title: A large and persistent outbreak of typhoid fever caused by consuming contaminated water and street-vended beverages: Kampala, Uganda, January - June 2015.
abstract: On 6 February 2015, Kampala city authorities alerted the Ugandan Ministry of Health of a "strange disease" that killed one person and sickened dozens. We conducted an epidemiologic investigation to identify the nature of the disease, mode of transmission, and risk factors to inform timely and effective control measures.
  
  
  
  We defined a suspected case as onset of fever (≥37.5 °C) for more than 3 days with abdominal pain, headache, negative malaria test or failed anti-malaria treatment, and at least 2 of the following: diarrhea, nausea or vomiting, constipation, fatigue. A probable case was defined as a suspected case with a positive TUBEX® TF test. A confirmed case had blood culture yielding Salmonella Typhi. We conducted a case-control study to compare exposures of 33 suspected case-patients and 78 controls, and tested water and juice samples.
  
  
  
  From 17 February-12 June, we identified 10,230 suspected, 1038 probable, and 51 confirmed cases. Approximately 22.58% (7/31) of case-patients and 2.56% (2/78) of controls drank water sold in small plastic bags (ORM-H= 8.90; 95%CI = 1.60-49.00); 54.54% (18/33) of case-patients and 19.23% (15/78) of controls consumed locally-made drinks (ORM-H= 4.60; 95%CI: 1.90-11.00). All isolates were susceptible to ciprofloxacin and ceftriaxone. Water and juice samples exhibited evidence of fecal contamination.
  
  
  
  Contaminated water and street-vended beverages were likely vehicles of this outbreak. At our recommendation authorities closed unsafe water sources and supplied safe water to affected areas.
authors.affiliation: Uganda Public Health Fellowship Program, Field Epidemiology Track, Ministry of Health, Kampala, Uganda. skabwama@musph.ac.ug.
authors.forename: Steven Ndugwa
authors.identifier: 0000-0002-0354-9571
authors.initials: SN
authors.lastname: Kabwama
authors.affiliation: Uganda Public Health Fellowship Program, Field Epidemiology Track, Ministry of Health, Kampala, Uganda.
authors.forename: Lilian
authors.initials: L
authors.lastname: Bulage
authors.affiliation: Uganda Public Health Fellowship Program, Field Epidemiology Track, Ministry of Health, Kampala, Uganda.
authors.forename: Fred
authors.initials: F
authors.lastname: Nsubuga
authors.affiliation: Uganda Public Health Fellowship Program, Field Epidemiology Track, Ministry of Health, Kampala, Uganda.
authors.forename: Gerald
authors.initials: G
authors.lastname: Pande
authors.affiliation: Uganda Public Health Fellowship Program, Field Epidemiology Track, Ministry of Health, Kampala, Uganda.
authors.forename: David Were
authors.initials: DW
authors.lastname: Oguttu
authors.affiliation: Uganda Public Health Fellowship Program, Field Epidemiology Track, Ministry of Health, Kampala, Uganda.
authors.forename: Richardson
authors.initials: R
authors.lastname: Mafigiri
authors.affiliation: Uganda Public Health Fellowship Program, Field Epidemiology Track, Ministry of Health, Kampala, Uganda.
authors.forename: Christine
authors.initials: C
authors.lastname: Kihembo
authors.affiliation: Uganda Public Health Fellowship Program, Field Epidemiology Track, Ministry of Health, Kampala, Uganda.
authors.forename: Benon
authors.initials: B
authors.lastname: Kwesiga
authors.affiliation: Uganda Public Health Fellowship Program, Field Epidemiology Track, Ministry of Health, Kampala, Uganda.
authors.forename: Ben
authors.initials: B
authors.lastname: Masiira
authors.affiliation: Uganda Public Health Fellowship Program, Field Epidemiology Track, Ministry of Health, Kampala, Uganda.
authors.forename: Allen Eva
authors.initials: AE
authors.lastname: Okullo
authors.affiliation: Makerere University College of Health Science Microbiology Laboratory, Kampala, Uganda.
authors.forename: Henry
authors.initials: H
authors.lastname: Kajumbula
authors.affiliation: Makerere University School of Public Health, Kampala, Uganda.
authors.forename: Joseph K B
authors.initials: JKB
authors.lastname: Matovu
authors.affiliation: Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda.
authors.forename: Issa
authors.initials: I
authors.lastname: Makumbi
authors.affiliation: Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda.
authors.forename: Milton
authors.initials: M
authors.lastname: Wetaka
authors.affiliation: Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda.
authors.forename: Sam
authors.initials: S
authors.lastname: Kasozi
authors.affiliation: Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda.
authors.forename: Simon
authors.initials: S
authors.lastname: Kyazze
authors.affiliation: Public Health Emergency Operations Center, Ministry of Health, Kampala, Uganda.
authors.forename: Melissa
authors.initials: M
authors.lastname: Dahlke
authors.affiliation: Medical Research Council, Kampala, Uganda.
authors.forename: Peter
authors.initials: P
authors.lastname: Hughes
authors.affiliation: Medical Research Council, Kampala, Uganda.
authors.forename: Juliet Nsimire
authors.initials: JN
authors.lastname: Sendagala
authors.affiliation: Epidemiology and Surveillance Division, Ministry of Health, Kampala, Uganda.
authors.forename: Monica
authors.initials: M
authors.lastname: Musenero
authors.affiliation: Epidemiology and Surveillance Division, Ministry of Health, Kampala, Uganda.
authors.forename: Immaculate
authors.initials: I
authors.lastname: Nabukenya
authors.affiliation: US Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
authors.forename: Vincent R
authors.initials: VR
authors.lastname: Hill
authors.affiliation: US Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Mintz
authors.affiliation: US Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
authors.forename: Janell
authors.initials: J
authors.lastname: Routh
authors.affiliation: US Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
authors.forename: Gerardo
authors.initials: G
authors.lastname: Gómez
authors.affiliation: US Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
authors.forename: Amelia
authors.initials: A
authors.lastname: Bicknese
authors.affiliation: US Centers for Disease Control and Prevention, Atlanta, Georgia, USA.|US Centers for Disease Control and Prevention, Kampala, Uganda.
authors.forename: Bao-Ping
authors.initials: BP
authors.lastname: Zhu
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use; D001628:Beverages / Q000382:microbiology; D002648:Child; D003967:Diarrhea / Q000453:epidemiology / Q000209:etiology / Q000382:microbiology; D004196:Disease Outbreaks; D060766:Drinking Water / Q000382:microbiology*; D005243:Feces; D005260:Female; D005334:Fever / Q000209:etiology; D005506:Food Contamination; D000067030:Fruit and Vegetable Juices / Q000382:microbiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D012485:Salmonella typhi / Q000187:drug effects / Q000254:growth & development / Q000302:isolation & purification; D014435:Typhoid Fever / Q000453:epidemiology / Q000209:etiology / Q000382:microbiology / Q000635:transmission; D014454:Uganda / Q000453:epidemiology; D014876:Water Pollution; D014881:Water Supply; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D060766:Drinking Water
keywords: Case-control; Outbreak; Typhoid fever; Uganda