30cf-5381-4964-8d06-2ed860065bcd\",\"order_by\":0,\"name\":\"Megan 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incarceration.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7707029/v1/34d6bb5eb92526ce7b0f9497.png\"},{\"id\":92845142,\"identity\":\"2597986e-a325-4a6a-862d-acb00b2363ec\",\"added_by\":\"auto\",\"created_at\":\"2025-10-06 09:25:40\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":31614,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eAssociations between duration of incarceration and the baseline prevalence of TB infection among household contacts.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7707029/v1/849361eac5da2cd7bc09c158.png\"},{\"id\":92846851,\"identity\":\"0281ba90-be2a-4e96-be23-36ed25959305\",\"added_by\":\"auto\",\"created_at\":\"2025-10-06 09:41:40\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":844307,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7707029/v1/9af838ed-9e02-4f1b-9238-f91a6de474de.pdf\"}],\"financialInterests\":\"There is \\u003cb\\u003eNO\\u003c/b\\u003e Competing Interest.\",\"formattedTitle\":\"The Hidden Epidemic: Post-Release Tuberculosis Risk in Formerly Incarcerated Populations\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003ePrisons are high-risk environments for TB transmission due to overcrowding, poor ventilation, and inadequate healthcare. Prolonged close contact among persons deprived of liberty (PDLs) facilitates TB spread, while high rates of HIV infection, malnutrition, and substance use increase individual susceptibility.(1\\u0026ndash;5) Limited access to accurate diagnostic tools, inconsistent treatment protocols, and inadequate infection control measures further contribute to the spread of drug-resistant TB (DR-TB) and multidrug-resistant TB (MDR-TB).(2,6) Globally, PDLs face a more than tenfold higher risk of TB compared to the general population within the same communities. (2,7) The greatest disparity in TB incidence between PDLs and the general population is in Latin America, where the rapid expansion of the incarcerated population has driven an increase in national TB notifications.(8) In Peru, TB incidence rates among PDLs exceed those of the general population by more than 25-fold.(1,9)\\u003c/p\\u003e\\u003cp\\u003eWhile incarceration is a well-established risk factor for \\u003cem\\u003eMycobacterium tuberculosis\\u003c/em\\u003e (\\u003cem\\u003eMtb\\u003c/em\\u003e) infection and TB disease,(10) its full impact on community transmission is likely underestimated.(3) High turnover in prisons, coupled with TB\\u0026rsquo;s long and variable latency period, means that many individuals may acquire infection while incarcerated but develop active disease after release. Cross-sectional studies identify TB genomic clusters that include individuals with and without a history of incarceration, indicating spillover from prisons into the community.(3,11,12) However, the extent of this transmission remains unclear. While the elevated TB risk among PDLs is well documented, research on those who develop disease after release from prison is limited\\u0026mdash;despite their key role in understanding how incarceration contributes to broader TB transmission dynamics.\\u003c/p\\u003e\\u003cp\\u003eIn this study, we leveraged a prospective cohort of TB patients and their household contacts in Lima, Peru, to examine the relationship between incarceration history and TB outcomes after release. By integrating detailed epidemiological data and incarceration history, we aimed to provide insights into the interaction of TB transmission between prisons and the community.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eIndex Patients\\u003c/h2\\u003e\\u003cdiv id=\\\"Sec4\\\" class=\\\"Section3\\\"\\u003e\\u003ch2\\u003eIncarceration history and established risk factors for TB transmission\\u003c/h2\\u003e\\u003cp\\u003eAmong 3,666 index patients aged 15\\u0026ndash;60, 188 (5.1%) reported a history of incarceration. Index patients with a history of incarceration were more likely to be male, smoke, drink alcohol, and have a positive sputum smear at the time of diagnosis (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eCharacteristics of index TB patients aged 15\\u0026ndash;60, stratified by recent incarceration history.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"13\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" 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align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c11\\\" colnum=\\\"11\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c12\\\" colnum=\\\"12\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c13\\\" colnum=\\\"13\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c5\\\" namest=\\\"c4\\\"\\u003e\\u003cp\\u003eTotal\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c8\\\" namest=\\\"c7\\\"\\u003e\\u003cp\\u003eWithout incarceration 