Shifts in Geographic Distribution and Antimicrobial Resistance during a Prolonged Typhoid Fever Outbreak — Bundibugyo and Kasese Districts, Uganda, 2009–2011
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Date
2014
Journal Title
Journal ISSN
Volume Title
Publisher
PLoS Negl Trop Dis
Abstract
Salmonella enterica serovar Typhi is transmitted by fecally contaminated food and water and causes
approximately 22 million typhoid fever infections worldwide each year. Most cases occur in developing countries, where
approximately 4% of patients develop intestinal perforation (IP). In Kasese District, Uganda, a typhoid fever outbreak
notable for a high IP rate began in 2008. We report that this outbreak continued through 2011, when it spread to the
neighboring district of Bundibugyo.
Methodology/Principal Findings: A suspected typhoid fever case was defined as IP or symptoms of fever, abdominal pain,
and $1 of the following: gastrointestinal disruptions, body weakness, joint pain, headache, clinically suspected IP, or nonresponsiveness
to antimalarial medications. Cases were identified retrospectively via medical record reviews and
prospectively through laboratory-enhanced case finding. Among Kasese residents, 709 cases were identified from August 1,
2009–December 31, 2011; of these, 149 were identified during the prospective period beginning November 1, 2011. Among
Bundibugyo residents, 333 cases were identified from January 1–December 31, 2011, including 128 cases identified during
the prospective period beginning October 28, 2011. IP was reported for 507 (82%) and 59 (20%) of Kasese and Bundibugyo
cases, respectively. Blood and stool cultures performed for 154 patients during the prospective period yielded isolates from
24 (16%) patients. Three pulsed-field gel electrophoresis pattern combinations, including one observed in a Kasese isolate in
2009, were shared among Kasese and Bundibugyo isolates. Antimicrobial susceptibility was assessed for 18 isolates; among
these 15 (83%) were multidrug-resistant (MDR), compared to 5% of 2009 isolates.
Conclusions/Significance: Molecular and epidemiological evidence suggest that during a prolonged outbreak, typhoid
spread from Kasese to Bundibugyo. MDR strains became prevalent. Lasting interventions, such as typhoid vaccination and
improvements in drinking water infrastructure, should be considered to minimize the risk of prolonged outbreaks in the
future.
Description
Keywords
Geographic Distribution, Antimicrobial Resistance, Typhoid Fever Outbreak
Citation
Walters MS, Routh J, Mikoleit M, Kadivane S, Ouma C, et al. (2014) Shifts in Geographic Distribution and Antimicrobial Resistance during a Prolonged Typhoid Fever Outbreak — Bundibugyo and Kasese Districts, Uganda, 2009–2011. PLoS Negl Trop Dis 8(3): e2726. doi:10.1371/journal.pntd.0002726