Epidemic multidrug-resistant typhoid fever in Tajikistan associated with a contaminated municipal water supply

Between January 1 and March 23,1997,6,005 cases of typhoid fever and 80 deaths were reported in Dushanbe, Tajikistan. Fifty-two (93%) of 56 Salmonella Typhi isolates from patients were resistant to chloramphenicol, ampicillin, trimethoprimsulfamethoxazole, and tetracycline. We conducted a case-control study involving 45 patients and 123 age- and neighborhood-matched controls. Illness with bactehologically confirmed Salmonella Typhi infection was associated with drinking unboiled water (matched odds ratio [MOR]: 7,95% confidence interval [CI]: 3-25, p: 0.000001), and obtaining water for one's home from a tap outside the house (MOR: 9, CI: 2-82, p: 0.003). Drinking boiled water at home was associated with a decreased risk for illness (MOR: 0.2, CI: 0.1-0.5, p: 0.0006). A random sampling of tap water from throughout the city showed 97% of samples contaminated with fecal coliforms, with a mean level of 175 CFU/100 ml. Water outages were common throughout the city, and we measured approximately 1,000 liters per person per day of water wastage preventable by turning off, repairing, or installing taps, and repairing pipes. These data suggest that drinking water was contaminated by sewage through cross connections and backflows during water outages. Plans have been made to initiate a water conservation campaign to improve water pressure as well as repair, upgrade, and improve chlorination and coagulation at the water treatment plants. Ciprofloxacin should be considered for first-line treatment of typhoid fever in Tajikistan and antimicrobial resistance patterns of S. Typhi should be carefully monitored.