Migration and tuberculosis transmission in a middle-income country: a cross-sectional study in a central area of São Paulo, Brazil

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Abstract

Background

Little is known about the impact of growing migration on the pattern of tuberculosis (TB) transmission in middle-income countries. We estimated TB recent transmission and its associated factors and investigated the presence of cross-transmission between South American migrants and Brazilians.

Methods

We studied a convenient sample of cases of people with pulmonary TB in a central area of São Paulo, Brazil, diagnosed between 2013 and 2014. Cases with similar restriction fragment length polymorphism (IS 6110-RFLP) patterns of their Mycobacterium tuberculosis complex isolates were grouped in clusters (recent transmission). Clusters with both Brazilian and South American migrants were considered mixed (cross-transmission). Risk factors for recent transmission were studied using logistic regression.

Results

Isolates from 347 cases were included, 76.7% from Brazilians and 23.3% from South American migrants. Fifty clusters were identified, which included 43% South American migrants and 60.2% Brazilians (odds ratio = 0.50, 95% confidence interval = 0.30–0.83). Twelve cross-transmission clusters were identified, involving 24.6% of all clustered cases and 13.8% of all genotyped cases, with migrants accounting for either an equal part or fewer cases in 11/12 mixed clusters.

Conclusions

Our results suggest that TB disease following recent transmission is more common among Brazilians, especially among those belonging to high-risk groups, such as drug users. Cross-transmission between migrants and Brazilians was present, but we found limited contributions from migrants to Brazilians in central areas of São Paulo and vice versa.

Electronic supplementary material

The online version of this article (10.1186/s12916-018-1055-1) contains supplementary material, which is available to authorized users.

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Most cited references 23

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Reinfection and mixed infection cause changing Mycobacterium tuberculosis drug-resistance patterns.

Julia M. Richardson, C Pittius, Paul van Helden … (2005)

Multiple infections with different strains of Mycobacterium tuberculosis may occur in settings where the infection pressure is high. The relevance of mixed infections for the patient, clinician, and control program remains unclear. This study aimed to describe reinfection and mixed infection as underlying mechanisms of changing drug-susceptibility patterns in serial sputum cultures. Serial M. tuberculosis sputum cultures from patients diagnosed with multi-drug-resistant (MDR) tuberculosis were evaluated by phenotypic drug-susceptibility testing and mutation detection methods. Genotypic analysis was done by IS6110 DNA fingerprinting and a novel strain-specific polymerase chain reaction amplification method. DNA fingerprinting analysis of serial sputum cultures from 48 patients with MDR tuberculosis attributed 10 cases to reinfection and 1 case to mixed infection. In contrast, strain-specific polymerase chain reaction amplification analysis in 9 of the 11 cases demonstrated mixed infection in 5 cases, reinfection in 3 cases, and laboratory contamination in 1 case. Analysis of clinical data suggests that first-line therapy can select for a resistant subpopulation, whereas poor adherence or second-line therapy resulted in the reemergence of the drug-susceptible subpopulations. We have shown that, in some patients with MDR tuberculosis, mixed infection may be responsible for observations attributed to reinfection by DNA fingerprinting. We conclude that treatment and adherence determines which strain is dominant. We hypothesize that treatment with second-line drugs may lead to reemergence of the drug-susceptible strain in patients with mixed infection.

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Risk factors associated with recent transmission of tuberculosis: systematic review and meta-analysis.

E. Harris, Douglas A. Mitchell, Laura Velazquez-Villegas … (2008)

A systematic review of published articles was performed to identify risk factors associated with recent transmission of tuberculosis (TB). The computerized search identified studies in PubMed, Ovid, CDSR, CINAHL and EMBASE published between 1994 and 2005. Of 137 articles, 30 satisfied all the inclusion criteria for meta-analysis. A random effects model estimated the odds ratio (OR), confidence interval (CI), and heterogeneity between studies. Recent transmission of TB was associated with: ethnic minority (OR 3.03, 95%CI 2.21- 4.16), being a native of the country (OR 2.33, 95%CI 1.76-3.08), residing in an urban area (OR 1.52, 95%CI 1.35-1.72), drug use (OR 3.01, 95%CI 2.14-4.22), excessive alcohol consumption (OR 2.27, 95%CI 1.69-3.06), homelessness (OR 2.87, 95%CI 2.04-4.02), previous incarceration (OR 2.21, 95%CI 1.71-2.86), human immunodeficiency virus infection/acquired immune-deficiency syndrome (OR 1.66, 95%CI 1.36-2.05), young age (OR 2.09, 95%CI 1.69-2.59), sputum smear positivity (OR 1.39, 95%CI 1.20-1.60) and male sex (OR 1.37, 95%CI 1.19-1.58). The results should be useful for improving prevention and control strategies, thus contributing to a reduction in Mycobacterium tuberculosis transmission.

