María José Iglesias

Systematic Molecular Characterization of Multidrug-Resistant Mycobacterium tuberculosis Complex Isolates from Spain

ABSTRACT We used spoligotyping and restriction fragment length polymorphism (RFLP) of the IS6110-insertion sequence to study the molecular epidemiology of multidrug-resistant (MDR) tuberculosis in Spain. We analyzed 180 Mycobacterium tuberculosis complex isolates collected between January 1998 and December 2000. Consecutive isolates from the same patients (n = 23) always had identical genotypes, meaning that no cases of reinfection occurred. A total of 105 isolates (58.3%) had unique RFLP patterns, whereas 75 isolates (41.7%) were in 20 different RFLP clusters. Characterization of the katG and rpoB genes showed that 14 strains included in the RFLP clusters did not actually cluster. Only 33.8% of the strains isolated were suggestive of MDR transmission, a frequency lower than that for susceptible strains in Spain (46.6%). We found that the Beijing/W genotype, which is prevalent worldwide, was significantly associated with immigrants. The 22 isolates in the largest cluster corresponded to the Mycobacterium bovis strain responsible for two nosocomial MDR outbreaks in Spain.

Long-term molecular surveillance of multidrug-resistant tuberculosis in Spain.

The data presented here span 11 years (1998-2008) of monitoring of multidrug-resistant tuberculosis (MDR-TB) clustering through molecular typing techniques in Spain. The molecular and epidemiological data of 480 multidrug-resistant Mycobacterium tuberculosis complex isolates were analyzed. Thirty-one clusters involving 157 (32.7%) patients were identified. The proportion of immigrants increased substantially over the study period reaching 65% in 2008; however, the clustering rate remained stable indicating that local transmission was little influenced by imported MDR-TB. The three major clusters respond to the persistence of two autochthonous strains throughout the study period and an extensively drug-resistant (XDR) Mycobacterium bovis outbreak with only two cases was reported since 2002. Molecular and epidemiological evidence for the importation of new strains and their spread within the community was found. Immigrant-only clusters most often grouped patients infected abroad with strains belonging to rare spoligotypes. Conversely, widespread spoligotypes of the Latin-American and Mediterranean (LAM) and Haarlem families were responsible for the majority of the MDR-TB local transmission. The demonstration of clusters spanning several Spanish regions that have been ongoing throughout the study period makes it advisable to maintain a continuous molecular surveillance in order to monitor the spread of MDR-TB.

Single nucleotide polymorphism (SNP) analysis used for the phylogeny of the Mycobacterium tuberculosis complex based on a pyrosequencing assay

BackgroundDifferent polymorphisms have been described as markers to classify the lineages of the Mycobacterium tuberculosis complex. The analysis of nine single nucleotide polymorphisms (SNPs) was used to describe seven SNPs cluster groups (SCGs). We attempted to classify those strains that could not been categorized into lineages by the genotyping methods used in the routine testing.ResultsThe M. tuberculosis complex isolates collected in 2010 in our region were analysed. A new method based on multiplex-PCRs and pyrosequencing to analyse these SNPs was designed. For the pyrosequencing assay nine SNPs that defined the seven SCGs were selected from the literature: 1977, 74092, 105139, 232574, 311613, 913274, 2460626, 3352929 and gyrA 95. In addition, SNPs in kat G463, mgtC182, Ag85C103 and RDRio deletion were detected.ConclusionsThis work has permitted to achieve a better classification of Aragonian strains into SCGs and in some cases, to assign strains to its certain lineage. Besides, the description of a new pattern shared by two isolates “SCG-6c” reinforces the interest of SNPs to follow the evolution of M. tuberculosis complex.