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align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c13\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eFemale\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1,396\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e38%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e1,392\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e40%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e2%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eMale\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e2,262\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e62%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e2,078\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e60%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e184\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e98%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eSmoking status (n\\u0026thinsp;=\\u0026thinsp;3,583)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c13\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eNon-smoker\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e3,485\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e97%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e3,327\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e98%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e158\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e89%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eSmoker\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e98\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e3%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e78\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e2%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e20\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e11%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eDrinking status (n\\u0026thinsp;=\\u0026thinsp;3,495)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c13\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eNon-drinker\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1,913\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e55%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e1,877\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e57%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e36\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e21%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eDrinker\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1,582\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e45%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e1,443\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e44%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e139\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e79%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eSputum smear status (n\\u0026thinsp;=\\u0026thinsp;3,658)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c13\\\"\\u003e\\u003cp\\u003e0.045\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eNegative\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1,011\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e28%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e971\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e28%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e40\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e21%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePositive\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e2,647\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e72%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e2,499\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e72%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e148\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e79%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eCavitary disease (n\\u0026thinsp;=\\u0026thinsp;3,590)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c13\\\"\\u003e\\u003cp\\u003e0.276\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eNo\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e2,605\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e73%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e2,475\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e73%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e130\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e69%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eYes\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e985\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e27%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e927\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e27%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e58\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e31%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c2\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eDrug resistant profiles (n\\u0026thinsp;=\\u0026thinsp;3,044)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c13\\\"\\u003e\\u003cp\\u003e0.503\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eSensitive\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1,875\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e62%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e1,766\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e62%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e109\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e63%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eMono-resistance\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e487\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e16%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e466\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e16%