A massive epidemic of multidrug-resistant typhoid fever in Tajikistan associated with consumption of municipal water

From 1 January through 30 June 1997, 8901 cases of typhoid fever and 95 ass ociated deaths were reported in Dushanbe, Tajikistan. Of 29 Salmonella sero type Typhi isolates tested, 27 (93%) were resistant to ampicillin, chloramp henicol, nalidixic acid, streptomycin, sulfisoxazole, tetracycline, and tri methoprim-sulfamethoxazole. In a case-control study of 45 patients and 123 controls, Salmonella Typhi infection was associated with drinking unboiled water(matched odds ratio, 7; 95% confidence interval, 3-24; P<.001). Of tap water samples, 97% showed fecal coliform contamination (mean level, 175 cf u/100 mt). Samples taken from water treatment plants revealed that fecal co liform contamination occurred both before and after treatment. Lack of chlo rination, equipment failure, and back-siphonage in the water distribution s ystem led to contamination of drinking water. After chlorination and coagul ation were begun at the treatment plants and a water conservation campaign was initiated to improve water pressure, the incidence of typhoid fever dec lined dramatically.