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Hechaichi A, Bouguerra H, Letaief H, Safer M, Missaoui L, Cherif A, Farah S, Jabrane H, Atawa T, Yahia H, Hamdouni H, Zitoun K, Chahed K, Laamouri R, Daaboub J, Rabhi M, Salah AB, Chahed MK, Bouafif Ben Alaya N. Outbreak Investigation of Typhoid Fever in the District of Gabes, South of Tunisia. Epidemiologia (Basel) 2023; 4:223-234. [PMID: 37489494 PMCID: PMC10366729 DOI: 10.3390/epidemiologia4030023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/28/2023] [Accepted: 05/08/2023] [Indexed: 07/26/2023] Open
Abstract
Typhoid fever is a significant public health concern in many parts of the world, particularly in developing countries with poor sanitation and hygiene conditions. In July 2016, an outbreak of typhoid fever occurred in Ghannouche, located in the south of Tunisia. This paper reports the results of a field investigation undertaken to identify possible transmission pathways and risk factors in order to propose control and preventive measures. A retrospective cohort study including a passive and active case finding, as well as an environmental and bacteriological investigation was conducted from July to September 2016. A case was defined as a person residing or having stayed in Ghannouche and having presented from the beginning of June clinical signs suggestive of typhoid fever, with, for a confirmed case, laboratory isolation of S.Tyhi, and for a probable case, an epidemiological link with a confirmed case. Attack rates were determined, and risk ratios were estimated with respect to exposures. Unadjusted and adjusted odds ratios were estimated using binary logistic regression. Among the 628 subjects investigated, 102 cases of typhoid fever were identified (74 confirmed and 28 probable) with an overall attack rate of 16.24%. Over 56% of cases were male and those under 10 years old were most affected (38.2%% of cases) with a median age of 12 years (interquartile range 5 to 25 years). The main clinical signs were fever (95%) and diarrhea (57%). Young age (adjusted OR = 0.95 and 95% CI = 0.93-0.97), low level of education (adjusted OR = 4.76 and 95% CI = 1.34-16.81), and the habitat type Arab or rudimentary house (adjusted OR = 4.93 and 95% CI = 2.61-8.27) were the socio-demographic factors independently associated with typhoid fever. Typhoid fever was found to be associated with drinking softened water (adjusted OR = 2.64 and 95% CI = 1.16-4.82), eating raw fruit and vegetables from family gardens (adjusted OR = 6.13 and 95% CI = 3.66-11.06), and using uncontrolled waste disposal (adjusted OR = 3.52 and 95% CI = 2.03-6.94). A total of 110 drinking water samples were analyzed; out of the 38 samples of softened water, 12 were non-compliant and 5 were positive for Salmonella. The screening activity identified two asymptomatic carriers, one of whom was a softened water seller. We concluded that drinking softened water from informal or unauthorized sale units, consuming fruit and vegetables from family gardens, uncontrolled dumping of household waste, and poor socio-economic conditions increase the risk of typhoid fever in this region. Many recommendations were implemented to stop this outbreak and to prevent further episodes.
