Typhoid Fever

Typhoid fever/ Paratyphoid fever

Definition

An infectious disease caused by the bacterium Salmonella typhi(Salmonella enterica Serovar Typhi ) and less commonly by Salmonella paratyphi.

Acute generalized infection of the

reticulo endothelial system,
intestinal lymphoid tissue, and the gall bladder.


The infection always comes from another human, either an ill person or a healthy carrier of the bacterium. The bacterium is passed on with water and foods and can withstand both drying and refrigeration.

Typhoid fever

Typhoid fever is a systemic bacterial disease caused primarily by Salmonella Typhi, a new salmonella nomenclature has been proposed based on DNA correlation. The proposed nomenclature would change S. typhi to S. enterica serovar Typhi, abbreviated S.Typhi
paratyphoid fever is a similar illness but is usually much milder and is caused by the organism Salmonella Paratyphi three serotypes A, B and C.

History

Antonius Musa, a Roman physician who
achieved fame by treating the Emperor
Augustus 2,000 year ago, with cold baths
when he fell ill with typhoid.

Thomas Willis who is credited with the first

description of typhoid fever in 1659.

French physician Pierre Charles

Alexandre Louis first proposed
the name “typhoid fever”

William Wood Gerhard who was the first

to differentiate clearly between typhus
fever and typhoid in 1837.

Carl Joseph Eberth who discovered the

typhoid bacillus in 1880.


Georges Widal who described the
‘Widal agglutination reaction’ of the blood in 1896.

1. The best known carrier was "Typhoid

Mary“; Mary Mallon was a cook in Oyster
Bay, New York in 1906 who is known to
have infected 53 people, 5 of whom died.

2. Later returned with false name but

detained and quarantined after another
typhoid outbreak.

3. She died of pneumonia after 26 years in

quarantine.

Causes

1. Caused by the bacterium Salmonella Typhi .

2. Ingestion of contaminated food or water.

3. Contact with an acute case of typhoid fever.
4. Water is contaminated where inadequate sewerage systems and poor sanitation.

5. Contact with a chronic asymptomatic carrier.

6. Eating food or drinking beverages that handled by a person carrying the bacteria.
7. Salmonella enteriditis and Salmonella typhi murium are other salmonella bacteria,
cause food poisoning and diarrhoea.






Salmonella Entrica
Member of the genus Salmonella.
Rod shaped, flagellated, aerobic,
Gram negative bacterium.
Large number of fimbrial and non-fimbrial adhesins
are present, mediate biofilm formation and contact to host cells.
Secreted proteins involved in host cell invasion and intracellular proliferation.
Infects cattle, poultry, domestic cats, hamsters, humans etc.
Refrigeration and freezing substantially slow or halt their growth.
Pasteurizing and food irradiation kill Salmonella for commercially-produced foodstuffs containing raw eggs such as ice cream.
Foods prepared in the home from raw eggs can spread salmonella if t properly cooked before consumption.

Ingestion of contaminated food or waterSalmonella bacteria

Invade small intestine and enter the bloodstream


Carried by white blood cells in the liver, spleen, and bone marrow

Multiply and reenter the bloodstream

Bacteria invade the gallbladder, biliary system, and the lymphatic tissue of the bowel and multiply in high numbers

Then pass into the intestinal tract and can be identified for diagnosis in cultures from the stool tested in the laboratory

Incubation period

For typhoid fever ranges from 3 days to 1 months (depending on the infecting dose), with a usual range of 1-2 weeks, for paratyphoid fever, the incubation period is usually 1-10 days

Reservoirs

Humans are the reservoir for S. Typhi and S. Paratyphi. Domestic animals may harbor S. Paratyphi but this rare. Chronic carriers are the most important reservoirs for S. Typhi. About 2-5% of typhoid fever cases become chronic carriers, some after mild or inapparent infection.

Reservoirs

Persons with abnormalities of the genitourinary system, including schistosomiasis have a much higher prevalence of urinary carriage than those with a normal system.

Mode of transmission

S. Typhi is transmitted by ingestion of food or water contaminated with feces or urine of infected people or directly from person-to-person. Shellfish harvested from sewage-contaminated water are potential vehicles, as are fruits and vegetables grown in soil fertilized with human waste in developing countries. Person-to-person transmission can also occur through certain types of sexual contact (e.g., oral-anal contact).

Typhoid fever

Period of communicability or infectious period: The disease is communicable for as long as the person excrete S. Typhi or Paratyphi in the feces or urine. This usually begins about a week after onset of illness and continues through convalescence and for a variable period thereafter. If a carrier state develops, excretion could be permanent, although carriage may be eliminated with antibiotics.


Period of communicability
Persons with S. Paratyphi infections become carriers less frequently than person infected with S. Typhi.

Occurrence

The annual incidence of typhoid fever worldwide is approximately 17 million cases, with an estimated 600,000 deaths.

Clinical Description

Typhoid fever has a different presentation than common salmonellosis, initial symptoms typically include sustained fever, anorexia, lethargy, malaise; dull continuous headache, splenomegaly relative bradycardia and non-productive cough.

Clinical Description

After the first week or so, many cases develop a maculopapular rash on the trunk and upper abdomen, mild and atypical infections are common, but as many as_10-20% of untreated infection may be fatal, relapse are not uncommon. Paratyphoid fever is a similar illness but is usually much milder.

• Time frame

• First-Stage Typhoid Fever
• The beginning stage is characterized by high fever,fatigue, weakness, headache, sore throat, diarrhea, constipation, stomach pain and a skin rash on the chest and abdominal area. According to the Mayo Clinic, adults are most likely to experience constipation, while children usually experience diarrhea.

• Second stage

• Second-stage typhoid fever is characterized by weight loss, high fever, severe diarrhea and severe constipation. Also, the abdominal region
• may appear severely distended.
• Typhoid State
• When typhoid fever continues untreated for more than two or three weeks, the effected individual may be delirious or unable to stand and move, and the eyes may be partially open during this time. At this point fatal complications may emerge.


Rose spots

High fever

Diarrhea

Typhoid Meningitis

Aches and pains

Chest congestion

Case classification
• 1. Confirmed: A clinically compatible case, with isolation of S. Typhi from blood, stool, or other clinical specimen.
• 2. Probable: A clinically compatible case that is epidemiologically linked to a confirmed case in an outbreak.
• Note: Serologic evidence alone is not sufficient for diagnosis. Asymptomatic carriage should be reported as Salmonella Typhi not typhoid fever

Prevention

And
Treatment

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


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………
HEALTH PROMOTION

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 4ºc
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
• Injectable Typhoid vaccine
• (TYPHIM –Vi,TYPHIVAX)
• 2. The live oral vaccine (TYPHORAL)
• 3. TAB vaccine

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

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

• Travelers going to endemic areas who will be staying for a prolonged period of time,

• 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


002.0

A01.0

1




2

*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