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Published ahead of print on December 18, 2003, doi:10.1164/rccm.200306-856OC

Am. J. Respir. Crit. Care Med., Volume 169, Number 7, April 2004, 806-810

A more recent version of this article appeared on April 1, 2004
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Submitted on July 1, 2003
Accepted on December 16, 2003

Clustered tuberculosis cases:Do they represent recent transmission and can they be detected earlier?

Henk van Deutekom1*, Susan P Hoijng1, Petra E.W. de Haas2, Miranda W Langendam3, Alice Horsman1, Dick van Soolingen2, and Roel A Coutinho4

1 Tuberculosis Control, Municipal Health Service, Amsterdam, The Netherlands, 2 Diagnostic Laboratory for Infectious Diseases and Perinatal Screening, National Institute of Public Health and the Environment, Bilthoven, The Netherlands, 3 HIV and STI Research, Municipal Health Service, Amsterdam, The Netherlands, 4 Tuberculosis Control, Municipal Health Service, Amsterdam, The Netherlands; HIV and STI Research, Municipal Health Service, Amsterdam, The Netherlands; Human Retrovirology, Academic Medical Centre, Amsterdam, The Netherlands

* To whom correspondence should be addressed. E-mail: hvdeutekom{at}gggd.amsterdam.nl.

Clustered tuberculosis cases with Mycobacterium tuberculosis isolates showing identical restriction fragment length polymorphism (RFLP) patterns are assumed to be the result of disease transmission. In a prospective, population-based study in the province of North Holland, the Netherlands, we combined molecular methods with highly detailed epidemiological information to determine why many clustered cases are not detected at an early stage. Of 481 patients, 138 (29 %) fell into 43 clusters, suggesting recent transmission in 20 %. Of 155 patients in clusters occurring within 2 years before or after their diagnosis, 21 (14 %) had no epidemiological links with other patients. Independent predictors of not having such links were female sex, and Turkish, Moroccan or other African ethnicity. Of 47 patients with a clear epidemiological link, 37 (24 % of 155) were identified early, e.g. by contact-tracing, and 10 (6 %) were missed. In 85 (55 %) patients, an epidemiological link was likely but undetected using conventional contact-tracing. Compared with clearly linked patients, only male sex was independently associated with presence in this last group. Our results indicate that 86 % of clustered study patients had epidemiological links and that opportunities for earlier identification using conventional tuberculosis control strategies are limited.
Key words: tuberculosis, transmission, DNA fingerprinting, epidemiology, contact-tracing




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