title: Advanced survey of tuberculosis transmission in a complex socioepidemiologic scenario with a high proportion of cases in immigrants.
abstract: BACKGROUND
  An increase in the incidence of tuberculosis (TB) in immigrants has changed the socioepidemiologic scenario in Spain. It is generally assumed that TB in immigrants is the result of importation of infection, but the role of recent transmission is rarely considered. Standard contact tracing is not suitable for the survey of transmission in this complex scenario.
  
  
  METHODS
  During the study period (2003-2006), we genotyped 356 (90.4%) of 394 isolates from patients with microbiologically confirmed TB in Almería, the province with the highest percentage of TB cases among immigrants in Spain. The epidemiologic survey of TB transmission was performed by active data collection using standardized interviews of the patients with TB and subsequent interviews of the clustered patients (who were clustered on the basis of the restriction fragment-length polymorphism types of their isolates) to identify transmission locations (supported by nominal and/or photographic recognition by the clustered patients).
  
  
  RESULTS
  Of all 356 genotyped isolates, 131 (36.8%) were clustered, suggesting recent transmission. The difference between the clustering rate for immigrants (32.8%) and that for native patients (41.6%) was not statistically significant (P = .087); of the 45 clusters, 15 (33.3%) involved only immigrants, 17 (37.8%) involved only autochthonous patients, and 13 (28.9%) involved both immigrants and autochthonous patients. The advanced system to investigate the clustered patients succeeded in detecting links in 10 of the 12 clusters that involved >4 patients, whereas the conventional approach, based on contact tracing, could detect links in only 2 clusters.
  
  
  CONCLUSIONS
  Recent transmission among immigrants and transmission permeability between the immigrant and autochthonous populations were found. Epidemiologic strategies that combine universal genotyping and refined surveys of the clustered patients are needed to investigate transmission patterns in complex scenarios.
authors.affiliation: Servicio de Microbiología, Hospital Gregorio Marañón, Madrid, Spain.
authors.forename: Miguel
authors.initials: M
authors.lastname: Martínez-Lirola
authors.forename: Noelia
authors.initials: N
authors.lastname: Alonso-Rodriguez
authors.forename: M Luisa
authors.initials: ML
authors.lastname: Sánchez
authors.forename: Marta
authors.initials: M
authors.lastname: Herranz
authors.forename: Sandra
authors.initials: S
authors.lastname: Andrés
authors.forename: Teresa
authors.initials: T
authors.lastname: Peñafiel
authors.forename: M Cruz
authors.initials: MC
authors.lastname: Rogado
authors.forename: Teresa
authors.initials: T
authors.lastname: Cabezas
authors.forename: Juan
authors.initials: J
authors.lastname: Martínez
authors.forename: M Angeles
authors.initials: MA
authors.lastname: Lucerna
authors.forename: Manuel
authors.initials: M
authors.lastname: Rodríguez
authors.forename: Magdalena Del Carmen
authors.initials: Mdel C
authors.lastname: Bonillo
authors.forename: Emilio
authors.initials: E
authors.lastname: Bouza
authors.forename: Darío
authors.initials: D
authors.lastname: García de Viedma
mesh_terms: D000328:Adult; D015373:Bacterial Typing Techniques; D016000:Cluster Analysis; D016358:Contact Tracing / Q000379:methods; D054242:Emigrants and Immigrants; D005260:Female; D005838:Genotype; D006801:Humans; D015994:Incidence; D008297:Male; D009169:Mycobacterium tuberculosis / Q000145:classification / Q000235:genetics / Q000302:isolation & purification; D012307:Risk Factors; D012959:Socioeconomic Factors; D013030:Spain / Q000453:epidemiology; D014376:Tuberculosis / Q000453:epidemiology* / Q000635:transmission*