Overlapping prison/community tuberculosis outbreaks in Costa Rica revealed by alternative analysis of suboptimal material

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Abstract
Costa Rica has a low incidence of tuberculosis. Thus, identifying transmission hotspots is key to implement interventions. A tuberculosis outbreak was suspected in a prison in Costa Rica. Given the suboptimal quality of the samples received in our laboratory in Madrid, we applied alternative schemes for their analysis. In the first scheme, we bypassed the standard approach of applying systematic Mycobacterial Interspersed Repetitive Units‐Variable Number of Tandem Repeats (MIRU‐VNTR) and used a strain‐specific Polymerase Chain Reaction (PCR) that allowed identifying a cluster involving six cases (C1). The second scheme followed the canonical MIRU‐VNTR path coupled with a whole genomic amplification step, by which a second unsuspected overlapping cluster (C2) was detected in the same prison. These findings justified the implementation of a surveillance program adapted to local resources based on a tailored multiplex allele‐specific oligonucleotide (ASO)‐PCR targeting C1 and C2. Presence of the C2 strain at a different prison was determined. ASO‐PCR was applied extensively and alerted to the active circulation of one of the strains within and beyond prisons. Our study shows that alternative methodological strategies may provide useful data in settings with lack of resources for performing systematic standard molecular epidemiology programs and/or with suboptimal material for analysis.

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