• J. Infect. Dis. · Jan 2013

    Nosocomial transmission of extensively drug-resistant tuberculosis in a rural hospital in South Africa.

    • Neel R Gandhi, Darren Weissman, Prashini Moodley, Melissa Ramathal, Inga Elson, Barry N Kreiswirth, Barun Mathema, Elena Shashkina, Richard Rothenberg, Anthony P Moll, Gerald Friedland, A Willem Sturm, and N Sarita Shah.
    • Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA. neelgandhi@alumni.williams.edu
    • J. Infect. Dis. 2013 Jan 1; 207 (1): 9-17.

    BackgroundExtensively drug-resistant tuberculosis (XDR-tuberculosis) is a global public health threat, but few data exist elucidating factors driving this epidemic. The initial XDR-tuberculosis report from South Africa suggested transmission is an important factor, but detailed epidemiologic and molecular analyses were not available for further characterization.MethodsWe performed a retrospective, observational study among XDR-tuberculosis patients to identify hospital-associated epidemiologic links. We used spoligotyping, IS6110-based restriction fragment-length polymorphism analysis, and sequencing of resistance-determining regions to identify clusters. Social network analysis was used to construct transmission networks among genotypically clustered patients.ResultsAmong 148 XDR-tuberculosis patients, 98% were infected with human immunodeficiency virus (HIV), and 59% had smear-positive tuberculosis. Nearly all (93%) were hospitalized while infectious with XDR-tuberculosis (median duration, 15 days; interquartile range: 10-25 days). Genotyping identified a predominant cluster comprising 96% of isolates. Epidemiologic links were identified for 82% of patients; social network analysis demonstrated multiple generations of transmission across a highly interconnected network.ConclusionsThe XDR-tuberculosis epidemic in Tugela Ferry, South Africa, has been highly clonal. However, the epidemic is not the result of a point-source outbreak; rather, a high degree of interconnectedness allowed multiple generations of nosocomial transmission. Similar to the outbreaks of multidrug-resistant tuberculosis in the 1990s, poor infection control, delayed diagnosis, and a high HIV prevalence facilitated transmission. Important lessons from those outbreaks must be applied to stem further expansion of this epidemic.

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