Journal Article

Typhoid Fever: A Massive, Single-Point Source, Multidrug-Resistant Outbreak in Nepal

Michael D. Lewis, Oralak Serichantalergs, Chittima Pitarangsi, Niphon Chuanak, Carl J. Mason, Laxmi R. Regmi, Prativa Pandey, Ranjan Laskar, Chandrika D. Shrestha and Sarala Malla

in Clinical Infectious Diseases

Published on behalf of Infectious Diseases Society of America

Volume 40, issue 4, pages 554-561
Published in print February 2005 | ISSN: 1058-4838
Published online February 2005 | e-ISSN: 1537-6591 | DOI:
Typhoid Fever: A Massive, Single-Point Source, Multidrug-Resistant Outbreak in Nepal

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Background. In the summer of 2002, a total of 5963 cases of typhoid fever were recorded in Bharatpur, Nepal (population, 92,214) during a 7-week period. A team from the Armed Forces Research Institute of Medical Sciences in Bangkok, Thailand, and the CIWEC Travel Medicine Clinic (Kathmandu, Nepal) assisted the Nepal National Public Health Laboratory (Kathmandu, Nepal) in the further investigation of this large, explosive febrile disease outbreak.

Methods. Investigators conducted a thorough epidemiologic and laboratory investigation to assess the size and scope of the outbreak. In addition to subculturing of previously collected samples, blood samples were obtained from 100 febrile patients, and culture and susceptibility testing were done by standard laboratory methods. Pulsed field gel electrophoresis (PFGE) and plasmid analysis were done.

Results. The majority of the isolates, including 1 from the municipal water supply, were multidrug resistant. The minimum inhibitory concentrations (MICs) of ciprofloxacin ranged from 0.19 µg/mL to 0.125 µg/mL. With use of PFGE, all isolates, including isolates from the water supply, showed an analytical similarity of 96%–100%. Multidrug-resistant isolates had a plasmid encoding for resistance, and those with resistance to nalidixic acid had a single-point mutation.

Conclusions. To the best of our knowledge, this outbreak is the largest single—point source outbreak of multidrug-resistant typhoid fever yet reported, and it was molecularly traced to the city's single municipal water supply. Isolates were uniformly resistant to nalidixic acid, there was a decrease in their susceptibility as measured by MIC of fluoroquinolones, and 90% of isolates obtained were resistant to >1 antibiotic.

Journal Article.  4251 words.  Illustrated.

Subjects: Infectious Diseases ; Immunology ; Public Health and Epidemiology ; Microbiology

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