{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T13:35:37Z","timestamp":1788183337791,"version":"build-2803163510"},"reference-count":33,"publisher":"Public Library of Science (PLoS)","issue":"2","license":[{"start":{"date-parts":[[2021,2,24]],"date-time":"2021-02-24T00:00:00Z","timestamp":1614124800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Chinese Center for Disease Control and Prevention (CN), Chinese Field Epidemiology Training Program","award":["131031001000160016"],"award-info":[{"award-number":["131031001000160016"]}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>In October 2016, a senior high school student was diagnosed with sputum-smear positive [SS(+)] pulmonary tuberculosis (TB). We conducted an investigation of an outbreak in the school, including among students and teachers diagnosed with latent TB, who we followed until July 2019.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>We defined latent TB infection (LTBI) as a tuberculin skin test (TST) induration of 15mm or larger; probable TB as a chest radiograph indicative of TB plus productive cough\/hemoptysis for at least 2 weeks, or TST induration of 15mm or larger; and confirmed TB as two or more positive sputum smears or one positive sputum smear plus a chest radiograph indicative of TB or culture positive with <jats:italic>M<\/jats:italic>. <jats:italic>tuberculosis<\/jats:italic>. We conducted mycobacterial interspersed repetitive unit\u2013variable number tandem repeat (MIRU-VNTR) typing based on 24 loci in the isolates.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Between October 2016 and July 2019, we identified 52 cases, including nine probable, six confirmed, and 37 LTBI cases. The index case-student had attended school continuously despite having TB symptoms for almost three months before being diagnosed with TB. We obtained three isolates from classmates of the index case in 2016; all had identical MIRU-VNTR alleles with the index case. The LTBI rate was lower among students (7.41%, 30\/405) than among teachers (26.92%, 7\/26) (rate ratio [RR] = 0.28, 95% confidential interval [CI]: 0.13\u20130.57). Among the 17 students who had latent TB and refused prophylaxis in October 2016, 23.53% (4\/17) became probable\/confirmed cases by July 2019. None of the six teachers who also refused prophylaxis became probable or confirmed cases. Of the 176 students who were TST(-) in October 2016, 1.70% (3\/176) became probable\/confirmed cases, and among the 20 teachers who were TST(-), 1 became a probable case.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>Delayed diagnosis of TB in the index patient may have contributed to the start of this outbreak; lack of post-exposure chemoprophylaxis facilitated spread of the outbreak. Post-exposure prophylaxis is strongly recommended for all TST-positive students; TST-negative students exposed to an SS(+) case should be followed up regularly so that prophylaxis can be started if LTBI is detected.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0247564","type":"journal-article","created":{"date-parts":[[2021,2,24]],"date-time":"2021-02-24T18:38:05Z","timestamp":1614191885000},"page":"e0247564","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":22,"title":["An outbreak of pulmonary tuberculosis and a follow-up investigation of latent tuberculosis in a high school in an eastern city in China, 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(WHO)","year":"2010"},{"issue":"4","key":"pone.0247564.ref002","doi-asserted-by":"crossref","first-page":"307","DOI":"10.2188\/jea.JE20120216","article-title":"Outbreak of Pulmonary Tuberculosis in a Chinese High School,2009\u20132010.","volume":"23","author":"YR Fang","year":"2013","journal-title":"J Epidemiol"},{"issue":"5","key":"pone.0247564.ref003","first-page":"400","article-title":"Study on early warning for tuberculosis outbreaks in school using moving average method","volume":"32","author":"YR Fang","year":"2017","journal-title":"Disease surveillance"},{"issue":"6","key":"pone.0247564.ref004","first-page":"662","article-title":"Epidemic trends and characteristics of pulmonary tuberculosis in students in China from 2014 to 2018.","volume":"41","author":"H Chen","year":"2019","journal-title":"Chin J Antitubrec."},{"issue":"11","key":"pone.0247564.ref005","doi-asserted-by":"crossref","first-page":"e0225042","DOI":"10.1371\/journal.pone.0225042","article-title":"An outbreak of tuberculosis in a middle school in Henan, China: Epidemiology and risk factors.","volume":"14","author":"J Xu","year":"2019","journal-title":"PLoS ONE"},{"issue":"1","key":"pone.0247564.ref006","first-page":"55","article-title":"Tuberculosis outbreak in a grammar school, Serbia, 2016.","volume":"55","author":"M Ilic","year":"2019","journal-title":"Ann Ist Super Sanit\u00e0."