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Affiliation(s)
- Aicha Hechaichi
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
| | - Hind Bouguerra
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
| | - Hajer Letaief
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
| | - Mouna Safer
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
| | - Lamia Missaoui
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Amal Cherif
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Saffar Farah
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Houcine Jabrane
- Direction Régionale de Santé Gabès, Place du Gouvernorat, Gabès 6000, Tunisia
| | - Taoufik Atawa
- Direction des Soins de Santé de Base, Ministry of Health, 31 Khartoum Street, Tunis 1002, Tunisia
| | - Hamdi Yahia
- Direction Régionale de Santé Gabès, Place du Gouvernorat, Gabès 6000, Tunisia
| | - Hayet Hamdouni
- Direction des Soins de Santé de Base, Ministry of Health, 31 Khartoum Street, Tunis 1002, Tunisia
| | - Khadija Zitoun
- Direction Régionale de Santé Tunis, 9 Rue Ibn El Haythem, Tunis 1002, Tunisia
| | - Karim Chahed
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Ramzi Laamouri
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Jaber Daaboub
- Direction de L'hygiène du Milieu et de la Protection de L'environnement, Ministry of Health, Bab Saadoun, Tunis 1006, Tunisia
| | - Mohamed Rabhi
- Direction de L'hygiène du Milieu et de la Protection de L'environnement, Ministry of Health, Bab Saadoun, Tunis 1006, Tunisia
| | - Afif Ben Salah
- Graduate Studies and Research, Arabian Gulf University, Road 2904 Building 293, Manama 329, Bahrain
| | - Mohamed Kouni Chahed
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
| | - Nissaf Bouafif Ben Alaya
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
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Lhomme S, Magne S, Perelle S, Vaissière E, Abravanel F, Trelon L, Hennechart-Collette C, Fraisse A, Martin-Latil S, Izopet J, Figoni J, Spaccaferri G. Clustered Cases of Waterborne Hepatitis E Virus Infection, France. Viruses 2023; 15:v15051149. [PMID: 37243235 DOI: 10.3390/v15051149] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/06/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
The identification of seven cases of hepatitis E virus infection in a French rural hamlet in April 2015 led to investigations confirming the clustering and identifying the source of the infection. Laboratories and general practitioners in the area actively searched for other cases based on RT-PCR and serological tests. The environment, including water sources, was also checked for HEV RNA. Phylogenetic analyses were performed to compare HEV sequences. No other cases were found. Six of the seven patients lived in the same hamlet, and the seventh used to visit his family who lived there. All HEV strains were very similar and belonged to the HEV3f subgenotype, confirming the clustering of these cases. All the patients drank water from the public network. A break in the water supply to the hamlet was identified at the time the infection probably occurred; HEV RNA was also detected in a private water source that was connected to the public water network. The water flowing from the taps was quite turbid during the break. The private water supply containing HEV RNA was the likely source of the contamination. Private water supplies not disconnected from the public network are still frequent in rural areas, where they may contribute to public water pollution.
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Affiliation(s)
- Sébastien Lhomme
- Centre National de Référence (CNR) des Virus des Hépatites à Transmission Entériques (Hépatite A et E), Laboratoire de Virologie, CHU Toulouse, 31300 Toulouse, France
- Infinity, Université Toulouse, CNRS, Inserm, UPS, 31024 Toulouse, France
| | - Sébastien Magne
- Regional Health Agency of Auvergne-Rhône-Alpes, 15000 Aurillac, France
| | - Sylvie Perelle
- Laboratory for Food Safety, Université Paris-Est, Anses, 94700 Maisons-Alfort, France
| | - Emmanuelle Vaissière
- Santé Publique France (French National Public Health Agency), 63000 Clermont-Ferrand, France
| | - Florence Abravanel
- Centre National de Référence (CNR) des Virus des Hépatites à Transmission Entériques (Hépatite A et E), Laboratoire de Virologie, CHU Toulouse, 31300 Toulouse, France
- Infinity, Université Toulouse, CNRS, Inserm, UPS, 31024 Toulouse, France
| | - Laetitia Trelon
- Regional Health Agency of Auvergne-Rhône-Alpes, 15000 Aurillac, France
| | | | - Audrey Fraisse
- Laboratory for Food Safety, Université Paris-Est, Anses, 94700 Maisons-Alfort, France
| | - Sandra Martin-Latil
- Laboratory for Food Safety, Université Paris-Est, Anses, 94700 Maisons-Alfort, France
| | - Jacques Izopet
- Centre National de Référence (CNR) des Virus des Hépatites à Transmission Entériques (Hépatite A et E), Laboratoire de Virologie, CHU Toulouse, 31300 Toulouse, France
- Infinity, Université Toulouse, CNRS, Inserm, UPS, 31024 Toulouse, France
| | - Julie Figoni
- Santé Publique France (French National Public Health Agency), 94410 Saint-Maurice, France
| | - Guillaume Spaccaferri
- Santé Publique France (French National Public Health Agency), 63000 Clermont-Ferrand, France
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Franceschelli A, Bonadonna L, Cacciò SM, Sannella AR, Cintori C, Gargiulo R, Coccia AM, Paradiso R, Iaconelli M, Briancesco R, Tripodi A. An outbreak of cryptosporidiosis associated with drinking water in north-eastern Italy, August 2019: microbiological and environmental investigations. Euro Surveill 2022; 27. [PMID: 36052722 PMCID: PMC9438396 DOI: 10.2807/1560-7917.es.2022.27.35.2200038] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cryptosporidium is a leading global cause of waterborne disease, with many reported outbreaks related to main water supplies. In August 2019, an outbreak of cryptosporidiosis involving 80 cases occurred among 114 vacationers in a small municipality located in the Tuscan-Emilian Apennines, north-eastern Italy. After excluding a potential food-borne outbreak, the epidemiological investigation focussed on the hypothesis of a waterborne outbreak. This was confirmed by the finding of Cryptosporidium oocysts in stools of the cases and in water samples from the municipal water network. Molecular characterisation revealed the zoonotic species Cryptosporidium parvum as the causative agent. A single subtype (IIdA25G1) was found among all cases, and in one of two positive water samples. The municipality's water supply used spring water that only received a disinfection treatment insufficient to inactivate the parasite. Possible entry means into the water mains were found through further environmental investigations. As these types of water supplies are particularly vulnerable to various environmental factors, a control system based on the risk assessment of each phase of the water supply chain is required to guarantee water safety. Effective methods for detection of protozoan pathogens, which are generally excluded from routine water supply analysis, should be applied.