Multidrug-Resistant Mycobacterium tuberculosis Strain from Equatorial Guinea Detected in Spain

To the Editor: Eleven years of molecular epidemiologic data allowed the Spanish Multidrug-resistant Tuberculosis (MDR TB) Surveillance Network to identify a specific MDR Mycobacterium tuberculosis strain that had been imported into Spain from Equatorial Guinea (1). Our study brings to light the potential dissemination of this strain (named MDR-TBEG) in Equatorial Guinea, a country where little is known about the extent and features of TB or MDR TB. It also highlights that MDR strains can spread across continents, and thus MDR TB’s emergence in any country becomes a global problem. Ten MDR M. tuberculosis isolates obtained from 10 patients from Equatorial Guinea were detected in Spain during 2000 through 2008. Evidence of clonality was found within the 10 isolates because all exhibited identical genetic profiles defined by different molecular epidemiology methods (2,3) and mutations involved in drug resistance (Figure). Notably, none of the remaining 504 MDR isolates in the Spanish database matched SIT177, a spoligotype belonging to the Latin American–Mediterranean 9 (LAM9) subfamily (4). Figure Genetic profile of the multidrug-resistant tuberculosis Equatorial Guinea (MDR-TBEG) strain. RFLP, restriction fragment length polymorphism; SIT, spoligotype international type; LAM, Latin American-Mediterranean; MIRU-VNTR, mycobacterial interspersed ... The data routinely collected for all cases of MDR TB have been previously described (1). All 10 patients in the study were from Equatorial Guinea, a small African country on the Gulf of Guinea with a population of ≈500,000, an MDR TB rate >2.0% (5) of all combined (new and previously treated) TB cases, and an estimated adult HIV prevalence rate of 3.2% (www.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_GQ.pdf). The MDR TB isolates were collected within a 9-year period (Technical Appendix): 1 in 2000, 2 in 2001, 3 in 2003, 1 in 2004, 2 in 2007, and 1 in 2008. According to their hospitals of origin, the patients were geographically dispersed in 6 different Spanish cities. We found that the interval between the patients’ arrival in Spain to the initiation of anti-TB treatment was <3 months in 6 patients, 3 of whom were clinically ill at the time of arrival. Seven patients were adult men, 2 were adult women, and 1 was an 8-year-old girl. The patients’ mean age was 30 years (range 8–54 years). Three patients were seropositive and 4 were seronegative for HIV infection (the HIV status of 3 patients was unknown). Data on prior anti-TB treatment was available for 7 case-patients, of whom only 1 had a history of antecedent TB chemotherapy. Altogether, 3 patients died before completing treatment, including 2 patients affected by miliary TB, 1 of whom was HIV-coinfected. The third patient who died was a student without a known history of immunosuppression or previous TB who had lived for 2 years in Spain. We could not establish any epidemiologic links between these patients during their stay in Spain. Analysis of drug resistance genes showed that all isolates harbored the inhA promoter mutation –15C→T (6). Alterations in the inhA gene were previously reported in 80% of the isoniazid-resistant isolates from Equatorial Guinea (5). Notably, a double mutation in the rpoB gene affecting codons 531 (Ser531Leu) and 561 (Ile561Val) was detected in the 10 MDR isolates. The presence of this uncommon mutation, Ile561Val, outside the rifampin resistance–determining region supports the hypothesis that the MDR isolates are clonal in origin. Furthermore, we demonstrated the absence of Ile561Val mutation in 3 drug-susceptible M. tuberculosis strains with an SIT177-LAM 9 spoligotype pattern, which ruled out a relationship between this spoligotype and the Ile561Val mutation. Further analysis with phylogenetic markers assigned MDR-TBEG to the principal genetic group 2, the Euro-American lineage of M. tuberculosis and its West African sublineage, on the basis of polymorphisms in codons katG463 and gyrA95, the 7-bp pks15/1 deletion, and RD174 (7,8), respectively. The analysis of the RDRio deletion confirmed that the strain belongs to the major RDRio sublineage of the LAM M. tuberculosis spoligotype family (9). This sublineage is a major cause of TB in Rio de Janeiro (Brazil) but has disseminated globally. Additional information on the geographic distribution of SIT177-LAM 9 was obtained from the updated International Spoligotyping Database (SITVIT2) of the Institut Pasteur de Guadeloupe. SITVIT2 (consulted on 23 July 2008) contained 57 isolates belonging to SIT177. Almost 50% (n = 28) came from Brazil, and 14% from Africa (Morocco, n = 6; Senegal, n = 2). The remaining isolates with known countries of origin (n = 9) were distributed in other unrelated countries. These data indicate that this particular spoligotype pattern is widely distributed. We identified 1 MDR strain of M. tuberculosis RDRio sublineage isolated in Spain from Equatorial Guinean patients. Although the transmission of MDR-TBEG in Spain could not be conclusively ruled out, the fact that MDR TB developed in most patients within 3 months after their arrival, as well as the spatiotemporal distribution of the MDR TB cases and its clonal origin, strongly suggest that MDR-TBEG was imported into Spain and that active transmission of this particular clone could be occurring in Equatorial Guinea. However, additional molecular and epidemiologic studies should be conducted in this sub-Saharan country to ascertain its role in recent transmission of MDR TB. Greater international efforts should be made to provide appropriate tools to resource-limited areas for fighting against MDR TB and preventing development of extensively drug-resistant TB.

