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

I have no known conflicts of interest to disclose Funding source: New York City Tuberculosis Control Program funds Disclosure statements

Background

Number of Cases Rate/100,000 *Rates since 2000 are based on population estimates. Tuberculosis cases and rates, New York City * 1991: Selective genotyping begins in NYC 2001: Universal genotyping implemented

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

Methods

Cluster investigation NYC TB cluster: two or more cases with matching IS6110-based restriction fragment length polymorphism analysis (RFLP) pattern and spacer oligonucleotide type (spoligotype) result o 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, Jul 1, 2011

Cluster investigation Assign cluster Communicate with case managers Collect and analyze existing data Develop transmission hypotheses Generate final report Develop cluster questionnaire Re-interview patient Communicate results Steps in a routine cluster investigation, New York City * When indicated, intervention(s) are developed to stop transmission

EPIDEMIOLOGIC LINK POSSIBLE (weakest) 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 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 Cluster investigation DEFINITE (strongest) Epidemiological links are categorized as possible, probable or definite

Results

Year Number of Cases Drug susceptible Other-drug-resistant Multidrug-resistant Universal genotyping 29 cases121 cases Number of cluster cases counted by year and drug resistance, January 1, July 1, 2001 (n=150) 54 recently diagnosed

Among all cluster cases (n=149*): o 62% male o Median age: 45 (Range: 16-95) o 76% US-born 78% of foreign-born in US >5 years when diagnosed o 37% HIV-positive (125 cases with known HIV status) Among cases counted since 2001 (n=120*): o 20% known history of homelessness o 28% known history of drug use o 23% known history of incarceration o Cases commonly had more than one of above Patient characteristics * One individual was a counted cluster case in two different years. This individual’s patient characteristics were only counted once

RFLP Spoligotype: o Octal Code: band RFLP pattern All cluster cases counted since January 1, 2004 (n=78) have MIRU-12 results o 19 MIRU-12 patterns  11 unique patterns Genotyping

MIRU-12 results among cluster cases and corresponding PCR type* (n=78) MIRU-12 patternNumber of cases Corresponding PCR type* PCR PCR PCR PCR PCR PCR PCR PCR00027 Other unique patterns11N/A * PCR type: CDC definition of complete genotype using spoligotype and MIRU-12 results

Select epidemiologic links identified for recently-diagnosed cluster cases 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 Probable epidemiologic link Possible epidemiologic link Same person

Select epidemiologic links identified for recently-diagnosed cluster cases by MIRU-12 and drug susceptibility results R M M R I I II II I S SSS S S S SS S M SS S S S S S S S S S M I S S S SS S I,P NA S S S M M M S S P 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 MIRU-12 pattern: Definite linkPossible linkProbable link No MIRU-12

Conclusions

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

Acknowledgements NYC Department of Health and Mental Hygiene, Bureau of Tuberculosis Control staff o Co-authors: Janelle A. Anderson, Bianca R. Perri, Shama D. Ahuja o Cluster investigators: A. Regner, R. Espinoza, R. Fernandez, J. Abdelwahab, J. Park, M. Macaraig o 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