title: A large outbreak of typhoid fever associated with a high rate of intestinal perforation in Kasese District, Uganda, 2008-2009.
abstract: BACKGROUND
  Salmonella enterica serovar Typhi (Salmonella Typhi) causes an estimated 22 million typhoid fever cases and 216 000 deaths annually worldwide. In Africa, the lack of laboratory diagnostic capacity limits the ability to recognize endemic typhoid fever and to detect outbreaks. We report a large laboratory-confirmed outbreak of typhoid fever in Uganda with a high proportion of intestinal perforations (IPs).
  
  
  METHODS
  A suspected case of typhoid fever was defined as fever and abdominal pain in a person with either vomiting, diarrhea, constipation, headache, weakness, arthralgia, poor response to antimalarial medications, or IP. From March 4, 2009 to April 17, 2009, specimens for blood and stool cultures and serology were collected from suspected cases. Antimicrobial susceptibility testing and pulsed-field gel electrophoresis (PFGE) were performed on Salmonella Typhi isolates. Surgical specimens from patients with IP were examined. A community survey was conducted to characterize the extent of the outbreak.
  
  
  RESULTS
  From December 27, 2007 to July 30, 2009, 577 cases, 289 hospitalizations, 249 IPs, and 47 deaths from typhoid fever occurred; Salmonella Typhi was isolated from 27 (33%) of 81 patients. Isolates demonstrated multiple PFGE patterns and uniform susceptibility to ciprofloxacin. Surgical specimens from 30 patients were consistent with typhoid fever. Estimated typhoid fever incidence in the community survey was 8092 cases per 100 000 persons.
  
  
  CONCLUSIONS
  This typhoid fever outbreak was detected because of an elevated number of IPs. Underreporting of milder illnesses and delayed and inadequate antimicrobial treatment contributed to the high perforation rate. Enhancing laboratory capacity for detection is critical to improving typhoid fever control.
authors.affiliation: Epidemic Intelligence Service, Scientific Education and Professional Development Office, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA. kneil@cdc.gov
authors.forename: Karen P
authors.initials: KP
authors.lastname: Neil
authors.forename: Samir V
authors.initials: SV
authors.lastname: Sodha
authors.forename: Luswa
authors.initials: L
authors.lastname: Lukwago
authors.forename: Shikanga
authors.initials: S
authors.lastname: O-Tipo
authors.forename: Matthew
authors.initials: M
authors.lastname: Mikoleit
authors.forename: Sherricka D
authors.initials: SD
authors.lastname: Simington
authors.forename: Peter
authors.initials: P
authors.lastname: Mukobi
authors.forename: Stephen
authors.initials: S
authors.lastname: Balinandi
authors.forename: Samuel
authors.initials: S
authors.lastname: Majalija
authors.forename: Joseph
authors.initials: J
authors.lastname: Ayers
authors.forename: Atek
authors.initials: A
authors.lastname: Kagirita
authors.forename: Edward
authors.initials: E
authors.lastname: Wefula
authors.forename: Frank
authors.initials: F
authors.lastname: Asiimwe
authors.forename: Vianney
authors.initials: V
authors.lastname: Kweyamba
authors.forename: Deborah
authors.initials: D
authors.lastname: Talkington
authors.forename: Wun-Ju
authors.initials: WJ
authors.lastname: Shieh
authors.forename: Patricia
authors.initials: P
authors.lastname: Adem
authors.forename: Brigid C
authors.initials: BC
authors.lastname: Batten
authors.forename: Sherif R
authors.initials: SR
authors.lastname: Zaki
authors.forename: Eric
authors.initials: E
authors.lastname: Mintz
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D016000:Cluster Analysis; D004196:Disease Outbreaks; D016521:Electrophoresis, Gel, Pulsed-Field; D005260:Female; D006801:Humans; D007223:Infant; D007416:Intestinal Perforation / Q000175:diagnosis / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D058889:Molecular Typing; D012485:Salmonella typhi / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D014435:Typhoid Fever / Q000150:complications* / Q000175:diagnosis / Q000453:epidemiology* / Q000473:pathology; D014454:Uganda / Q000453:epidemiology; D055815:Young Adult