MAJOR ARTICLE

Multidrug-Resistant Typhoid Fever With

Neurologic Findings on the Malawi-Mozambique
Border
Emily Lutterloh,1,a Andrew Likaka,2 James Sejvar,3 Robert Manda,2 Jeremias Naiene,4 Stephan S. Monroe,3
Tadala Khaila,2 Benson Chilima,2 Macpherson Mallewa,5 Sam D. Kampondeni,6 Sara A. Lowther,1 Linda Capewell,1,7
Kashmira Date,1,7 David Townes,1 Yanique Redwood,1 Joshua G. Schier,8 Benjamin Nygren,7 Beth Tippett Barr,9
Austin Demby,9 Abel Phiri,2 Rudia Lungu,2 James Kaphiyo,2 Michael Humphrys,7 Deborah Talkington,7 Kevin Joyce,7
Lauren J. Stockman,10 Gregory L. Armstrong,10 and Eric Mintz7
1Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention (CDC),
Atlanta, Georgia; 2Ministry of Health, Lilongwe, Malawi; 3Division of High-Consequence Pathogens and Pathology, CDC, Atlanta, Georgia; 4Ministerio da
Saude, Maputo, Mozambique; 5Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, and 6Department of Radiology,
Queen Elizabeth Central Hospital, Blantyre, Malawi; 7Division of Foodborne, Waterborne, and Environmental Diseases, and 8Division of Environmental
Hazards and Health Effects, CDC, Atlanta, Georgia; 9Global AIDS Program, CDC, Lilongwe, Malawi; and 10Division of Viral Diseases, CDC, Atlanta, Georgia

(See the Major Article by Neil et al, on pages 10919 and the Editorial Commentary by Crump, on pages 11079.)

Background. Salmonella enterica serovar Typhi causes an estimated 22 million cases of typhoid fever and
216 000 deaths annually worldwide. We investigated an outbreak of unexplained febrile illnesses with neurologic
findings, determined to be typhoid fever, along the MalawiMozambique border.
Methods. The investigation included active surveillance, interviews, examinations of ill and convalescent
persons, medical chart reviews, and laboratory testing. Classification as a suspected case required fever and $1 other
finding (eg, headache or abdominal pain); a probable case required fever and a positive rapid immunoglobulin M
antibody test for typhoid (TUBEX TF); a confirmed case required isolation of Salmonella Typhi from blood or stool.
Isolates underwent antimicrobial susceptibility testing and subtyping by pulsed-field gel electrophoresis (PFGE).
Results. We identified 303 cases from 18 villages with onset during MarchNovember 2009; 214 were suspected,
43 were probable, and 46 were confirmed cases. Forty patients presented with focal neurologic abnormalities,
including a constellation of upper motor neuron signs (n 5 19), ataxia (n 5 22), and parkinsonism (n 5 8). Eleven
patients died. All 42 isolates tested were resistant to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole;
4 were also resistant to nalidixic acid. Thirty-five of 42 isolates were indistinguishable by PFGE.
Conclusions. The unusual neurologic manifestations posed a diagnostic challenge that was resolved through
rapid typhoid antibody testing in the field and subsequent blood culture confirmation in the Malawi national
reference laboratory. Extending laboratory diagnostic capacity, including blood culture, to populations at risk for
typhoid fever in Africa will improve outbreak detection, response, and clinical treatment.

Typhoid fever is a systemic illness that often presents
with fever, headache, and abdominal pain. The etiologic
agent is Salmonella enterica serovar Typhi (Salmonella
Received 20 June 2011; accepted 13 October 2011; electronically published 22
February 2012.
a
Present affiliation: New York State Department of Health, Albany.
Correspondence: Eric Mintz, MD, MPH, Division of Foodborne, Waterborne, and
Environmental Diseases, CDC, Mailstop C-09, 1600 Clifton Rd, Atlanta, GA 30333
(emintz@cdc.gov).
Clinical Infectious Diseases 2012;54(8):11006
Published by Oxford University Press on behalf of the Infectious Diseases Society of
America 2012.
DOI: 10.1093/cid/cis012
Typhi), which is transmitted by the fecal-oral route.
Multiple severe complications can occur, including
intestinal hemorrhage, intestinal perforation, hepatitis,
pneumonia, abscess, and neuropsychiatric abnormali-
ties [1]. An estimated 22 million cases and 216 000
deaths occur worldwide each year [2].
Typhoid fever is endemic in Malawi and Mozambique
[37]. Both are considered medium-incidence countries
with estimated rates of 10100 per 100 000 persons
per year [2]. Multidrug-resistant strains of Salmonella
Typhi, defined as resistant to ampicillin, chloram-
phenicol, and trimethoprim-sulfamethoxazole, have

