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TYPHOID FEVER & CONTROL MEASURES

Dr . I. Selvaraj

Mary Mallon
(wearing glasses)
photographed
with
bacteriologist
Emma Sherman
on North Brother
Island in 1931 or
1932, over 15
years after she
had been
quarantined there
permanently.

In 1906, Irish immigrant Mary Mallon worked as a cook in the


Oyster Bay summer home of New York banker Charles Henry
Warren and his family. By the end of the summer, six members of
the household had contracted typhoid fever. The Warrens hired
sanitary engineer, George Soper, to determine the source of the
disease. Soper concluded that Mallon, while immune herself to the
disease, was its carrier. For three years, she was isolated on North
Brother Island, near Rikers Island, earning the nickname
"Typhoid Mary." Instructed not to cook for others upon her
release, she nevertheless changed her name and became a cook at a
maternity hospital in Manhattan. At least 25 staff members
contracted typhoid. "Typhoid Mary" returned to North Brother
Island, where she lived alone for 23 years, until her death in 1938.
She is shown here on the island in an undated photo. She died of a
stroke after 23 years in quarantine.

Typhos in Greek means ,smoke and


typhus fever got its name from smoke
that was believed to cause it. Typhoid
means typhus-like and thus the name
given to this disease.
The term Typhoid was given by Louis
1829 to distinguish it from typhus
fever.
It is a disease of poor environmental
sanitation and hence occurs in parts of
the world where water supply is unsafe
and sanitation is substandard.

The term enteric fever or typhoid fever is a


communicable disease, found only in man
and includes both typhoid fever caused by
S.Typhi and paratyphoid fever caused by
S.Paratyphi A, B and C . It is an acute
generalized infection of the reticulo
endothelial system, intestinal lymphoid
tissue,
and
the
gall
bladder.

EPIDEMIOLOGY

According to the World Health Organization,


globally some 16 million cases occur annually
resulting in more than 600,000 deaths. More than
62% of the global cases occur in Asia, of which, 7
million occur annually in South East Asia. Other
countries with a high incidence include Central and
South America, Africa and Papua New Guinea.

The incidence of this disease in UK is reported to be just


one case per 1,00,000 population.
In 1994, for example, 26,55,000 cases (incidence : 500
cases/ million) were reported from Africa with 1,30,000
deaths
The mean incidence of typhoid fever in developing
countries is estimated between 150 cases/million
population/year in Latin America to 1000cases/million
population/year in some Asian countries.

India
World largest outbreak of typhoid in SANGLI on
December 1975 to February 1976 . This disease is
endemic in India
1992 : 3,52,980 cases with 735 deaths
1993 : 3,57,452 cases and 888 deaths
1994 : 2,78,451 cases and 304 deaths
Case fatality rate due to typhoid has been varying
between 1.1% to 2.5 % in last few years.

In 1885, pioneering american veterinary


scientist, daniel E. Salmon, discovered the first
strain of salmonella from the intestine of a pig.
This strain was called salmonella choleraesuis,
It is still used to describe the genus and species
of this common human pathogen.

In 1880s, the typhoid bacillus was first


discovered by Eberth in spleen sections and
mesenteric lymph nodes from a patient who
died from typhoid.
Robert Koch confirmed a related finding and
succeeded in cultivating the bacterium in
1881.
Serodiagnosis of typhoid was thus made
possible by 1896.
Wright and his team prepared heat killed
vaccine from S.Typhi in 1896

Salmonellae are gram ve rods, facultatively aerobic, Motile


with peritrichate flagella, non-spore-forming
1-3m 0.5m in size
Salmonella currently comprise 2000 serotypes
Two groups a) Enteric fever group
b) Food poisoning group
The bacilli are killed at 55c in one hour or at 60c in 15
minutes.
They are killed within 5 minutes by mercuric cholride or 5%
phenol
Boiling or chlorination of water and pasteurization of milk
destroy the bacilli
The proportion of typhoid to paratyphoid A is 10:1,
Paratyphoid B is rare and paratyphoid C is very rare in
India

Salmonella enterica.

Age group : Typhoid fever may occur


at any age but it is considered to be
a disease mainly of children and
young adults. In endemic areas, the
highest attack rate occurs in children
aged 8-13 years. In a recent study
from slums of Delhi, it was found that
contrary to popular belief, the
disease affects even children aged 15 years

Gender and race : Typhoid fever cases


are more commonly seen in males
than in females. On the contrary,
females have a special predilection to
become chronic carriers.
Occupation : Certain categories of
persons handling the infective material
and live cultures of S. typhi are at
increased risk of acquiring infection.
Socio-economic factors : It is a disease
of poverty as it is often associated with
inadequate sanitation facilities and
unsafe water supplies.

