title: A typhoid fever outbreak in a slum of South Dumdum municipality, West Bengal, India, 2007: evidence for foodborne and waterborne transmission.
abstract: BACKGROUND
  In April 2007, a slum of South Dumdum municipality, West Bengal reported an increase in fever cases. We investigated to identify the agent, the source and to propose recommendations.
  
  
  METHODS
  We defined a suspected case of typhoid fever as occurrence of fever for > or = one week among residents of ward 1 of South Dumdum during February - May 2007. We searched for suspected cases in health care facilities and collected blood specimens. We described the outbreak by time, place and person. We compared probable cases (Widal positive > or = 1:80) with neighbourhood-matched controls. We assessed the environment and collected water specimens.
  
  
  RESULTS
  We identified 103 suspected cases (Attack rate: 74/10,000, highest among 5-14 years old group, no deaths). Salmonella (enterica) Typhi was isolated from one of four blood specimens and 65 of 103 sera were > or = 1:80 Widal positive. The outbreak started on 13 February, peaked twice during the last week of March and second week of April and lasted till 27 April. Suspected cases clustered around three public taps. Among 65 probable cases and 65 controls, eating milk products from a sweet shop (Matched odds ratio [MOR]: 6.2, 95% confidence interval [CI]: 2.4-16, population attributable fraction [PAF]: 53%) and drinking piped water (MOR: 7.3, 95% CI: 2.5-21, PAF-52%) were associated with illness. The sweet shop food handler suffered from typhoid in January. The pipelines of intermittent non-chlorinated water supply ran next to an open drain connected with sewerage system and water specimens showed faecal contamination.
  
  
  CONCLUSIONS
  The investigation suggested that an initial foodborne outbreak of typhoid led to the contamination of the water supply resulting in a secondary, waterborne wave. We educated the food handler, repaired the pipelines and ensured chlorination of the water.
authors.affiliation: Field Epidemiology Training Programme, National Institute of Epidemiology (Indian Council of Medical Research), Chennai, India. rbhunia@gmail.com
authors.forename: Rama
authors.initials: R
authors.lastname: Bhunia
authors.forename: Yvan
authors.initials: Y
authors.lastname: Hutin
authors.forename: Ramachandran
authors.initials: R
authors.lastname: Ramakrishnan
authors.forename: Nishith
authors.initials: N
authors.lastname: Pal
authors.forename: Tapas
authors.initials: T
authors.lastname: Sen
authors.forename: Manoj
authors.initials: M
authors.lastname: Murhekar
mesh_terms: D000293:Adolescent; D000328:Adult; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D005260:Female; D005516:Food Microbiology; D006801:Humans; D006920:Hygiene; D007194:India / Q000453:epidemiology; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D011204:Poverty Areas; D012485:Salmonella typhi / Q000472:pathogenicity*; D012499:Sanitation / Q000379:methods; D014435:Typhoid Fever / Q000097:blood / Q000453:epidemiology* / Q000382:microbiology / Q000635:transmission*; D014871:Water Microbiology; D055815:Young Adult