Tuberculosis treatment outcomes after transfer or release from incarceration: a retrospective cohort study from Brazil

BACKGROUND: Tuberculosis (TB) disproportionately affects people deprived of liberty (PDL). Prior studies have shown higher TB treatment completion rates among PDL compared to the general population. However, little is known about how incarceration-related movements such as transfers between facilities and releases to the community affect TB treatment outcomes. METHODS: We linked person-level incarceration data with TB notifications data from the Notifiable Disease Information System for the Brazilian state of Mato Grosso do Sul between January 2006 and December 2018. We constructed a cohort of PDL who were newly diagnosed with drug-susceptible TB and initiated treatment. We compared treatment outcomes between individuals who remained in the same carceral facility and those who were transferred to other facilities or released from incarceration during treatment. We computed the covariate-adjusted relative risk of unfavorable treatment outcomes for individuals transferred or released during treatment. RESULTS: We identified 1261 PDL who initiated TB treatment. Of these individuals, 842 (66.8%) remained in the same carceral facility, 256 (20.3%) were transferred to other facilities, and 163 (12.9%) were released to the community during treatment. Among those who remained in the same carceral facility, 72.9% (614/842) were successfully treated within 8 months following treatment initiation. In contrast, only 61.7% (158/256) of those who were transferred and 50.3% (82/163) of those who were released achieved TB treatment success within 8 months. After adjusting for covariates, the risk of unfavorable treatment outcomes was 1.4 (95% CI: 1.2 to 1.7) times as high for individuals transferred to other facilities and 1.6 (95% CI: 1.3 to 2.0) times as high for individuals released from incarceration, compared to those who remained in the same facility during treatment. For individuals released less than 2 months into treatment, the risk of unfavorable treatment outcomes was twice as high (adjusted relative risk [aRR]: 2.1, 95% CI: 1.6-2.7). CONCLUSIONS: Transfers between facilities and releases from incarceration are common and may pose barriers to TB treatment completion. Strategies for ensuring continuity of care across carceral facilities and between prison and community health systems are urgently needed to improve TB outcomes for individuals impacted by incarceration.