Mary Mallon was a cook who was the first identified healthy carrier of typhoid fever. In 1906, she worked for a family where several members contracted typhoid. An investigation found Mallon to be the source, though she did not show symptoms. She was quarantined from 1907 to 1910. After her release, she obtained work under an alias as a cook and infected over 20 people. She was then permanently isolated from 1915 until her death in 1938. Typhoid fever remains endemic in parts of Asia and Africa, with over 16 million cases estimated annually. Diagnosis involves blood and stool cultures while treatment is usually with antibiotics like ciprofloxacin or azithromycin. Complications can include intestinal perforation or

1. DR.SMRUTI HAVAL
M.B.B.S.D.N.B.( FAMILY MEDICINE )
ENTERIC FEVER

2. 
HISTORY

3. In 1906, Irish immigrant Mary Mallon worked as a cook in the
Oyster Bay summer home of New York banker Charles Henry
Warren and his family. By the end of the summer, six members of
the household had contracted typhoid fever. The Warrens hired
sanitary engineer, George Soper, to determine the source of the
disease. Soper concluded that Mallon, while immune herself to the
disease, was its carrier. For three years, she was isolated on North
Brother Island, near Rikers Island, earning the nickname
"Typhoid Mary." Instructed not to cook for others upon her release,
she nevertheless changed her name and became a cook at a
maternity hospital in Manhattan. At least 25 staff members
contracted typhoid. "Typhoid Mary" returned to North Brother
Island, where she lived alone for 23 years, until her death in 1938.
She is shown here on the island in an undated photo. She died of a
stroke after 23 years in quarantine.

4. Mary Mallon
(wearing glasses)
photographed
with
bacteriologist
Emma Sherman
on North Brother
Island in 1931 or
1932, over 15
years after she
had been
quarantined there
permanently.

5.  In 1880s, the typhoid bacillus was first discovered by
Eberth in spleen sections and mesenteric lymph nodes
from a patient who died from typhoid.
 Robert Koch confirmed a related finding and succeeded in
cultivating the bacterium in 1881.
 Serodiagnosis of typhoid was thus made possible by 1896.
 Wright and his team prepared heat killed vaccine from
S.Typhi in 1896

6.  Typhos in Greek means ,smoke and typhus fever got its name
from smoke that was believed to cause it. Typhoid means typhus-
like and thus the name given to this disease.
 The term Typhoid was given by Louis 1829 to distinguish it from
typhus fever.
 It is a disease of poor environmental sanitation and hence occurs
in parts of the world where water supply is unsafe and sanitation is
substandard.

7. term enteric fever or typhoid fever is a communicable
disease, found only in man and includes both typhoid
fever caused by S.Typhi and paratyphoid fever caused by
S.Paratyphi A,Band C.It is an acute generalized infection
of the reticuloendothelial system,intestinal lymphoid
tissue, and the gallbladder.

8. EPIDEMIOLOGY

9. According to the World Health Organization,
globally some 16 million cases occur annually
resulting in more than 600,000 deaths. More than 62%
of the global cases occur in Asia, of which, 7 million
occur annually in South East Asia. Other countries
with a high incidence include Central and South
America, Africa and Papua New Guinea.

12.  The incidence of this disease in UK is reported to be just
one case per 1,00,000 population.
 In 2O10, for example, 26,55,000 cases (incidence : 500
cases/ million) were reported from Africa with 1,30,000
deaths
 The mean incidence of typhoid fever in developing
countries is estimated between 150 cases/million
population/year in Latin America to 1000cases/million
population/year in some Asian countries

13. INDIA
 World largest outbreak of typhoid in SANGLI on
December 1975 to February 1976.This disease is
endemic in India
 1992 : 3,52,980 cases with 735 deaths
 1999 : 3,57,452 cases and 888 deaths
 2005 : 2,78,451 cases and 304 deaths
 Case fatality rate due to typhoid has been varying
between 1.1% to 2.5 % in last few years.