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e21\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e12%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePoly-resistance\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e235\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e8%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e222\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e8%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e13\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e8%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eMultidrug-resistance\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e447\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e15%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e418\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e15%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c10\\\"\\u003e\\u003cp\\u003e29\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u003cp\\u003e17%\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eTB severity scores and treatment outcomes\\u003c/h3\\u003e\\n\\u003cp\\u003eAmong 3,666 index patients aged 15\\u0026ndash;60, 513 (14%) had an unsuccessful treatment outcome. The mean TB severity score was 2.7 (standard deviation\\u0026thinsp;=\\u0026thinsp;1.38). In the univariate analysis, those with a history of incarceration had higher TB severity scores at enrollment (mean difference [MD]\\u0026thinsp;=\\u0026thinsp;0.30; 95% CI: 0.10\\u0026ndash;0.50) and experienced more unsuccessful treatment outcomes (risk ratio [RR]\\u0026thinsp;=\\u0026thinsp;2.59; 95% CI: 1.99\\u0026ndash;3.38) compared to patients who had never been incarcerated. This association persisted after adjusting for age and sex (MD for severity score\\u0026thinsp;=\\u0026thinsp;0.25; 95% CI: 0.05\\u0026ndash;0.47; RR for unsuccessful treatment outcomes\\u0026thinsp;=\\u0026thinsp;2.17; 95% CI:1.63\\u0026ndash;2.90). Further adjustment for the DST profile of index patients had little impact on these associations (MD for severity score\\u0026thinsp;=\\u0026thinsp;0.26; 95% CI: 0.06\\u0026ndash;0.47; RR for unsuccessful treatment outcomes\\u0026thinsp;=\\u0026thinsp;2.10; 95% CI:1.59\\u0026ndash;2.76).\\u003c/p\\u003e\\n\\u003ch3\\u003eTime interval between release and TB diagnosis\\u003c/h3\\u003e\\n\\u003cp\\u003eAmong 188 index patients with a history of incarceration within 60 months prior to their TB diagnosis, 138 (73%) reported their time of release. Of these, 100 (73%) were released\\u0026thinsp;\\u0026le;\\u0026thinsp;24 months before their TB diagnosis. TB diagnoses did not occur uniformly over time (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) but instead clustered around the time of release (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). This pattern remained when we restricted the analysis to the 45 patients with DR-TB, of whom 35 (78%) were diagnosed with TB\\u0026thinsp;\\u0026le;\\u0026thinsp;24 months post-release. In a sensitivity analysis restricted to 72 index patients who had been incarcerated for 12 months or less, 51 (71%) were diagnosed with TB within 24 months of their release.\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eHousehold contacts\\u003c/h3\\u003e\\n\\u003cp\\u003eAmong 7,101 HHCs aged 15\\u0026ndash;60, 121 (1.7%) reported recent incarceration. In the univariate analysis, HHCs with a history of incarceration had a 1.34-fold higher prevalence risk of TB infection (95% CI: 1.20\\u0026ndash;1.49) at enrollment compared to those without such a history. This association remained nearly unchanged after adjusting for potential confounders (Prevalence Risk Ratio [PRR]\\u0026thinsp;=\\u0026thinsp;1.33; 95% CI: 1.16\\u0026ndash;1.52).\\u003c/p\\u003e\\u003cp\\u003eWe did not observe a dose-response relationship between the duration of incarceration and TB infection risk. However, the risk of TB infection at enrollment was higher among those reporting any duration of incarceration (\\u0026le;\\u0026thinsp;3 months vs. no history: PRR: 1.37; 95% CI: 1.06\\u0026ndash;1.78; 4\\u0026ndash;17 months vs. no history: PRR: 1.24; 95% CI: 0.96\\u0026ndash;1.59; \\u0026gt;17 months vs. no history: PRR: 1.28; 95% CI: 1.03\\u0026ndash;1.59) (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eCompared to those without a recent incarceration history, index TB patients with such a history were more likely to have well-established risk factors for transmission, present with advanced disease at diagnosis, and experience worse treatment outcomes. Notably, over 70% of index TB patients with a recent incarceration history were diagnosed within two years of release. Household contacts with a recent incarceration history were also more likely to be infected at enrollment, even after adjusting for potential risk factors for TB infection. This increased risk persisted even among HHCs who had served only short sentences.\\u003c/p\\u003e\\u003cp\\u003eOur finding that a substantial proportion of TB patients with a recent incarceration history were diagnosed shortly after release aligns with the results of studies in Brazil, Paraguay, and France. Mabud et al. found that TB incidence among former PDLs in the Brazilian state of Mato Grosso do Sul between 2007 and 2013 was five times higher than baseline community incidence in the first year after release, declining over time.