we obtained individual - level data on tb cases reported during 20072014 in the brazil national notification database ( sistema de informao de agravos de notificao ; sinan ) . a new form for sinan was introduced in 2007 , which led to an increase in documentation of incarceration status from 68% in 2007 to 94% in 2009 . our analysis therefore focuses on data from 20092014 , when documentation rates were consistently > 92% . we extracted demographic data on incarceration status , sex , age , and state as well as clinical presentation , hiv status , and sputum smear positivity . this work was approved by the human research protection program at yale university and the institutional review board at the federal university of grande dourados . among prisoners , tb case - patients were defined as persons for whom tb was notified while they were incarcerated , including those in penal institutions awaiting trial or sentencing . to calculate annual tb notification rates ( cases per 100,000 persons ) , we used population estimates for brazil from the 2010 census and projections and mid - year incarcerated population data from the ministry of justice . to compare tb notification rates between incarcerated and nonincarcerated populations , aggregated at the state level , we used the pearson product - moment correlation . during 20092014 , a total of 38,327 ( 7.3% ) of the 526,569 cases of tb reported in brazil occurred in prisoners . the total number of cases reported in prisoners increased 28.8% , from 5,556 to 7,157 per year , and the proportion of cases notified among prisoners increased from 6.2% in 2009 to 8.4% in 2014 . during the same period , the prison population grew from 409,287 to 579,781 , an increase of 41.7% , as overall incarceration rates rose 33.9% , from 214 to 287/100,000 persons . because of that increase , the rate of tb notifications dropped from 1,357 to 1,234/100,000 for prisoners ( 9.1% decrease ) ; meanwhile , the rate of tb notifications for nonprisoners dropped 12.2% ( from 43.7 to 38.4/100,000 persons ) . overall , the mean annual notification rate among prisoners was 31.3 times that of the general population ( table ) .   * p values calculated with the welch t - test comparing prisoners annual data by sex . hiv status based on a positive or negative status result or aids diagnosis from the time of tuberculosis notification . % hiv co - infection calculated as percentage positive hiv+ results among those with hiv status reported . hiv status was known for 66% of all tb patients ; prevalence was 15.9% among prisoners and 17.4% among nonprisoners ( table ) . average annual 20092014 notification rates among prisoners ranged from 225 ( rondnia ) to 2,548 ( rio de janeiro ) . at the state level , 2014 notification rates were positively correlated ( pearson  0.54 ; p = 0.002 ) between the nonincarcerated population and prisoners . men comprised 93.8% of the prison population and accounted for 91.9% of prison tb cases ; 74.7% were 1839 years of age , compared with only 39.8% in this age range among nonprisoners with tb . in 2014 , a total of 25.6% of all men 2029 years of age were prisoners ( state range for all prisoners 0%47.8% ; figure 1 , panels a , b ) . although there were far fewer female prisoners , incarceration rates rose faster for women ( 50.0% vs. 30.2% ; figure 2 ) , and the average annual tb notification rate was higher for female prisoners than for male prisoners ( 1,703 vs. 1,281 ; figure 2 ) . the prevalence of extrapulmonary disease among women was twice that in men ( 16.7% vs. 7.4% ; p = 0.0002 ) . hiv co - infection rates were also higher for female prisoners ( 24.1% vs. 15.2% ; p = 0.003 , table ) . a ) geographic distribution by state of the proportions of all tb cases diagnosed among male prisoners ages 2029 . prisoners comprised 047.7% of all tb cases in this age group , with highest rates at the western border of brazil . b ) sex and age distribution of the proportions of all notified tb cases diagnosed among prisoners in brazil for 2009 compared with 2014 . prisoners of both sexes represent an increasingly disproportionate percentage of notified cases in all age groups , and male prisoners 2029 of age represented > 25% of cases among the age group in 2014 . ac , acre ; al , alagoas ; ap , amap ; am , amazonas ; ba , bahia ; ce , cear ; df , distrito federal ; es , esprito santo ; go , gois ; ma , maranho ; mt , mato grosso ; ms , mato grosso do sul ; mg , minas gerais ; pr , paran ; pb , paraba ; pa , par ; pe , pernambuco ; pi , piau ; rj , rio de janeiro ; rn , rio grande do norte ; rs , rio grande do sul ; ro , rondnia ; rr , roraima ; sc , santa catarina ; se , sergipe ; sp , so paulo ; to , tocantins . temporal distribution of incarceration rates ( prisoners/100,000 population ) and tb notification rates ( cases/100,000 prisoners ) , by sex , brazil , 20092014 . there was an appreciable