Background

Tuberculosis (TB) continues to be one of the most devastating infectious diseases worldwide, with more than 10 million new TB cases and 1.5 million TB-related deaths reported annually [1]. Despite being preventable and curable, TB remains a leading cause of antimicrobial resistance (AMR)-related mortality, accounting for nearly one-quarter of all AMR deaths globally [2]. Low- and middle-income countries, including Ethiopia, shoulder the greatest TB burden worldwide [1,3].

Correctional facilities, especially prisons, constitute one of the most neglected yet pivotal settings for tuberculosis control and prevention [4]. The combination of overcrowding, inadequate ventilation, poor nutrition, lack of access to clean water, delayed case detection, and limited access to preventive interventions makes the prevention of Mycobacterium tuberculosis transmission particularly challenging [4]. Consequently, incarcerated populations remain disproportionately burdened by TB infection and disease, representing a critical but under-addressed component of national and global TB elimination strategies [5]. Thus, prisons represent one of the most overlooked yet critical environments for TB control and prevention as inmates are a marginalized population at exceptionally high risk of developing and transmitting the disease. Globally, 11 million people are incarcerated, 1.4 million of them in Africa [6], and the burden of TB among incarcerated populations is estimated to be up to ten times higher than in the general population [4,5]. Yet, these settings and the most vulnerable population living in the prisons are often excluded from national TB surveillance and health system planning.

Experiences from multiple correctional facilities across Ethiopia reveal that, despite adherence to national TB guidelines, major systemic barriers continue to undermine effective disease control and prevention. This viewpoint draws on direct observations across multiple correctional facilities in Ethiopia and interviews with prison health professionals and individuals undergoing TB treatment while incarcerated.

The overlooked epidemic in Ethiopian prisons

Ethiopia is among the 30 high TB burden countries [3], with an incidence of approximately 146 per 100,000 in 2023 [7]. While national TB incidence and mortality rates have steadily declined in recent years, the burden within correctional facilities remains disproportionately high [8]. According to the Ministry of Health mid-term review, prison notification rates reached 867 per 100,000 population in 2025, approximately six times the national incidence rate [8]. Many Ethiopian prisons operate far beyond their intended capacity, with inmates confined in overcrowded, poorly ventilated, and unhygienic environments, creating ideal conditions for TB transmission and persistence [4].

Drug-resistant TB remains a concern. Nationally, the prevalence of RR/MDR-TB among new TB cases was 1.13% in 2025, reflecting sustained but persistent transmission [8]. Although comprehensive molecular transmission studies within prisons remain limited, periodic community-based screening campaigns conducted in 53 prison facilities detected substantial numbers of bacteriologically confirmed TB and RR-TB cases, underscoring ongoing active transmission in these high-density environments [8]. Furthermore, limited routine implementation of systematic latent TB infection (LTBI) screening in prisons constrains understanding of transmission dynamics and progression from infection to active disease.

Experiences from Yirgalem prison in southern Ethiopia illustrate how these structural factors shape daily clinical realities. A health professional described an inmate undergoing TB treatment whose therapy was interrupted during transfer to police custody: “He had started the medication several months ago and stopped taking it after being taken to the police station.” In overcrowded cells housing far more inmates than intended, such interruptions, combined with close physical proximity and limited isolation space, increase the risk of ongoing transmission. Health staff further reported that inadequate food provision frequently leads to malnutrition among TB patients, undermining treatment outcomes despite the availability of medication.

Interviews with incarcerated individuals further highlighted the daily realities behind these interruptions. One prisoner described persistent coughing and progressive weight loss while waiting for treatment to resume, explaining that “the medicine was strong, but the food was not enough.” Such accounts illustrate how treatment gaps and malnutrition intersect within overcrowded environments.

While national TB programs provide medications and periodic screening, broader determinants of TB transmission, such as nutrition, water, sanitation, and hygiene (WASH), and mental health, remain inadequately addressed. This neglect reflects broader systemic challenges seen across sub-Saharan Africa, where prison health often falls outside mainstream public health policy and accountability mechanisms.

Major challenges identified for TB control and prevention in Ethiopian prisons

Systemic implications and human rights dimensions

Prison health is an essential component of the human right to health, as enshrined in the UN Mandela Rules and the WHO’s Prisons and Health framework [14]. Yet, conditions in many low-resource prisons in Ethiopia violate these standards. The failure to ensure adequate food, sanitation, and medical care undermines both human dignity and public health goals. The right to health within prisons extends beyond disease treatment, it encompasses living conditions, mental well-being, and rehabilitation opportunities. In alignment with the WHO End TB Strategy, this calls for comprehensive, multisectoral interventions that address the social determinants of health and strengthen TB prevention and care within prisons [15]. Health staff expressed concern that untreated or interrupted cases inside prisons may contribute to transmission beyond prison walls upon release.

Recommendations and action points

Experiences from Ethiopian prisons reveal practical approaches to improving TB control and prevention in similar contexts across sub-Saharan Africa.

Conclusion

Ethiopian prisons reflect the global neglect of TB in correctional facilities, settings that concentrate vulnerability, poverty, and disease. Yet, it also offers a model for change. The existing collaboration between prison authorities, the Regional Health Bureau, and NGOs demonstrates that progress is possible even in resource-limited settings.

Prisons should not remain blind spots in TB control and prevention. Strengthening health systems within these institutions is both a moral imperative and a public health necessity. TB control in prisons benefits not only inmates but also the wider community by reducing transmission and drug resistance. Integrating prison health into national TB and AMR strategies, investing in infrastructure and workforce development, and ensuring human rights standards are upheld will be essential for achieving the End TB goals. TB control in prisons is, ultimately, TB control for all. No one should be left behind, not even those behind bars.