Outbreak of epidemic typhus associated with trench fever in Burundi.
BACKGROUND
After a 12-year absence, epidemic typhus has re-emerged among the displaced population of Burundi. Following the outbreak of civil war in 1993, over 760000 people now inhabit refugee camps, under appalling conditions. A typhus outbreak occurred among prisoners in a jail in N'Gozi in 1995. At the time, the disease was not recognised, and was referred to as sutama. Reports of sutama among the civilian population date back to late 1995 and, in association with body-louse infestation, the disease has subsequently swept across the higher and colder regions of the country.


METHODS
During a field study in February, 1997, 102 refugees with sutama underwent clinical examination and interview. Serum samples were collected and infesting body lice removed. Microbiological analysis included antibody estimations and specific PCRs aimed at diagnosis of Rickettsia prowezekii, Bartonella quintana, and Borrelia recurrentis. Between January and September, 1997, nationwide epidemiological data on the prevalence and distribution of sutama was obtained through liaison with local health services. A second field study in March, 1997, entailed the collection of further serum samples from suspected cases of sutama in different regions of Burundi.


RESULTS
Most of the 102 patients with sutama during initial assessment presented with manifestations similar to those previously described for typhus in Africa, though skin eruptions occurred in only 25 (25%) cases. Microbiological testing revealed evidence of R prowazeki infection in 76 (75%) patients, confirming that most cases of clinically-diagnosed sutama were epidemic typhus, and supporting the reliability of clinical diagnosis as a basis for the nationwide surveillance of the disease. Up to September, 1997, 45558 typhus cases were clinically diagnosed, most of which occurred in regions at an altitude of over 1500 m. Serological testing of 232 individuals from different regions of Burundi provided microbiological evidence to support clinical diagnoses in seven provinces, confirming the widespread nature of the outbreak. Serum from 13 of the original 102 patients and 19 (8%) of the 232 suspected cases had raised antibody titres against B quintana. A fatality rate of 15% among jail inmates fell to 0.5% after administration of a single dose of 200 mg doxycycline to suspected cases.


CONCLUSIONS
A gigantic outbreak of R prowazekii-induced typhus and B quintana-induced trench fever is continuing in Burundi. Transmission of both diseases to such a large number of people has followed a widespread epidemic of body-louse infestation. Diagnosis of typhus could be reliably made by means of clinical criteria, and the disease could be efficiently and easily treated by antibiotics. This epidemic highlights the appalling conditions in central-African refugee camps and the failure of public-health programmes to serve their inhabitants. Louse-associated disease remains a major health threat in this and other war-torn regions of the world.
WHO Reference Centre for Rickettsial Diseases, Université de la Méditerranée, Marseille, France. Didier.Raoult@medicine.univ-mrs.fr
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Ndihokubwayo
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Tissot-Dupont
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Birtles
D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000907:Antibodies, Bacterial / Q000097:blood; D018413:Bartonella quintana / Q000235:genetics / Q000276:immunology; D001898:Borrelia / Q000145:classification / Q000235:genetics / Q000276:immunology; D002063:Burundi / Q000453:epidemiology; D015897:Comorbidity; D004196:Disease Outbreaks; D004318:Doxycycline / Q000627:therapeutic use; D006801:Humans; D010373:Lice Infestations / Q000453:epidemiology; D011159:Population Surveillance; D015995:Prevalence; D011329:Prisoners / Q000706:statistics & numerical data; D011634:Public Health; D012036:Refugees / Q000706:statistics & numerical data; D012061:Relapsing Fever / Q000453:epidemiology; D015203:Reproducibility of Results; D012283:Rickettsia prowazekii / Q000235:genetics / Q000276:immunology; D015996:Survival Rate; D014205:Trench Fever / Q000453:epidemiology*; D014438:Typhus, Epidemic Louse-Borne / Q000453:epidemiology*; D014857:Warfare
D000900:Anti-Bacterial Agents; D000907:Antibodies, Bacterial; D004318:Doxycycline