Oropharyngeal Tularemia Outbreak Associated with Drinking Contaminated Tap Water, Turkey, July-September 2013.

Dilber Aktas,Bao-Ping Zhu,Fehminaz Temel,Celal Tutus,Mehmet Emirhan Isik,Bekir Celebi,Mecit Kizilaslan,Huseyin Ozturk

doi:10.3201/eid2112.142032

Abstract

In 2013, an oropharyngeal tularemia outbreak in Turkey affected 55 persons. Drinking tap water during the likely exposure period was significantly associated with illness (attack rate 27% vs. 11% among non–tap water drinkers). Findings showed the tap water source had been contaminated by surface water, and the chlorination device malfunctioned.

Highlights

Oropharyngeal Tularemia and Contaminated Tap WaterWe hypothesized that the outbreak was caused by waterborne bacteria for 3 reasons: case-patients predominantly had oropharangeal symptoms; case-patients’ age and geographic distributions suggested a ubiquitous exposure; and villagers reported that the tap water had a dead-animal smell during Ramadan
In 2013, an oropharyngeal tularemia outbreak in Turkey affected 55 persons
A severe epizootic disease caused by the gram-negative, intracellular coccobacillus Francisella tularensis [1,2], has 5 clinical forms: glandular/ ulceroglandular, oculoglandular, pneumonic, typhoidal, and oropharyngeal [2]

Summary

Oropharyngeal Tularemia and Contaminated Tap Water

We hypothesized that the outbreak was caused by waterborne bacteria for 3 reasons: case-patients predominantly had oropharangeal symptoms; case-patients’ age and geographic distributions suggested a ubiquitous exposure; and villagers reported that the tap water had a dead-animal smell during Ramadan. Sensitivity analyses showed slightly stronger associations between drinking tap water and illness when only confirmed cases (RR 3.4, 95% CI 1.4–8.4) or cases with onset during the week of July 22 (RR 3.0, 95% CI 1.1–8.4) were included. Water samples collected from site B on August 22 had high levels of total coliform (>100 CFU) and E. coli (50 CFU) (online Technical Appendix Figure). Culture of 2 water samples collected on August 28 and September 4, respectively, did not yield F. tularensis. Risk for acquiring oropharyngeal tularemia among persons who drank water from different sources, Sancaktepe Village, Turkey, July–August 2013*

Underground spring

Findings

Conclusions