Transmission in Birmingham, UK, 2009-19: An Observational Study

Background: Over 10-years of whole-genome sequencing (WGS) of in Birmingham presents an opportunity to explore epidemiological trends and risk factors for transmission in new detail.

Methods: Between 1st January 2009 and 15th June 2019, we obtained the first WGS isolate from every patient resident in a postcode district covered by Birmingham's centralised tuberculosis service. Data on patients' sex, country of birth, social risk-factors, anatomical locus of disease, and strain lineage were collected. Poisson harmonic regression was used to assess seasonal variation in case load and a mixed-effects multivariable Cox proportionate hazards model was used to assess risk factors for a future case arising in clusters defined by a 5 single nucleotide polymorphism (SNP) threshold, and by 12 SNPs in a sensitivity analysis.

Findings: 511/1653 (31%) patients were genomically clustered with another. A seasonal variation in diagnoses was observed, peaking in spring, but only among clustered cases. Risk-factors for a future clustered case included UK-birth (aHR=2·03 (95%CI 1·35-3·04),  < 0·001), infectious (pulmonary/laryngeal/miliary) tuberculosis (aHR=3·08 (95%CI 1·98-4·78),  < 0·001), and lineage 3 (aHR=1·91 (95%CI 1·03-3·56),  = 0·041) and 4 (aHR=2·27 (95%CI 1·21-4·26),  = 0·011), vs. lineage 1. Similar results pertained to 12 SNP clusters, for which social risk-factors were also significant (aHR 1·72 (95%CI 1·02-2·93),  = 0·044). There was marked heterogeneity in transmission patterns between postcode districts.

Interpretation: There is seasonal variation in the diagnosis of genomically clustered, but not non-clustered, cases. Risk factors for clustering include UK-birth, infectious forms of tuberculosis, and infection with lineage 3 or 4.

Funding: Wellcome Trust, MRC, UKHSA.