1.2 Transmission

M. tuberculosis is mainly transmitted from human-to-human and spread is mainly airborne. The source of infection is usually a person with pulmonary TB (PTB) or laryngeal TB. During coughing, speaking, or sneezing, the person produces tiny infectious droplets. These particles, called droplet nuclei, are about 1 to 5 microns in diameter. They can remain suspended in the air for several hours.

Transmission may occur when these infectious droplets are inhaled. UV light and ventilation reduce the risk of transmission (Chapter 14).

Other modes of transmission are far less common. Inoculation of cutaneous or mucous membranes rarely occurs [1] Citation 1. Brito AC et al. Cutaneous tuberculosis: epidemiological, clinical, diagnostic and therapeutic update. An Bras Dermatol. 2022 Mar-Apr;97(2):129-144.
https://doi.org/10.1016/j.abd.2021.07.004 . Congenital infection (by transplacental transmission or via aspiration or swallowing of infected amniotic fluid at birth) has been reported, but is rare [2] Citation 2. Schaaf HS, Bekker A, Rabie H. Perinatal tuberculosis-An approach to an under-recognized diagnosis. Front Public Health. 2023 Nov 7;11:1239734. https://doi.org/10.3389/fpubh.2023.1239734 . Transmission through breast milk does not occur.

The infectiousness of a person is associated with the quantity of bacilli contained in their sputum. Patients with smear-positive sputum on microscopy are by far the most infectious. Those with smear-negative/culture-positive results are less infectious, but still contribute to TB transmission due to more frequent delays in diagnosis. 

Persons infected with M. tuberculosis, but who have not developed active TB (i.e. persons with latent tuberculosis infection), are not infectious. Persons with extrapulmonary TB (EPTB) are only infectious in exceptional circumstances.

Children are generally less infectious than adults. This may be due to weaker cough mechanics, less sputum production and lower bacillary load.

Not everyone who is exposed to an infectious TB patient becomes infected with M. tuberculosis. The probability that TB will be transmitted depends on several factors:

Infectiousness of the source (the most important factor)
• Bacteriological status: smear-positive patients are the most infectious.
• Virulence of the bacilli: some strains are highly transmissible (and/or more likely to cause active TB).

Environment where the exposure occurred
• Outdoor environments or those with good ventilation and sunlight are less likely to lead to transmission. Small rooms or rooms with no ventilation are conditions most likely to lead to transmission.
• The proximity of the contact person to the person with TB is also important (e.g. the risk is higher if the contact person sleeps next to the person with TB than if they sleep 20 metres away from the person with TB).

Duration of exposure
People in close and prolonged contact with a person with TB are at highest risk of becoming infected with M. tuberculosis. They may be family members, roommates, friends, co-workers or other people who spend several hours a day with the infectious patient.

The best way to stop transmission is to start effective TB treatment as soon as possible as persons with untreated smear-positive TB transmits the bacillus.