An outbreak of typhoid fever occurred at the PATI Immigration Detention Depot in Langkap, Perak, Malaysia. 22 cases of typhoid were detected through active and passive surveillance. Risk factors for the outbreak included overcrowded living conditions with up to 300 detainees sharing only 2 toilets, close contact among detainees and food handlers, and unsanitary food preparation areas. Control measures included active case detection, screening of contacts and food handlers, disinfection of affected areas, health education, monitoring, and mass drug administration of antibiotics. The outbreak was successfully controlled and declared over on March 16, 2015.

1. Typhoid Outbreak in Depot
Tahanan Imigresen PATI
Langkap , Perak

2. Definition
a.k.a OUTBREAK

3. How to know it's an
OUTBREAK/EPIDEMIC ?

4. A Little Intro On Typhoid (Demam Kepialu)
Typhoid fever is an illness caused by Salmonella Typhi bacteria.
Persons with typhoid fever carry the bacteria in their bloodstream and/or
intestinal tract and is excreted through their feces.
Human are the only source of this disease.
You can get typhoid fever by eating or drinking food or water
contaminated with Salmonella Typhi.
The illness usually lasts 4 to 7 days, and most persons recover without
treatment. However, in some persons, the diarrhea may be so severe that
the patient needs to be hospitalized.
Symptoms include:
-Step-Pattern Fever (The peaks and troughs rise progressively over time.)
-Diffuse abdominal pain
- Rose spots
-Foul, green-yellow, liquid diarrhea

5. Typhoid burden in Malaysia

6. Outbreak Analysis
1
Casualty

7. Outbreak Analysis (Risk Factor w respect to the case)
Overcrowded living areas
(1400 residents)
Have a close contact with someone who is infected or
has recently been infected with typhoid fever (Some of
the immigrants are working as food handlers ;
(Typhidot test was conducted on food handlers ( 5
Malaysians ) & ( 5 PATI Immigrants) who wre in charge for
food in the canteen.
Only one PATI Immigrants food handler detected as
POSITIVE IgG ( suggest convalescence case or
carrier) on 14/1/2015

9. Inspection of food premises in DTS Langkap food kitchen was
conducted by the Food Quality Unit Quality Control Office . Case .
Hilir Perak on 31.12.2014 and the
rating obtained is 44.9 %

13. All toilets are of flush latrines . Toilet situation is not satisfactory when
examined . Toilet bowl was found to have cracks and some had broken causing
water stagnation and emits foul smell .
The number of toilets provided for each block were only 2 toilets and average
residents of each block is 200-300 people cause more detainees are exposed to
the risk of the spread of infectious diseases , especially if the toilet is more common
among prisoners . ( eg : diarrhea )
Toilet / Bathroom

14. Chronology of Typhoid Outbreak in
Depot Tahanan Imigresen PATI
Langkap , Perak

19. Housing Prisoners
•Prisoners without permission are placed in five blocks apart. Woman and a child under 12 years
old in block F and placing men in four other blocks (C1, C2, E1, E2).
• -Immigration Detention Depot occupants PATI Langkap were always swapped out and come in
every week depending on the catchment and delivery by the Immigration return to their home
countries after being accepted by the embassies of each country, by such a number the number of
occupants changed from time to time.
• - Prisoners inhabit detainees blocks in dense and mingled among them in a crowded number
(increasing the risk of disease transmission). Prisoners are also not allowed out of the blocks. -
They will receive food and eat within a block of prisoners and sleep on the floor (wooden)
without a mattress next to each others causes the effect of body contact between the prisoners.

20. Toilets / Bathroom
• All of the blocks have a bathroom and toilet for the detainees. For women ,the block has a toilet
(covered) and a separate bathroom. There is also a toilet connected to a residence for the use of
prisoners, especially at night.
•- For men , there is also a separate building for a shower and toilet (open), and the toilets (open)
is not covered for daily use. All toilets are of flush latrines. Toilet situation is not satisfactory when
examined. Toilet bowl was found to have cracks and some had broken causing water stagnation
and smelly.
•- The number of toilets provided for each block were only 2 toilets and average residents of each
block is 200-300 people cause more detainees are exposed to the risk of the spread of infectious
diseases, especially if the toilet is more common use among prisoners. (Ex: diarrhea)

