TYPHOID FEVER

TYPHOID FEVER
The disease is clinically characterised by a typical continuous fever for 3 to 4 weeks, relative bradycardia with involvement of lymphoid tissues. The term enteric fever includes both typhoid and paratyphoid fevers.

PROBLEM STATEMENT : WORLD : Typhoid fever occurs in all parts of the world where water supplies and sanitation are sub standard. The disease is now uncommon in the developed countries. In South East Asia, 50% or more of the strains of the bacteria may already be resistant to several antibiotics.

India :

Typhoid fever is endemic in India A limited study in an urban slum showed 1% of children up to 17 yrs of age suffer from typhoid fever every year.

Epidemiological determinants : Agent determinants : 1. Salmonella typhosa is the major cause of enteric fever with a few cases due to salmonella paratyphosa A and B 2. The bacilli are readily killed by heat and common disinfectants 3. Antigenically 3 components H or flagellar antigen O or somatic antigen VI or virulence antigen 4. Endo-toxin liberated on autolysis

 a) b) c) d)

Which of the following is not true about Typhoid fever? Incubation period is 10 14 days Transmission via faeco - oral route Highest incidence in 5-19 yrs age group S. typhi resistant to drying and common disinfectives

Chronic carriers are those who excrete typhoid bacilli after clinical attack for more than: a) 8 weeks b) 3 months c) 6 months d) 12 months

Chronic carriers of S. typhi carry the bacteria in a) Gall bladder b) urinary bladder c) Large intestine d) respiratory tract

Reservoir of Infection : Man is the only known reservoir of infection Carriers : Temporary or chronic. Convalescent carriers excrete the bacilli for 6 to 8 weeks, after which their numbers diminish rapidly. Persons who excrete the bacilli for more than a year after a clinical attack are called chronic carriers. In most chronic carriers, the organisms persist in the gall bladder and in the biliary tract.

Typhoid Mary : Typhoid Mary who gave rise to more than 1300 cases in her life time is a good example of a chronic carrier.

Source of Infection :
Faeces and urine of cases or carriers

 A) B) C) D)

Typhoid mary was a typhoid case Chronic carrier of typhoid Incubatory carrier of typhoid Convalescent carrier of typhoid

Host Factors : 1. Commonly 10 30 yrs age group. Highest incidence of this disease occurs in the 5 19 yrs of age group.
2. Sex : males are more frequently affected but carrier rate is higher among females 3. Immunity status : people aged more than 30 yrs acquire immunity through subclinical infection.

Environmental Factors : Enteric fevers are observed all through the year. The peak incidence is reported during july sept. the rainy season . Increase in fly population. Water : The bacilli are found in water, ice, food, milk and soil for varying periods of time. Typhoid bacilli do not multiply in water The bacilli survive in soil up to 70 days

 Flies carry bacilli from faeces to food. Social factors incriminated are unhygienic health practices (like using the same water source of washing, drinking, bathing and ablutions) low standards of personal hygiene (like no washing hands after toilet). Open air defecation and urination, low standards of food and kitchen hygiene, illiteracy and ignorance, lack of safe drinking water, etc., Incubation period : 10 15 days

Mode of Transmission : 1. Vehicle transmission : (faeco oral route ) chief mode. Through the medium of contaminated water, food, milk and vegetables.
2. Direct contact from actual case through contaminated hands. 1. Flies also play a part.

Social Factors
C U L T U R A L F A C T O R S E C O N O M I C F A C T O R S

Faces
And Urine From Cases Or Carriers

Water

Food
Soil

Mouths Of Well Persons

Raw Or
Flies

Cooked
Fingers

Quality of Life

Clinical Features
The onset is usually insidious but in children may be abrupt, with chills and high fever. Prodromal stage : malaise, headache, cough and sore throat, often with abdominal pain and constipation. The fever ascends in a stepladder fashion. After about 7 to 10 days, the fever reaches a plateau. There may be constipation, especially in early stage or pea soup diarrhoea.

Marked abdominal distention. Leukopenia. If there are no complications the patients condition improves over 7 to 10 days.
physical findings : Late stage : spleenomegaly, abdominal distention and tenderness, relative bradycardia.

Serious complications : Intestinal haemorrhage (rare) Intestinal perforation.

Case-fatality rate : 1 % to 4 % In children aged less than 4 yrs : 10 times higher than in older children.

Laboratory diagnosis of typhoid : a) Microbiological Procedures : Blood culture b) Serological Procedure : Felix-Widal test : Usually, O antibodies appear on day 6 8 and H antibodies on day 10 12 after the onset of diseases.

c) New diagnostic tests :IDL Tubex test : It can detect IgM09 antibodies within few minutes.
Typhidot test : for the detection of specific IgM and IgG antibodies against 50 kD antigen of S typhi. Typhidot M : to detect specific IgM antibodies only.