1100 d CID 2012:54 (15 April) d Lutterloh et al

been identified in reports from Ghana [8], Egypt [9], Kenya
[10], Nigeria [11], Democratic Republic of the Congo [12], and
South Africa [13]. Previous reports from Malawi and Mozambi-
que have described only fully susceptible strains [4, 6, 14, 15].
We investigated an outbreak of unexplained febrile illnesses
with neurologic findings, later determined to be typhoid fever,
in villages along the MalawiMozambique border. The outbreak
was detected in June 2009 when Neno District health personnel
in Malawi identified hospitalized patients from the region with
a distinctive constellation of findings including fever, headache,
confusion, inability to walk, dysarthria, and hyperreflexia.
A tendency to hold limbs in a flexed posture, neck stiffness,
ataxia, clonus, and convulsions were also described in certain
patients. Gastrointestinal complaints reportedly were present in
a minority of patients but were not prominent.
Personnel from the Ministry of Health in Malawi and the
Ministerio da Saude in Mozambique conducted the investigation
with representatives from the Atlanta-based Centers for Disease
Control and Prevention (CDC, an agency of the US Department
of Health and Human Services) and CDCs office of the Global
AIDS Program, Malawi. The objectives were to characterize the
outbreak, determine the etiology, and recommend prevention
and control measures.
MATERIALS AND METHODS
Outbreak Area
The affected villages are located in a remote area of Neno Dis-
trict, Malawi, and Tsangano District, Mozambique, at an altitude
of approximately 1600 m. The international border runs through
the area (Figure 1). Nsambe Health Centre in Malawi, which is
located approximately 8.5 km from the affected villages, serves
the health needs of the population; Neno District Hospital is
1 hour away by motor vehicle.
Figure 1. Location of the typhoid outbreak in villages on the MalawiMozambique border, in the center of the circle, 2009.
Typhoid Fever With Neurologic Findings
Epidemiologic Investigation
Beginning in June 2009, activities included structured interviews
with recovered or convalescing persons in affected villages; in-
terviews, chart reviews, and examinations of acutely ill patients;
and review of medical records of patients admitted to Neno
District Hospital with a clinically compatible illness. Two village-
based clinics, 1 in Malawi and 1 in Mozambique, were estab-
lished. Neno District outbreak response personnel conducted
active surveillance by periodically visiting affected villages to
identify possible cases and by prospectively documenting per-
sons presenting at Nsambe Health Centre and the village clinics
with signs and symptoms compatible with the illness under
investigation. District personnel in Malawi and Mozambique
worked together to maintain a unified database of cases.
Laboratory Investigation
In July and August 2009 clinical samples of serum, cerebrospinal
fluid, nasopharyngeal swabs, rectal swabs, stool, and urine from
acutely ill and convalescent patients were subjected to testing at
CDC laboratories, including polymerase chain reaction (PCR)
for neuroinvasive and other pathogens (eg, enteroviruses, ar-
boviruses, and herpesviruses). Serologic testing was performed
for viral pathogens as appropriate. Additional testing included
viral culture, random primer PCR, and 16S ribosomal RNA
sequencing. Autopsy specimens from 1 decedent, including
central nervous system tissue, meninges, lung, spleen, kidney,
and liver, were examined histologically.
Because no capacity exists to perform blood or stool cultures
locally, a rapid antibody-based diagnostic kit for Salmonella
Typhi (TUBEX TF, IDL Biotech, Bromma, Sweden) was used in
the field starting in August 2009 for preliminary serologic test-
ing, following the product insert instructions. The same test was
repeated at CDC for some specimens; if results were discordant
the CDC result was used for purposes of case classification. After
d CID 2012:54 (15 April) d 1101
capacity to collect and transport specimens to reference labo-
ratories was established, confirmatory blood and stool cultures
were performed at the Community Health Study Unit, Malawis
national reference laboratory. Blood specimens were inoculated
to commercially prepared BD BACTEC or BBL Septi-Check
blood culture bottles according to manufacturers specifications
for manual subculture (BD, Franklin Lakes, New Jersey). When
available, stool and rectal swab specimens were collected for
culture. All specimens were transported to the reference labo-
ratory at times ranging from immediately after collection to
1 week, depending on availability of transportation. Specimens
were subcultured according to CDC standard protocols for
isolation of Salmonella Typhi from blood and stool specimens
[16]. Isolates were biochemically confirmed to be Salmonella
