Typhoid fever is due to systemic infection mainly by Salmonella typhi

1. TYPHOID
Mr. Kuldeep Vyas
M.Sc. Community Health Nursing
1Kuldeep Vyas M.Sc.
CHN

2. TYPHOID
• Typhoid fever is due to systemic
infection mainly by Salmonella typhi
• Salmonella typhi infection is
found only in men
• The disease is clinically
characterized by a typical
continuous fever for 2-3 weeks,
with relative bradycardia with
involvement of lymphoid tissues
and considerable constitutional
symptoms
• The term “ENTERIC FEVER” includes
both typhoid and Para typhoid fevers
• The disease may occur
sporadically, epidemically or
endemically
2Kuldeep Vyas M.Sc.
CHN

3. EPIDEMIOLOGICAL DETERMINANTS
• AGENT:
1. Salmonella typhi is the major cause of entric
fever
2. S.para A & S.para B are relatively infrequent
TYPHOIDBACILLI
3Kuldeep Vyas M.Sc.
CHN

4. 4Kuldeep Vyas M.Sc.
CHN

5. • S.typhi has three main antigens : O, H & Vi and
a number of phage types
• S.typhi survives intra cellularly in the tissues of
various organs
• It is readily killed by drying,
pasteurization and common
disinfectants
• The factors which influence the onset of
typhoid fever in man are the infecting dose
and virulence of the organism
• RESERVOIR OF INFECTION: Man is the only
known reservoir of infection (via cases &
carriers)
• CASES: A case is infectious as long as bacilli
appears in stools or urine
• CARRIERS: The carriers may be temporary
(incubatory, convalescent) or chronic
• Convalescent carriers excrete bacilli for 6-8
weeks (after which their numbers diminish
rapidly by the end of three months)
5Kuldeep Vyas M.Sc.
CHN

6. • Persons who excrete bacilli for more than one
year are after clinical attack are called chronic
carriers
• In most chronic carriers the bacilli exists in
gall bladder and in the billiary tract. A chronic
carrier may excrete the bacili for several years
(may be as long as 50 years)
• A famous case of “Typhoid Mary” who
gave raise to 1300 cases in her life time
is an example for a chronic carrier
state
• Faecal carriers are more common than
urinary carriers
6Kuldeep Vyas M.Sc.
CHN

7. SOURCE OFINFECTION
• The primary sources of infection are faeces
and urine of cases or carriers
• The secondary sources include contaminated
water, food, fingers and flies
HOST FACTORS
• AGE: Typhoid fever may occur at any age
• GENDER: Males are more
affected than females
• IMMUNITY: All ages are
susceptible to infection
• The host factors that contributes to resistance
to the bacilli are gastric acidity & local
intestinal immunity
7Kuldeep Vyas M.Sc.
CHN

8. ENVIRONMENTAL& SOCIAL FACTORS
• Enteric fevers are observed all throughout the
year
• The peak incidence is reported during July-
September
• Vegetables grown in sewage farmlands or
washed in contaminated water are positive
health hazard
• Typhoid bacilli grow rapidly in milk without
altering in taste or appearance in anyway, in
which case ingestion of such raw milk poses a
threat to the consumer
• These factors are compounded by such social
factors as pollution of drinking water supplies,
open air defecation and urination, low
standards of food and personal hygiene and
health ignorance
• Therefore typhoid fever may be regarded as an
index of general sanitation in any country
8Kuldeep Vyas M.Sc.
CHN

9. INCUBATIONPERIOD
• Usually 10-14 days
• But the it can be as short as 3 days or as long as
3 weeks, depending on the dose of bacilli
ingested
MODE OFTRANSMISSION
• Typhoid fever is transmitted via the faecal-oral
route or urine- oral routes
• This may take place directly through soiled
hands contaminated with faeces or urine of
cases or carriers or indirectly by the ingestion
of contaminated water, milk, food or through
flies
9Kuldeep Vyas M.Sc.
CHN

