TYPHOID FEVER & CONTROL MEASURES

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 typhuslike 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.

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

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EPIDEMIOLOGY .

Africa and Papua New Guinea. Other countries with a high incidence include Central and South America. of which. globally some 16 million cases occur annually resulting in more than 600.000 deaths. . 7 million occur annually in South East Asia. More than 62% of the global cases occur in Asia.According to the World Health Organization.

000 cases (incidence : 500 cases/ million) were reported from Africa with 1.55.000 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. 26.• The incidence of this disease in UK is reported to be just one case per 1.000 population. for example.30. • In 1994. .00.

451 cases and 304 deaths • Case fatality rate due to typhoid has been varying between 1.57.52.452 cases and 888 deaths • 1994 : 2.980 cases with 735 deaths • 1993 : 3.India • World largest outbreak of typhoid in SANGLI on December 1975 to February 1976 .78. .1% to 2. This disease is endemic in India • 1992 : 3.5 % in last few years.

discovered the first strain of salmonella from the intestine of a pig. . Salmon. daniel E. This strain was called salmonella choleraesuis.In 1885. pioneering american veterinary scientist. It is still used to describe the genus and species of this common human pathogen.

• Serodiagnosis of typhoid was thus made possible by 1896.• In 1880s. • Wright and his team prepared heat killed vaccine from S. 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.Typhi in 1896 .

non-spore-forming • 1-3μm ×0. 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.• Salmonellae are gram – ve rods. Paratyphoid B is rare and paratyphoid C is very rare in India .5μm in size • Salmonella currently comprise 2000 serotypes • Two groups a) Enteric fever group b) Food poisoning group The bacilli are killed at 55ºc in one hour or at 60ºc in 15 minutes. Motile with peritrichate flagella. facultatively aerobic.

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.Salmonella enterica.

it was found that contrary to popular belief. the disease affects even children aged 1-5 years . the highest attack rate occurs in children aged 8-13 years.• 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. In a recent study from slums of Delhi.

. Occupation : Certain categories of persons handling the infective material and live cultures of S. females have a special predilection to become chronic carriers.Gender and race : Typhoid fever cases are more commonly seen in males than in females. On the contrary. 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.

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

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.cases or carriers. Period of communicability: A case is infectious as long as the bacilli appear in stool or urine.Nutritional status :Malnutrition may enhance the susceptibility to typhoid fever by altering the intestinal flora or other host defences. . Reservoir of infection : Man is the only known reservoir of infection .

Contaminated ice.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. food. milk. and milk products are a rich source of infection. ice-creams.Mode of transmission : The disease is transmitted by faeco . . or through flies.

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

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

there is a high risk (5-10%) of intestinal hemorrhage and perforation. Diarrhoea will then become apparent. • Rare complications: Typhoid hepatitis.• First week: The disease classically presents with step-ladder fashion rise in temperature (40 .Emphyema. If left untreated by this time. and Psychosis. disorientation and/or coma. delirium. accompanied by headache. • Second week: Between the 7 th -10 th day of illness. 2-5% patients may become Gall-bladder carriers . Relative bradycardia may occur and rose-spots may be seen.41°C) over 4 to 5 days. • Third week: The patient will appear in the "typhoid state" which is a state of prolonged apathy. mild hepato- splenomegally occurs in majority of patients. toxaemia. Osteomyelitis. and constipation. vague abdominal pain.

Rose spots .

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DIAGNOSIS .

. In the absence of recent immunization. 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.• 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. a high titre of antibody to O antigen > 1:640 is suggestive but not specific.

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 .• Polymerase chain reaction (PCR) can be performed on peripheral mononuclear cells.

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. Specificity 75%) • Typhidot-M.RAPID TESTS FOR DIAGNOSING TYPHOID • Typhidot test that detects presence of IgM and IgG in one hour (sensitivity>95%. • 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. 3rd generation cephalosporins (ceftriaxone) . Ampicillin . Specific: Antimicrobial therapy is the mainstay treatment. Selection of antibiotic should be based on its efficacy. availability and cost. • Chloramphenicol . Appropriate nutrition.Fluroquinolones • In case of quinolone resistance – Azithromycin.Amoxicillin . Trimethoprim &Sulphamethoxazole . Antipyretics.

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 .

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

• Store perishable food in refrigerator. wear gloves if necessary. • Clean and defrost refrigerator regularly and keep the temperature at or below 4ºc • Cook food thoroughly. refrigerate cooked leftover food and consume as soon as possible. • 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. Discard any addled food items. • Do not handle cooked food with bare hands. Reheat thoroughly before consumption. • If necessary. • Exclude typhoid carrier from handling food and from providing care to children. well covered. . • Consume food as soon as it is done.

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

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

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

Travelers going to endemic areas who will be staying for a prolonged period of time. Microbiology laboratory technologists who work frequently with S.Indications for Vaccination 1. Persons with intimate exposure to a documented S. typhi 4. Military personnel .Immigrants 5. 2. typhi carrier 3.

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

0 Typhoid & paratyphoid fevers 002 Typhoid fever 002.International Classification of Disease Codes for Typhoid fever Disease ICD-9 ICD-10 A01 A01.0 .

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

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