and serotyped as Typhi by using specific antisera for Vi, O9, and
Hd antigens at CDC. Antimicrobial susceptibility testing of
Salmonella Typhi isolates using an automated broth micro-
dilution assay (Sensititre, Trek Diagnostics, Cleveland, Ohio)
and pulsed-field gel electrophoresis (PFGE) were also performed
at CDC [17].
Case Definition
We defined a suspected case of typhoid fever as illness in
a resident of Neno District, Malawi, or Tsangano District,
Mozambique, with onset on or after 1 March 2009, who pre-
sented with fever (subjective or with a documented temperature
$38C), and at least 1 of the following signs and symptoms:
gastrointestinal illness (abdominal pain, vomiting, diarrhea, or
constipation), joint pain, muscle pain, headache, neck pain
or stiffness, difficulty walking or talking, arms held in flexion,
or mental status changes, with no alternative explanation for
the illness. A probable case required fever and a positive rapid
typhoid test (TUBEX TF), and a confirmed case required either
a blood culture yielding Salmonella Typhi, or fever and a stool
culture yielding Salmonella Typhi. Patients with positive
malaria smears were counted as cases only if there was no
response to an initial course of antimalarial medication.
A neurologic case was defined as illness in a patient with
objective, focal neurologic findings documented in the medical
chart or elicited on examination. The presence of altered mental
status or dysarthria did not satisfy the definition of a neurologic
case because in this setting, these findings could not reliably
differentiate true neurologic deficits from symptoms referable
to severe systemic illness. Similarly, reports of hearing loss or
vertigo did not satisfy the definition of a neurologic case
because of the necessarily subjective nature of the complaints in
this setting.
Water Source Assessment
Water samples from unprotected springs in 2 villages and from
a semiprotected spring in 1 village, all of which were used as
drinking water sources, were tested for total coliform bacteria
1102 d CID 2012:54 (15 April) d Lutterloh et al
and Escherichia coli by using presence-absence broth with
4-methylumbelliferyl-b-D-glucuronide (Hach Company,
Loveland, Colorado).
Ethics
This investigation was initiated and conducted in response to
an illness outbreak. Human subjects research designees at
CDC determined that the activities constituted public health
response and program evaluation rather than research. Verbal
consent for specimen collection was obtained from patients or
guardians.
RESULTS
Epidemiologic Investigation
A total of 303 persons with illness onset during 1 March13
November 2009 met the case definition; 214 suspected, 43
probable, and 46 confirmed cases were identified. The outbreak
appeared to peak in September 2009 (Figure 2). The median age
of patients was 21 years (range, 181 years); 125 of 299 (42%)
patients with known age were aged 519 years. Overall, 166 of
299 (56%) patients in whom sex was known were female;
females outnumbered males in all but 2 age groups (Figure 3).
Eighty-one persons (27%) were hospitalized, and 11 died
(case fatality rate: 4%). Clinical data for the 303 cases are
displayed in Table 1.
Forty persons (13%) had objective, focal neurologic findings
documented in the medical chart or elicited on examination;
27 (68%) of these patients were hospitalized; 5 (13%) died. An
additional 27 persons had altered mental status but no focal
neurologic findings. Twenty-six of the 40 persons with focal
neurologic signs met criteria for a suspected case, 10 for
a probable case, and 4 for a confirmed case. Patients with focal
neurologic findings did not differ from those without neuro-
logic findings by age (P 5 .29) or sex (P 5 .68). The median age
of patients with neurologic findings was 18 years (range, 357
years), and 53% were female. Neurologic signs and symptoms
among all hospitalized patients are displayed in Table 2.
Nineteen of the 40 persons (48%) with objective neurologic
manifestations had a constellation of findings indicative of
upper motor neuron dysfunction, defined as documentation of
at least 2 of the following findings: limb hyperreflexia, spas-
ticity, presence of Babinski sign, or sustained ankle clonus.
Other notable neurologic features included ataxia (22, 55%)
and features of parkinsonism (gait instability, global slowness
of movement, facial masking) (8, 20%). Subjective hearing loss
(9, 23%) and vertigo (2, 5%) were noted among the 40 patients
with objective, focal neurologic findings and also among
patients without objective findings (Table 1). Magnetic reso-
nance imaging of the brain and spinal cord was performed on
3 persons with focal neurologic findings at the time of the
Figure 2. Typhoid fever cases, by date of illness onset and case status, Neno District, Malawi, and Tsangano District, Mozambique, 1 March13
November 2009; n 5 289 cases with known illness onset date.

