Jonathan L Zelner1, Megan B Murray2, Mercedes C Becerra3, Jerome Galea4, Leonid Lecca4, Roger Calderon4, Rosa Yataco4, Carmen Contreras4, Zibiao Zhang5, Justin Manjourides6, Bryan T Grenfell7, Ted Cohen8. 1. Robert Wood Johnson Foundation Health and Society Scholars Program, Interdisciplinary Center for Innovative Theory and Empirics (INCITE) & Mailman School of Public Health, Columbia University, New York, New York. 2. Department of Global Health and Social Medicine, Harvard Medical School, Department of Epidemiology, Harvard School of Public Health. 3. Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts. 4. Socios En Salud, Lima, Peru. 5. Division of Global Health Equity, Brigham and Women's Hospital. 6. Department of Health Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts. 7. Department of Ecology and Evolutionary Biology, Princeton University, New Jersey Fogarty International Center, National Institutes of Health, Bethesda, Maryland. 8. Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut.
Abstract
BACKGROUND: We aimed to identify and determine the etiology of "hotspots" of concentrated multidrug-resistant tuberculosis (MDR-tuberculosis) risk in Lima, Peru. METHODS: From 2009 to 2012, we conducted a prospective cohort study among households of tuberculosis cases from 106 health center (HC) areas in Lima, Peru. All notified tuberculosis cases and their household contacts were followed for 1 year. Symptomatic individuals were screened by microscopy and culture; positive cultures were tested for drug susceptibility (DST) and genotyped by 24-loci mycobacterial interspersed repetitive units-variable-number tandem repeats (MIRU-VNTR). RESULTS: 3286 individuals with culture-confirmed disease, DST, and 24-loci MIRU-VNTR were included in our analysis. Our analysis reveals: (1) heterogeneity in annual per-capita incidence of tuberculosis and MDR-tuberculosis by HC, with a rate of MDR-tuberculosis 89 times greater (95% confidence interval [CI], 54,185) in the most-affected versus the least-affected HC; (2) high risk for MDR-tuberculosis in a region spanning several HCs (odds ratio = 3.19, 95% CI, 2.33, 4.36); and (3) spatial aggregation of MDR-tuberculosis genotypes, suggesting localized transmission. CONCLUSIONS: These findings reveal that localized transmission is an important driver of the epidemic of MDR-tuberculosis in Lima. Efforts to interrupt transmission may be most effective if targeted to this area of the city.
BACKGROUND: We aimed to identify and determine the etiology of "hotspots" of concentrated multidrug-resistant tuberculosis (MDR-tuberculosis) risk in Lima, Peru. METHODS: From 2009 to 2012, we conducted a prospective cohort study among households of tuberculosis cases from 106 health center (HC) areas in Lima, Peru. All notified tuberculosis cases and their household contacts were followed for 1 year. Symptomatic individuals were screened by microscopy and culture; positive cultures were tested for drug susceptibility (DST) and genotyped by 24-loci mycobacterial interspersed repetitive units-variable-number tandem repeats (MIRU-VNTR). RESULTS: 3286 individuals with culture-confirmed disease, DST, and 24-loci MIRU-VNTR were included in our analysis. Our analysis reveals: (1) heterogeneity in annual per-capita incidence of tuberculosis and MDR-tuberculosis by HC, with a rate of MDR-tuberculosis 89 times greater (95% confidence interval [CI], 54,185) in the most-affected versus the least-affected HC; (2) high risk for MDR-tuberculosis in a region spanning several HCs (odds ratio = 3.19, 95% CI, 2.33, 4.36); and (3) spatial aggregation of MDR-tuberculosis genotypes, suggesting localized transmission. CONCLUSIONS: These findings reveal that localized transmission is an important driver of the epidemic of MDR-tuberculosis in Lima. Efforts to interrupt transmission may be most effective if targeted to this area of the city.
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