Editorial Commentary: Nonspecific Beneficial Effects of BCG Vaccination in High-income Countries, Should We Extend Recommendation of BCG Vaccination?

BCG, or Bacille Calmette-Guerin, is a live attenuated vaccine derived from Mycobacterium bovis, originally isolated from cattle. BCG is the only vaccine available for the prevention of human forms of tuberculosis. BCG is effective in reducing the rate of severe forms of tuberculosis and is included as part of the routine immunization schedule in developing countries. Since 1974, BCG vaccination at birth has been included in the World Health Organization (WHO) Expanded Programme on Immunization resulting in more than 3 billion cumulative vaccinations worldwide [1]. Today BCG is the most widely administered vaccine in humans being one of the vaccines with minimum recorded adverse events. However, BCG is very reactogenic and combined with its inconsistency in preventing spread of pulmonary tuberculosis, BCG is generally not recommended for use in the United States or other highincome countries considered low-burden of tuberculosis. In the past, the efficacy of BCG in the prevention of tuberculosis in children was usually estimated by observing tuberculosis mortality. Going back to the first efficacy studies with BCG reported by Calmette and Guérin from 1921 to 1926 conducted in more than 50 000 BCG-vaccinated children, results showed that the mortality rate of previously immunized tuberculosis contacts decreased to 1.8% as compared to 25%–32.6% among those not vaccinated with BCG. It is important to note that the outcome assessed was overall mortality and not only mortality due to tuberculosis [2]. Since the beginning of BCG use, different studies suggest that BCG at birth has beneficial nontargeted effects on general infant morbidity and mortality in lowincome countries, a BCG scar is associated with better survival and 50% mortality reduction due to pneumonia in vaccinated children [3]. Vaccination at birth in randomized trials in West Africa showed that BCG reduces neonatal mortality by >40%, mainly by preventing neonatal sepsis and respiratory infections [3]. The WHO Global Tuberculosis Report (2014) [4] indicates that over 95% of tuberculosis deaths occur in lowand middle-income countries, and tuberculosis mortality is falling in different regions of the world. The tuberculosis mortality rate in highincome regions such as theWHO European region is 4.1 (4–4.2) per 100 000 population, and in theWHORegion of the Americas mortality is 1.5 (1.2–1.7) vs 42 (32–54) cases per 100 000 in the low-incomeWHO African Region, which makes difficult to use mortality as measure of BCG efficacy and vaccine effectiveness in high-income countries. BCG vaccine has been the subject of numerous efficacy trials and recently for systematic reviews and meta-analysis studies. The vaccine efficacy data are generally expressed as a proportionate reduction against pulmonary, miliary, or meningeal tuberculosis between unvaccinated and vaccinated with BCG children [5]. However, vaccine efficacy studies can measure otheroutcomes, includinghospitalizations, medical visits, and costs in preventing pulmonary tuberculosis. In the last years new studies have shown that BCG could induce trained immunity and nonspecific protection from infections against unrelated pathogens through epigenomic reprograming of innate immune cells by inducing NOD2-dependent reprogramming of Received 18 February 2015; accepted 18 February 2015; electronically published 27 February 2015. Comment on the manuscript of de Castro et al recently accepted for publication in Clinical Infectious Diseases and entitled “Nonspecific (heterologous) protection of neonatal BCG vaccination against hospitalization due to respiratory infection and sepsis”. Correspondence: Carlos Martin, MD, PhD, Genética de Micobacterias, University of Zaragoza, IIS Aragon, CIBERES (carlos@unizar.es). Clinical Infectious Diseases 2015;60(11):1620–1