14. International Classification of
Disease Codes for Typhoid fever
Disease ICD-9 ICD-10
Typhoid & paratyphoid fevers 002 A01
Typhoid fever 002.0 A01.0

15.  Salmonellae are gram – ve rods, facultative aerobic, Motile with
peritrichate flagella, non-spore-forming
 1-3μm ×0.5μm in size
 Salmonella currently comprise 2000 serotypes
 Two groups a) Enteric fever group
b) Food poisoning group
The bacilli are killed at 55ºc in one hour or at 60ºc in 15 minutes.
They are killed within 5 minutes by mercuric chloride or 5% phenol
Boiling or chlorination of water and pasteurization of milk destroy
the bacilli
The proportion of typhoid to paratyphoid A is 10:1, Paratyphoid B is
rare and paratyphoid C is very rare in India

16. Mode of transmission : The disease is transmitted by
faeco - oral route or urine – oral routes – either
directly through hands soiled with faeces or urine of
cases or carriers or indirectly by ingestion of
contaminated water, milk, food, or through flies.
Contaminated ice, ice-creams, and milk products are a
rich source of infection.

17. Nutritional status :Malnutrition may enhance the susceptibility to
typhoid fever by altering the intestinal flora or other host defences.
Incubation period : Usually 10-14 days but it may be as short as 3 days
or as long as 21 days depending upon the dose of the inoculums.
Reservoir of infection : Man is the only known reservoir of infection -
cases or carriers.
Period of communicability: A case is infectious as long as the bacilli
appear in stool or urine
Age group : Typhoid fever may occur at any age but it is considered to
be a disease mainly of children and young adults. In endemic areas,
the highest attack rate occurs in children aged 8-13 years. In a recent
study from slums of Delhi, it was found that contrary to popular
belief, the disease affects even children aged 1-5 years.

18. Gender and race : Typhoid fever cases are more
commonly seen in males than in females. On the contrary,
females have a special predilection to become chronic
carriers.
Occupation : Certain categories of persons handling the
infective material and live cultures of S. typhi are at
increased risk of acquiring infection.
Socio-economic factors : It is a disease of poverty as it is
often associated with inadequate sanitation facilities and
unsafe water supplies. Carriers may be temporary or
chronic.
Temporary (convalescent or incubatory) carriers usually
excrete bacilli up to 6-8 weeks. By the end of one year, 3-4
per cent of cases continue to excrete typhoid bacilli.
Persons who excrete the bacilli for more than a year after a
clinical attack are called chronic carriers.

19. PATHOGENESIS

23. DIAGNOSIS

24.  First week: The disease classically presents with step-ladder
fashion rise in temperature (40 - 41°C) over 4 to 5 days,
accompanied by headache, vague abdominal pain, and
constipation.
 Second week: Between the 7 th -10 th day of illness, mild hepato-
splenomegaly occurs in majority of patients. Relative bradycardia
may occur and rose-spots may be seen.
 Third week: The patient will appear in the "typhoid state"
which is a state of prolonged apathy, toxaemia, delirium,
disorientation and/or coma. Diarrhea will then become apparent. If
left untreated by this time, there is a high risk (5-10%) of intestinal
hemorrhage and perforation.

25.  Rare complications:
 1.NEUROPSYCHIATRIC COMPLICATIONS:
 Delirium
 Encephalopathy syndrome
 Convulsions
 Neuritis
 Psychosis
 HEART IN TYPHIOD:
 ECG alteration in cases of typhoid are due to structural
damage to myocardium due salmonella typhi infection.
 Clinically myocarditis in case of typhoid suspected if patient
has incordinate tachycardia, diminished intensity and soft
quality first heard sound. gallop rhythm ,rapidly developing
cardiac enlargent,condution defect & signs of CCF.

