Environmental and social factors impacting on epidemic and endemic tuberculosis: a modelling analysis

Tuberculosis (TB) transmission results from the interaction between infective sources and susceptible individuals within enabling socio-environmental conditions. As TB is an airborne pathogen, the transmission probability is determined by the volume of air inhaled from an infected source and the concentration of Mycobacterium tuberculosis containing respirable particles (doses) per volume of air. In this study, we model the contributions of infectious dose production, prevalence of infectious cases and daily rebreathed air volume (RAV) for defining the boundary conditions necessary to sustain endemic TB transmission at the population level. Results suggest that in areas with high RAV (range 300–1000 l d −1 ), such as prisons, TB transmission is contributed by both super-spreaders (exhaling ≥10 infectious doses hr −1 ) and lower infectivity individuals (exhaling less than 10 infectious doses hr −1 ). In settings with a low quantity of RAV (less than 100 l d −1 ), TB transmission occurs only from super-spreaders. Point-source epidemics occur in low rebreathed environments when super-spreaders infect a number of susceptibles but subsequent transmission is limited by the mean infectivity of secondary cases. By contrast, endemic TB occurs in poor socio-environmental conditions where mean infectivity cases are able to maintain a sufficiently high effective contact number.