Typhoid FeverTyphoid Fever

Reportable DiseasesReportable Diseases

Surveillance & InvestigationSurveillance & Investigation

Louisville Metro Health DepartmentLouisville Metro Health Department

Louisville, Kentucky, 40202Louisville, Kentucky, 40202

Typhoid Fever OutbreakTyphoid Fever Outbreak

On Monday, May 3,2004, a positive blood culture On Monday, May 3,2004, a positive blood culture for for Salmonella typhiSalmonella typhi in a 12 y.o. female was in a 12 y.o. female was reported by a local hospitalreported by a local hospital

Due to the uncommon occurrence of typhoid fever Due to the uncommon occurrence of typhoid fever in the community an investigation was initiated to in the community an investigation was initiated to identify the source of infection as well as any identify the source of infection as well as any activities associated with the spread of the infection activities associated with the spread of the infection

State Health Dept. notified. Sporadic cases State Health Dept. notified. Sporadic cases occasionally occur and are not considered a cause occasionally occur and are not considered a cause for alarm unless additional cases are identifiedfor alarm unless additional cases are identified

Second Case ReportedSecond Case Reported

On Tuesday, May 4, On Tuesday, May 4, SalmonellaSalmonella (serotype (serotype unknown) cultured from the blood of a 39 yo unknown) cultured from the blood of a 39 yo male at a local hospitalmale at a local hospital

Clinical presentation consistent with typhoid Clinical presentation consistent with typhoid fever (fever 103, headache, mild diarrhea)fever (fever 103, headache, mild diarrhea)

Newly employed as a manager-in-training at a Newly employed as a manager-in-training at a local restaurant (Restaurant A)local restaurant (Restaurant A)

Specimen sent to state lab for serotypingSpecimen sent to state lab for serotyping Investigation started on the assumption that Investigation started on the assumption that

possible typhoid outbreak (2 or more cases possible typhoid outbreak (2 or more cases associated by time and place) in progressassociated by time and place) in progress

Clinical Manifestations of Clinical Manifestations of Salmonella Salmonella typhityphi Disease (Typhoid fever) Disease (Typhoid fever)

Clinical course : a gradual onset of illness Clinical course : a gradual onset of illness with fever, headache, malaise, anorexia, with fever, headache, malaise, anorexia, lethargy, abdominal pain, hepatomegaly, lethargy, abdominal pain, hepatomegaly, splenomegaly, and possibly a “rose spot” splenomegaly, and possibly a “rose spot” rash on the trunk or a nonproductive cough rash on the trunk or a nonproductive cough

Epidemiology of Typhoid FeverEpidemiology of Typhoid Fever

Bacterial disease-Bacterial disease-Salmonella typhiSalmonella typhi Humans are the only source of infection Humans are the only source of infection

– Asymptomatic carrier state may follow illness, Asymptomatic carrier state may follow illness, including subclinical infectionincluding subclinical infection

OccurrenceOccurrence– Estimated 17 million cases annually with Estimated 17 million cases annually with

approx. 600,000 deaths worldwideapprox. 600,000 deaths worldwide– Fewer than 500 cases annually in USFewer than 500 cases annually in US– Fewer than 5 cases annually in KentuckyFewer than 5 cases annually in Kentucky

Mode of TransmissionMode of Transmission Fecal-oralFecal-oral By food and water contaminated By food and water contaminated

by feces and urine of patients and by feces and urine of patients and carriers (shellfish, raw fruits and carriers (shellfish, raw fruits and vegetables, milk products)vegetables, milk products)

Incubation period 3 days-1 month with Incubation period 3 days-1 month with a usual range of 8-14 daysa usual range of 8-14 days

Salmonella typhi Salmonella typhi Case DefinitionCase Definition

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

Interviews conductedInterviews conducted

»We conducted interviews to collect We conducted interviews to collect information regarding:information regarding:

clinical dataclinical datademographic informationdemographic informationcomplications and treatment complications and treatment epidemiological informationepidemiological information

Results of Epidemiologic InvestigationResults of Epidemiologic Investigation Cases were investigated thoroughly to Cases were investigated thoroughly to

assess risk factors for acquiring illness, assess risk factors for acquiring illness, similarities in activities and risk of spread to similarities in activities and risk of spread to the communitythe community

– Onset dates (4/18/04 and 4/12/04)Onset dates (4/18/04 and 4/12/04)

– Occupation (1 student, 1 food handler)Occupation (1 student, 1 food handler)

