Original Research

Epidemiological investigation of a typhoid fever outbreak in Sekhukhune District, Limpopo province, South Africa – 2017

Unarine B. Makungo, Tshilidzi E. Ramutshila, Mantwa C. Mabotja, Juno Thomas, Ruth Lekalakala-Mokaba, Anthony M. Smith, Joy Ebonwu, Shannon L. Williams, Jimmy Khoza, Queen Ranoto, Ntshengedzeni Muvhango, Mmatjatji Mosoma, Elizabeth Phokane, Genevie Ntshoe, Katherine Calver, Vivien Essel, Marlene F. Ngobeni, Kerrigan McCarthy
Southern African Journal of Infectious Diseases | Vol 35, No 1 | a107 | DOI: https://doi.org/10.4102/sajid.v35i1.107 | © 2020 Unarine B. Makungo, Tshilidzi E. Ramutshila, Mantwa C. Mabotja, Juno Thomas, Ruth Lekalakala-Mokaba, Anthony M. Smith, Joy Ebonwu, Shannon L. Williams, Jimmy Khoza, Queen Ranoto, Ntshengedzeni Muvhango, Mmatjatji Mosoma, Elizabeth Phokane, Genevie Ntshoe, | This work is licensed under CC Attribution 4.0
Submitted: 28 May 2019 | Published: 16 November 2020

About the author(s)

Unarine B. Makungo, Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, Johannesburg, South Africa; and Public Health Directorate, Limpopo Department of Health, Polokwane, South Africa
Tshilidzi E. Ramutshila, South African Field Epidemiology Training Program, National Institute for Communicable Diseases, Johannesburg, South Africa; and School of Health Systems and Public Health, University of Pretoria, South Africa
Mantwa C. Mabotja, Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, Johannesburg, South Africa; and School of Public Health, University of Witwatersrand, Johannesburg, South Africa
Juno Thomas, Centre for Enteric Diseases, National Institute for Communicable Diseases, Johannesburg, South Africa
Ruth Lekalakala-Mokaba, Department of Medical Microbiology, National Health Laboratory Services, Polokwane, Limpopo, South Africa; and Department of Medical Microbiology, University of Limpopo, Polokwane, South Africa
Anthony M. Smith, Centre for Enteric Diseases, National Institute for Communicable Diseases, Johannesburg, South Africa
Joy Ebonwu, Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, Johannesburg, South Africa
Shannon L. Williams, Centre for Enteric Diseases, National Institute for Communicable Diseases, Johannesburg, South Africa
Jimmy Khoza, Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, Johannesburg, South Africa
Queen Ranoto, Public Health Directorate, Limpopo Department of Health, Polokwane, South Africa
Ntshengedzeni Muvhango, Department of Public Health Medicine, Limpopo Department of Health, Polokwane, South Africa
Mmatjatji Mosoma, Sekhukhune District, Limpopo Department of Health, Polokwane, South Africa
Elizabeth Phokane, Sekhukhune District, Limpopo Department of Health, Polokwane, South Africa
Genevie Ntshoe, Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, Johannesburg, South Africa
Katherine Calver, Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, Johannesburg, South Africa
Vivien Essel, Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, Johannesburg, South Africa
Marlene F. Ngobeni, Public Health Directorate, Limpopo Department of Health, Polokwane, South Africa
Kerrigan McCarthy, Division of Public Health Surveillance and Response, National Institute for Communicable Diseases, Johannesburg, South Africa


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Abstract

Background: Typhoid fever remains a public health concern in South Africa, where the risk of transmission is high because of poor access to safe water and sanitation. This study describes the investigation of typhoid fever outbreak in Limpopo province.

Methodology: Following notification of laboratory-confirmed cases, a descriptive study was conducted at Sekhukhune District, Limpopo province. A suspected case was defined as any person residing in Makhuduthamaga Municipality from November 2017 to January 2018, presenting with fever and gastrointestinal symptoms. Data were collected using case investigation forms. Whole-genome sequencing (WGS) was carried out on Salmonella Typhi isolates and polymerase chain reaction (PCR) test was done for Salmonella species from water samples. Location of cases and water sources were mapped using ArcGIS mapping tool.

Results: Amongst 122 cases, 54% (n = 66) were female and 6% (n = 7) laboratory-confirmed. The median age of the cases was 11 years (range 2–83 years), with 79% (n = 102) being children under the age of 14 years. Salmonella species were detected in 37% (10/27) of water samples and geographic information system (GIS) mapping showed clustering of cases in Tswaing-Kgwaripe and Vlakplaas villages. Six isolates were available for WGS analysis, with resulting data showing that five of the six isolates were genetically related. Phylogenetic analysis showed that the five isolates clustered together were genetically related showing < 22 single nucleotide polymorphisms when compared to each other.

Conclusion: Molecular epidemiology of isolates suggests a common source outbreak, supported by the detection of Salmonella species from water sources. Consumption of water from contaminated open water sources, because of ongoing interruption of municipal water supply, was the likely cause of the outbreak. The investigation highlights the importance of consistent safe water supply and the ability of district surveillance systems to identify and contain outbreaks.


Keywords

typhoid fever; open water sources; outbreak; Limpopo; South Africa.

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