Enteric fever (म्याधे ज्वरो )

Prepared by:

Chandra Shekhar Yadav

Deepak Subedi

Dhirendra Yadav
 Enteric fever
• Enteric fever is the disease clinically characterized
by a typical continuous fever for 3-4 weeks,
relative bradycardia with involvement of
lymphoid tissues and considerable constitutional
symptoms
• It includes both typhoid and paratyphoid fevers
• It is the result of systemic infection mainly
caused by Salmonella typhi found only in man.
 Global scenario
• Typhoid fever occurs in all parts of the world
where water supplies and sanitation are sub-
standard
• According to the most recent estimates
(published in 2014), approximately 21 million
cases and 222,000 typhoid-related deaths
occur annually worldwide
• Since 1950, the organism’s resistance to
antibiotics has also been a growing problem
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 National scenario
According to annual report of
Department of Health Services
(DoHS)2072/73

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 Epidemiological determinants
• Agent factors
• Host factors
• Environmental and social factors
 Agent factors
• Agent : Salmonella typhi ( major), Salmonella
paratyphi A and B (infrequent)
• S. typhi has 3 main antigens : O, H and Vi
• Reservior of infection : man(cases and
carriers)
1. Cases: a case is infectious as long as
bacilli appear in stool and urine
2. Carriers: Temporary( incubatory and
convalescent) or Chronic
 Agent factors
• Convalescent carriers: excrete bacilli for 6 to 8
weeks
• Chronic carriers: excrete bacilli for more than
one year after a clinical attack
• The famous case of ‘‘Typhoid Mary’’ who gave
rise to 1300 cases in her lifetime is a good
example of chronic carrier
Mary Mallon(Typhoid Mary)
 Agent factors
• Source of infection: primary(faeces and urine
of cases and carriers) and secondary
(contaminated water, food ,fingers and flies)
• No evidence of typhoid bacilli in sputum or
milk
 Salmonella typhi
• Gram negative, motile( peritrichous flagella),
non-sporing, non-capsulated bacilli
• size : 1-3 x 0.5 μm
 Host factors
• Age : may occur at any age
highest incidence : 5-19 years
• Sex : male > female ( case)
female > male ( carrier)
• Immunity : intracellular and cell mediated
immunity
• Factors that contribute to resistance to S. typhi
are gastric acidity and local intestinal immunity.
 Environmental and social factors
• Season: occurs throughout the year
• Peak incidence: July to September (due to
increase in fly population)
• Outside the human body, the bacilli are found in
water, ice, food, milk and soil
• Social factors :
- pollution of drinking water supplies
- open air defecation and urination
- low standard of food and personal hygiene
- health ignorance
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• Incubation period= Usually 10-14 days( 3 days

to 3 weeks)
Mode of transmission
1. Faeco-oral route
2. Urine-oral route
Mode of transmission
 Pathogenesis
Ingestion of contaminated food

Stomach barrier (some eliminated)

Bacilli enters the small intestine

Penetrate the mucus layer

 Pathogenesis
Enter mononuclear phagocytes of ileal Peyer’s
patches and mesenteric lymph nodes

Proliferate into mononuclear phagocytes

Spread to blood

Initial bacteraemia( Incubation period)

 Pathogenesis

Seeding of Reticulo-endothelial system( liver,

spleen, bone marrow)

Secondary bacteraemia

Widespread dissemination
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 Clinical features
• Onset : insidious, abrupt in children with chills
and high fever
• Most prominent symptom is prolonged fever(
101.8-104.9° F )
• Continue up to 4 weeks if untreated
• Fever ascends in a step ladder fashion and
reaches plateau in 7-10 days.
• Prodromal stage: malaise, headache, cough, sore
throat, abdominal pain and constipation or ‘pea
soup’ diarrhoea
 Clinical features
• Later stage: splenomegaly, abdominal
distention and tenderness, relative
bradycardia, dicrotic pulse and occasionally
meningismus
• Rose spot commonly appear during second
week
-Pink papule 2-3 mm in diameter that fades
on pressure
-Found mainly on trunk
Clinical features
Clinical features
 Complications
• Major
- Intestinal haemorrhage
- Intestinal perforation ( 3rd week)