21. Food Premises
•There are 2 types of premises that handle food for all detainess
i. kitchen ( the main source )
ii. Canteens .
•Food pantry run by entrepreneurs who are appointed . The kitchen provides food to all detainees
in 3 times ( breakfast, lunch and dinner )
Menu
• morning meal : bread (slice ) 2 -piece tea and water .
•Lunch menu : white rice , fried fish and vegetables ( boiled ) . The provision was restricted to the
food supplied unbalanced and lacking quality .
•There is a canteen run by two people , local residents and the foreigners ( immigrants ) and they
already get typhim injection . The customers of this canteen are among staff , depot prisoners and
visitors .

22. Food Handling
a . kitchen
•Officers food in the kitchen run by 5 people Malaysians and 11 foreigners ( detention of illegal
immigrants ) .
• Food handlers locals are workers employed on a regular basis by employers kitchen. Operator
foreigners ( prisoners ) were selected to work for a period of 3 months in turns by their
background who had worked as a cook in a stall or a restaurant as a way to get resources to cover
the purchase of a return ticket to their home country .
b. canteen
•The canteen is run by two Malaysians people .

23. Water Disposal System
•Garbage disposal system managed by the prisoners in turn. Bins provided in each blocks, but not
managed properly . A visit to the blocks found garbage scattered around the trash bins as full and
uncovered. This type of plastic is thrown away food , beverage containers collected from visitors (
family members / friends / etc. ) and food waste
•.
• All waste is collected daily and placed in a communal bin and transported to the bins provided by
the Municipality of Teluk Intan , which is located outside the block by the prisoners to be collected
by the Municipality of Teluk Intan on 2x per week .

24. The Drainage System
•Each block resistance , in the kitchen and the canteen has a current drainage system . There is no
standing water and no trash pile during the inspection . The drainage system is channeled into the
main drain which is connected to the main drainage system

25. OUTBREAK CONTROL
TYPHOID

26. 1.ACTIVE CASE DETECTION AND PASSIVE CASE
DETECTION(ACD/PCD)
 ACD was initiated when the first case was reported(13.12.14). ACD has detected 10
contact and contact was made for screening. All of screening among CONTACT in the
first round proved negative.
 22 Positive cases were detected during control activities . A total of 17 positive cases
detected by the ACD and 5 cases for PCD.
 The treatment of positive cases by DOTS run in DTS Langkap , The number of positive
cases admitted to HTI is a total of 11 cases. 1 of them was given intensive care (ICU) and
died.
 A total of 18 people from Myanmar who tested positive for Salmonella Typhi, 2
Bangladeshis, Nepalese citizen and a citizen of Pakistan.
10/22/2015

27. 2.RECTAL SWABS AND STOOL SAMPLE
 For contact , food handlers and immigration workers
 Number of stool samples and rectal swabs ( early screening ) to
PATI( 424 ) and immigration workers( 17 ) have been conducted in
healthy total of 441 people and tested negative. They are no carrier
detected through screening .
10/22/2015

28. 3. BLOOD TEST FOR TYPHIDOT
 Typhidot test was conducted on 12 local food handlers, 5 PATI in
charge until December 2014) and the 2 food handlers in the
canteen. Only one PATI food handlers detected POSITIVE IgG
(carrier) on 14/1/2015.
 Immediately and a directive to stop him from carrying out his
work in food preparation have been issued upon receiving the
decision 15.01.2015. DOTS treatment begins 15/01/2015.
10/22/2015

29. 4.DISINFECTION
 Disinfecting Kitchen , Cafeteria and Blocks
 Disinfection of the first residential block , toilet , kitchen, bathroom
drains and landfills have been carried out in all the blocks on
31/12/2014 . Disinfection is carried out by members of BAKAS Unit ,
Clinic Langkap . Disinfection using Dettol solution .
10/22/2015