26. GI COMPLICATION
 INTESTINAL PERFORATION
 Patients with intestinal hemorrhage need intensive care, monitoring and blood
transfusion. Intervention is not needed unless there is significant blood loss.
 Surgical consultation for suspected intestinal perforation is indicated.
 If perforation is confirmed, surgical repair should not be delayed longer than
six hours.
 Metronidazole and gentamicin or ceftriazone should be administered before
and after surgery if a fluoroquinolone is not being used to treat leakage of
intestinal bacteria into the abdominal cavity. Early intervention is crucial, and
mortality rates increase as the delay between perforation and surgery
lengthens. Mortality rates vary between 10% and 32%

27.  TYPHOID HEPATITIS:
 Important complication & should be seriously
consider in patient with fever with jaundice.
 OSTEOMYLITIS :
 OSTEOOMYLITIS IN SICKLE CELL DISEASE:

28.  RENAL STATUS IN TYPHOID:
 Typhoid nephritis leads to renal failure.
 Renal involvement is functional or pathological
 In form of transient glomerular disease or acute
renal failure due to haemolysis

29.  HAEMATOLOGICAL PROFILE:
 Leucopenia
 Eosinophilia
 Haemolytic uremic syndrome
 Harmolytic anaemia
 DIC
 Normocellular bone marrow

30. RELAPSE
 5-20% of typhoid fever cases that have apparently been
treated successfully.
 A relapse is heralded by the return of fever soon after the
completion of antibiotic treatment. The clinical
manifestation is frequently milder than the initial illness.
Cultures should be obtained and standard treatment
should be administered.

32. Rose spots

33. INVESTIGATIONS

34.  Typhoid should be considered in any patient with
prolonged unexplained fever in endemic areas and in
those with a history of recent travel to endemic area.
 Prolonged fever, rose spots, relative bradycardia and
leucopenia make typhoid strongly suggestive.
 Widal test measures titres of serum agglutinins against
somatic (O) and flagellar (H) antigens which usually
begin to appear during the 2nd week. In the absence
of recent immunization, a high titre of antibody to O
antigen > 1:640 is suggestive but not specific.

35.  Polymerase chain reaction (PCR) can be performed on
peripheral mononuclear cells. The test is more sensitive
than blood culture alone (92% compared with 50-70%)
but requires significant technical expertise
 Blood cultures are positive in 70-80% of cases during
the 1st week.
 Stool and urine cultures are usually positive (45-75%)
during the 2nd-3rd week.
 Bone marrow aspirate cultures give the best
confirmation (85-95%)
 The tracing of carriers in cities by sewer – swab
technique

36. RAPID TESTS FOR DIAGNOSING
TYPHOID
 Typhi dot test that detects presence of Ig M and Ig G
in one hour (sensitivity>95%, Specificity 75%)
 Typhi dot-M, that detects Ig M only (sensitivity 90%
and specificity 93%)
 Typhi dot rapid (sensitivity 85% and Specificity
99%) is a rapid 15 minute immuno chromatographic
test to detect Ig M.
 Ig M dipstick test
 IDEAL TUBEX: ONLY FOR SALMONELLA
TYPHI

37. Wilson and Blair bismuth sulphite medium jet black colony with a
metallic sheen

39. Salmonella enterica.

40. Differential Diagnosis
Other disease or conditions that need to be eliminated
Other infectious diseases Other problems
•Brucellosis
•Infectious mononucleosis
•Leptospirosis
•Malaria
•Miliary tuberculosis
•Rickettsioses
•Tularemia
•Viral hepatitis
•Lymphoma

41. 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)