– Travel (both denied personal travel , but had Travel (both denied personal travel , but had recent contact with immigrants)recent contact with immigrants)

– Restaurant patronage (1 facility identified by Restaurant patronage (1 facility identified by both patients- Restaurant B)both patients- Restaurant B)

Patient 1Patient 1

An interview was conducted with the An interview was conducted with the mother of the 13 yo femalemother of the 13 yo female

The interview process revealed:The interview process revealed:

– a recent history of aiding Somolian a recent history of aiding Somolian refugees re-settle through church programrefugees re-settle through church program

» Stool specimens were negativeStool specimens were negative

– Ate at Restaurant B every Friday nightAte at Restaurant B every Friday night

Patient 1 (cont.)Patient 1 (cont.)

Attends a local middle school Attends a local middle school

– LMHD issued an advisory to the school LMHD issued an advisory to the school about about SalmonellaSalmonella (did not specify type) and (did not specify type) and the importance of hand hygiene the importance of hand hygiene

– A team of LMHD nurses visited the school A team of LMHD nurses visited the school to assess the hand washing facilities and to assess the hand washing facilities and procedures of the kitchen staff as well as the procedures of the kitchen staff as well as the students and teaching staffstudents and teaching staff

Patient 2Patient 2 An interview was conducted with the 39 yo maleAn interview was conducted with the 39 yo male

Interview process revealedInterview process revealed

– Employed as a manager-in-training at a local Employed as a manager-in-training at a local restaurant-Restaurant A. Notified the restaurant-Restaurant A. Notified the environmental health/food hygiene office of environmental health/food hygiene office of LMHD to notify employer of exclusion from LMHD to notify employer of exclusion from work until released by LMHDwork until released by LMHD

– Many co-workers in restaurant are recent Many co-workers in restaurant are recent immigrants from Senegalimmigrants from Senegal

– Identified Restaurant B as a frequent choice for Identified Restaurant B as a frequent choice for diningdining

Restaurant A (Employer of Patient 2)Restaurant A (Employer of Patient 2)

– Upon being notified of Pt. 2’s exclusion from work Upon being notified of Pt. 2’s exclusion from work due to illness, restaurant obtained a contract due to illness, restaurant obtained a contract physician to evaluate risk to the businessphysician to evaluate risk to the business

– Contract physician (Dr. C.) obtained a consent for Contract physician (Dr. C.) obtained a consent for release of information from Pt. 2, and obtained release of information from Pt. 2, and obtained hospital recordhospital record

– Dr. C. felt clinical presentation consistent with Dr. C. felt clinical presentation consistent with typhoid fever. Inquired about testing all restaurant typhoid fever. Inquired about testing all restaurant staff. Decision made by KDPH to wait until staff. Decision made by KDPH to wait until serotype confirmedserotype confirmed

Second Case ConfirmedSecond Case Confirmed

Contract physician for Restaurant A notified that Contract physician for Restaurant A notified that their employee (Pt. 2) confirmed to have their employee (Pt. 2) confirmed to have S. typhiS. typhi

Dr. C. recommends (as does CDC) to Restaurant Dr. C. recommends (as does CDC) to Restaurant A’s corporate office that all employees in Pt. 2’s A’s corporate office that all employees in Pt. 2’s store be screened for typhoidstore be screened for typhoid

Dr. C. travels to Louisville to personally instruct Dr. C. travels to Louisville to personally instruct restaurant staff on stool specimen collection and restaurant staff on stool specimen collection and to instruct staff about hygiene and the to instruct staff about hygiene and the importance of reporting any illnessimportance of reporting any illness

Specimens are sent to a private lab for evaluation Specimens are sent to a private lab for evaluation per choice of Restaurant A.per choice of Restaurant A.

Restaurant B. InvestigatedRestaurant B. Investigated Owner of Restaurant B. contacted and advised Owner of Restaurant B. contacted and advised

that his facility was identified as the only link that his facility was identified as the only link between two ill citizens (exact nature of illness between two ill citizens (exact nature of illness not revealed to prevent information leak and not revealed to prevent information leak and public panic)public panic)

Requested he arrange for staff to be present for Requested he arrange for staff to be present for lab specimen collection to screen for the source lab specimen collection to screen for the source of illnessof illness

Assured that no mention of the situation will be Assured that no mention of the situation will be made to the press at this timemade to the press at this time

Clinic Planned at Restaurant B.Clinic Planned at Restaurant B. Arrangements made for LMHD to arrive at Restaurant Arrangements made for LMHD to arrive at Restaurant

B. in the early morning in order to finish prior to B. in the early morning in order to finish prior to restaurant’s opening for lunch at 11:00 a.m.restaurant’s opening for lunch at 11:00 a.m.