10. DYNAMICS OF TRANSMISSION
10Kuldeep Vyas M.Sc.
CHN

11. CLINICAL FEATURES
• The onset is insidious, but in children may be abrupt
with chills and high fever
• During the prodromal stage , there is malaise,
headache, cough and sore throat often with
abdominal pain and constipation
• The fever ascends in step ladder fashion
• After about 7-10 days, the fever reaches a plateau
and the patient looks toxic appearing exhausted
and often prostrated
• There may be marked constipation, especially in the
early stages or “pea soup diarrhoea”
• There is marked abdominal distension
• There is leukopenia and blood, urine and stool culture
is positive for salmonella
• If there are no complications the patient’s condition
improves over 7-10 days
• However relapse may occur for up to 2 weeks after
termination of therapy
• During early phase, physical findings are few
• Later splenomegaly, abdominal distension and
tenderness, relative bradycardia, dicrotic pulse and
ocassionaly meningsmus appear
• The rash (rose spots)commonly appear during the
second week of the disease
• The individual spot , found principally on the trunk, is
a pink papule 2-3 mm in diameter that fades on
pressure. It disappears in in 3-4 days 11Kuldeep Vyas M.Sc.
CHN

12. ROSESPOTS
• Serious complication occur in up to 10 percent
of patients (especially those who have been ill
for longer than 2 weeks and who have not
received proper treatment)
• Intestinal haemorrhage is manifested by a
sudden drop in temperature and signs of
shock, followed by dark or fresh blood in the
stool
• Intestinal perforation is most likely to occur
during the third week
• Less frequent complications are urinary
retention, pneumonia, thrombophlebitis,
myocarditis, psychosis, cholecystitis, nephritis
and oeteomyelitis 12Kuldeep Vyas M.Sc.
CHN

13. LABORATORYDIAGNOSIS
• MICROBIOLOGICAL PROCEDURES
The definitive diagnosis of typhoid fever
depends on the isolation of the bacilli from
blood, bone marrow and stools. Blood culture
is the mainstay of diagnosis of this disease
SEROLOGICAL PROCEDURE
• Felix-Widal test measures
agglutinating antibody levels against
O & H antigens
• Usually “O” antibodies appear on day 6-8 and
“H” antibodies on day 10-12 after the onset
of disease
• The test is usually performed on an acute
serum (at first contact with the patient)
• The test has moderate sensitivity and
specificity
• It can be negative up to 30% of culture –
proven case of typhoid fever
• This may be because of prior antibiotic
therapy, that has blunted the antibody
response
13Kuldeep Vyas M.Sc.
CHN

14. NEW DIAGNOSTIC TESTS
• The IDL tubex test can detect specific IgM
antibodies in samples to S. Typhi
liposaccharide (LPS) antigen and the staining
of bound antibodies by anti-human IgM
antibody conjugated to colloidal dye particles
DIAGNOSISREGIMEN
14Kuldeep Vyas M.Sc.
CHN

15. CONTROL OF TYPHOID FEVER
• The control or elimination of the typhoid fever is
well within the scope of modern public health
• There are generally three lines of defence
against typhoid fever:
• 1. Control of reservoir
• 2. Control of sanitation
• 3. Immunization
CONTROL OF RESERVOIR
• The usual methods of control of reservoir are
their identification, isolation, treatment &
disinfection
• CASES: EARLY DIAGNOSIS–This is of vital
importance as the early symptoms are non-
specific
• Culture of blood and stools are important
investigations in the diagnosis of cases
15Kuldeep Vyas M.Sc.
CHN

16. NOTIFICATION:
Notification must be done in areas where it is
mandatory
ISOLATION:
Since typhoid is an infectious disease the cases are
to be transferred to hospital
As a rule cases should be isolated till three
bacteriologically negative stools and urine
reports are obtained on three separate days
TREATMENT
• Flouroquinolones are widely regarded as the drug
of choice for the treatment of of typhoid fever
16Kuldeep Vyas M.Sc.
CHN

17. TREATMENT
17Kuldeep Vyas M.Sc.
CHN

18. • They are relatively inexpensive and well tolerated
and more reliably and effectively than
chloremphenicol, ampicillin, amoxicillin, and
trimethoprim & sulphamethoxazole
• Patients seriously ill and profoundly toxic
should be given Inj of hydrocortisone 100 mg
daily for 3-4 days
• DISINFECTION: stools and urine are the sole
sources f infection. They should be received in
in closed containers and disinfected with 5%
cresol for at least 2 hours
• All soiled clothes and linen should be
soaked in a solution of 2% chlorine and be
stream sterilized
• Doctors and nurses should disinfect
their hands
FOLLOWUP
• Examination of stools and urine should be
should be done for S.typhi 3-4 months after
discharge and again 12 months to prevent
development of carrier state
18Kuldeep Vyas M.Sc.
CHN

