Evolution of virulent genotypes and an emerging threat of multidrug resistant tuberculosis in Bamako, Mali

Background: Bamako, Mali, has a well-structured hierarchyfor tuberculosis (TB) case management. However, in recent yearsBamako has been faced with an emerging threat from multidrugresistant TB (MDR-TB). Here we present insights into the genomicepidemiology of TB and the evolutionary mechanisms driving theemergence of MDR-TB in Bamako.Methods & Materials:Isolates recovered from tuberculosispatients from local reference centers and the University Teach-ing Hospital at Point G, in Bamako, Mali between 2006 and 2012(n = 208), were tested for antimicrobial susceptibility at the MRCUnit The Gambia. A subset of 76 isolates were analysed using wholegenome sequencing. A time dated phylogenetic tree was recon-structed using BEAST. Lineage and resistance conferring mutationswere inferred using PhyResSe.Results:Patients included 21 females and 55 males agedbetween 3 to 78 years, among whom 12(16%) were infectedby MDR-TB. Most patients 61(80%) were new cases and among15 retreatment cases 9(60%) were MDR-TB. The phylogeny wasreconstructed from 8508 variant core genome sites. The dom-inant lineage was the Euro-American super lineage, lineage 4.Within lineage 4, the Cameroon genotype was the most preva-lent genotype (n = 20, 26%) followed by the Ghana genotype (n = 16,21%). Cameroon genotype isolates diverged from a common recentancestor∼161 years ago to form three clusters, one of whichemerged∼22 years ago and is likely to be involved in on-goingtransmission. Seven Ghana genotype isolates were MDR-TB repre-senting over half all MDR-TB in this dataset (7/12). Ghana genotypeisolates were more likely to cause MDR-TB than other genotypesafter controlling for treatment status (OR = 5.6, p-value = 0.043).The MDR-TB Ghana genotype isolates formed a clade that divergedapproximately 30 years ago, in which thekatGSer315Thr mutationwas conserved. Other Euro-American genotypes included the sixLAM, two H37Rv-like and one Uganda. Four patients were infectedwith closely related Beijing strains and five patients were infectedwith non-MDRMycobacterium africanum2.