(11) Sequera et al. reported that among individuals incarcerated in Paraguay between 2010 and 2021, more than 40% of all TB cases were diagnosed after prison release. Within their cohort of former PDLs, TB notifications were highest in the first year following release and the elevated risk persisted for at least eight years. (3) Similarly, Niaux et al. reported that among 40 individuals who developed TB post-release in France from 2008 to 2020, 35% were diagnosed within two years after release.(18) This pattern of diagnosis suggests that many of these individuals acquired their TB infections while incarcerated.\\u003c/p\\u003e\\u003cp\\u003eAdditional evidence for the spillover of TB from prisons comes from genetic studies. Research from Brazil and Thailand has demonstrated that TB patients with a history of incarceration are more likely to belong to large \\u003cem\\u003eMtb\\u003c/em\\u003e genetic clusters. Miyahara et al. reported that formerly incarcerated TB patients in Chiang Rai, Thailand were 4.5 times more likely than never-incarcerated individuals to be included in large genetic clusters and that 28% of individuals in these clusters had an incarceration history​.(19) Similarly, Walter et al. found in Central West Brazil that 71% of genomic clusters involving never-incarcerated individuals also included people with a recent incarceration history. Moreover, over half (51%) of TB cases in non-incarcerated individuals were genetically clustered with those with incarceration history.(8) Using the \\u003cem\\u003eMtb\\u003c/em\\u003e WGS data of the index patients of our study, we previously showed that index patients with a history of incarceration were approximately 3 to 11 times more likely than others to transmit TB to another patient in our community-based cohort.(20) These findings support the hypothesis that prisons serve as reservoirs for TB and that former PDLs may be drivers of transmission.\\u003c/p\\u003e\\u003cp\\u003eDespite strong evidence linking incarceration to TB infection, we are not aware of studies that have specifically examined its prevalence among former PDLs. However, many studies that have conducted large-scale TB infection screenings in prisons have consistently reporting higher TB infection prevalence than in the general population, with increases varying widely (ranging from 5- to 83-fold) across countries.(1,7)\\u003c/p\\u003e\\u003cp\\u003eSeveral studies in Ethiopia and Brazil have assessed the association between incarceration duration and TB infection prevalence among PDLs, finding a stronger trend in Ethiopia than in Brazil. Chekesa et al. reported that in prisons in the East Wollega Zone, western Ethiopia, the prevalence of TB infection among PDLs incarcerated for more than 12 months was 16% higher than among those incarcerated for 12 months or less (61% vs. 45%).(21) Similarly, de Navarro et al. found that TB infection prevalence in Minas Gerais, Brazil was 3% higher among those incarcerated for at least 15 months compared to those with shorter stays (27% vs. 24%).(22) Notably, the reported 45% prevalence among PDLs with shorter prison stays in Ethiopia was considerably higher than the estimated TB infection prevalence in the general population (31%).(23) In our study, we also observed that HHCs with short prison stays already faced an increased risk of TB infection. These findings indicate that the extremely high TB burden in prisons contributes to substantial transmission risk, even for individuals incarcerated for short durations.\\u003c/p\\u003e\\u003cp\\u003eSome countries, including Brazil and Peru, have implemented active case-finding (ACF) programs incorporating TB symptom screening and chest radiography (CXR) to reduce TB transmission within prisons and prevent spillover into the community.(24\\u0026ndash;26) However, the timing of diagnosis in our cohort and in similar studies indicates that many TB-infected PDLs only develop active disease after release. This is especially likely for PDLs incarcerated for a short period, who make up a substantial proportion of the prison population in Latin America. For example, in a prison in Lima, housing approximately 8,500 PDLs, more than 50% were incarcerated for less than one year.(27) This included many individuals held in pre-trial detention, who may be imprisoned for months without a conviction due to overburdened court systems.(28,29) Thus, for a substantial proportion of PDLs, prisons may function as a revolving door of short detention, TB infection, and release, with the resulting transmission risk ultimately borne by the community. Consequently, an ACF program alone is unlikely to be sufficient to curb the TB spillover effect from prisons into the community.\\u003c/p\\u003e\\u003cp\\u003eOur study has several limitations. First, index TB patients enrolled in our prospective cohort study were likely to have better treatment outcomes than those in routine practice settings. Also, all HHCs were exposed to TB at home, so the prevalence of TB infection at enrollment among HHCs without a history of incarceration was higher than that in the general population of the same age group. Therefore, the effect sizes of the associations between individuals\\u0026rsquo; incarceration history and TB outcomes were likely underestimated compared to the true relative risks that would be observed in the general population. Second, recall bias regarding incarceration history may have introduced non-differential misclassification of exposure, which likely biased our results toward the null.