Control of typhoid fever : 1. Control of reservoir 2. Control of sanitation, and 3. immunization

Control of reservoir : a. Identification

a. Isolation b. Treatment c. Disinfection

1. 2. 3.

4. 5. 6.

Cases : Early diagnosis : Notification Isolation :cases should be isolated 3 bacteriologically negative stools and urine reports. Treatment :fluoroquinolones disinfection followup

Drug of choice for treatment of chronic typhoid carrier is a)Ampicillin Drug of choice for treatment of typhoid case is a) chloramphenicol

Carriers : 1. Identification : 2. Treatment : intensive course of ampicillin or amoxycillin 4-6 g a day together with probenecid 2 g / day for 6 weeks.
1. Surgery 2. Surveillance 3. Health education

Control of sanitation : Protection and purification of drinking water of supplies

Improvement of basic sanitation. Promotion of food hygiene

Health education :

Immunization : It can be given at any age upwards of two years. It is recommended to : 1. Those living in endemic areas 2. Household contacts 3. Groups at risk of infection such as school children and hospital staff 4. Travelers proceeding to endemic areas 5. Those attending meals and yatras

Anti-typhoid vaccines :
The Vi polysaccharide vaccine : Schedule : licensed for individuals aged > 2 years. Only one dose is required. To maintain protection re vaccination is recommended every 3 years. Safety

Ty21a vaccine Live attenuated oral vaccine Schedule Indicated in adults and children above 6 yrs of age. Enteric coated capsule is taken on days 1, 3 and 5. Efficacy: 85%.
Safety and precautions

Hookworm infection

Any infection caused by Ancylostoma duodenale or Necator americanus. Endemic Index: Morbidity and mortality depends much on the worm load.

Chandler Index
chandler worked out an index on the basis of average number of hookworm eggs per gram of faeces for the entire community Average number of eggs per gram of stools: Below 200: infection is not of much significance 200-250 : may be regarded as potential danger

250-300 :

minor public health problem

Above 300 : important public health problem

Chandlers index is still used in epidemiological studies of hookworm disease.

By this index, worm loads in different population groups can be compared and also the degree of reduction of egg output after mass treatment.

PROBLEM STATEMENT IN INDIA: Nector americanus is predominant in South India.

Ancylostoma duodenale is in North India. The heavily infected areas are found in Assam, West Bengal, Bihar, Orissa, Andhra Pradesh.

Epidemiological determinants: Agent factors: Infection occurs when Rhabditiform larva enters the body through the skin , most commonly through the foot. Lymphatics blood stream lungs alveoli bronchi trachea and are coughed up and swallowed to reach the small intestine to become sexually mature. Reservoir : Man is the only important reservoir.

Infective material : Faeces containing the ova of hookworms. Soil contaminated with infective larvae. Host Factors : Age & Sex : Highest incidence is found in the age group 15-25 yrs Nutrition : malnutrition is a predisposing factor Occupation : farming community

Environmental factors : Soil: Temperature : Favourable temperature : 24-32 deg. C Oxygen : Moisture : Rain fall : Shade : Human habits :

Mode of Transmission : Hookworms (infective larvae) enter the body, usually feet, by penetrating the skin. Ancylostoma may also be acquired by the oral route by direct ingestion of infective larvae via contaminated fruits and vegetables. Incubation period : N. americanus : 7 weeks A. duodenale : 5 weeks 9 months

Effects of the disease :

Individual : Hook warm infection causes Chronic blood loss depletion of bodys iron stores iron deficiency anaemia. For children : Retarded physical growth and development For mothers : increased morbidity, low birth weight babies, abortion, still births and impaired lactation

Prevention and Control

Sanitary disposal of faeces Chemotherapy Correction of anaemia, and Health education.

Sanitation technology:
Installation of sanitary disposal system in urban areas and promoting the use of low cost sanitary latrines in rural areas. Chemotherapy: Periodic case finding and treatment of all infected persons. Albendazole Mebendazole Levamisole, pyrantel.

Treatment of anaemia: Ferrous sulphate 200mg thrice a day orally And continued for 3 months
Deworming

Health education: Promoting the use of sanitary latrines, Prevention of soil pollution Wearing of foot wears Making use of health facilities

DRACUNCULIASIS : Dracunculiasis or guineaworm disease is a vectorborne parasitic disease, mainly of the subcutaneous tissues (usually leg and foot) caused by the nematode parasite, dracunculus medinensis. Mode of Transmission : Through the consumption of water containing cyclops harboring the infective stages of the parasite. It is a totally water based disease

Eradication : Guinea worm disease is amenable to eradication. Provision of safe drinking water (e.g: piped water, installation of hand pump) Control of cyclops Health education of the public: in matters relating to boiling of drinking water through a double thickness cotton cloth for personal protection. prevention of water contamination by infected persons.

4. Surveillance : active search for new cases 5. Treatment of cases : the drugs available for this purpose are Niridazole, mebendazole and metronidazole. Guineaworm eradication was the target for the United Nations Water Decade (1981 1990)