Raoult D, Ndihokubwayo J B, Tissot-Dupont H, Roux V, Faugere B, Abegbinni R, Birtles R J
WHO Reference Centre for Rickettsial Diseases, Université de la Méditerranée, Marseille, France.
Lancet. 1998 Aug 1;352(9125):353-8. doi: 10.1016/s0140-6736(97)12433-3.
After a 12-year absence, epidemic typhus has re-emerged among the displaced population of Burundi. Following the outbreak of civil war in 1993, over 760000 people now inhabit refugee camps, under appalling conditions. A typhus outbreak occurred among prisoners in a jail in N'Gozi in 1995. At the time, the disease was not recognised, and was referred to as sutama. Reports of sutama among the civilian population date back to late 1995 and, in association with body-louse infestation, the disease has subsequently swept across the higher and colder regions of the country.
During a field study in February, 1997, 102 refugees with sutama underwent clinical examination and interview. Serum samples were collected and infesting body lice removed. Microbiological analysis included antibody estimations and specific PCRs aimed at diagnosis of Rickettsia prowezekii, Bartonella quintana, and Borrelia recurrentis. Between January and September, 1997, nationwide epidemiological data on the prevalence and distribution of sutama was obtained through liaison with local health services. A second field study in March, 1997, entailed the collection of further serum samples from suspected cases of sutama in different regions of Burundi.
Most of the 102 patients with sutama during initial assessment presented with manifestations similar to those previously described for typhus in Africa, though skin eruptions occurred in only 25 (25%) cases. Microbiological testing revealed evidence of R prowazeki infection in 76 (75%) patients, confirming that most cases of clinically-diagnosed sutama were epidemic typhus, and supporting the reliability of clinical diagnosis as a basis for the nationwide surveillance of the disease. Up to September, 1997, 45558 typhus cases were clinically diagnosed, most of which occurred in regions at an altitude of over 1500 m. Serological testing of 232 individuals from different regions of Burundi provided microbiological evidence to support clinical diagnoses in seven provinces, confirming the widespread nature of the outbreak. Serum from 13 of the original 102 patients and 19 (8%) of the 232 suspected cases had raised antibody titres against B quintana. A fatality rate of 15% among jail inmates fell to 0.5% after administration of a single dose of 200 mg doxycycline to suspected cases.
A gigantic outbreak of R prowazekii-induced typhus and B quintana-induced trench fever is continuing in Burundi. Transmission of both diseases to such a large number of people has followed a widespread epidemic of body-louse infestation. Diagnosis of typhus could be reliably made by means of clinical criteria, and the disease could be efficiently and easily treated by antibiotics. This epidemic highlights the appalling conditions in central-African refugee camps and the failure of public-health programmes to serve their inhabitants. Louse-associated disease remains a major health threat in this and other war-torn regions of the world.
在消失12年后，流行性斑疹伤寒在布隆迪的流离失所人群中再度出现。1993年内战爆发后，如今有超过76万人生活在条件恶劣的难民营中。1995年，恩戈齐的一所监狱里的囚犯中爆发了斑疹伤寒。当时，这种疾病未被识别出来，被称为“苏塔马”。平民中关于“苏塔马”的报告可追溯到1995年末，并且与体虱感染相关，这种疾病随后席卷了该国地势较高且较寒冷的地区。
1997年2月的一项实地研究中，对102名患有“苏塔马”的难民进行了临床检查和访谈。采集了血清样本，并去除了寄生的体虱。微生物学分析包括抗体检测以及旨在诊断普氏立克次体、五日热巴尔通体和回归热疏螺旋体的特异性聚合酶链反应。1997年1月至9月期间，通过与当地卫生服务机构联络，获取了关于“苏塔马”患病率和分布情况的全国性流行病学数据。1997年3月的第二项实地研究，涉及从布隆迪不同地区疑似“苏塔马”病例中采集更多血清样本。
在初步评估的102例“苏塔马”患者中，大多数人的表现与先前非洲斑疹伤寒的描述相似，不过只有25例（25%）出现了皮疹。微生物学检测显示，76例（75%）患者有普氏立克次体感染的证据，证实大多数临床诊断为“苏塔马”的病例是流行性斑疹伤寒，支持将临床诊断作为该病全国监测基础的可靠性。截至1997年9月，临床上诊断出45558例斑疹伤寒病例，其中大多数发生在海拔超过1500米的地区。对来自布隆迪不同地区的232人进行的血清学检测为七个省份的临床诊断提供了微生物学证据，证实了此次疫情的广泛性。最初102例患者中的13例以及232例疑似病例中的19例（8%）血清中抗五日热巴尔通体抗体滴度升高。监狱囚犯中的死亡率为15%，在对疑似病例单次给予200毫克强力霉素后降至0.5%。
布隆迪正在持续爆发由普氏立克次体引起的斑疹伤寒和由五日热巴尔通体引起的战壕热。这两种疾病传播到如此多的人身上是在体虱广泛流行之后。斑疹伤寒可以通过临床标准可靠地诊断出来，并且可以用抗生素有效且轻松地治疗。这次疫情凸显了中非难民营的恶劣状况以及公共卫生项目未能为居民提供服务的情况。与虱子相关的疾病在这个以及世界其他饱受战争蹂躏的地区仍然是主要的健康威胁。