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eOur study highlights the important role of incarceration in shaping TB transmission dynamics beyond prison walls, underscoring the need for interventions that bridge both prison and community settings. Implementing TB infection screening at prison entry or prior to release\\u0026mdash;paired with appropriate interventions such as TPT\\u0026mdash;may help mitigate spillover and reduce transmission in high-burden communities.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eStudy Setting and Data Collection\\u003c/h2\\u003e\\u003cp\\u003eWe conducted a prospective cohort study of TB patients and their household contacts in Lima, Peru. We identified individuals over 15 years of age with newly diagnosed pulmonary tuberculosis and invited them to participate as index patients. We confirmed TB diagnoses by sputum smear microscopy or mycobacterial culture. At enrollment, we collected detailed information on index patients\\u0026rsquo; sociodemographic characteristics, history of previous tuberculosis, tobacco and alcohol use, incarceration history, duration of symptoms before diagnosis, presence of cavitary lesions, and comorbidities including diabetes mellitus and HIV infection. The detailed study design and data collection process have been previously described. (13) Informed consent was obtained from all participants, and this study protocol was approved by the Harvard University Institutional Review Board and by the Research Ethics Committee of the National Institute of Health of Peru.\\u003c/p\\u003e\\u003cp\\u003eHousehold contacts (HHCs) of consenting index patients were enrolled within two weeks of the index patient\\u0026rsquo;s recruitment. We referred those with signs or symptoms suggestive of TB disease to their local health center for further evaluation, including chest radiography and sputum smear testing. At enrollment, HHCs without a prior positive tuberculin skin test (TST) or history of tuberculosis disease had a TST to determine TB infection status. Those with an induration size\\u0026thinsp;\\u0026ge;\\u0026thinsp;10 mm or a known positive TST were classified as TB-infected at enrollment. We also collected sociodemographic data from HHCs, including age, sex, incarceration history, comorbidities (e.g., diabetes mellitus and HIV status), Bacillus Calmette-Gu\\u0026eacute;rin (BCG) vaccination status, and use of isoniazid preventive therapy.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eTB severity score and TB treatment outcomes of index patients\\u003c/h2\\u003e\\u003cp\\u003eWe assessed TB severity in index patients using a modified Bantim TB Severity Score, incorporating the presence of cough, hemoptysis, night sweats, dyspnea, fever (\\u0026gt;\\u0026thinsp;37\\u0026deg;C), and BMI (\\u0026lt;\\u0026thinsp;18 kg/m\\u0026sup2;).(14) Each of these factors contributed one point to the score, with an additional point assigned for BMI\\u0026thinsp;\\u0026lt;\\u0026thinsp;16 kg/m\\u0026sup2;, resulting in a maximum total score of seven. We followed index patients until they achieved TB cure, were lost to follow-up, died, or reached a maximum of five years, whichever occurred first. We classified treatment outcomes following World Health Organization (WHO) guidelines which define TB treatment outcomes as either successful (cure or treatment completion) or unsuccessful (treatment failure, loss to follow-up, or death).(15)\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eIncarceration History\\u003c/h2\\u003e\\u003cp\\u003eWe asked index TB patients and HHCs whether they had been incarcerated for more than one day during the 60 months preceding enrollment. For those who reported incarceration, we collected the start and end dates (month and year) and calculated the time from release to disease diagnosis for index patients and the duration of incarceration of HHCs.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eStatistical Analysis\\u003c/h2\\u003e\\u003cdiv id=\\\"Sec15\\\" class=\\\"Section3\\\"\\u003e\\u003ch2\\u003eIndex patients\\u003c/h2\\u003e\\u003cp\\u003eWe excluded index patients older than 60 years at enrollment from the analyses, as none of these patients reported a history of incarceration. We considered that TB patients with known risk factors for transmission may be more likely to contribute to community-level TB transmission. Therefore, we evaluated the association between incarceration history and well-established TB transmission risk factors using Fisher\\u0026rsquo;s exact test. These factors included sex, tobacco use, alcohol use, sputum smear status at enrollment, and the presence of cavitary disease.(13)\\u003c/p\\u003e\\u003cp\\u003eWe used linear and modified Poisson regression to assess associations between the incarceration history of index TB patients and (1) TB severity scores at enrollment and (2) treatment outcomes. We built univariate analyses and multivariate models adjusted for age and sex. Because previous studies have reported a high prevalence of drug-resistant TB (DR-TB) in prisons,(2) we performed a sensitivity analysis that adjusted for the drug susceptibility testing (DST) profiles of the index TB patients. We did not disaggregate these results by sex due to the very small number of female participants reporting an incarceration history.