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Risk factors for clustering of tuberculosis cases: a systematic review of population-based molecular epidemiology studies.

A Fok, Y Numata, M Schulzer … (2008)

Many molecular epidemiology studies have been conducted to identify risk factors for clustering of tuberculosis (TB) cases in the population. To estimate the impact of commonly investigated risk factors on TB clustering. Ten electronic databases were searched up to January 2006 along with a hand search of the International Journal of Tuberculosis and Lung Disease and bibliographies of review articles. Meta-analyses of odds ratios (ORs) for various risk factors were conducted using random effect models, stratified by TB incidence. Meta-regressions were employed to account for the heterogeneity in clustering proportions and the magnitudes of risk. The TB clustering proportion varied greatly (7.0-72.3%) among 36 studies in 17 countries. In multiple meta-regression analyses, high TB incidence, mean cluster size and conventional contact tracing were significantly associated with higher clustering. The pooled ORs (95%CIs) for low and high/intermediate TB incidence studies, using a cut off of 25/100000 per year, were 3.4 (2.7- 4.2) and 1.6 (1.3-2.1) for local-born status, 1.6 (1.5-1.7) and 1.7 (1.3-2.2) for pulmonary TB and 1.2 (1.1-1.3) and 1.3 (1.1-1.7) for smear-positive cases, respectively. Male sex, local birth, alcohol abuse and injection drug use were significantly higher risks in low TB incidence studies than in the high/intermediate ones. Meta-analyses yielded significant estimates of ORs for several risk factors across both levels of TB incidence. Alcohol abuse, injection drug use and homelessness--all characteristics of marginalized populations--were found to be consistently significant in populations of low TB incidence. More research is needed to better understand TB transmission dynamics in high-burden countries.

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Author and article information

Contributors

Julia Moreira Pescarini: juliapescarini@gmail.com

Journal

Journal ID (nlm-ta): BMC Med

Journal ID (iso-abbrev): BMC Med

Title: BMC Medicine

Publisher: BioMed Central (London )

ISSN (Electronic): 1741-7015

Publication date (Electronic): 30 April 2018

Publication date PMC-release: 30 April 2018

Publication date Collection: 2018

Volume: 16

Electronic Location Identifier: 62

Affiliations

[1 ]ISNI 0000 0004 1937 0722, GRID grid.11899.38, Faculdade de Saúde Pública, , Universidade de São Paulo, ; São Paulo, Brazil

[2 ]ISNI 0000 0004 0620 4215, GRID grid.417672.1, Instituto Adolfo Lutz, ; São Paulo, Brazil

[3 ]ISNI 0000 0004 0425 469X, GRID grid.8991.9, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Public Health, , London School of Hygiene and Tropical Medicine, ; London, UK

[4 ]ISNI 0000 0004 0425 469X, GRID grid.8991.9, TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, ; London, UK

Article

Publisher ID: 1055

DOI: 10.1186/s12916-018-1055-1

PMC ID: 5925834

PubMed ID: 29706130

SO-VID: f9bf2bc4-a42b-4ad7-96ac-83e7d17b2c5f

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 25 August 2017

Date accepted : 10 April 2018

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100003593, Conselho Nacional de Desenvolvimento Científico e Tecnológico;

Award ID: 141998/2013-0

Award ID: 202310/2015-9

Award ID: 309647/2015-0

Award Recipient : Julia Moreira Pescarini Eliseu Alves Waldman

Custom metadata

ScienceOpen disciplines: Medicine

Keywords: tuberculosis,molecular epidemiology,transmission,migration,middle-income; disease control

Data availability:

ScienceOpen disciplines: Medicine

Keywords: tuberculosis, molecular epidemiology, transmission, migration, middle-income; disease control

Migration and tuberculosis transmission in a middle-income country: a cross-sectional study in a central area of São Paulo, Brazil

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Point-Of-Care Testing for Tuberculosis

Most cited references 23

Reinfection and mixed infection cause changing Mycobacterium tuberculosis drug-resistance patterns.

Risk factors associated with recent transmission of tuberculosis: systematic review and meta-analysis.

Risk factors for clustering of tuberculosis cases: a systematic review of population-based molecular epidemiology studies.

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