},{"key":"pone.0247564.ref007","doi-asserted-by":"crossref","first-page":"101","DOI":"10.3855\/jidc.10952","article-title":"Tuberculosis outbreak among high school students in Novi Pazar, Serbia 2016: a retrospective-cohort study.","volume":"13","author":"MB Stosic","year":"2019","journal-title":"J Infect Dev Ctries."},{"issue":"4","key":"pone.0247564.ref008","doi-asserted-by":"crossref","first-page":"728","DOI":"10.4269\/ajtmh.19-0533","article-title":"Outbreak of Mycobacterium tuberculosis Beijing Strain in a High School in Yunnan, China","volume":"102","author":"J Hou","year":"2020","journal-title":"Am J Trop Med Hyg"},{"issue":"1","key":"pone.0247564.ref009","doi-asserted-by":"crossref","first-page":"972","DOI":"10.1186\/s12879-019-4573-3","article-title":"Tuberculosis outbreaks among students in mainland China: a systematic review and meta-analysis","volume":"19","author":"H Bao","year":"2019","journal-title":"BMC Infect Dis"},{"issue":"3","key":"pone.0247564.ref010","doi-asserted-by":"crossref","first-page":"485","DOI":"10.3201\/eid1902.120527","article-title":"Tuberculosis Outbreak in a Primary School, Milan","volume":"19","author":"M Faccini","year":"2013","journal-title":"Italy, Emerging Infectious Diseases"},{"issue":"24","key":"pone.0247564.ref011","doi-asserted-by":"crossref","first-page":"1900332","DOI":"10.2807\/1560-7917.ES.2019.24.24.1900332","article-title":"High rate of transmission in a pulmonary tuberculosis outbreak in a primary school, north-eastern Italy, 2019.","volume":"24","author":"S Cinquetti","year":"2019","journal-title":"Euro Surveill"},{"issue":"3","key":"pone.0247564.ref012","doi-asserted-by":"crossref","first-page":"514","DOI":"10.3201\/eid1703.101440","article-title":"Tuberculosis in Kindergarten and Primary School,Italy, 2008\u20132009.","volume":"17","author":"A Filia","year":"2011","journal-title":"Emerg Infect Dis"},{"key":"pone.0247564.ref013","unstructured":"Ministry of Health of the Peoples Republic of China. Guideline of China Tuberculosis Control Program. Beijing: Peking Union Medical College Publishing House. 2008. (In Chinese)."},{"key":"pone.0247564.ref014","volume-title":"Tuberculosis Control and Prevention.","author":"DL Wang","year":"2004"},{"issue":"2","key":"pone.0247564.ref015","doi-asserted-by":"crossref","first-page":"98","DOI":"10.3109\/00365548.2013.858182","article-title":"Genotypes of Mycobacterium tuberculosis isolates in rural China: Using MIRU-VNTR and spoligotyping methods","volume":"46","author":"W Lu","year":"2014","journal-title":"Scand J Infect Dis"},{"issue":"1","key":"pone.0247564.ref016","doi-asserted-by":"crossref","first-page":"447","DOI":"10.1186\/s12879-018-3351-y","article-title":"Role of MIRU-VNTR and spoligotyping in assessing the genetic diversity of Mycobacterium tuberculosis in Henan Province, China.","volume":"18","author":"J Shi","year":"2018","journal-title":"BMC Infect Dis"},{"issue":"12","key":"pone.0247564.ref017","first-page":"4498","article-title":"Proposal for Standardization of Optimized Mycobacterial Interspersed Repetitive Unit\u2013Variable-Number Tandem Repeat Typing of Mycobacterium tuberculosis.","volume":"44","author":"P Supply","year":"2006","journal-title":"JClin Mirobiol"},{"key":"pone.0247564.ref018","doi-asserted-by":"crossref","first-page":"2161","DOI":"10.1056\/NEJMoa1108789","article-title":"National Survey of Drug-Resistant Tuberculosis in China","volume":"366","author":"YL Zhao","year":"2012","journal-title":"N Engl J Med"},{"issue":"8","key":"pone.0247564.ref019","doi-asserted-by":"crossref","first-page":"2692","DOI":"10.1128\/JCM.00540-08","article-title":"Niemann, S. Evaluation and user-strategy of MIRU-VNTRplus, a multifunctional database for online analysis of genotyping data and phylogenetic identification of Mycobacterium tuberculosis complex isolates","volume":"46","author":"C Allix-B\u00e9guec","year":"2008","journal-title":"J Clin Microbiol"},{"issue":"4","key":"pone.0247564.ref020","first-page":"573","article-title":"A case control study on risk factors of school-based tuberculosis clustering.","volume":"38","author":"YR Fang","year":"2017","journal-title":"Chin J Sch Health"},{"issue":"10","key":"pone.0247564.ref021","doi-asserted-by":"crossref","first-page":"e0141511","DOI":"10.1371\/journal.pone.0141511","article-title":"High Latent TB Infection Rate and