\\u003c/p\\u003e\\u003cp\\u003eWe used the time interval from the patient\\u0026rsquo;s reported date of release from prison until their disease diagnosis to evaluate whether TB disease in patients with an incarceration history was linked to infections that were acquired in prison. Since TB progression risk is highest in the first 24 months after infection,(16) we expected that if incarceration was driving TB risk, disease onset times in this group would be clustered near the time of prison release and incident disease would be less common as time since release increased. If incarceration had no impact, the time interval between release and disease onset would follow a uniform distribution. We tested this hypothesis using the Kolmogorov-Smirnov (K-S) test.(17) We also considered that some patients incarcerated for extended periods may have been infected early in their prison stay and therefore have a relatively constant risk of TB progression by the time they are released. To account for this, we conducted a sensitivity analysis restricting the sample to individuals incarcerated for 12 months or less.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eHousehold contacts\\u003c/h2\\u003e\\u003cp\\u003eWe excluded HHCs younger than 15 years or older than 60 years at enrollment from the analyses, as very few reported a history of incarceration. We used modified Poisson regression to evaluate the association between HHC incarceration history and their TB infection risk at enrollment. We constructed a univariate and multivariate model adjusting for index-patient and HHC characteristics identified a priori as potential modifiers of TB infection risk at enrollment. These included the index patient's age, sex, smoking and drinking status, sputum smear grade, duration of cough symptoms, and presence of cavitary disease, as well as the HHC's age, sex, BCG vaccination history, and socioeconomic status.\\u003c/p\\u003e\\u003cp\\u003eWe examined the impact of the duration of incarceration on TB infection risk among HHCs at enrollment, categorizing the duration of incarceration into tertiles: \\u0026le;3 months, 4\\u0026ndash;17 months, and \\u0026gt;\\u0026thinsp;17 months.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eRole of funding source\\u003c/h2\\u003e\\u003cp\\u003eThe sponsor had no role in the study design, data collection, data analysis, data interpretation, manuscript writing, or the decision to submit the manuscript for publication.\\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis work was supported by the National Institutes of Health grants U01AI057786, U19AI076217, U19AI109755, U19AI111224., U19AI142793, to MBM; K01AI151083 to M.B.B. and Burke Fellowship to C.-C.H.. The views expressed in this article are our own and not an official position of these funders.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contributions:\\u003c/h2\\u003e\\u003cp\\u003eM.B.B., M.B.M. and C.-C.H. conceptualized the study and designed the methodology. J.J. and J.T.G. were responsible for project administration, C.C.C. and R.M.Y. led the study implementation and data collection, and L.W.L. provided supervision. R.I.C. oversaw the clinical laboratory input. Z.Z. oversaw the data management and data quality assurance. C.-C.H. performed the analysis; M.B.M, C.-C.H., and A.E.M wrote the first draft of the manuscript. C.-C.H. and Z.Z. accessed and verified all the data. All authors revised critically for interpretation and content. All authors had final responsibility for the decision to submit for publication.\\u003c/p\\u003e\\u003ch2\\u003eAcknowledgements:\\u003c/h2\\u003e\\u003cp\\u003e We thank the patients and their families who gave their time and energy to contribute to this study, the National Strategy for Tuberculosis Control at the Peruvian Ministry of Health, and the healthcare personnel at the participating health centers in Lima. This work was also supported by Kathy and Bob Burke through the Burke Global Health Fellowship Program at The Harvard Global Health Institute. The authors gratefully acknowledge their support, which made this research possible.\\u003c/p\\u003e\\u003ch2\\u003eData Availability:\\u003c/h2\\u003e\\u003cp\\u003eReasonable data requests can be made to Megan Murray (megan_murray@hms.harvard.edu).\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eMartinez L, Warren JL, Harries AD, Croda J, Espinal MA, Olarte RAL, et al. Global, regional, and national estimates of tuberculosis incidence and case detection among incarcerated individuals from 2000 to 2019: a systematic analysis. Lancet Public Health [Internet]. 2023 Jul 1 [cited 2024 Feb 24];8(7):e511\\u0026ndash;9. Available from: http://www.thelancet.com/article/S246826672300097X/fulltext\\u003c/li\\u003e\\n\\u003cli\\u003eBiadglegne F, Rodloff AC, Sack U. Review of the prevalence and drug resistance of tuberculosis in prisons: A hidden epidemic. Epidemiol Infect. 2015 Apr 11;143(5):887\\u0026ndash;900.\\u003c/li\\u003e\\n\\u003cli\\u003eSequera G, Aguirre S, Estigarribia G, Walter KS, Horna-Campos O, Liu YE, et al. Incarceration and TB: the epidemic beyond prison walls. BMJ Glob Health [Internet]. 