This autumn and winter marks the centenary of the largest outbreak of typhoid fever ever reported in the United Kingdom (UK). The epidemic occurred in Maidstone, the county town of Kent, in south east England. It began September 1897 and ended in January 1898 (1), affecting nearly 2000 people, 143 of whom died. At its peak 900 people contracted the disease in a two week period. The cause was traced to contaminated mains water and its continuing spread was linked to the poor state of the drainage system and the housing of many of the victims.
It was a turning point in public health, featuring the first recorded trial of immunisation against typhoid and also of the sterilisation of a mains water supply, using chloride of lime. The typhoid immunisation trial was led by Professor Almoth Wright, who had developed the vaccine along with Richard Pfeiffer and Walter Kolle in 1896. Staff at a large psychiatric hospital near Maidstone were asked to volunteer for the trial: none of the 84 who received the new vaccine developed the disease, compared with four cases in the 120 who were not vaccinated (2). This established the vaccine’s potential value and led to larger trials.
The chlorination of the water supply, organised by the bacteriologist Sims Woodhead, was a difficult procedure that required several attempts. Its success laid the foundations for continuous water treatment. The Maidstone outbreak may also have been the first in which telephones were used in the control of an epidemic, allowing doctors and nurses in the emergency hospitals to pass on information about cases.
The epidemic received unprecedented press attention. A fund for ‘stricken Maidstone’ attracted donations from all over Europe, particularly France and Italy. Queen Victoria, 78 years old and celebrating her 50th year on the throne at the time of the epidemic, sent a donation and a message of sympathy. Typhoid was common among the aristocracy: victims in the royal family included Victoria herself, Prince Albert (who died from typhoid in 1861), and two of their children. The story of the outbreak reveals the plight of hop pickers - itinerant workers who helped with the hop and fruit harvest - as well as political and commercial pressures. The outbreak was costly and affected local businesses badly, with two exceptions: sales of bottled mineral water soared and breweries also benefited. Beer was considered safe because it was made using water from private wells. Poor communications and false economies were singled out by the Public Inquiry, held in 1898: for example, no water samples had been taken for three months before the outbreak to save money, and there was confusion about the number of cases and when the outbreak had started. The numbers of cases recorded in the Public Inquiry were probably a gross underestimate as no precise case definition was used and cases in the workhouse for the homeless poor were not notified. It is likely that the introduction of typhoid immunisation and water sterilisation - a remarkable coincidence of two major public health advances during one outbreak - ensured that no epidemic as large has occurred in the UK since that time. The next largest waterborne outbreak in the UK, which occurred in Croydon in 1937 (341 cases, 43 deaths) was associated with a failure to chlorinate water during repairs to a well (3). Other famous outbreaks in Europe include: Zermatt, Switzerland in 1963 (437 cases, including skiers from all over Europe) (4), Aberdeen, Scotland in 1964 (507 cases) (5), and Kos, Greece in 1983 (58 cases from several European states) (6). All were linked to contaminated water, although the Aberdeen and Kos outbreaks involved food exposed to contaminated water (imported corned beef and a tomato salad respectively), and the Zermatt outbreak was traced to sewage ingress into the water supply. As in the Maidstone epidemic, itinerant workers, suspected to be typhoid carriers, were implicated as the source of the outbreak.
The more recent outbreaks of typhoid mentioned above show that typhoid still deserves a great deal of respect, through vigorous maintenance and monitoring of water and sewage systems and dedication of public health staff to infection surveillance. Antibiotic resistance to Salmonella typhi is developing in many areas (7), and the centenary of the Maidstone outbreak should remind us both that large outbreaks of typhoid in Europe are still possible and that treatment continues to pose problems.