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    1 : Dr. Priyamadhaba Behera References WHO Document, 5th edition OTPH, 18th edition Harrison principle of medicine, Articles however applicable 1 Enteric Fever
    2 : Epidemiology Etiologic agents of enteric fever S. typhi and S. paratyphi serotypes A, B, and C No known hosts other than humans Estimated 22 million cases, with 200,000 deaths annually Incidence
    3 : Epidemiology
    4 : Epidemiology Multidrug-resistant (MDR) strains of S. Typhi emerged in 1989 in China and southeast Asia Resistance to chloramphenicol, ampicillin and trimethoprim antibiotics long used to treat enteric fever Increased use of fluoroquinolones to treat MDR enteric fever in 1990s, reduced susceptibility to ciprofloxacin [MIC, 0.125–1 g/ml] have emerged in the Indian subcontinent, southern Asia Resistance - first-generation Quinolone nalidixic acid detects most but not all strains with reduced susceptibility to ciprofloxacin
    5 : Disease Outbreak Reported 17 June 2003 (Haiti) As of 30 May, 200 cases and 40 deaths, reported by WHO regional office for the Americas (PAHO) and the MoH, Haiti Epidemic started in April in villages in the Grand Bois area, bordering the Dominican Republic 15 December 2004 (Kinshasa) Total of 13400 cases were reported Between 1st October and 10th December 2004, 615 severe cases with peritonitis, with or without perforation, including 134 deaths (case fatality rate, 21.8%) have occurred 19 January 2005 From 27 September 2004 - 11 January 2005, WHO reported total of 42564 cases and 214 deaths (case fatality ratio, 0.5%), and 696 severe cases of intestinal perforation in Kinshasa Very poor sanitary conditions and a lack of drinking water have been reported in all these areas
    6 : Mode of transmission Most commonly, food-borne or waterborne Faecal contamination by ill or asymptomatic chronic carriers Health care workers -exposure to infected patients or during processing of clinical specimens and cultures Sexual transmission between male partners has been described
    7 : Role of asymptomatic carrier in typhoid George Soper Dr. Sara Josephine Baker
    8 : Risk factors Contaminated water or ice Flooding Contaminated food and drinks Raw fruits and vegetables grown in fields fertilized with sewage Lack of hand washing and toilet access Evidence of prior helicobacter pylori infection
    9 : Risk factors Severe disease ( 10–15% of patients) Host factors (immunosuppression, antacid therapy, previous exposure, and vaccination) Strain virulence and inoculums Choice of antibiotic therapy Incubation period 3 - 21 days (average 10-14 days)
    10 : Symptoms Enteric fever is a misnomer Hallmark features of this disease—fever and abdominal pain—are variable Fever >75% of cases, abdominal pain is reported in only 30–40%
    11 : Symptoms Sytemic symptoms Headache (80%) Chills (35–45%) Cough (30%) Sweating (20–25%) Myalgias (20%) Malaise (10%) Arthralgia (2–4%)
    12 : Symptoms Gastrointestinal symptoms Anorexia (55%) Abdominal pain (30–40%) Nausea (18–24%) Vomiting (18%) Diarrhea (22–28%) Constipation (13–16%) 2nd week
    13 : Signs Relative bradycardia Coated tongue (51–56%) Splenomegaly (5–6%) Abdominal tenderness (4–5%) Rose spots (30%) End of the first week and resolves without a trace after 2–5 days Two or three crops of lesions Salmonella can be cultured from punch biopsies of these lesions Faintness of rash makes difficult to detect in highly pigmented patients
    14 : Investigations Definitive diagnosis of enteric fever by isolation of S. Typhi or S. Paratyphi from blood, bone marrow, other sterile sites, rose spots, stool, or intestinal secretions Serologic tests- widal test ?Timing of test is important ?Single test is usually of not much value ?Baseline titre of the population must be known before attaching significance to the titres (=100 for O and =200 for H) Treated with antibiotics may not show any rise False positive reactions Anamnestic response ??
    15 : Investigations None of these tests is sufficiently sensitive or specific to replace culture-based methods for the diagnosis PCR and DNA probe assays to detect S. typhi in blood have been identified but have not yet been developed for clinical use
    16 : Treatment
    17 : Control Health education about personal hygiene, especially regarding hand-washing after toilet use and before food preparation Provision of a safe water supply Proper sanitation systems Excluding disease carriers from food handling
    18 : Control Possible to eliminate enteric fever since they survive only in human hosts and spread by contaminated food and water High prevalence of the disease in developing countries that lack adequate sewage disposal and water treatment, goal is currently unrealistic Travelers to developing countries should be advised to monitor their food and water intake carefully and to consider vaccination
    19 : Typhoid vaccines Two typhoid vaccines are commercially available . Currently, there is no licensed vaccine for paratyphoid fever Ty21a Oral live attenuated S. Typhi vaccine Days 1, 3, 5, and 7, with a booster every 5 years Minimal age for vaccination is 6 years
    20 : Typhoid vaccines Vi CPS Parenteral vaccine consisting of purified vi polysaccharide from the bacterial capsule Given in 1 dose, with a booster every 2 years Minimal age for vaccination is 2 years Meta-analysis of vaccine trials comparing whole-cell vaccine, ty21a, and vi CPS in populations in endemic areas indicates All three vaccines are similarly effective for the first year 3-year cumulative efficacy of the whole-cell vaccine (73%) exceeds both ty21a (51%) and vi CPS (55%)
    21 : Typhoid vaccine is not required for international travel, but recommended for travellers to moderate to high risk areas (Asia, Africa, the Caribbean, and Central and South America) Typhoid vaccine should be considered even for persons planning <2 weeks of travel to high-risk areas laboratory workers who deal with S. typhi and household contacts of known S. typhi carriers Immunization is not recommended for adults residing in typhoid-endemic areas or for the management of persons who may have been exposed in a common-source outbreak Typhoid vaccines

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