Environmental factors : Though the cases


are observed through out the year, the
peak
incidence of typhoid fever is
reported during July - September. This
period coincides with the rainy season
and a substantial increase in fly
population.
Social factors : pollution of drinking
water supplies, open air defecation, and
urination, low standards of food and
personal hygiene, and health ignorance.

Nutritional status :Malnutrition may enhance the


susceptibility to typhoid fever by altering the intestinal
flora or other host defences.
Incubation period : Usually 10-14 days but it may be as
short as 3 days or as long as 21 days depending upon
the dose of the inoculums.
Reservoir of infection : Man is the only known
reservoir of infection - cases or carriers.
Period of communicability: A case is
infectious as long as the bacilli appear in
stool or urine.

Mode of transmission : The disease is transmitted by


faeco - oral route or urine oral routes either
directly through hands soiled with faeces or urine of
cases or carriers or indirectly by ingestion of
contaminated water, milk, food, or through flies.
Contaminated ice, ice-creams, and milk products are a
rich source of infection.

Carriers may be temporary or


chronic.
Temporary (convalescent or incubatory)
carriers usually excrete bacilli up to 6-8
weeks. By the end of one year, 3-4 per
cent of cases continue to excrete
typhoid bacilli.
Persons who excrete the bacilli for more
than a year after a clinical attack are
called chronic carriers.

Salmonella typhi infecting the body via the


Peyer's patches of the small intestine. The
bacteria migrates to mesenteric lymph nodes and
arrive via the blood in the liver and spleen
during the first exposure. After multiple
replication in the above locations, the bacteria
Migrates back into the Peyer's patches of the
small intestine for the secondary exposure and
consequently the clinical symptoms are seen.
Inflammation in the small intestine leads to
ulcers and necrosis.

The disease classically presents with step-ladder


fashion rise in temperature (40 - 41C) over 4 to 5 days,
accompanied by headache, vague abdominal pain, and
constipation.

First week:

Between the 7 th -10 th day of illness, mild hepatosplenomegally occurs in majority of patients. Relative bradycardia
may occur and rose-spots may be seen.

Second week:

Third week: The patient will appear in the "typhoid state"


which is a state of prolonged apathy, toxaemia, delirium,
disorientation and/or coma. Diarrhoea will then become apparent.
If left untreated by this time, there is a high risk (5-10%) of
intestinal hemorrhage and perforation.
Rare complications:
Typhoid hepatitis,Emphyema, Osteomyelitis, and Psychosis .
2-5% patients may become Gall-bladder carriers

Rose spots

DIAGNOSIS

Typhoid should be considered in any patient with


prolonged unexplained fever in endemic areas and in
those with a history of recent travel to endemic area.
Prolonged fever, rose spots, relative bradycardia and
leucopenia make typhoid strongly suggestive.
Widal test measures titres of serum agglutinins
against somatic (O) and flagellar (H) antigens which
usually begin to appear during the 2nd week. In the
absence of recent immunization, a high titre of
antibody to O antigen > 1:640 is suggestive but not
specific.

Polymerase chain reaction (PCR) can be performed on


peripheral mononuclear cells. The test is more sensitive
than blood culture alone (92% compared with 50-70%)
but requires significant technical expertise
Blood cultures are positive in 70-80% of cases during
the 1st week.
Stool and urine cultures are usually positive (45-75%)
during the 2nd-3rd week.
Bone marrow aspirate cultures give the best
confirmation (85-95%)
The tracing of carriers in cities by sewer swab
technique

RAPID TESTS FOR DIAGNOSING TYPHOID


Typhidot test that detects presence of IgM and IgG in
one hour (sensitivity>95%, Specificity 75%)
Typhidot-M, that detects IgM only (sensitivity 90%
and specificity 93%)
Typhidot rapid (sensitivity 85% and Specificity 99%)
is a rapid 15 minute immunochromatographic test to
detect IgM.
IgM dipstick test

Wilson and Blair bismuth sulphite medium jet black colony with a
metallic sheen

Differential Diagnosis
Other disease or conditions that need to be eliminated
Other infectious diseases

Other problems
Lymphoma

Brucellosis
Infectious mononucleosis
Leptospirosis
Malaria
Miliary tuberculosis
Rickettsioses
Tularemia
Viral hepatitis

Management of typhoid fever:

General: Supportive care includes


Maintenance of adequate hydration.
Antipyretics.
Appropriate nutrition.
Specific: Antimicrobial therapy is the mainstay
treatment. Selection of antibiotic should be based on
its efficacy, availability and cost.
Chloramphenicol , Ampicillin ,Amoxicillin ,
Trimethoprim &Sulphamethoxazole ,Fluroquinolones
In case of quinolone resistance Azithromycin, 3rd
generation cephalosporins (ceftriaxone)

Control of Typhoid fever


MEASURES DIRECTED TO RESERVOIR
a) Case detection and treatment

b) Isolation
c)Disinfection of stools and urine
d)Detection & treatment of carriers
MEASURES AT ROUTES OF TRANSMISSION
a) Water sanitation

b) Food sanitation
c) Excreta disposal
d) Fly control
MEASURES FOR SUSCEPTIBLES

a) immunoprophylaxis
b)health education

HEALTH PROMOTION

Keep the premises and kitchen utensils clean.


Dispose rubbish properly.
Keep hands clean and fingernails trimmed.
Wash hands properly with soap and water before eating or handling
food, and after toilet or changing diapers.
Drinking water should be from the mains and preferably boiled.
Purchase fresh food from reliable sources. Do not patronize illegal
hawkers.
Avoid high-risk food like shellfish, raw food or semi-cooked food.
Wear clean washable aprons and caps during food preparation.
Clean and wash food thoroughly.
Scrub and rinse shellfish in clean water. Immerse them in clean water
for sometime to allow self-purification.
Remove the viscera if appropriate
Cont

Store perishable food in refrigerator, well covered.


Handle and store raw and cooked food especially seafood
separately (upper compartment of the refrigerator for
cooked food and lower compartment for raw food) to avoid
cross contamination.
Clean and defrost refrigerator regularly and keep the
temperature at or below 4c
Cook food thoroughly.
Do not handle cooked food with bare hands; wear gloves if
necessary.
Consume food as soon as it is done.
If necessary, refrigerate cooked leftover food and consume
as soon as possible. Reheat thoroughly before consumption.
Discard any addled food items.
Exclude typhoid carrier from handling food and from
providing care to children.

Specific protection
THREE TYPES OF VACCINES
1. Injectable Typhoid vaccine
(TYPHIM Vi,TYPHIVAX)
2. The live oral vaccine (TYPHORAL)
3. TAB vaccine

Injectable Typhim -Vi


1. This single-dose injectable typhoid vaccine, from the
bacterial capsule of S. typhi strain of Ty21a.
2. This vaccine is recommended for use in children
over 2 years of age.
3. Sub-cutaneous or intramuscular injection
4. Efficacy : 64% -72%

Typhoral
This is a live-attenuated-bacteria vaccine manufactured
from the Ty21a strain of S. typhi.
2. The efficacy rate of the oral typhoid vaccine ranges
from 50-80%
3. Not recommended for use in children younger than 6
years of age.
4. The course consists of one capsule orally, taken an hour
before food with a glass of water or milk (1stday,3rd day
&5th day)
5. No antibiotic should be taken during this period
6. Immunity starts 2-3 weeks after administration and lasts
for 3 years
7. A booster dose after 3 years
1.

Indications for Vaccination

1.Travelers going to endemic areas who will


be staying for a prolonged period of time,
2. Persons with intimate exposure to a
documented S. typhi carrier
3. Microbiology laboratory technologists who
work frequently with S. typhi
4.Immigrants
5. Military personnel

SIDE EFFECTS.

Injectable Typhim -Vi


The most common adverse reactions are injection site
pain, erythema, and induration, which almost always
resolve within 48 hours of vaccination. Occasional fever,
flu-like episodes, headache, tremor, abdominal pains,
vomiting, diarrhea, and cervical pains have been
reported.
Typhoral
Nausea, abdominal pain and cramps, vomiting, fever,
headache, and rash or urticaria may occur in some
instances but are rare.

International Classification of
Disease Codes for Typhoid fever

Disease

ICD-9

ICD-10

Typhoid & paratyphoid fevers 002

A01

Typhoid fever

A01.0

002.0

*Bir Singh* Addl. Professor Centre for Community Medicine,


AIIMS, New Delhi-110 029, India
Text book of Microbiology by CKJ Panicker
K.PARK ( PREVENTIVE AND SOCIAL MEDICINE)
Text book of community medicine (A.P.KULKARNI)
TEXT OF COMMUNITY MEDICINE (T.BHASKAR RAO)
www.cdc.gov/ncidod/dbmd/diseaseinfo/typhoidfever_
www.netdoctor.co.uk/travel/diseases/typhoid.htm
www.who.int/mediacentre/factsheets/
en.wikipedia.org/wiki/Typhoid_fever
history1900s.about.com/od/1900s/a/typhoidmary.htm

THANK YOU

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