<?xml version="1.0" encoding="UTF-8"?><xml><records><record><source-app name="Biblio" version="7.x">Drupal-Biblio</source-app><ref-type>17</ref-type><contributors><authors><author><style face="normal" font="default" size="100%">Timothy M Walker</style></author><author><style face="normal" font="default" size="100%">Matthias Merker</style></author><author><style face="normal" font="default" size="100%">Astrid M Knoblauch</style></author><author><style face="normal" font="default" size="100%">Peter Helbling</style></author><author><style face="normal" font="default" size="100%">Otto D Schoch</style></author><author><style face="normal" font="default" size="100%">J van der Werf</style></author><author><style face="normal" font="default" size="100%">Katharina Kranzer</style></author><author><style face="normal" font="default" size="100%">Lena Fiebig</style></author><author><style face="normal" font="default" size="100%">Stefan Kröger</style></author><author><style face="normal" font="default" size="100%">Walter Haas</style></author><author><style face="normal" font="default" size="100%">Harald Hoffmann</style></author><author><style face="normal" font="default" size="100%">Indra, Alexander</style></author><author><style face="normal" font="default" size="100%">Adrian Egli</style></author><author><style face="normal" font="default" size="100%">Daniela M Cirillo</style></author><author><style face="normal" font="default" size="100%">Jérôme Robert</style></author><author><style face="normal" font="default" size="100%">Thomas R Rogers</style></author><author><style face="normal" font="default" size="100%">Ramona Groenheit</style></author><author><style face="normal" font="default" size="100%">Anne T Mengshoel</style></author><author><style face="normal" font="default" size="100%">Vanessa Mathys</style></author><author><style face="normal" font="default" size="100%">Marjo Haanperä</style></author><author><style face="normal" font="default" size="100%">Dick van Soolingen</style></author><author><style face="normal" font="default" size="100%">Stefan Niemann</style></author><author><style face="normal" font="default" size="100%">Erik C Böttger</style></author><author><style face="normal" font="default" size="100%">Peter M Keller</style></author></authors><translated-authors><author><style face="normal" font="default" size="100%">MDR-TB Cluster Consortium</style></author></translated-authors></contributors><titles><title><style face="normal" font="default" size="100%">A cluster of multidrug-resistant Mycobacterium tuberculosis among patients arriving in Europe from the Horn of Africa: a molecular epidemiological study.</style></title><secondary-title><style face="normal" font="default" size="100%">Lancet Infect Dis</style></secondary-title></titles><keywords><keyword><style  face="normal" font="default" size="100%">Cluster</style></keyword><keyword><style  face="normal" font="default" size="100%">Tuberculosis</style></keyword></keywords><dates><year><style  face="normal" font="default" size="100%">2018</style></year><pub-dates><date><style  face="normal" font="default" size="100%">08-jan-2018</style></date></pub-dates></dates><language><style face="normal" font="default" size="100%">eng</style></language><abstract><style face="normal" font="default" size="100%">&lt;p&gt;&lt;b&gt;BACKGROUND: &lt;/b&gt;The risk of tuberculosis outbreaks among people fleeing hardship for refuge in Europe is heightened. We describe the cross-border European response to an outbreak of multidrug-resistant tuberculosis among patients from the Horn of Africa and Sudan.&lt;/p&gt;

&lt;p&gt;&lt;b&gt;METHODS: &lt;/b&gt;On April 29 and May 30, 2016, the Swiss and German National Mycobacterial Reference Laboratories independently triggered an outbreak investigation after four patients were diagnosed with multidrug-resistant tuberculosis. In this molecular epidemiological study, we prospectively defined outbreak cases with 24-locus mycobacterial interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR) profiles; phenotypic resistance to isoniazid, rifampicin, ethambutol, pyrazinamide, and capreomycin; and corresponding drug resistance mutations. We whole-genome sequenced all Mycobacterium tuberculosis isolates and clustered them using a threshold of five single nucleotide polymorphisms (SNPs). We collated epidemiological data from host countries from the European Centre for Disease Prevention and Control.&lt;/p&gt;

&lt;p&gt;&lt;b&gt;FINDINGS: &lt;/b&gt;Between Feb 12, 2016, and April 19, 2017, 29 patients were diagnosed with multidrug-resistant tuberculosis in seven European countries. All originated from the Horn of Africa or Sudan, with all isolates two SNPs or fewer apart. 22 (76%) patients reported their travel routes, with clear spatiotemporal overlap between routes. We identified a further 29 MIRU-VNTR-linked cases from the Horn of Africa that predated the outbreak, but all were more than five SNPs from the outbreak. However all 58 isolates shared a capreomycin resistance-associated tlyA mutation.&lt;/p&gt;

&lt;p&gt;&lt;b&gt;INTERPRETATION: &lt;/b&gt;Our data suggest that source cases are linked to an M tuberculosis clone circulating in northern Somalia or Djibouti and that transmission probably occurred en route before arrival in Europe. We hypothesise that the shared mutation of tlyA is a drug resistance mutation and phylogenetic marker, the first of its kind in M tuberculosis sensu stricto.&lt;/p&gt;

&lt;p&gt;&lt;b&gt;FUNDING: &lt;/b&gt;The Swiss Federal Office of Public Health, the University of Zurich, the Wellcome Trust, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), the Medical Research Council, BELTA-TBnet, the European Union, the German Center for Infection Research, and Leibniz Science Campus Evolutionary Medicine of the Lung (EvoLUNG).&lt;/p&gt;
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