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Affiliation(s)
- Armando Franceschelli
- Food Hygiene and Nutrition Service, Public Health Department, Local Health Unit of Modena, Modena, Italy
| | - Lucia Bonadonna
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | - Simone M Cacciò
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Anna Rosa Sannella
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Christian Cintori
- Prevention Service and Collective Public Health, General Directorate of Care to Person, Health and Welfare, Emilia-Romagna Region, Italy.,Public Hygiene Service, Public Health Department, Local Health Unit of Modena, Modena, Italy
| | - Raffaele Gargiulo
- Provincial Laboratory of Microbiology, Local Health Unit of Modena, Modena, Italy
| | - Anna Maria Coccia
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | - Rosa Paradiso
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | - Marcello Iaconelli
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | - Rossella Briancesco
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | - Alberto Tripodi
- Food Hygiene and Nutrition Service, Public Health Department, Local Health Unit of Modena, Modena, Italy
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Lavallee S, Latchmore T, Hynds PD, Brown RS, Schuster-Wallace C, Anderson SD, Majury A. Drinking Water Consumption Patterns among Private Well Users in Ontario: Implications for Exposure Assessment of Waterborne Infection. Risk Anal 2021; 41:1890-1910. [PMID: 33438270 DOI: 10.1111/risa.13676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/17/2020] [Accepted: 12/26/2020] [Indexed: 06/12/2023]
Abstract
Understanding the water consumption patterns within a specific population informs development of increasingly accurate, spatially specific exposure and/or risk assessment of waterborne infection. The current study examined the consumption patterns of private well users in Ontario while considering potentially influential underlying sociodemographics, household characteristics, and experiential factors. A province-wide online survey was circulated between May and August 2018 (n = 1,162). Overall, 81.5% of respondents reported daily well water consumption (i.e., tap water). Results indicate a mean daily well water consumption rate of 1,132 mL/day (SD = 649 mL/day) among well water consumers. Gender was significantly associated with well water consumption, with higher consumption rates found among female respondents. The experience of acute gastrointestinal illness (AGI) symptoms or diagnosis in the past 12 months did not impact the volume of water consumed, suggesting that experiencing previous AGI does not decrease consumption volumes, and therefore exposure over time. Significantly higher rates of well water consumption were found among respondents who reported previous testing or ongoing water treatment. Approximately 45.5% of survey respondents who stated that they do not consume well water selected bottled water as their primary household drinking water supply. Bottled water consumption was also not associated with previous AGI experiences. Findings will inform future quantitative microbial risk assessments associated with private well water use by providing spatially and demographically specific estimates of well water consumption.
