Abstract
BackgroundCongregate settings may serve as institutional amplifiers of tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB). We analyze spatial, epidemiological, and pathogen genetic data prospectively collected from neighborhoods surrounding a prison in Lima, Peru, where inmates experience a high risk of MDR-TB, to investigate the risk of spillover into the surrounding community.MethodsUsing hierarchical Bayesian statistical modeling, we address three questions regarding the MDR-TB risk: (i) Does the excess risk observed among prisoners also extend outside the prison? (ii) If so, what is the magnitude, shape, and spatial range of this spillover effect? (iii) Is there evidence of additional transmission across the region?ResultsThe region of spillover risk extends for 5.47 km outside of the prison (95% credible interval: 1.38, 9.63 km). Within this spillover region, we find that nine of the 467 non-inmate patients (35 with MDR-TB) have MDR-TB strains that are genetic matches to strains collected from current inmates with MDR-TB, compared to seven out of 1080 patients (89 with MDR-TB) outside the spillover region (p values: 0.022 and 0.008). We also identify eight spatially aggregated genetic clusters of MDR-TB, four within the spillover region, consistent with local transmission among individuals living close to the prison.ConclusionsWe demonstrate a clear prison spillover effect in this population, which suggests that interventions in the prison may have benefits that extend to the surrounding community.
Highlights
Congregate settings may serve as institutional amplifiers of tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB)
An analysis based on programmatic data [5] and an inference based on fitting transmission dynamic models to data [6] reveal that direct transmission of MDR-TB is the dominant mechanism driving incidence in most settings
The factor most closely associated with increased risk of MDR-TB is previous treatment for TB; 18.6% of previously treated individuals have MDR-TB compared to 7.3% of treatment naive individuals
Summary
Congregate settings may serve as institutional amplifiers of tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB). In 2016, the latest year for which estimates are available, there were 490,000 incident cases of multidrug-resistant tuberculosis (MDR-TB) [1]. MDR-TB arises as a consequence of failed treatment or by direct transmission from an individual infectious with MDR-TB. Measures of the relative importance of failed treatment and direct transmission as drivers of MDR-TB are not easy to obtain in the setting of complex epidemics, where reports of treatment history and prior drug susceptibility results are often unreliable or unavailable. An analysis based on programmatic data [5] and an inference based on fitting transmission dynamic models to data [6] reveal that direct transmission of MDR-TB is the dominant mechanism driving incidence in most settings. The success of interventions that aim to mitigate the rise of MDR-TB will depend critically on their ability to identify
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