42. ANTIBIOTICS THERAPY
IN ADULTS

43. INDICATION AGENT DOSAGE(ROUTE) DURATION
DAYS
EMPERICAL
TREATMENT
CEFTRIAXONE 1-2 G/D(IV) 7-14
AZITHROMYCIN 1 G/D (PO) 5
FULLY SUCEPTIBLE
CIPROFLOXACIN
(FIRST LINE)
500 MG BID (PO)
OR 400 MG q 12 h (IV)
14
AMOXICILLIN(SECOND
LINE)
1 G TID (PO) OR 2 GM q 6
H (IV)
14
CHLORAMPHENICOL 25 MG /KG TID (PO OR IV) 14-21
TRIMETHOPRIM-
SULFAMETHOXAZOLE
160 /800 MG BID (PO) 7-14
MULTIDRUG RESISTANT
CIPROFLOXACIN 500 MG BID (PO)
OR 400 MG q 12 h (IV)
5-7
CEFTRIAXONE 2-3 G/D (IV) 7-14
AZITHROMYCIN 1 GM/D (PO)c 5
NALIDIXIC ACID
RESISTANT
CEFTRIAXONE 2-3 G/D (IV) 7-14
AZITHROMYCIN 1 GM/D (PO) 5
HIGH DOSE
CIPROFLOXACIN
750 MG BID (PO) OR 400
MG q8h (IV)
10-14

44. Antibiotic Therapy for Non
typhoidal Salmonella
Infection in Adults

45. INDICATION AGENT DOSAGE(ROUTE) DURATION
DAYS
PREEMTIVE TRETMENTa
CIPROFLOXACINb 500 MG BID (PO) 2-3
BACTEREMIA
CEFTRIXONE 2 G/D (IV) 7-14
CIPROFLOXACIN 400 MG q 12 h (IV) THEN 500 MG BID (PO)
ENDOCARDITIS OR ARTHIRITIS
CEFTRIXONE 2 G/D (IV) 42
CIPROFLOXACIN 400 MG q 8 h (IV) THEN 750 MG BID (PO)
AMPICILLIN 2 GMq 4 h(IV)
MENINGITIS
CEFTRIAXONE 2G q 12 h (IV) 14-21
AMPICILLIN 2G q 4 h (IV)
OTHER LOCALISED INFECTIONS
CEFTRIAXONE 2 G/D (IV) 14-28
CIPROFLOXACIN 400 MG q 12 h (IV) OR 500 MG BID (PO)
AMPICILLIN 2 G q 6 h (IV)
SEVERE GASTROENTERITIS
CIPROFLOXACIN 400 MG q 12 h (IV) OR 500 MG BID (PO) 3-7
TRIMETHOPRIM-
SULFAMETHOXAZOLE
160/800 mg bid (po)
AMOXICILLIN 1 g tid (PO)
CEFTRIAXONE 2G q 6 h (IV)

46. DEXAMETHASONE FOR CNS
COMPLICATION
 Should be immediately be treated with high-dose
intravenous dexamethasone in addition to antimicrobials
 Initial dose of 3 mg/kg by slow i.v. infusion over 30
minutes
 1 mg/kg 6 hourly for 2 days
 Mortality can be reduced by some 80-90% in these high-
risk patients

47. SPECIFIC PROTECTION
THREE TYPES OF VACCINES
1. Injectable Typhoid vaccine
(TYPHIM –Vi, TYPHIVAX)
2. The live oral vaccine (TYPHORAL)
3. TAB vaccine

48. Indications for Vaccination
1. Persons with intimate exposure to a
documented S. typhi carrier
2.Microbiology laboratory technologists who
work frequently with S. typhi
3.Immigrants
4. Military personnel
5.Travelers going to endemic areas who will be
staying for a prolonged period of time,

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

50. 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.

51. Injectable Typhim -Vi
1. This single-dose injectable typhoid vaccine, from the
bacterial capsule of S. typhi strain of Ty21a.
2. This vaccine is recommended for use in children
over 2 years of age.
3. Subcutaneous or intramuscular injection
4. Efficacy : 64% -72%

52. 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

53.  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

HEALTH PROMOTION

54.  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.

55. THE FUTURE OF TYPHOID
 Cheap, Rapid and reliable serological test
 Fluoroquinolone and cephalosporin resistant case
 Combination chemotherapy
 New drugs

56. THANK YOU