30. 5.INSPECTION OF PREMISES
 Inspection of Premises (kitchen and cafeteria)
 Inspection on food kitchen DTS Langkap was conducted by the
Food Quality Unit Quality Control Office Hilir Perak on 31.12.2014.
 The assessment found the work of food preparation is carried
out improper and the food is exposed to the risk of
contamination. The equipment used for food preparation, food
containers (tray) in bad condition and not cleaned properly.
Place and frozen food storage methods do not meet required
standards. Dry food stor also unsatisfactory and inadequate
lighting.
 Cleaning work orders have been issued to food contractors to
perform cleaning work in the last 3 days.
10/22/2015

31.  Notice under Section 32B for not complying with regulation 34
(Regulation of Food Hygiene Regulations 2009)
 Canteen food premises inspections on DTS Langkap was
conducted by Quality Food Quality Control Unit on the same
day 31.12.2014. Rating obtained was 65.6%.
 Food handlers received Typhim injection. Cleaning work orders
were issued to the canteen.
10/22/2015

32. 6.ENVIRONMENT SAMPLING SWAB
 A total of nine environmental swabs were taken at the DTS Langkap
kitchen appliances cooking by the Food Safety and Quality Unit PKD
Hilir Perak and results were negative.
 A total of 11 water samples were taken in all the blocks and by the
Drinking Water Quality Control Unit PKD Hilir Perak and results were
negative.
10/22/2015

33. 7.TYPHIM INJECTION
 Typhim injections were given to all food handlers who did not
manage to prove the facts as follows injection ( control group
meals until December 2015 ) :
 Costs paid by food contrators.
10/22/2015

34. 8.HEALTH EDUCATION
 Health education carried out by members of the medical team that
goes conduct screening and examination at each visit . Health
education is carried out with the assistance of an interpreter (
illegal immigrants ) who can speak Malay.
10/22/2015

35. 9.MONITOR
 Monitoring and daily report.
 Typhoid epidemic monitoring carried out up to 56 days of the date
of the last case. Daily reports were sent to the Department of State
Health by Unit Office CD Health Hilir Perak .
 Ongoing monitoring is carried out by members of the DTS
Langkap Health clinic . Declared the outbreak ended on
16/03/2015 .
10/22/2015

36. 10.Mass Drug Administration (Direct Observe
Treatment Service)
 MDA for DOTS using T. Ciprofloxacin was conducted through 2
stages to ensure that all vulnerable cases received treatment for
breaking the chain of infection.
 DOTS method is controlled by an assistant medical officer KK
Langkap under observation Epidemiology or Medical Officer.
 MDA entire duration of treatment (DOTS) has been running
smoothly. No side effects / adverse drug reaction is detected
among the recipients of the treatment.
10/22/2015

37. •Control of the outbreak has been a success
• Mass Drug Administration = T. Ciprofloxacin
500mg BD x 1/52-26.1.2015
•
•Chemotheraphy was given on 2 levels
–first group to receive MDA on 26.1.2015 -1.2.2015
–consist of 1403 detainee
–all the detainee receive the treatment in the morning
and the evening
–second group to receive MDA on 2.2.2015-8.2.2015
–consist of 89 detainee( newly admitted detainee)
–all the MDA treatment have been a success, no
adverse drug reaction detected
lOutbreak outcome

38. Something To Ponder About
These outbreak primarily originates from the illegal immigrants that continues to infect the
Malysian citizen who are working at the depot thus :
Should we provide proper healthcare to immigrants ???
Enhance screening activities among immigrants ??
Allocate proper depot & food for illegal immigrants ?? … Is it worth the investment ?? …
They are still human beings...

39. Preventive measures
Primary
 Keep nails short and wash your hand after a trip to a toilet (Prevent Fecal-Oral
transmission)
 Avoid raw fruits and vegetables
 Vaccinations for food handlers
 Regular inspection of food premises
Secondary
 Typhidot
 Widal Test
 Screening test for food handlers
Tertiary
 Quarantine
 Antibiotic Ciprofloxacin (Cipro),Ceftriaxone (Rocephin)

40. References
1)LAPORAN AKHIR WABAK TFOID DI DEPOH TAHANAN prepared by
DR. ABDULLOH BIN MAZALAN PEG. EPIDEMIOLOGI II (PEG. PERUBATAN/KESIHATAN UD 48)
PEJ KES HILIR PERAK
1)Trip to the immigration depot
2)Health Inspector En. Azhar & PKD Hilir Perak
THANK YOU