19. CARRIERS:
• Since carriers are the ultimate source of
infection, their identification and treatment is
one of the most radical ways of controlling
typhoid fever
• The following are the measures recommended:
• IDENTIFICATION: Carriers are identified by
cultural and serological examinations.
Duodenal drainage establishes the presence of
salmonella in the biliary tract of carriers
• The antibodies are present in about 80% of
chronic carriers
TREATMENTOF CARRIERS:
• The carriers should be given an intensive course
of ampicillin or amoxycillin (4-6 g a day)
together with probenecid (2g/day) for 6 weeks
19Kuldeep Vyas M.Sc.
CHN

20. 20Kuldeep Vyas M.Sc.
CHN

21. • These drugs are concentrated in the bile and
may achieve eradication
• Chloromycetin is considered worthless for
clearing the carrier state
SUREGERY
• Cholecyctectomy with concomitant ampicillin
therapy has been regarded as the most
successful approach to the treatment of carriers
• Urinary carriers are eassy to treat, but
refractory cases may need nephrectomy when
one kidney is damaged and the other is
healthy
• SURVEILLANCE: The carriers should be
kept under surveillance. They should be
prevented from handling food, milk or water for
others
21Kuldeep Vyas M.Sc.
CHN

22. HEALTHEDUCATION
• Health education regarding washing of hands
with soap after defecations or urination and
before preparing food is an essential element
• In short, the management of carriers
continues to be an unsolved problem
• This is the crux of the problem, in the
elimination of typhoid
CONTROL OF SANITATION
• Protection and purification of drinking water
supplies, improvement of basic sanitation and
promotion of food hygiene are essential
measures to interrupt transmission of typhoid
fever
22Kuldeep Vyas M.Sc.
CHN

23. IMMUNIZATION
• Immunization is a complimentary approach in
the prevention of typhoid
• It yields the highest benefit to the money
spent
• Immunization against typhoid does not give
100% protection, but it definitely lowers both
the incidence and seriousness of the
infection
• It can be given at any age
upwards 2 years
• Immunization is recommended to those
who live in endemic areas, house hold
contacts and groups at risk of infection
such as school children and hospital staff,
travellers proceeding to endemic areas
and those attending melas and yatras
23Kuldeep Vyas M.Sc.
CHN

24. ANTI TYPHOIDVACCINES
• Two vaccines are available:
1. Vi polyssaccharide vaccine
2. The Type 21a vaccine
24Kuldeep Vyas M.Sc.
CHN

25. Vi POLYSSACCHARIDEVACCINE
• The vaccine is composed of purified Vi capsular
polysaccharide from the Ty2 S typhi strain and
elicits a T-cell independent IgG response that is
not boosted by additional doses
• The vaccine is administered sub cutaneously
or intra muscularly . The target value of each
single human dose is about 25 micro gram
of antigen
• The vaccine is stable for 6 months at 370 C and
for 2 years at 220 C
• The recommended storage temperature is 2-
8oC.The Vi vaccine does not elicit adequate
immune responses in children aged less than
2 yrs
• Only one dose is required and the vaccine
confers protection after 7 days of
vaccination
25Kuldeep Vyas M.Sc.
CHN

26. • To maintain protection revaccination is
recommended every three years.
• The vaccine can be co- administered with other
vaccines (such as yellow fever, and hepatitis A
and with routine childhood vaccinations)
• No serious adverse events and minimum
of local effects are associated with Vi
vaccination
• There are no contra indications to the vaccine
other than previous hypersensitivity reaction
to vaccine components
THE TYPE 21aVACCINE
• Is an orally administered live attenuated Ty2 strain
of S.typhi. The lyophilized vaccine is available as
enteric coated capsules
TYPE 21 aVACCINE:
26Kuldeep Vyas M.Sc.
CHN

27. • The vaccine has to be stored at 2-80C, it
retains potency for approximately 14 days
at 250 C
• The capsules are licensed for use in individuals
aged above 5 yrs
• The vaccine is administered every other day
(on 3 and 5 day) a 3-dose regimen is
recommended
• Protective immunity is achieved 7 days after
the last dose
• The recommendation is to repeat the series
every 3 years for people living in endemic
areas and every year for individuals travelling
from non endemic to endemic areas
27Kuldeep Vyas M.Sc.
CHN

28. 28Kuldeep Vyas M.Sc.
CHN

29. 29Kuldeep Vyas M.Sc.
CHN

30. 30Kuldeep Vyas M.Sc.
CHN