Data-driven model for the assessment of Mycobacterium tuberculosis transmission in evolving demographic structures

Significance Even though tuberculosis (TB) is acknowledged as a strongly age-dependent disease, it remains unclear how TB epidemics would react, in the following decades, to the generalized aging that human populations are experiencing worldwide. This situation is partly caused by the limitations of current transmission models at describing the relationship between demography and TB transmission. Here, we present a data-driven epidemiological model that, unlike previous approaches, explicitly contemplates relevant aspects of the coupling between age structure and TB dynamics, such as demographic evolution and contact heterogeneities. Using our model, we identify substantial biases in epidemiological forecasts rooted in an inadequate description of these aspects, at the level of both aggregated incidence and mortality rates and their distribution across age strata. In the case of tuberculosis (TB), the capabilities of epidemic models to produce quantitatively robust forecasts are limited by multiple hindrances. Among these, understanding the complex relationship between disease epidemiology and populations’ age structure has been highlighted as one of the most relevant. TB dynamics depends on age in multiple ways, some of which are traditionally simplified in the literature. That is the case of the heterogeneities in contact intensity among different age strata that are common to all airborne diseases, but still typically neglected in the TB case. Furthermore, while demographic structures of many countries are rapidly aging, demographic dynamics are pervasively ignored when modeling TB spreading. In this work, we present a TB transmission model that incorporates country-specific demographic prospects and empirical contact data around a data-driven description of TB dynamics. Using our model, we find that the inclusion of demographic dynamics is followed by an increase in the burden levels predicted for the next decades in the areas of the world that are most hit by the disease today. Similarly, we show that considering realistic patterns of contacts among individuals in different age strata reshapes the transmission patterns reproduced by the models, a result with potential implications for the design of age-focused epidemiological interventions.

A data-driven model for the assessment of age-dependent patterns of Tuberculosis burden and impact evaluation of novel vaccines.

In the case of tuberculosis (TB), the capabilities of epidemic models to produce quantitatively robust forecasts are limited by multiple hindrances. Among these, understanding the complex relationship between disease epidemiology and populations9 age structure has been highlighted as one of the most relevant. TB dynamics depends on age in multiple ways, some of which are traditionally simplified in the literature. That is the case of the heterogeneities in contact intensity among different age-strata that are common to all air-borne diseases, but still typically neglected in the TB case. Furthermore, whilst demographic structures of many countries are rapidly aging, demographic dynamics is pervasively ignored when modeling TB spreading. In this work, we present a TB transmission model that incorporates country-specific demographic prospects and empirical contact data around a data-driven description of TB dynamics. Using our model, we find that the inclusion of demographic dynamics is followed by an increase in the burden levels prospected for the next decades in the areas of the world that are most hit by the disease nowadays. Similarly, we show that considering realistic patterns of contacts among individuals in different age-strata reshapes the transmission patterns reproduced by the models, a result with potential implications for the design of age-focused epidemiological interventions.