Tuberculosis cluster in an immigrant community: case identification issues and a transcultural perspective

OBJECTIVES In a low incidence area for tuberculosis (TB), a computerized database identified an unusually high proportion of patients coming from one single country between 2004 and 2006. To determine whether they constituted a cluster, whether clustering was due to recent transmission, and to understand what undermined the efficacy of the contact tracing procedure, we conducted a retrospective study of all patients with TB from this country. METHODS Mycobacterium tuberculosis isolates of 15 TB cases originating from the same country over a 21/2 year period were analysed by restriction fragment length polymorphism (RFLP) and/or Rep-PCR. To identify links between patients, we revisited the social worker's files, cross-matched contacts' databases, and performed internet searches. A cultural evaluation was conducted by an anthropologist and an expert physician, through patient and community key informant interviews and a literature review. RESULTS Genotyping confirmed that 11 of 15 patients had identical isolates. Additional data revealed an unsuspected complex network of social links between 9 of these 11 patients. The transcultural evaluation pointed out the major obstacles to efficient contact tracing, such as importance of social stigma related to TB, differences in communication style and health beliefs, and linguistic barriers. CONCLUSION The combined finding of identical genotypes and important social links between patients confirmed the suspicion of a TB cluster due to recent transmission. The cultural evaluation helped to explain the difficulties encountered during the contact tracing procedure, and offered strategies to improve its efficacy despite the magnitude of the social stigma attached to TB in this community.