Associated Risk Factors in the Eastern China of Low TB Incidence.","volume":"10","author":"C Chen","year":"2015","journal-title":"PLoS ONE"},{"key":"pone.0247564.ref022","doi-asserted-by":"crossref","first-page":"e59","DOI":"10.1017\/S0950268820000552","article-title":"An office building outbreak: the changing epidemiology of tuberculosis in Shenzhen, China.","volume":"148","author":"XJ Guo","year":"2020","journal-title":"Epidemiol Infect"},{"key":"pone.0247564.ref023","doi-asserted-by":"crossref","first-page":"10","DOI":"10.3389\/fped.2020.00010","article-title":"Tuberculosis Transmission in a Primary School and a Private Language School.","volume":"8","author":"S Debulpaep","year":"2020","journal-title":"An Estimation of Infectivity. Front Pediatr"},{"issue":"7","key":"pone.0247564.ref024","doi-asserted-by":"crossref","first-page":"4377","DOI":"10.21037\/jtd.2018.06.138","article-title":"Effects of preventive therapy for latent tuberculosis infection and factors associated with treatment abandonment: a cross-sectional study.","volume":"10","author":"H Huang","year":"2018","journal-title":"J Thorac Dis"},{"key":"pone.0247564.ref025","unstructured":"American Thoracic Society, CDC, and Infectious Diseases Society of America. Treatment of Tuberculosis [J]. MMWR. 2003,52(RR-11):1\u201377. https:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/rr5211a1.htm."},{"issue":"5","key":"pone.0247564.ref026","doi-asserted-by":"crossref","first-page":"986","DOI":"10.1183\/09031936.06.00002506","article-title":"Tuberculosis outbreak among students in a boarding school","volume":"28","author":"C Stein-Zamir","year":"2006","journal-title":"Eur Respir J"},{"issue":"9","key":"pone.0247564.ref027","doi-asserted-by":"crossref","first-page":"4224","DOI":"10.1128\/JCM.41.9.4224-4230.2003","article-title":"Molecular typing of mycobacterium tuberculosis by using nine novel variable -number tandem repeats across the Beijing family and low -copy -number IS6110 isolates [J]","volume":"41","author":"RS Spurgiesz","year":"2003","journal-title":"J Clin Microbiol"},{"key":"pone.0247564.ref028","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1016\/j.ebiom.2018.07.019","article-title":"A Quantitative Evaluation of MIRU-VNTR Typing Against Whole-Genome Sequencing for Identifying Mycobacterium tuberculosisTransmission: A Prospective Observational Cohort Study.","volume":"34","author":"DH Wyllie","year":"2018","journal-title":"EBioMedicine"},{"key":"pone.0247564.ref029","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1007\/978-3-319-64371-7_3","article-title":"The Evolution of Strain Typing in the Mycobacterium tuberculosis Complex","volume":"1019","author":"M Merker","year":"2017","journal-title":"Adv Exp Med Biol"},{"issue":"2","key":"pone.0247564.ref030","doi-asserted-by":"crossref","first-page":"338","DOI":"10.4014\/jmb.1704.04042","article-title":"Comparison of PFGE, IS6110-RFLP, and 24-Locus MIRU-VNTR for molecular epidemiologic typing of Mycobacterium tuberculosis isolates with known epidemic connections","volume":"28","author":"S Jeon","year":"2018","journal-title":"J. Microbiol. Biotechnol"},{"issue":"12","key":"pone.0247564.ref031","doi-asserted-by":"crossref","first-page":"3234","DOI":"10.1128\/JCM.33.12.3234-3238.1995","article-title":"Predominance of a single genotype of Mycobacterium tuberculosis in countries of east Asia","volume":"33","author":"D Van Soolingen","year":"1995","journal-title":"J Clin Microbio"},{"issue":"3","key":"pone.0247564.ref032","doi-asserted-by":"crossref","first-page":"242","DOI":"10.1038\/ng.3195","article-title":"Evolutionary history and global spread of the Mycobacterium tuberculosis Beijing lineage","volume":"47","author":"M Merker","year":"2015","journal-title":"Nat Genet"},{"key":"pone.0247564.ref033","article-title":"A First Insight into the Genetic Diversity and Drug Susceptibility Pattern of Mycobacterium tuberculosis Complex in Zhejiang, China.","author":"ZW Liu","year":"2016","journal-title":"BioMed Res Int"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0247564","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,2,24]],"date-time":"2021-02-24T18:38:59Z","timestamp":1614191939000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0247564"}},"subtitle":[],"editor":[{"given":"Igor","family":"Mokrousov","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2021,2,24]]},"references-count":33,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2021,2,24]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0247564","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,2,24]]}}}