Investigation of a community outbreak of typhoid fever assosiated with drinking water

Research Journal: BMC Public Health

(Published in december 2009)

Researchers: Amber Farooqui*, Adnan Khan and Shahana Urooj Kazmi.

Introduction
Salmonella is the most commonly involved bacteria in gastrointestinal tract infections, its significant involvement in human mortality and morbidity, morbidity is a major health concern. The most important pathogen of this genus is Salmonella typhi. Which causes typhoid fever in humans.
All members of this genus are gram

negative short bacilli that occurs singly. Motile by peritrichous flagella, they are noncapsulated and nonsporing

Background
This report is based on the investigation of an outbreak of typhoid fever occured in the Nek Muhahammad village, situated 25km far from metropolitan city of Karachi. In Oct. 2004, an outbreak of diarrhea and vomitting with high grade fever hits this area. Onset of symptoms was rapid, infected more than 300 people within a week! Local people contacted EDHI Foundation, that immediately set up a medical camp. They provide treatment and sent severe patients to local hospitals. BUT... Only in 5 days three people were DEAD...!!! So, the team of microbiologists of Karachi Univesity visited the vicinity.

 They found the village is so poor and have very limited

facilities of water, food, electricity and health care. They also discovered a Well, which was polluted with dead and decaying bodies of birds & amphibians. This Well was cleaned 2 days before the onset of symptoms. They interviewed the villagers, collected the enviornmental & clinical samples.

Methods
Sample Collection:
100 Stool samples from patients >38C temp. 10 water samples from well 90 water samples from houses which was collected from

contaminated well.

Laboratory diagnosis of Collected Samples

Enviornmental samples:
The quality of collected water samples were checked by standard methods:
SPC MPN

MFT

 Clinical samples:
For the Clinical specimens diarrheal stool samples were collected and analyzed by following methods:
Microscopic (for ova & parasites) Bateriology (for Salmonella, Shigella, E.coli (O157:H7), Yersinia &

Vibrio cholerae.

The following media were used for culture:

MacConkeys agar SS agar TCBS agar Sorbitol MacConkeys agar (Oxoid)

For bacteriological identification following biochemical reactions were performed:

Oxidase TSI Sulfide Citrate Urease API20E strips (analytical profile index) Antisera (Specifically for Salmonella)

Results:
The typhoid fever hit the remort area of Nek village in Oct . 2004

typically after cleaning of well 2 days before the onset . In the cleaning no chemical method was followed. In the tatal 500 villagers 300 people showed the symptoms.

Enviornmental samples:
Microbiological analysis showed the presence of Salmonella

enterica serovar Typhi in all well water samples. Gram positive and Gram negative bacteria were also detected as normal flora. E.coli H157:O7 and other enteric pathogens were also observed.

Clinical Samples:
Salmonella typhi was isolated as sole pathogen from ALL clinical

samples. 22 patients were positive by MDR Salmonella typhi. No other significant pathogen was isolated from any patient stool sample. No evidence of protozoal and parasitic involvement was observed by microscopy .

Quality of Clinical & Eniornmental Samples

Samples No. Of samples (n) Average total viable Total coliform count* Count*^ (CFU/ml or g) 3 106 - 1 107 5 104 - 4 107 2 103 - 1 104 1800 1800 0 Sample positive for Samples positive Salmonella typhi for Fecal idicators (%) (%) 22 100 72 2 100 65 0

Clinical Samples (feces) Well water samples Household water samples Cooked food samples

100 10 90 50

Percent of typhoid patients showing symptoms during the outbreak. (n = 300)

Discussion:
Drinking safe and healthy water is the right of every human

being. Unsafe drinking water and inadequate sanitary conditions increase the risk of various public health hazards such as typhoid fever. In Pakistan, 13.6% of total deaths are due to water sanitation and hygiene. It is important to keep continuous vigilance in remote areas where people still live under inhumane conditions and provide them basic necessities of life.

Conclusion:
Our study presented the link of contaminated well water with the outbreak of typhoid fever in a remote village which claimed three human lives and left more than 300 people suffered within one week. In order to avoid such incidences in future, we contacted the local health authorities and urged them to immediately make arrangements for safe drinking water supply