Endemic or Outbreak? Differentiating recent transmission of an historic tuberculosis strain in New Y...
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Endemic or Outbreak? Differentiating recent transmission of an historic tuberculosis strain in New York City IUATLD-NAR 16 th Annual Meeting February 23-25, 2012 Jeanne Sullivan Meissner, MPH New York City Department of Health and Mental Hygiene Bureau of Tuberculosis Control.

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I have no known conflicts of interest to disclose

Endemic or Outbreak? Differentiating recent transmission of an historic tuberculosis strain in New York City IUATLD-NAR 16th Annual MeetingFebruary 23-25, 2012Jeanne Sullivan Meissner, MPHNew York City Department of Health and Mental HygieneBureau of Tuberculosis Control


I have no known conflicts of interest to disclose

Disclosure statements

  • I have no known conflicts of interest to disclose

  • Funding source: New York City Tuberculosis Control Program funds


Background

Background


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Tuberculosis cases and rates, New York City

1980-2010*

1991: Selective genotyping begins in NYC

2001: Universal genotyping implemented

Number of Cases

Rate/100,000

*Rates since 2000 are based on population estimates.


I have no known conflicts of interest to disclose

  • A tuberculosis (TB) strain first detected in New York City (NYC) in 1995 has continued to cause disease through 2011

  • Recently-diagnosed cases with this strain were investigated to identify epidemiologic links and assess recent transmission


I have no known conflicts of interest to disclose

Methods


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Cluster investigation

  • NYC TB cluster: two or more cases with matching IS6110-basedrestriction fragment length polymorphism analysis (RFLP) pattern and spacer oligonucleotide type (spoligotype) result

    • 12-loci mycobacterial interspersed repetitive-unit variable-number tandem repeat analysis (MIRU-12) results were obtained for cluster cases counted since January 1, 2004

  • Cluster cases are routinely investigated to identify epidemiologic links and develop transmission hypotheses

  • Recently-diagnosed cases for this investigation: Cluster cases counted between Jan 1, 2006 - Jul 1, 2011


I have no known conflicts of interest to disclose

Cluster investigation

Steps in a routine cluster investigation, New York City

Collect and analyze existing data

Generatefinal report

Assign cluster

Develop cluster questionnaire

Communicate with case managers

Develop transmissionhypotheses

Re-interview

patient

Communicate results

* When indicated, intervention(s) are developed to stop transmission


I have no known conflicts of interest to disclose

Cluster investigation

  • Epidemiological links are categorized as possible, probable or definite

POSSIBLE

(weakest)

DEFINITE

(strongest)

EPIDEMIOLOGIC LINK

  • DEFINITE

  • Cases name each other as contacts

  • Cases share common contact without naming each other

  • Cases frequent same location during infectious period of at least one of the cases

  • POSSIBLE

  • Cases live/spend time in area within approximately 0.5 miles of each other (regardless of infectious period)

  • Cases have similar social environment (e.g., similar social networks)

  • PROBABLE

  • Cases frequent same location during same date range, exclusive of infectious period of either case


I have no known conflicts of interest to disclose

Results


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29 cases

54 recently diagnosed

121 cases

Number of cluster cases counted by year and drug resistance, January 1, 1995 - July 1, 2001 (n=150)

Drug susceptible

Other-drug-resistant

Universal genotyping

Multidrug-resistant

Number of Cases

Year


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Patient characteristics

  • Among all cluster cases (n=149*):

    • 62% male

    • Median age: 45 (Range: 16-95)

    • 76% US-born

      • 78% of foreign-born in US >5 years when diagnosed

  • 37% HIV-positive (125 cases with known HIV status)

  • Among cases counted since 2001 (n=120*):

    • 20% known history of homelessness

    • 28% known history of drug use

    • 23% known history of incarceration

    • Cases commonly had more than one of above

  • * One individual was a counted cluster case in two different years. This individual’s patient characteristics were only counted once


    I have no known conflicts of interest to disclose

    Genotyping

    • Spoligotype:

      • Octal Code: 777776777760601

    • 2-band RFLP pattern

    • All cluster cases counted since January 1, 2004 (n=78) have MIRU-12 results

      • 19 MIRU-12 patterns

        • 11 unique patterns

    RFLP


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    MIRU-12 results among cluster cases and corresponding PCR type* (n=78)

    * PCR type: CDC definition of complete genotype using spoligotype and MIRU-12 results


    I have no known conflicts of interest to disclose

    Select epidemiologic links identified for recently-diagnosed cluster cases

    1990

    Recently diagnosed cluster case

    Cluster case; not recently diagnosed

    NYC case with incomplete genotype; same RFLP

    NYC case; no genotype information available

    Definite epidemiologic link

    Same person

    Probable epidemiologic link

    Possible epidemiologic link

    2003

    2005

    2007

    2009

    2011


    I have no known conflicts of interest to disclose

    Select epidemiologic links identified for recently-diagnosed cluster cases by MIRU-12 and drug susceptibility results

    1990

    S

    S

    MIRU-12 pattern:

    M

    223325153323

    224325153324

    224325153323

    S

    NA

    NA

    I

    224325143323

    224325183325

    224325163323

    S

    224325153314

    224325153322

    No MIRU-12

    Definite link

    Probable link

    Possible link

    S

    S

    Drug susceptibility: S: Drug-susceptible I: Isoniazid-resistant R: Rifampin-resistant M: Multidrug-resistant NA: No results available

    I,P: Isoniazid- and pyrazinamide-resistant P: Pyrazinamide-resistant

    R

    2003

    S

    S

    S

    M

    2005

    S

    S

    S

    M

    M

    S

    I

    I

    S

    S

    S

    M

    M

    S

    S

    S

    M

    S

    S

    I,P

    2007

    S

    I

    I

    S

    S

    I

    I

    S

    2009

    S

    I

    R

    S

    S

    S

    P

    S

    S

    S

    2011


    I have no known conflicts of interest to disclose

    Conclusions


    I have no known conflicts of interest to disclose

    • Transmission of this endemic TB strain is ongoing in NYC, while disease among remotely-infected persons continues

    • Identification of multiple links across different years and patient characteristics highlights the difficulty of differentiating recent transmission of endemic TB strains

      • Common characteristics, activities and geographic locations among cases suggest social networks and community transmission

    • Implications of epidemiologic links across different MIRU-12 results warrants further investigation

    • New genotyping and investigative tools may help further differentiate large, endemic clusters such as this one


    I have no known conflicts of interest to disclose

    Acknowledgements

    • NYC Department of Health and Mental Hygiene, Bureau of Tuberculosis Control staff

      • Co-authors: Janelle A. Anderson, Bianca R. Perri, Shama D. Ahuja

      • Cluster investigators: A. Regner, R. Espinoza, R. Fernandez, J. Abdelwahab, J. Park, M. Macaraig

      • Clinic and field staff

    • Lab partners: NYC Public Health Lab, New York State Wadsworth Center, Public Health Research Institute

    • New Jersey Department of Health

    • New York State Department of Health

    • Centers for Disease Control and Prevention


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