scan. No focal abnormalities were present, although all 3
demonstrated generalized cortical and cerebellar atrophy
disproportionate to age.
Laboratory Investigation
A total of 412 individual tests for viral, bacterial, parasitic, and
rickettsial pathogens were performed on specimens taken at the
beginning of the investigation from persons meeting the case
definition (Supplementary Table). All pathogen-specific PCR,
random-primer PCR, and 16S ribosomal RNA sequencing
results were negative for potential pathogens. Serologic testing
was negative for acute infection with all viruses tested. All
viral cultures were negative. Autopsy specimens from a decedent
who had focal neurologic findings revealed only patchy ne-
crosis in the liver; central nervous system samples showed no
significant histopathologic changes.
Seventeen patients (8 neurologic) underwent cerebrospinal
fluid examination; all parameters tested were normal. Human
immunodeficiency virus serologic testing was performed on
14 patients (5 neurologic); serology was positive in 1 non-
neurologic patient. Malaria smears were performed in 44
persons (14 neurologic); 8 (18%) were positive (3 neurologic).

Table 1. Frequency of Selected Clinical Findings Among

Patients With Typhoid Fever (N 5 303), Neno District, Malawi,
and Tsangano District, Mozambique, 2009

Characteristic No. (%)

Muscle or joint pain 229 (76)
Headache 221 (73)
Abdominal pain 119 (39)
Neck pain or stiffness 117 (39)
Dysarthria 70 (23)
Cough 64 (21)
Altered mental status 43 (14)
Objective neurologic signs 40 (13)
Hearing loss (subjective) 28 (9)
Jaw stiffness 19 (6)
Vertigo 15 (5)
Figure 3. Typhoid fever cases, by age group and sex; n 5 295 with
Intestinal perforation 4 (1)
known age and sex.

Typhoid Fever With Neurologic Findings d CID 2012:54 (15 April) d 1103
Table 2. Neurologic Signs and Symptoms Among Hospitalized were distinguished from the predominant pattern only by the
Typhoid Fever Patients (n 5 81), Neno District, Malawi, and second enzyme (BlnI); 2 differed by the first enzyme (XbaI) but
Tsangano District, Mozambique, 2009 not the second; 1 differed by both enzymes.

Characteristic No. (%)

