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Household Water Treatment Uptake during a Public Health Response to a Large Typhoid Fever Outbreak in Harare, Zimbabwe

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  • Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia; Field Epidemiology & Laboratory Training Program, National Institute for Communicable Diseases, Johannesburg, South Africa; School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa; Safe Water Systems, Population Services International-Zimbabwe, Harare, Zimbabwe; Water Sanitation and Hygiene, Welthungerhilfe-Zimbabwe, Harare, Zimbabwe; Collaborating Centre for Operational Research and Evaluation, United Nations Children's Fund-Zimbabwe, Harare, Zimbabwe; City of Harare Health Services Department, Harare, Zimbabwe; Laboratory Services, National Microbiology Reference Laboratory, Harare Zimbabwe; Ministry of Health and Child Welfare, Harare, Zimbabwe; Centers for Disease Control and Prevention-Zimbabwe, Harare, Zimbabwe; Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia; Tufts University, Medford, Massachusetts

Locally manufactured sodium hypochlorite (chlorine) solution has been sold in Zimbabwe since 2010. During October 1, 2011–April 30, 2012, 4,181 suspected and 52 confirmed cases of typhoid fever were identified in Harare. In response to this outbreak, chlorine tablets were distributed. To evaluate household water treatment uptake, we conducted a survey and water quality testing in 458 randomly selected households in two suburbs most affected by the outbreak. Although 75% of households were aware of chlorine solution and 85% received chlorine tablets, only 18% had reportedly treated stored water and had the recommended protective level of free chlorine residuals. Water treatment was more common among households that reported water treatment before the outbreak, and those that received free tablets during the outbreak (P < 0.01), but was not associated with chlorine solution awareness or use before the outbreak (P > 0.05). Outbreak response did not build on pre-existing prevention programs.

Author Notes

* Address correspondence to Maho Imanishi, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road NE MSC-09, Atlanta, GA 30329. E-mail: m.imanishi@gmail.com† These authors are co-first authors.‡ Zimbabwe Typhoid Fever Outbreak Working Group 2011–2012: Ajay Paul (Welthungerhilfe-Zimbabwe); Chiwurawa Zinyama and Phineas Jasi (Population Services International-Zimbabwe); Boiketho Murima, Blessing Zindi, Belete Woldeamanuel, and Susan M. L. Laver (United Nations Children's Funds-Zimbabwe); Innocent Mukeredzi (City of Harare Health Services Department); Peter Gumbo (National Microbiology Reference Laboratory-Zimbabwe); Panganai Dhliwayo (Centers for Disease Control and Prevention-Zimbabwe); Geofrey Jagero and Jane Juma (Centers for Disease Control and Prevention-Kenya/Kenya Medical Research Institute); Seymour Williams (Centers for Disease Control and Prevention-South Africa); Peter Wasswa (African Field Epidemiology Network); Gladys Gonzalez-Aviles, Kevin J. Joyce, Katherine A. O'Connor, and Michele B. Parsons (Centers for Disease Control and Prevention-Atlanta).

Financial support: This investigation was supported by the U.S. Centers for Disease Control and Prevention Division of Global Disease Detection and Emergency Response, the U.S. Agency for International Development's Office of U.S. Foreign Disaster Assistance, the United Nations Children's Fund-Zimbabwe, Welthungerhilfe-Zimbabwe, and Population Services International-Zimbabwe.

Authors' addresses: Maho Imanishi and Rachel B. Slayton, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA, and Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, GA, E-mails: m.imanishi@gmail.com and via3@cdc.gov. Tracy Ayers, Molly M. Freeman, and Eric Mintz, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA, E-mails: eyk6@cdc.gov, evy7@cdc.gov, and emintz@cdc.gov. Patience F. Kweza and Lazarus R. Kuonza, Field Epidemiology and Laboratory Training Program, National Institute for Communicable Diseases, Johannesburg, South Africa, E-mails: Patiencek@nicd.ac.za and LazarusK@nicd.ac.za. Tanaka Urayai, Population Services International-Zimbabwe, Harare, Zimbabwe, E-mail: turayai@psi-zim.co.zw. Odrie Ziro, Welthungerhilfe-Zimbabwe, Harare, Zimbabwe, E-mail: Odrie.Ziro@welthungerhilfe.de. Wellington Mushayi and Monica Francis-Chizororo, Collaborating Centre for Operational Research and Evaluation, United Nations Children's Funds-Zimbabwe, Harare, Zimbabwe, E-mails: wmushayi@unicef.org and mchizororo@unicef.org. Emmaculate Govore, Clemence Duri, and Prosper Chonzi, City of Harare Health Services Department, Harare, Zimbabwe, E-mails: echotogovore@yahoo.com, kireduri@gmail.com, and chonziprosper@yahoo.com. Sekesai Mtapuri-Zinyowera, National Microbiology Reference Laboratory, Ministry of Health and Child Welfare, Harare, Zimbabwe, E-mail: zinyoweras@nmrl.org.zw. Portia Manangazira, Ministry of Health and Child Welfare, Harare, Zimbabwe, E-mail: directoredc@gmail.com. Peter H. Kilmarx, Centers for Disease Control and Prevention-Zimbabwe, Harare, Zimbabwe, and Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, GA, E-mail: pbk4@cdc.gov. Daniele Lantagne, Tufts University, Medford, MA, E-mail: daniele.lantagne@tufts.edu.

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