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Background  Tuberculosis (TB) incidence is decreasing worldwide and eradication is becoming plausible. In low-incidence countries, intervention on migrant populations is considered one of the most important strategies for elimination. However, such measures are inappropriate in European areas where TB is largely endemic, such as Porto in Portugal. We aim to understand transmission chains in Porto through a genetic characterization of  Mycobacterium tuberculosis  strains and through a detailed epidemiological evaluation of cases.    Methods  We genotyped the  M. tuberculosis  strains using the MIRU-VNTR system. We performed an evolutionary reconstruction of the genotypes with median networks, used in this context for the first time. TB cases from a period of two years were evaluated combining genetic, epidemiological and georeferencing information.    Results  The data reveal a unique complex scenario in Porto where the autochthonous population acts as a genetic reservoir of  M. tuberculosis  diversity with discreet episodes of transmission, mostly undetected using classical epidemiology alone.    Conclusions  Although control policies have been successful in decreasing incidence in Porto, the discerned complexity suggests that, for elimination to be a realistic goal, strategies need to be adjusted and coupled with a continuous genetic characterization of strains and detailed epidemiological evaluation, in order to successfully identify and interrupt transmission chains.

A complex scenario of tuberculosis transmission is revealed through genetic and epidemiological surveys in Porto