Cluster of typhoid fever cases links to a sandwich shop in
Paris: the situation on 5 November
Five cases of typhoid fever were reported in France during October 2003, in
patients who had not travelled in typhoid endemic countries, and who were
resident in four administrative departments in the Ile de France region (including
The patients had onset of symptoms for typhoid fever between 28 September
and 10 October (Figure), and were all admitted to hospital, but have since
Figure. Cluster of typhoid fever cases. Distribution of
cases by date of onset of fever. Ile de France, September-October 2003.
The five patients were questioned about possible sources of infection (travel,
places visited, contact with people who had fever or gastrointestinal symptoms,
foods consumed) during the month preceding the onset of their symptoms.
None of the patients had travelled in a typhoid endemic country. They all
reported having visited a number of different restaurants. Four of the patients
had eaten mixed salads from the same sandwich shop in the sixteenth arrondissement
in the west of Paris) (1). Two of these patients had visited the sandwich
shop several times during the weeks preceding symptom onset. Visiting this
sandwich shop was the only exposure common to all four patients. The fifth
patient worked in the sixteenth arrondissement for one day each week, and
reported occasionally buying sandwiches from different retailers, but could
not remember where these retailers were located.
Phagetyping and molecular typing of the strains isolated from these patients
is currently being undertaken at the national salmonella reference centre
at the Institut Pasteur.
About 90 cases of typhoid fever are reported each year in mainland France,
and 80% of these cases are contracted in a country where typhoid fever is
endemic, the most common areas being North Africa, Asia and sub-Saharan
Given the rarity of autochthonous cases of typhoid fever in France, the
temporal and geographical clustering of these authochthonous cases strongly
suggests the sandwich shop visited by at least four of the patients to be
the source of the infection.
Control and prevention measures
The sandwich shop visited by four of the five cases was closed on 3 November,
and an enquiry by the local veterinary and health authorities in Paris is
underway. The directorate general of health has alerted the hospitals and
health authorities in the Ile de France about this cluster of cases, so
that they will consider a diagnosis of the illness in patients without a
travel history, and has reminded them that such cases must be notified immediately
to the local health authorities and the Institut de Veille Sanitaire. No
additional autochthonous cases have yet been notified.
The date of the cluster suggests that transmission could have begun in
mid-September. The information available to date doesn’t allow calculation
of the duration of the contamination, and it is possible that infected persons
are currently in the incubation phase.
In France, people, who visited the incriminated sandwich shop in Paris
between mid-September and November, and who present or have presented with
a fever or bouts of diarrhoea, are encouraged to contact their doctors.
In particular, people working in the food sector or with young children,
and carers, should be especially vigilant in order to avoid secondary transmissions
of the disease.
The reservoir for Salmonella Typhi is strictly human. Most restaurant
outbreaks that have been described in the literature are due to the consumption
of raw or not reheated food contaminated by an infected foodhandler. Handwashing
before any handling of food, and after each visit to the toilet, is an indispensible
hygiene measure for the prevention of transmission of this disease.