Environmental Factors Associated with the Time to Tuberculosis Diagnosis in Prisoners in São Paulo, Brazil

Background: Environmental conditions play an important role in the high incidence of tuberculosis in pris-ons. We estimated the effect of environmental factors, including measurements based on cell dimensions, on the time to tuberculosis diagnosis in prison population of Brazil. Methods: This is a retrospective cohort of 2,257 prisoners diagnosed with tuberculosis in 2014 and 2015. We collected environmental data from 105 prisons and linked with routine tuberculosis surveil-lance and prison data. We estimated tuberculosis-free survival time with Cox risk models, guided by a validated directed acyclic graph. Results: The median disease-free time was 1.71 years (95% confidence interval [95% CI] 1.64-1.78). Each 50% increase in occupancy-rate, increased the tuberculosis speed incidence by 16% (95% CI 8%-25%) in the first 2 years, and 9% (95% CI 3%-16%) up to 5 years. An increase in the cell area per person (ln[m(2)/person]) reduced the hazard of tuberculosis by 13% (95% CI 3%-23%) for up to 2, and 12% (95% CI 3%-21%) for up to 5 years. Discussion: Most tuberculosis cases were diagnosed within 2 years of incarceration. Prison overcrowding and physical space per person in the cell were associated with the tuberculosis-free disease time. Conclusions: Interventions to reduce overcrowding or increase physical space are crucial to prevent tubercu-losis in prisons. (C) 2022 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.