title: Shifts in geographic distribution and antimicrobial resistance during a prolonged typhoid fever outbreak--Bundibugyo and Kasese Districts, Uganda, 2009-2011.
abstract: BACKGROUND
  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.
  
  
  RESULTS
  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 non-responsiveness 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
  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.
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America; Epidemic Intelligence Service Officer, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Maroya Spalding
authors.initials: MS
authors.lastname: Walters
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America; Epidemic Intelligence Service Officer, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Janell
authors.initials: J
authors.lastname: Routh
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Matthew
authors.initials: M
authors.lastname: Mikoleit
authors.affiliation: Kenya Field Epidemiology Training Program, Nairobi, Kenya.
authors.forename: Samuel
authors.initials: S
authors.lastname: Kadivane
authors.affiliation: CDC-Kenya, Kisumu, Kenya.
authors.forename: Caroline
authors.initials: C
authors.lastname: Ouma
authors.affiliation: Uganda Central Public Health Laboratory, Kampala, Uganda.
authors.forename: Denis
authors.initials: D
authors.lastname: Mubiru
authors.affiliation: Bundibugyo District Health Office, Bundibugyo, Uganda.
authors.forename: Ben
authors.initials: B
authors.lastname: Mbusa
authors.affiliation: Kasese District Health Office, Kasese, Uganda.
authors.forename: Amos
authors.initials: A
authors.lastname: Murangi
authors.affiliation: Bundibugyo Hospital, Bundibugyo, Uganda.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Ejoku
authors.affiliation: Kagando Hospital, Kagando, Uganda.
authors.forename: Absalom
authors.initials: A
authors.lastname: Rwantangle
authors.affiliation: St. Paul's Health Centre, Kasese, Uganda.
authors.forename: Uziah
authors.initials: U
authors.lastname: Kule
authors.affiliation: CDC-Uganda, Entebbe, Uganda.
authors.forename: John
authors.initials: J
authors.lastname: Lule
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Nancy
authors.initials: N
authors.lastname: Garrett
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Jessica
authors.initials: J
authors.lastname: Halpin
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Nikki
authors.initials: N
authors.lastname: Maxwell
authors.affiliation: Uganda Central Public Health Laboratory, Kampala, Uganda.
authors.forename: Atek
authors.initials: A
authors.lastname: Kagirita
authors.affiliation: Uganda Ministry of Health, Kampala, Uganda.
authors.forename: Fred
authors.initials: F
authors.lastname: Mulabya
authors.affiliation: Uganda Ministry of Health, Kampala, Uganda.
authors.forename: Issa
authors.initials: I
authors.lastname: Makumbi
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Molly
authors.initials: M
authors.lastname: Freeman
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Kevin
authors.initials: K
authors.lastname: Joyce
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Vince
authors.initials: V
authors.lastname: Hill
authors.affiliation: CDC-Uganda, Entebbe, Uganda.
authors.forename: Robert
authors.initials: R
authors.lastname: Downing
authors.affiliation: Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Eric
authors.initials: E
authors.lastname: Mintz
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D001769:Blood / Q000382:microbiology; D002648:Child; D002675:Child, Preschool; D016000:Cluster Analysis; D004196:Disease Outbreaks; D024881:Drug Resistance, Bacterial; D016521:Electrophoresis, Gel, Pulsed-Field; D005243:Feces / Q000382:microbiology; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D058889:Molecular Typing; D012485:Salmonella typhi / Q000145:classification / Q000187:drug effects* / Q000235:genetics / Q000302:isolation & purification; D019371:Topography, Medical; D014435:Typhoid Fever / Q000453:epidemiology* / Q000473:pathology; D014454:Uganda / Q000453:epidemiology; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents