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 infection
 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 regarding:
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
dining
Restaurant A (Employer of Patient 2)
– Upon being notified of Pt. 2’s exclusion from work
due to illness, restaurant obtained a contract
physician to evaluate risk to the business
– 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
A’s corporate office that all employees in Pt. 2’s
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
restaurant’s opening for lunch at 11:00 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 instructions
– All specimens negative for typhoid Vi
antibody
– 8 stool specimens returned- negative
 Public Health Decisions
 LMHD consulted KDPH throughout the course
of the investigation
 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 ED’s to
encourage increased index of suspicion for
typhoid in patient’s 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’ specimens
 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 identified

 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
daughter’s 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 pre-
arranged
 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.