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Affiliation(s)
- Sarah Lavallee
- School of Environmental Studies, Queen's University, Kingston, Ontario, Canada
| | - Tessa Latchmore
- School of Environmental Studies, Queen's University, Kingston, Ontario, Canada
| | - Paul D Hynds
- Environmental Sustainability & Health Institute, Technological University Dublin, Dublin, Ireland
| | - R Stephen Brown
- School of Environmental Studies, Queen's University, Kingston, Ontario, Canada
| | - Corinne Schuster-Wallace
- Department of Geography and Planning, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Anna Majury
- School of Environmental Studies, Queen's University, Kingston, Ontario, Canada
- Public Health Ontario, Kingston, Ontario, Canada
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Guzman Herrador BR, de Blasio BF, MacDonald E, Nichols G, Sudre B, Vold L, Semenza JC, Nygård K. Analytical studies assessing the association between extreme precipitation or temperature and drinking water-related waterborne infections: a review. Environ Health 2015; 14:29. [PMID: 25885050 PMCID: PMC4391583 DOI: 10.1186/s12940-015-0014-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 03/04/2015] [Indexed: 05/20/2023]
Abstract
Determining the role of weather in waterborne infections is a priority public health research issue as climate change is predicted to increase the frequency of extreme precipitation and temperature events. To document the current knowledge on this topic, we performed a literature review of analytical research studies that have combined epidemiological and meteorological data in order to analyze associations between extreme precipitation or temperature and waterborne disease.A search of the databases Ovid MEDLINE, EMBASE, SCOPUS and Web of Science was conducted, using search terms related to waterborne infections and precipitation or temperature. Results were limited to studies published in English between January 2001 and December 2013.Twenty-four articles were included in this review, predominantly from Asia and North-America. Four articles used waterborne outbreaks as study units, while the remaining articles used number of cases of waterborne infections. Results presented in the different articles were heterogeneous. Although most of the studies identified a positive association between increased precipitation or temperature and infection, there were several in which this association was not evidenced. A number of articles also identified an association between decreased precipitation and infections. This highlights the complex relationship between precipitation or temperature driven transmission and waterborne disease. We encourage researchers to conduct studies examining potential effect modifiers, such as the specific type of microorganism, geographical region, season, type of water supply, water source or water treatment, in order to assess how they modulate the relationship between heavy rain events or temperature and waterborne disease. Addressing these gaps is of primary importance in order to identify the areas where action is needed to minimize negative impact of climate change on health in the future.
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Affiliation(s)
| | - Birgitte Freiesleben de Blasio
- Department of Infectious Disease Epidemiology, Norwegian Institute of Public Health, Oslo, Norway.
- Oslo Centre for Statistics and Epidemiology, Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.
| | - Emily MacDonald
- Department of Infectious Disease Epidemiology, Norwegian Institute of Public Health, Oslo, Norway.
- European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control, Stockholm, Sweden.
| | - Gordon Nichols
- European Centre for Disease Prevention and Control, Stockholm, Sweden.
- Gastrointestinal, Emerging and Zoonotic Diseases Department, Public Health England, London, UK.
- Norwich Medical School, University of East Anglia, Norwich, UK.
- Department of Hygiene & Epidemiology, University of Thessaly, Thessaly, Greece.
| | - Bertrand Sudre
- European Centre for Disease Prevention and Control, Stockholm, Sweden.
| | - Line Vold
- Department of Infectious Disease Epidemiology, Norwegian Institute of Public Health, Oslo, Norway.
| | - Jan C Semenza
- European Centre for Disease Prevention and Control, Stockholm, Sweden.
| | - Karin Nygård
- Department of Infectious Disease Epidemiology, Norwegian Institute of Public Health, Oslo, Norway.
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Naumova EN, Egorov AI, Morris RD, Griffiths JK. The elderly and waterborne Cryptosporidium infection: gastroenteritis hospitalizations before and during the 1993 Milwaukee outbreak. Emerg Infect Dis 2003; 9:418-25. [PMID: 12702220 PMCID: PMC2957964 DOI: 10.3201/eid0904.020260] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We used the Temporal Exposure Response Surfaces modeling technique to examine the association between gastroenteritis-related emergency room visits and hospitalizations in the elderly and drinking water turbidity before and during the 1993 Milwaukee waterborne Cryptosporidium outbreak. Before the outbreak, the rate of such events increased with age in the elderly (p</=0.001), suggesting that the elderly are at an increased risk. During the outbreak, strong associations between turbidity and gastroenteritis-related emergency room visits and hospitalizations occurred at temporal lags of 5-6 days (consistent with the Cryptosporidium incubation period). A pronounced second wave of these illnesses in the elderly peaked at 13 days. This wave represented approximately 40% of all excess cases in the elderly. Our findings suggest that the elderly had an increased risk of severe disease due to Cryptosporidium infection, with a shorter incubation period than has been previously reported in all adults and with a high risk for secondary person-to-person transmission.
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Affiliation(s)
- Elena N Naumova
- Department of Family Medicine and Community Health, Tufts University School of Medicine, Boston, Massachusetts 02111, USA.
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