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Eurosurveillance, Volume 7, Issue 46, 13 November 2003
Articles

Citation style for this article: de Valk H, Thiolet JM, Weill FX, Cosson C, Salamanca D, Vaillant V. Cluster of typhoid fever cases links to a sandwich shop in Paris: the situation on 5 November. Euro Surveill. 2003;7(46):pii=2324. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=2324

Cluster of typhoid fever cases links to a sandwich shop in Paris: the situation on 5 November

Henriette De Valk1 (h.devalk@invs.sante.fr), Jean-Michel Thiolet2, François Xavier Weill3, Chantal Cosson2, Dominique Salamanca4, Véronique Vaillant1

1Institut de Veille Sanitaire, St Maurice; 2Direction Départementale des Affaires Sanitaires et Sociales, Paris; 3Centre National de Référence des Salmonelles, Institut Pasteur, Paris; 4Cellule Interrégionale d’épidémiologie, Ile de France, France.


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 Paris) (1).

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 recovered.

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 Africa (2).

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.

References:
  1. InVS. Cas groupés de fièvre typhoïde liés à un lieu de restauration à Paris. Point sur la situation au 5 novembre 2003. Press release, 5 November 2003. (http://www.invs.sante.fr/display/?doc=presse/2003/le_point_sur/typhoide_051103/index.html)
  2. Haeghebaert S, Bouvet P, de Valk H. Les fièvres typhoïdes et paratyphoïdes en France en 2001. Bulletin Epidémiologique Hebdomadaire 2003; (14): 1 April. (http://www.invs.sante.fr/beh/2003/14/beh_14_2003.pdf)

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