Supplies and staff organized to collect blood specimens Supplies and staff organized to collect blood specimens and to distribute stool specimen collection kitsand to distribute stool specimen collection kits

Health history questionnaire developed to screen for Health history questionnaire developed to screen for symptoms of typhoid fever as well as travel history and symptoms of typhoid fever as well as travel history and work history for past 2 yearswork history for past 2 years

Translators acquired as most of the staff at Restaurant Translators acquired as most of the staff at Restaurant B. spoke little EnglishB. spoke little English

Results of Restaurant Results of Restaurant InvestigationsInvestigations

Restaurant A: Total of 86 staffRestaurant A: Total of 86 staff– 55 voluntarily provided stool specimen55 voluntarily provided stool specimen– All specimens negative for All specimens negative for S. typhi S. typhi – Decision was made not to “require” staff to Decision was made not to “require” staff to

complycomply

Restaurant Results (Cont.)Restaurant Results (Cont.)

Restaurant B: Total of 25 staffRestaurant B: Total of 25 staff– 22 presented at on site clinic for health 22 presented at on site clinic for health

history and blood specimen collectionhistory and blood specimen collection» Stool collection kits distributed with instructionsStool collection kits distributed with instructions

– All specimens negative for typhoid Vi All specimens negative for typhoid Vi antibodyantibody

– 8 stool specimens returned- negative8 stool specimens returned- negative

Public Health DecisionsPublic Health Decisions

LMHD consulted KDPH throughout the course LMHD consulted KDPH throughout the course of the investigationof the investigation

KDPH consulted CDC Enteric pathogens branch KDPH consulted CDC Enteric pathogens branch for advice about outbreak investigationfor advice about outbreak investigation

CDC recommended extensive histories on both CDC recommended extensive histories on both patients as well as screening of employees at patients as well as screening of employees at both restaurant facilities involvedboth restaurant facilities involved

Public Health Advisory issued to local ED’s to Public Health Advisory issued to local ED’s to encourage increased index of suspicion for encourage increased index of suspicion for typhoid in patient’s with fever of unknown typhoid in patient’s with fever of unknown origin and rigors with or without GI symptomsorigin and rigors with or without GI symptoms

Laboratory ServicesLaboratory Services

CDC made arrangement for serum of CDC made arrangement for serum of Restaurant B.’s employees to be tested for Restaurant B.’s employees to be tested for Typhoid Vi antibody at their lab, as well as Typhoid Vi antibody at their lab, as well as PFGE testing of the cases’ specimensPFGE testing of the cases’ specimens

KDPH made arrangements for stool KDPH made arrangements for stool specimens of Restaurant B.’s employees to specimens of Restaurant B.’s employees to be cultured at the state labbe cultured at the state lab

Investigation ResultsInvestigation Results

No source of infection for patients No source of infection for patients 1 or 2 was identified1 or 2 was identified

No further cases of No further cases of S. typhi S. typhi reportedreported

Lessons LearnedLessons Learned Use of Environmental Food Hygiene staff Use of Environmental Food Hygiene staff

was beneficial due to established was beneficial due to established relationship with restaurant managersrelationship with restaurant managers

Confidentiality was extremely difficult to Confidentiality was extremely difficult to maintain due to large number of people maintain due to large number of people involvedinvolved– Mom of patient 1 told several people her Mom of patient 1 told several people her

daughter’s diagnosisdaughter’s diagnosis» A physician who is friend of mom informed her that A physician who is friend of mom informed her that

he had seen another case of typhoid recentlyhe had seen another case of typhoid recently

– Pt 2 discussed his diagnosis with othersPt 2 discussed his diagnosis with others

Lessons (cont.)Lessons (cont.)

Immigrant status of employees of Rest. B Immigrant status of employees of Rest. B contributed to a fear of cooperatingcontributed to a fear of cooperating

Payment for laboratory services needs to be pre-Payment for laboratory services needs to be pre-arrangedarranged

100% management/employee cooperation 100% management/employee cooperation necessary in order to identify carrier or exclude necessary in order to identify carrier or exclude facility as a possible sourcefacility as a possible source

Although no source was found, attempt was Although no source was found, attempt was necessary for public safety.necessary for public safety.