• Less frequent
-Urinary retention
- Pneumonia
- Thrombophlebitis
-Myocarditis
 Complications
-Psychosis
-Cholecystitis
-Nephritis
-Osteomyelitis
 Laboratory diagnosis
• Microbiological procedures
Isolation of S. typhi from
-Blood( mainstay of diagnosis)
-Bone marrow
-Stool
 Serological procedure
• Felix- Widal test
-measures the agglutinating antibody levels
against O and H antigens
- O antibodies appear on day 6 to 8 and H
antibodies on day 10 to 12 after the onset of
disease
- Demonstration of rising titre of antibodies in 2 or
more samples of 4 fold or greater of both H and
O agglutinins at an interval of 4 to 7 days is most
important diagnostic criterion.
 New diagnostic tests
• IDL Tubex test : detect IgM O9 antibodies
within few minutes
• Typhidot test : detect IgM and IgG antibodies.
Takes 3 hours to perform
• Typhidot-M : detect specific IgM antibodies
only
• Dipstick test : based on binding of IgM
antibodies to S. typhi LPS antigen
1st week Blood culture
2nd week Felix- Widal test
(Agglutination test)
3rd week Stool culture
4th week Urine culture

‘‘BASU’’
Widal Test Kit
 Prevention and control
• Prevention
- Safe water
-Food safety
-Sanitation
-Health education
-Vaccination
 Prevention and control
Safe water:
• Typhoid is waterborne disease
• main preventive measure is to ensure access
to safe water
Food safety
• Contaminated food is another important
vehicle for typhoid fever transmission
 Prevention and control
Basic hygiene measures should be adopted :
• washing hands with soap before preparing or
eating food
• avoiding raw food, shellfish, ice
• eating only cooked and still hot food or re-
heating it
 Prevention and control
Sanitation
• Appropriate facilities for human waste disposal
must be available for all the community. In an
emergency, pit latrines can be quickly built.
• Collection and treatment of sewage, especially
during the rainy season, must be implemented
• In areas where typhoid fever is known to be
present, the use of human excreta as fertilizers
must be discouraged
 Prevention and control
Health education
• Health education messages for the vulnerable
communities need to be adapted to local
conditions and translated into local languages.
• In order to reach communities, all possible
means of communication (e.g. media, schools,
women’s groups, religious groups) must be
applied
 Prevention and Control
In health facilities, all staff must be repeatedly
educated about the need for :
• excellent personal hygiene at work
• isolation measures for the patient
• disinfection measure
 Vaccination
1. The Vi polysaccharide vaccine
• Composed of purified Vi capsular polysaccharide
from the Ty 2 S. typhi
• Elicits IgG response
• Schedule: only 1 dose is required . Confers
protection 7 days after injection
• Route of administration: subcutaneous /
intramuscular
• Human dose : 25µg of antigen
• Minimal age: 2years ( does not elicit adequate
immune response below this age )
• Revaccination: every 3 years
• Side effects : minimal
 Vaccination
2. The Ty21a vaccine
• Live attenuated Ty2 strain of S. typhi in which
multiple genes, including the gene for production of
Vi, have been mutated chemically
• Lyophilized vaccine is available as enteric coated
tablets
• Route of administration : oral
• Schedule : 3 dose regimen (on 1, 3, and 5th day )
• Repeat dose every 3 years in endemic area, every
year for travellers from non-endemic to endemic area
Vaccination
 Vaccination
• Minimal age : 5 years
• Safety and precautions:
-well tolerated and low rates of adverse
events
-not efficacious if administered at the time of
ongoing diarrhoea
 Control
3 lines of defence :
• Control of reservoir
• Control of sanitation and
• Immunization
 Control of reservoir
Cases Carriers
Early diagnosis Identification
Notification Treatment
Isolation Surgery
Treatment Surveillance
Disinfection Health education
Follow up
 MDR typhoid
• The strains of S. typhi which are resistant to all of
three first line antibiotics- chloramphenicol,
ampicillin and cotrimoxazole
• By 1989 resistance was reported in number of
countries, particularly in Asia and Middle East
• Resistant strains have caused outbreaks of
disease in India and Pakistan in recent years
• In south east asia, 50% or more of the strains of
bacteria may already be resistance to several
antibiotics.
 Treatment for MDR typhoid

• Ciprofloxacin ( 15mg/kg for 5-7 days) OR

• Cefixime ( 15-20mg/kg for 7-14 days)

In case of fluoroquinolone resistance,

• Ceftriaxone ( 75mg/kg for10-14days) OR
• Azithromycin (8-10mg/kg for 7 days)
 National health programmes
• Typhoid is the neglected urgent in Nepal
• Pilot typhoid vaccination campaigns targeting
school children in Lalitpur and Bhaktapur districts
and adults who work in the tourism sector -
major risk groups for typhoid - were conducted in
2011 and 2012.
• Child Health Division of the Ministry of Health
and Population had successfully completed the
pilot introduction project of the Vi polysaccharide
typhoid vaccine with technical support from
International Vaccine Institute (IVI) in 2012
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. Wash your hands.

Avoid drinking untreated

water.
Avoid raw fruits and
vegetables

Choose hot foods.

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