increase in incarceration rates among men ( 30.2% ) and women ( 50.0% ) from 2009 to 2014 . although the incarceration rate of men averaged > 15 times that of women , the average tb notification rate for women was higher ( 1,703 vs. 1,281/100,000 prisoners ) . ac , acre ; al , alagoas ; ap , amap ; am , amazonas ; ba , bahia ; ce , cear ; df , distrito federal ; es , esprito santo ; go , gois ; ma , maranho ; mt , mato grosso ; ms , mato grosso do sul ; mg , minas gerais ; pr , paran ; pb , paraba ; pa , par ; pe , pernambuco ; pi , piau ; rj , rio de janeiro ; rn , rio grande do norte ; rs , rio grande do sul ; ro , rondnia ; rr , roraima ; sc , santa catarina ; se , sergipe ; sp , so paulo ; to , tocantins . prisoners have been recognized as a group at high risk for tb , but there has been limited assessment of the contribution of recent increases in tb prevalence in the prison population to the overall tb case burden in brazil . we combined data from a national tb notification database with incarceration data and found that prisons account for a growing proportion of the national tb burden in brazil . in 2014 , a total of 8.4% of all reported cases occurred among prisoners , who represent < 0.3% of the population , representing a 35.4% increase in the proportion of tb cases occurring among prisoners in 5 years . among young men 2029 years of age , a growing proportion ( > 25% ) of tb cases occurred among those who were incarcerated . for the nonincarcerated population , tb notification rates fell by 12.2% during this period ; however , when prisoners were included in assessments , 16.8% of these gains were offset by increasing incarceration rates , as notification rates among prisoners were 31.3 times higher than those for the general population . failure to address tb in an expanding incarcerated population may be a critical barrier to achieving national targets for tb control . incarceration rates among women rose faster , and tb notification rates and hiv co - infection rates were higher than corresponding rates among men . this finding is in contrast to the overall global epidemiology of tb and to national data for the nonincarcerated population , which demonstrated higher tb notification rates among men than women ( 50.1 vs. 26.5/100,000 persons ; table ) . a potential explanation is the higher rate of hiv - associated tb among female prisoners than among men ( 24.1% vs. 15.2% ) . we previously reported a higher prevalence of hiv among female prisoners in brazil ( 10 ) , as have others ( 11,12 ) . hiv alone is unlikely to explain the large disparities in tb rates between male and female prisoners ; more data are needed to explain the inverted sex disparities ( compared with the general population ) in tb patients in prisons in brazil . first , we assessed notification rates at the national and state level ; although we observed substantial heterogeneity at the state level , more data on prison characteristics and incarceration rates are needed to understand factors driving tb in prisons . in particular , the relative contribution of individual risk factors for tb reactivation and the effects of prison environments and policies on transmission are poorly understood . second , our use of data from reported cases may include demographic or diagnostic misclassification . third , we could not assess cases among recently released prisoners ; many prisoners are released without sentencing or after serving sentences of < 5 years ( 1 ) , and infections acquired in prison may be diagnosed after prisoners are released . consequently , the number of cases notified among prisoners ( incarcerated at the time of diagnosis ) probably underestimates the true effect of prisons on the population - level tb case burden . our findings demonstrate that the epidemic of tb in prisons represents a larger challenge to national tb control in brazil than the threat posed to prisoners health ( 4,13 ) . there is an urgent need to address notification rates in prisons in brazil by using effective interventions such as active case detection , preventive therapy , and transitional care for released prisoners ( 2,3,5,14 ) . a recent study demonstrated high rates of nonadherence to treatment among prison prisoners in brazil , underscoring the need to ensure that prisoners complete treatment to prevent transmission within and outside prisons ( 15 ) . in addition to improving access to tb diagnosis and treatment within prisons , addressing rising incarceration rates and improving living condtions that favor transmission in prisons may be critical to combat tb among prisoners ( 16 ) .
during 20092014 , incarceration rates in brazil rose 34% , and tuberculosis ( tb ) cases among prisoners rose 28.8% . 
 the proportion of national tb cases that occurred among prisoners increased from 6.2% to 8.4% overall and from 19.3% to 25.6% among men 2029 years of age .