Dysarthria 44 (54)
Altered mental status 33 (41)
Upper motor neuron sign(s) 28 (35)
Hyperreflexia 24 (30)
Clonus 18 (22)
Spasticity 12 (15)
Babinski sign present 5 (6)
$2 of these signs 19 (23)
Ataxia 22 (27)
Hearing loss (subjective) 19 (23)
Parkinsonism 8 (10)
Vertigo 7 (9)
Tremor 4 (5)
One hundred fifty-nine TUBEX TF serologic tests were per-
formed on 129 specimens from 124 persons meeting the case
definition (21 confirmed, 43 probable, 60 suspect). At least
1 positive result occurred in 51 (41%) of the cases tested
(8 confirmed, 43 probable). Among specimens taken $3 days
after illness onset, 48 of 88 (55%) persons had at least 1 positive
result, and among specimens taken $7 days after illness onset,
41 of 66 (62%) persons had at least 1 positive result.
Results were available for 112 blood cultures from 108
persons who met the case definition; Salmonella Typhi was
identified in 46 blood cultures (41%) from 44 persons (41%).
Three (60%) of 5 stool cultures yielded Salmonella Typhi; 1 of
these was from a person who also had documented Salmonella
Typhi bacteremia.
Among the 40 patients with focal neurologic findings, TUBEX
TF serologic tests were performed on 17 specimens from 14
persons; 11 persons (79%) (including 1 person with a positive
blood culture) had at least 1 positive result. Six blood cultures
were performed on 5 patients with focal neurologic findings;
Salmonella Typhi was identified in specimens from 3 persons
(60%). Additionally, Salmonella Typhi was identified in a stool
culture from 1 patient.
Antimicrobial susceptibility testing was performed on 42
isolates from patients meeting the case definition; all were
resistant to ampicillin, chloramphenicol, and trimethoprim-
sulfamethoxazole, and 4 were also resistant to nalidixic acid
(minimum inhibitory concentration [MIC] .32). The 4 nali-
dixic acidresistant isolates demonstrated decreased susceptibility
to ciprofloxacin, with MIC 5 0.25, compared with MIC ,0.015
for all other isolates. PFGE patterns of 35 of the 42 (83%)
isolates tested were indistinguishable with 2 restriction en-
zymes (XbaI and BlnI) [18]. Four of the remaining isolates
Water Source Assessment
Testing of 3 village springs used as drinking water sources
detected coliform bacteria and E. coli, markers of fecal con-
tamination.
DISCUSSION
This investigation documented an extended outbreak of
multidrug-resistant typhoid fever in rural communities along
the MalawiMozambique border in which severe neurologic
deficits were a prominent feature. The prominence of these
neurologic findings during the early stages of the outbreak
initially obscured the diagnosis of typhoid fever and led in-
vestigators to consider other potential etiologies.
Neuropsychiatric abnormalities are recognized complica-
tions of typhoid fever, and abnormal findings on neurologic
examination similar to those described in this outbreak
have been reported in case series, case reports, and reviews of
typhoid fever [1927]. Spasticity accompanied by abnormal
reflexes was documented among 3.1% of persons in a case se-
ries of 959 patients in Nigeria [20]. Similar signs were docu-
mented among 6.3% of persons in a series of 791 hospitalized
patients in India [23], and ataxia was described among 2.3%
of persons in a series of 718 patients in India [26].
To our knowledge, this is the first time such prominent signs
and symptoms of neurologic impairment have been reported
with such a high frequency in an outbreak setting. Reports of
outbreaks have presented epidemiologic investigations with
minimal clinical information, and other reports that include
clinical data have not described these neurologic findings
[2832]. The high frequency of neurologic findings in the
setting of a tightly localized outbreak is of particular interest
because the affected population is likely to share more genetic
and environmental features than a population comprising
a multiyear, hospital-based case series. In addition, laboratory
evidence confirms that a single clone of Salmonella Typhi
predominated in this outbreak, which might not be true in
a case series.
The pathophysiology of focal neurologic abnormalities in
typhoid fever is unknown. Possible explanations include host
or environmental factors or features specific to the strain of
Salmonella Typhi. The reasons for the apparent high prevalence
of neurologic disease in this outbreak are also unknown, but
possible explanations exist. In part, surveillance bias might have
occurred. Persons with neurologic symptoms might have pre-
sented for medical care at the health center or been admitted to
the hospital at higher rates than persons without neurologic

