A cluster of multidrug-resistant Mycobacterium tuberculosis among patients arriving in Europe from the Horn of Africa: a molecular epidemiological study  Timothy M Walker, MRCP, Matthias Merker, PhD, Astrid M Knoblauch, PhD, Peter Helbling, MD, Prof Otto D Schoch, MD, Marieke J van der Werf, PhD, Katharina Kranzer, MD, Lena Fiebig, PhD, Stefan Kröger, PhD, Prof Walter Haas, MD, Harald Hoffmann, MD, Alexander Indra, MD, Adrian Egli, MD, Daniela M Cirillo, MD, Prof Jérôme Robert, MD, Prof Thomas R Rogers, DMed, Ramona Groenheit, PhD, Anne T Mengshoel, MD, Vanessa Mathys, PhD, Marjo Haanperä, PhD, Prof Dick van Soolingen, PhD, Prof Stefan Niemann, DSc, Prof Erik C Böttger, MD, Peter M Keller, MD Korkut Avsar, Christoph Bauer, Enos Bernasconi, Emanuele Borroni, Sergio Brusin, Mireia Coscollá Dévis, Derrick W. Crook, Martin Dedicoat, Margaret Fitzgibbon, Sébastien Gagneux, Francisca Geiger, Jean-Paul Guthmann, David Hendrickx, Sabine Hoffmann-Thiel, Jakko van Ingen, Sarah Jackson, Katia Jaton, Christoph Lange, Jessica Mazza Stalder, Joan O'Donnell, Onya Opota, Tim E.A. Peto, Benjamin Preiswerk, Emma Roycroft, Mariko Sato, Regina Schacher, Bettina Schulthess, E. Grace Smith, Hanna Soini, Wladimir Sougakoff, Elisa Tagliani, Christian Utpatel, Nicolas Veziris, Christiane Wagner-Wiening, Mark Witschi Timothy M Walker, MRCP, Matthias Merker, PhD, Astrid M Knoblauch, PhD, Peter Helbling, MD, Prof Otto D Schoch, MD, Marieke J van der Werf, PhD, Katharina Kranzer, MD, Lena Fiebig, PhD, Stefan Kröger, PhD, Prof Walter Haas, MD, Harald Hoffmann, MD, Alexander Indra, MD, Adrian Egli, MD, Daniela M Cirillo, MD, Prof Jérôme Robert, MD, Prof Thomas R Rogers, DMed, Ramona Groenheit, PhD, Anne T Mengshoel, MD, Vanessa Mathys, PhD, Marjo Haanperä, PhD, Prof Dick van Soolingen, PhD, Prof Stefan Niemann, DSc, Prof Erik C Böttger, MD, Peter M Keller, MD Korkut Avsar, Christoph Bauer, Enos Bernasconi, Emanuele Borroni, Sergio Brusin, Mireia Coscollá Dévis, Derrick W. Crook, Martin Dedicoat, Margaret Fitzgibbon, Sébastien Gagneux, Francisca Geiger, Jean- Paul Guthmann, David Hendrickx, Sabine Hoffmann-Thiel, Jakko van Ingen, Sarah Jackson, Katia Jaton, Christoph Lange, Jessica Mazza Stalder, Joan O'Donnell, Onya Opota, Tim E.A. Peto, Benjamin Preiswerk, Emma Roycroft, Mariko Sato, Regina Schacher, Bettina Schulthess, E. Grace Smith, Hanna Soini, Wladimir Sougakoff, Elisa Tagliani, Christian Utpatel, Nicolas Veziris, Christiane Wagner-Wiening, Mark Witschi  The Lancet Infectious Diseases  Volume 18, Issue 4, Pages 431-440 (April 2018) DOI: 10.1016/S1473-3099(18)30004-5 Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 1 Genetic relationship or distances between 58 Mycobacterium tuberculosis isolates associated with a multidrug-resistant tuberculosis outbreak among migrants in 2016 and 2017 in Europe Maximum likelihood phylogeny (A) and minimum spanning tree (B). Numbers in B show genetic distances in SNP differences and solid black branches without annotation reflect 1 SNP difference. SNP=single-nucleotide polymorphism. The Lancet Infectious Diseases 2018 18, 431-440DOI: (10.1016/S1473-3099(18)30004-5) Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 2 Timeline of patient journeys until diagnosis The 1st of each month is shown as the country entry date. Subsequent countries visited in the same month are presented at 5-day intervals. The Lancet Infectious Diseases 2018 18, 431-440DOI: (10.1016/S1473-3099(18)30004-5) Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 3 Reported migration routes through Italy of 29 outbreak patients with a documented migration route, August, 2014, to February, 2017 The Lancet Infectious Diseases 2018 18, 431-440DOI: (10.1016/S1473-3099(18)30004-5) Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions