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Typhoid Fever


On Monday, May 3,2004, a positive blood culture for Salmonella typhi in a 12 y.o. ... to collect blood specimens and to distribute stool specimen collection kits ... – PowerPoint PPT presentation

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Title: Typhoid Fever

Typhoid Fever
  • Reportable Diseases
  • Surveillance Investigation
  • Louisville Metro Health Department
  • Louisville, Kentucky, 40202

Typhoid Fever Outbreak
  • On Monday, May 3,2004, a positive blood culture
    for Salmonella typhi in a 12 y.o. female was
    reported by a local hospital
  • Due to the uncommon occurrence of typhoid fever
    in the community an investigation was initiated
    to identify the source of infection as well as
    any activities associated with the spread of the
  • State Health Dept. notified. Sporadic cases
    occasionally occur and are not considered a cause
    for alarm unless additional cases are identified

Second Case Reported
  • On Tuesday, May 4, Salmonella (serotype unknown)
    cultured from the blood of a 39 yo male at a
    local hospital
  • Clinical presentation consistent with typhoid
    fever (fever 103, headache, mild diarrhea)
  • Newly employed as a manager-in-training at a
    local restaurant (Restaurant A)
  • Specimen sent to state lab for serotyping
  • Investigation started on the assumption that
    possible typhoid outbreak (2 or more cases
    associated by time and place) in progress

Clinical Manifestations of Salmonella typhi
Disease (Typhoid fever)
  • Clinical course a gradual onset of illness
    with fever, headache, malaise, anorexia,
    lethargy, abdominal pain, hepatomegaly,
    splenomegaly, and possibly a rose spot rash on
    the trunk or a nonproductive cough

Epidemiology of Typhoid Fever
  • Bacterial disease-Salmonella typhi
  • Humans are the only source of infection
  • Asymptomatic carrier state may follow illness,
    including subclinical infection
  • Occurrence
  • Estimated 17 million cases annually with approx.
    600,000 deaths worldwide
  • Fewer than 500 cases annually in US
  • Fewer than 5 cases annually in Kentucky

  • Mode of Transmission
  • Fecal-oral
  • By food and water contaminated by feces and urine
    of patients and carriers (shellfish, raw fruits
    and vegetables, milk products)
  • Incubation period 3 days-1 month with a usual
    range of 8-14 days

Salmonella typhi Case Definition
  • a case that meets the clinical case definition
    and is confirmed by isolation of S. typhi from
    blood, stool or other clinical specimens

Interviews conducted
  • We conducted interviews to collect information
  • clinical data
  • demographic information
  • complications and treatment
  • epidemiological information

Results of Epidemiologic Investigation
  • Cases were investigated thoroughly to assess risk
    factors for acquiring illness, similarities in
    activities and risk of spread to the community
  • Onset dates (4/18/04 and 4/12/04)
  • Occupation (1 student, 1 food handler)
  • Travel (both denied personal travel , but had
    recent contact with immigrants)
  • Restaurant patronage (1 facility identified by
    both patients- Restaurant B)

Patient 1
  • An interview was conducted with the mother of the
    13 yo female
  • The interview process revealed
  • a recent history of aiding Somolian refugees
    re-settle through church program
  • Stool specimens were negative
  • Ate at Restaurant B every Friday night

Patient 1 (cont.)
  • Attends a local middle school
  • LMHD issued an advisory to the school about
    Salmonella (did not specify type) and the
    importance of hand hygiene
  • A team of LMHD nurses visited the school to
    assess the hand washing facilities and procedures
    of the kitchen staff as well as the students and
    teaching staff

Patient 2
  • An interview was conducted with the 39 yo male
  • Interview process revealed
  • Employed as a manager-in-training at a local
    restaurant-Restaurant A. Notified the
    environmental health/food hygiene office of LMHD
    to notify employer of exclusion from work until
    released by LMHD
  • Many co-workers in restaurant are recent
    immigrants from Senegal
  • Identified Restaurant B as a frequent choice for

Restaurant A (Employer of Patient 2)
  • Upon being notified of Pt. 2s exclusion from
    work due to illness, restaurant obtained a
    contract physician to evaluate risk to the
  • Contract physician (Dr. C.) obtained a consent
    for release of information from Pt. 2, and
    obtained hospital record
  • Dr. C. felt clinical presentation consistent with
    typhoid fever. Inquired about testing all
    restaurant staff. Decision made by KDPH to wait
    until serotype confirmed

Second Case Confirmed
  • Contract physician for Restaurant A notified that
    their employee (Pt. 2) confirmed to have S. typhi
  • Dr. C. recommends (as does CDC) to Restaurant As
    corporate office that all employees in Pt. 2s
    store be screened for typhoid
  • Dr. C. travels to Louisville to personally
    instruct restaurant staff on stool specimen
    collection and to instruct staff about hygiene
    and the importance of reporting any illness
  • Specimens are sent to a private lab for
    evaluation per choice of Restaurant A.

Restaurant B. Investigated
  • Owner of Restaurant B. contacted and advised that
    his facility was identified as the only link
    between two ill citizens (exact nature of illness
    not revealed to prevent information leak and
    public panic)
  • Requested he arrange for staff to be present for
    lab specimen collection to screen for the source
    of illness
  • Assured that no mention of the situation will be
    made to the press at this time

Clinic Planned at Restaurant B.
  • Arrangements made for LMHD to arrive at
    Restaurant B. in the early morning in order to
    finish prior to restaurants opening for lunch at
    1100 a.m.
  • Supplies and staff organized to collect blood
    specimens and to distribute stool specimen
    collection kits
  • Health history questionnaire developed to screen
    for symptoms of typhoid fever as well as travel
    history and work history for past 2 years
  • Translators acquired as most of the staff at
    Restaurant B. spoke little English

Results of Restaurant Investigations
  • Restaurant A Total of 86 staff
  • 55 voluntarily provided stool specimen
  • All specimens negative for S. typhi
  • Decision was made not to require staff to comply

Restaurant Results (Cont.)
  • Restaurant B Total of 25 staff
  • 22 presented at on site clinic for health history
    and blood specimen collection
  • Stool collection kits distributed with
  • All specimens negative for typhoid Vi antibody
  • 8 stool specimens returned- negative

Public Health Decisions
  • LMHD consulted KDPH throughout the course of the
  • KDPH consulted CDC Enteric pathogens branch for
    advice about outbreak investigation
  • CDC recommended extensive histories on both
    patients as well as screening of employees at
    both restaurant facilities involved
  • Public Health Advisory issued to local EDs to
    encourage increased index of suspicion for
    typhoid in patients with fever of unknown origin
    and rigors with or without GI symptoms

Laboratory Services
  • CDC made arrangement for serum of Restaurant B.s
    employees to be tested for Typhoid Vi antibody at
    their lab, as well as PFGE testing of the cases
  • KDPH made arrangements for stool specimens of
    Restaurant B.s employees to be cultured at the
    state lab

Investigation Results
  • No source of infection for patients 1 or 2 was
  • No further cases of S. typhi reported

Lessons Learned
  • Use of Environmental Food Hygiene staff was
    beneficial due to established relationship with
    restaurant managers
  • Confidentiality was extremely difficult to
    maintain due to large number of people involved
  • Mom of patient 1 told several people her
    daughters diagnosis
  • A physician who is friend of mom informed her
    that he had seen another case of typhoid recently
  • Pt 2 discussed his diagnosis with others

Lessons (cont.)
  • Immigrant status of employees of Rest. B
    contributed to a fear of cooperating
  • Payment for laboratory services needs to be
  • 100 management/employee cooperation necessary in
    order to identify carrier or exclude facility as
    a possible source
  • Although no source was found, attempt was
    necessary for public safety.
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