1104 d CID 2012:54 (15 April) d Lutterloh et al

disease and would certainly have come to the attention of in-
vestigators earlier, when the focus was on patients with neuro-
logic illness. This is supported by the fact that when village
clinics opened in mid-August to provide easier access to medical
care, it became apparent that many persons had an illness
compatible with classic typhoid fever with symptoms (eg, fever,
headache, and mild abdominal pain) but without neurologic
manifestations.
To our knowledge, this is the first time that multidrug-
resistant Salmonella Typhi in Malawi or Mozambique has been
reported. Of particular note is the finding of nalidixic acid
resistance and decreased susceptibility to ciprofloxacin in 4
isolates, which can lead to treatment failure [3335]. Before
the outbreak was determined to be caused by typhoid fever,
patients presenting to the village clinics or local health center
with fever were empirically treated with antimalarial medica-
tion or with amoxicillin, chloramphenicol, or trimethoprim-
sulfamethoxazole, all of which would have been ineffective
against this multidrug-resistant strain of Salmonella Typhi.
Diagnosis of febrile illnesses in resource-poor settings can be
difficult. Absence of local blood culture capability prompted
us to use a rapid assay for immunoglobulin M antibodies to
Salmonella Typhi to help identify the etiology of the outbreak.
Following several positive results among the initial tests, ar-
rangements were made to establish blood culture collection in
the affected area and to transport culture bottles to the national
reference laboratory, where the etiology was confirmed and
multidrug resistance was identified. Results of this testing led
to an immediate change in treatment recommendations, il-
lustrating the importance of blood culture and antimicrobial
susceptibility testing on which to base guidelines for clinical
management in an outbreak setting.
This investigation had limitations. Our case definitions for
illness were altered after laboratory substantiation of typhoid as
the likely etiologic agent of illness, possibly resulting in dif-
ferential case assessment in the early and later phases of the
investigation. Our suspected case definition was necessarily
broad and atypical for typhoid fever because we wanted to
preserve as much as possible the original clinical definition that
was applied to the patients early in the outbreak before the
etiology was known; this would have resulted in a certain
amount of misclassification. In addition, differential access to
medical care and laboratory testing at different stages of the
investigation might have affected the number of identified cases
and the proportion classified as suspected, probable, or con-
firmed. Malaria and HIV testing were not performed in all
patients. Neurologic examinations were not performed on all
patients and included primarily those who were hospitalized,
which might have resulted in an underestimation of the
number of persons with neurologic findings. We did not per-
form a case-control study or other systematic assessment to
Typhoid Fever With Neurologic Findings
determine risk factors for disease, nor did we attempt to isolate
Salmonella Typhi from water or other environmental samples.
However, widespread, prolonged outbreaks of typhoid fever
are often waterborne [6, 28, 29, 36, 37], and the finding of
E. coli in the springs used for drinking water is compatible
with a waterborne source.
This outbreak demonstrates that typhoid fever should be
included in the differential diagnosis when a person who resides
in or has traveled to an endemic area presents with fever and
neurologic signs or symptoms. The physiologic mechanisms
that result in neurologic illness in typhoid fever are unknown
and should be explored. Although newer rapid serologic tests
can be useful in supporting the diagnosis of typhoid fever
in an outbreak setting, confirmatory cultures should be
performed to detect drug resistance and guide treatment
recommendations.
After the cause of the outbreak was determined to be Sal-
monella Typhi, recommendations for improvements in water
safety led to drilling of borehole wells in the affected area and
promotion of point-of-use water chlorination. Targeted ed-
ucational campaigns to limit other transmission routes (eg,
spread through unwashed hands, unsafely prepared food, and
inadequate sanitation) were also instituted. Despite these in-
terventions, cases of typhoid fever continued to occur in the
area for months, and in accordance with recently published
guidelines from the World Health Organization, vaccination
has been considered to prevent further transmission of typhoid
fever in this area [38].
Supplementary Data
Supplementary materials are available at Clinical Infectious Diseases online
(http://www.oxfordjournals.org/our_journals/cid/). Supplementary materials
consist of data provided by the author that are published to benefit the reader.
The posted materials are not copyedited. The contents of all supplementary
data are the sole responsibility of the authors. Questions or messages re-
garding errors should be addressed to the author.
Notes
Acknowledgments. We gratefully acknowledge the contributions of
Malawi Ministry of Health personnel Secretary Chris Kangombe, Kundai
Moyo, and Kapangaza Ntonya; the Malawi National Health Research In-
stitutional Review Board; the Neno District Rapid Response Team;
Partners in Health personnel Keith Joseph and Annemarie Ackerman;
World Health Organization personnel F. R. Zawaira, Kelias Msyamboza,
and Reggis Kasande; Population Services International; United Nations
Childrens Fund; US Agency for International Development; and CDC
personnel Rankin Thamanda, Laston Thamangira, Victor Samidu, Ethel
Mpagaja, Amy DuBois, Lisa Nelson, Ray Arthur, Cheryl Bopp, Michele
Parsons, Ermias Belay, Katie Schilling, Sherif Zaki, Wun-Ju Shieh, Thomas
Warne, and the CDC Emergency Operations Center staff.
Disclaimer. The findings and conclusions in this report are those of the
author(s) and do not necessarily represent the official position of the CDC.
Financial support. This work was supported by the governments of
Malawi and Mozambique and by the CDC.
d CID 2012:54 (15 April) d 1105
 Potential conflicts of interest. A. P. received support for travel to meet-
ings for the study or for other purposes from the government of Malawi;
R. L. received salary support; D. Talkington reported royalties for an
invention not related to this study and travel and expenses paid by CDC.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the
content of the manuscript have been disclosed.
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