2024 Feb 21 [cited 2024 Feb 22];9(2):e014722. Available from: https://pubmed.ncbi.nlm.nih.gov/38382977/\\u003c/li\\u003e\\n\\u003cli\\u003eHaeusler IL, Torres-Ortiz A, Grandjean L. A systematic review of tuberculosis detection and prevention studies in prisons. Glob Public Health [Internet]. 2022 [cited 2024 Feb 21];17(2):194\\u0026ndash;209. Available from: https://pubmed.ncbi.nlm.nih.gov/33427099/\\u003c/li\\u003e\\n\\u003cli\\u003eEdge CL, King EJ, Dolan K, McKee M. Prisoners co-infected with tuberculosis and HIV: A systematic review: A. J Int AIDS Soc. 2016 Jan 1;19(1).\\u003c/li\\u003e\\n\\u003cli\\u003eUtpatel C, Zavaleta M, Rojas-Bolivar D, M\\u0026uuml;hlbach A, Picoy J, Portugal W, et al. Prison as a driver of recent transmissions of multidrug-resistant tuberculosis in Callao, Peru: a cross-sectional study. Lancet Regional Health - Americas [Internet]. 2024 [cited 2024 Feb 21];0(0). Available from: http://www.thelancet.com/article/S2667193X24000012/fulltext\\u003c/li\\u003e\\n\\u003cli\\u003eCords O, Martinez L, Warren JL, O\\u0026rsquo;Marr JM, Walter KS, Cohen T, et al. Incidence and prevalence of tuberculosis in incarcerated populations: a systematic review and meta-analysis. Lancet Public Health [Internet]. 2021 May 1 [cited 2024 Feb 21];6(5):e300. Available from: /pmc/articles/PMC8168455/\\u003c/li\\u003e\\n\\u003cli\\u003eWalter KS, Martinez L, Arakaki-Sanchez D, Sequera VG, Estigarribia Sanabria G, Cohen T, et al. The escalating tuberculosis crisis in central and South American prisons. Lancet [Internet]. 2021 Apr 4 [cited 2024 Feb 24];397(10284):1591. Available from: /pmc/articles/PMC9393884/\\u003c/li\\u003e\\n\\u003cli\\u003ePai\\u0026atilde;o DSG, Lemos EF, Carbone A da SS, Sgarbi RVE, Junior AL, da Silva FM, et al. Impact of mass-screening on tuberculosis incidence in a prospective cohort of Brazilian prisoners. BMC Infect Dis. 2016 Oct 3;16(1).\\u003c/li\\u003e\\n\\u003cli\\u003eHaeusler IL, Torres-Ortiz A, Grandjean L. A systematic review of tuberculosis detection and prevention studies in prisons. Glob Public Health [Internet]. 2022 [cited 2025 Apr 12];17(2):194\\u0026ndash;209. Available from: https://pubmed.ncbi.nlm.nih.gov/33427099/\\u003c/li\\u003e\\n\\u003cli\\u003eMabud TS, de Lourdes Delgado Alves M, Ko AI, Basu S, Walter KS, Cohen T, et al. Evaluating strategies for control of tuberculosis in prisons and prevention of spillover into communities: An observational and modeling study from Brazil. PLoS Med. 2019;16(1).\\u003c/li\\u003e\\n\\u003cli\\u003eSalazar-De La Cuba AL, Ardiles-Paredes DF, Araujo-Castillo R V., Magui\\u0026ntilde;a JL. High prevalence of self-reported tuberculosis and associated factors in a nation-wide census among prison inmates in Peru. Tropical Medicine \\u0026amp; International Health [Internet]. 2019 Mar 1 [cited 2024 Feb 21];24(3):328\\u0026ndash;38. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/tmi.13199\\u003c/li\\u003e\\n\\u003cli\\u003eBecerra MC, Huang CC, Lecca L, Bayona J, Contreras C, Calderon R, et al. Transmissibility and potential for disease progression of drug resistant Mycobacterium tuberculosis: prospective cohort study. Bmj. 2019;367.\\u003c/li\\u003e\\n\\u003cli\\u003eRudolf F, Joaquim LC, Vieira C, Bjerregaard-Andersen M, Andersen A, Erlandsen M, et al. The Bandim tuberculosis score: reliability and comparison with the Karnofsky performance score. Scand J Infect Dis [Internet]. 2013 Apr [cited 2025 Apr 12];45(4):256\\u0026ndash;64. Available from: https://pubmed.ncbi.nlm.nih.gov/23113626/\\u003c/li\\u003e\\n\\u003cli\\u003eWorld Health Organization. WHO consolidated guidelines on tuberculosis: Module 4: Treatment - Drug-susceptible tuberculosis treatment. Geneva: World Health Organization; 2022. PMID: 35727905. 2022;\\u003c/li\\u003e\\n\\u003cli\\u003eBehr MA, Edelstein PH, Ramakrishnan L. Revisiting the timetable of tuberculosis. BMJ [Internet]. 2018 Aug 23 [cited 2025 Apr 13];362. Available from: https://www.bmj.com/content/362/bmj.k2738\\u003c/li\\u003e\\n\\u003cli\\u003eSmirnov N. Table for Estimating the Goodness of Fit of Empirical Distributions. The Annals of Mathematical Statistics. 1948 Jun;19(2):279\\u0026ndash;81.\\u003c/li\\u003e\\n\\u003cli\\u003eNiaux M, Boutrou M, Daniel M, Schiemsky V, Vierendeels E, Djossou F, et al. Tuberculosis in prison: What about after release? The example of French Guiana. Glob Public Health [Internet]. 2024 [cited 2025 Feb 10];19(1). Available from: https://pubmed.ncbi.nlm.nih.gov/38529772/\\u003c/li\\u003e\\n\\u003cli\\u003eMiyahara R, Piboonsiri P, Chiyasirinroje B, Imsanguan W, Nedsuwan S, Yanai H, et al. Risk for Prison-to-Community Tuberculosis Transmission, Thailand, 2017-2020. Emerg Infect Dis [Internet]. 2023 Mar 1 [cited 2023 May 3];29(3):477\\u0026ndash;83. Available from: https://pubmed.ncbi.nlm.nih.gov/36823074/\\u003c/li\\u003e\\n\\u003cli\\u003eTrevisi L, Brooks MB, Becerra MC, Calder\\u0026oacute;n RI, Contreras CC, Galea JT, et al. Who Transmits Tuberculosis to Whom: A Cross-Sectional Analysis of a Cohort Study in Lima, Peru. Am J Respir Crit Care Med [Internet]. 2024 Feb 28 [cited 2024 Mar 6]; Available from: https://pubmed.ncbi.nlm.nih.gov/38416532/\\u003c/li\\u003e\\n\\u003cli\\u003eChekesa B, Gumi B, Chanyalew M, Zewude A, Ameni G. Prevalence of latent tuberculosis infection and associated risk factors in prison in East Wollega Zone of western Ethiopia. PLoS One [Internet]. 2020 May 1 [cited 2025 Apr 13];15(5):e0233314. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0233314\\u003c/li\\u003e\\n\\u003cli\\u003eDe Navarro PD, De Almeida IN, Kritski AL, Ceccato MDG, Maciel MMD, Carvalho WDS, et al. Prevalence of latent Mycobacterium tuberculosis infection in prisoners. Jornal Brasileiro de Pneumologia [Internet]. 2016 Sep 1 [cited 2025 Mar 12];42(5):348. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5094871/\\u003c/li\\u003e\\n\\u003cli\\u003eLegesse M, Ameni G, Mamo G, Medhin G, Bjune G, Abebe F. Community-based cross-sectional survey of latent tuberculosis infection in Afar pastoralists, Ethiopia, using QuantiFERON-TB Gold In-Tube and tuberculin skin test. BMC Infect Dis [Internet]. 2011 Apr 9 [cited 2025 Apr 13];11(1):1\\u0026ndash;9. Available from: https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-11-89\\u003c/li\\u003e\\n\\u003cli\\u003ePuma D, Geadas C, Calderon RI, Yuen CM, Jim\\u0026eacute;nez J, C\\u0026oacute;rdova M, et al. Active case-finding for TB among incarcerated women in Peru. International Journal of Tuberculosis and Lung Disease. 2023 Oct 1;27(10):784\\u0026ndash;6.\\u003c/li\\u003e\\n\\u003cli\\u003eJung E, Alarc\\u0026oacute;n VA, Tupes WSS, Avalos-Cruz T, Tovar M, Abregu E, et al. National Active Case-Finding Program for Tuberculosis in Prisons, Peru, 2024 - Volume 31, Number 3\\u0026mdash;March 2025 - Emerging Infectious Diseases journal - CDC. Emerg Infect Dis [Internet]. 2025 Mar [cited 2025 Mar 4];31(3). Available from: https://wwwnc.cdc.gov/eid/article/31/3/24-1727_article\\u003c/li\\u003e\\n\\u003cli\\u003ede Araujo RCP, Martinez L, da Silva Santos A, Lemos EF, de Oliveira RD, Croda M, et al. Serial Mass Screening for Tuberculosis Among Incarcerated Persons in Brazil. Clin Infect Dis [Internet]. 2024 Jun 15 [cited 2025 Apr 13];78(6):1669\\u0026ndash;76. Available from: https://pubmed.ncbi.nlm.nih.gov/38324908/\\u003c/li\\u003e\\n\\u003cli\\u003eVeeken H. Lurigancho prison: Lima\\u0026rsquo;s \\u0026ldquo;high school\\u0026rdquo; for criminality. BMJ : British Medical Journal [Internet]. 2000 Jan 15 [cited 2025 Feb 10];320(7228):173. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC1128749/\\u003c/li\\u003e\\n\\u003cli\\u003eBrazil - United States Department of State [Internet]. [cited 2025 May 14]. Available from: https://www.state.gov/reports/2019-country-reports-on-human-rights-practices/brazil/\\u003c/li\\u003e\\n\\u003cli\\u003eCriminal Policy and Incarceration for Drug-Related Offenses in Costa Rica - Dejusticia [Internet]. [cited 2025 May 14]. Available from: https://www.dejusticia.org/publication/politica-criminal-y-encarcelamiento-por-delitos-relacionados-con-drogas-en-costa-rica/\\u003c/li\\u003e\\n\\u003c/ol\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"nature-portfolio\",\"isNatureJournal\":true,\"hasQc\":false,\"allowDirectSubmit\":false,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"Nature Portfolio\",\"twitterHandle\":\"\",\"acdcEnabled\":false,\"dfaEnabled\":false,\"editorialSystem\":\"ejp\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7707029/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7707029/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eIncarcerated 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\\u0026thinsp;\\u0026le;\\u0026thinsp;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\\u0026thinsp;=\\u0026thinsp;0.25) and had a higher risk of a poor treatment outcome compared to those who had not been incarcerated (risk ratio [RR]\\u0026thinsp;=\\u0026thinsp;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\\u0026ndash;60 years, 121 (1.7%) had a history of incarceration and these had a higher prevalence of TB infection (prevalence risk ratio [PRR]\\u0026thinsp;=\\u0026thinsp;1.33). The prevalence risk was similarly elevated in the subset who were incarcerated for only\\u0026thinsp;\\u0026le;\\u0026thinsp;3 months (PRR\\u0026thinsp;=\\u0026thinsp;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.\\u003c/p\\u003e\",\"manuscriptTitle\":\"The Hidden Epidemic: Post-Release Tuberculosis Risk in Formerly Incarcerated Populations\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-10-06 09:25:35\",\"doi\":\"10.21203/rs.3.rs-7707029/v1\",\"editorialEvents\":[],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"nature-communications\",\"isNatureJournal\":true,\"hasQc\":false,\"allowDirectSubmit\":false,\"externalIdentity\":\"NCOMMS\",\"sideBox\":\"Learn more about [Nature Communications](http://www.nature.com/ncomms/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://mts-ncomms.nature.com/\",\"title\":\"Nature Communications\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"ejp\",\"reportingPortfolio\":\"Nature Communications\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"af86fad8-4fb8-44b3-9ec8-b7aea287df1c\",\"owner\":[],\"postedDate\":\"October 6th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[{\"id\":55695055,\"name\":\"Health sciences/Diseases/Infectious diseases/Tuberculosis\"},{\"id\":55695056,\"name\":\"Health sciences/Risk factors\"}],\"tags\":[],\"updatedAt\":\"2026-05-05T01:56:00+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-10-06 09:25:35\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7707029\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7707029\",\"identity\":\"rs-7707029\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}