Wednesday, February 06, 2013

Indiana Reports Rare Typhoid Infection



Photo Credit NHS 


# 6910



Somewhat synchronistically, It was just a week ago that I briefly mentioned the infamous and sad story of `Typhoid’ Mary Mallon (see Influenza Transmission, PPEs & `Super Emitters’).


Mallon was a cook and housekeeper in the early part of the last century, who also happened to be an asymptomatic carrier of Typhoid bacteria. Over the years she infected scores of others, never really accepting that she was responsible. 


In 1910, after several years in quarantine she was released with her promise never to work again as a cook. In 1915 an investigation into another typhoid outbreak led to her once again, where they found her working under an assumed name, as a cook.


She spent  nearly 3 decades of her life in involuntary quarantine in a cottage on the grounds of Riverside Hospital on North Brother Island in the East River, New York City.


While still common in some developing countries, Typhoid fever is rarely seen today in the United States. The CDC’s Typhoid Fever FAQ states the U.S. sees only about 400 cases of Typhoid each year, of which 3/4ths are brought into this country via international travel. 


Fortunately - unlike in Typhoid Mary’s day - we have antibiotics to treat this often persistent Salmonella bacterial infection.


Deaths from Typhoid Fever (not to be confused with Typhus, which is a Rickettsia bacterial infection carried by lice, fleas or ticks), have declined greatly since the chlorination of water supplies in industrialized nations began early in the last century, along with the development of antibiotic treatments. 




Yesterday it was announced that a case of Typhoid has been detected in a food service worker at a restaurant at Purdue University. 


First the press release from the Indiana Health Department, then I’ll come back with more.


State Health Officials Investigating Typhoid Fever Case at Purdue University

Start Date: 2/5/2013 12:00 AM

INDIANAPOLIS—State health officials announced today a positive case of typhoid fever in a food handler at Purdue University. Local health officials and Purdue University are working with the Indiana State Department of Health to investigate the case and assess the risk to the public.


Anyone who ate at the Boiler Bistro, John Purdue Room, or the coffee shop, Lavazza, at Marriott Hall on the Purdue campus from Jan. 23 to Jan. 25, 2013, may be at risk. Health officials advise these individuals to see a healthcare provider right away if they start to experience symptoms such as a high fever (103° to 104° F), weakness, stomach pains, headache, nausea, vomiting, diarrhea, or loss of appetite. In some cases, a rash of flat, rose-colored spots may appear. Symptoms usually begin within 8-14 days after exposure, but could potentially appear for up to 30 days.


“Unfortunately, symptoms of typhoid fever can resemble other illnesses, so for those individuals who may have been exposed, it’s critical to see healthcare provider right away if you begin to experience symptoms,” said State Health Commissioner William VanNess II, M.D. “Be sure to tell your physician that you may have been exposed to typhoid fever.”


People are at risk of typhoid fever if they eat food or drink beverages that have been handled by someone who has Salmonella Typhi or if sewage contaminated with the bacteria gets into the water used for drinking or washing food. Typhoid fever is more common in areas where hand washing is less frequent and water can be contaminated with sewage.


The only way to know if an illness is typhoid fever is to have samples of stool or blood tested for the presence of Salmonella Typhi bacteria. If you suspect you have typhoid fever, do not prepare any food or drink for anyone or care for young children or hospitalized patients.


Typhoid fever is a life-threatening illness caused by the bacterium Salmonella Typhi. In the United States, approximately 400 cases of Typhoid fever occur each year with 75 percent of these acquired while traveling internationally. Typhoid fever is still common in the developing world, where it affects about 21.5 million persons each year. The case being investigated recently traveled internationally and this is where the infection was acquired.


Even if symptoms disappear, people can still carry Salmonella Typhi, and the illness could return or could be passed on to other people. Typhoid fever can be successfully treated with appropriate antibiotics and persons given antibiotics usually begin to feel better within two to three days. Deaths rarely occur; however, persons who do not get treatment may continue to have fever for weeks or months. If left untreated, typhoid fever may be fatal.


For more information about typhoid fever, visit To visit the Indiana State Department of Health, go to



Salmonella Typhi, the causative agent of Typhoid Fever, is a bacterium that has no known natural reservoir outside of humans. It is usually acquired via the fecal-oral route, often by consuming food or drink that has been handled by someone who is shedding the Salmonella Typhi bacteria.


The NCEZID (National Center For Emerging and Zoonotic Infectious Diseases lists the clinical features of infection:


Typhoid fever has an insidious onset characterized by fever, headache, constipation, malaise, chills, and myalgia with few clinical features that reliably distinguish it from a variety of other infectious diseases.

Diarrhea is uncommon, and vomiting is not usually severe. Confusion, delirium, intestinal perforation, and death may occur in severe cases. The etiologic agent may be recovered from the bloodstream or bone marrow, and occasionally from the stool or urine.


Of course, not everyone gets sick who contracts this bacteria, and some people can shed the pathogen for months or years asymptomatically.


The CDC’s MMWR Summary of Notifiable Diseases — United States, 2010 provides this overview.


Typhoid Fever

Typhoid fever is rare in the United States, and approximately 75% of cases are associated with international travel (1). The risk of infection is highest for international travelers visiting friends and relatives in countries where typhoid fever is endemic, perhaps because they are less likely than other travelers to seek pre-travel vaccination and to observe strict safe water and food practices.The risk also is higher for travelers who visit the most highly endemic areas, such as the Indian subcontinent, even for a short time (2).

From 1960 through 1999, a total of 60 outbreaks of typhoid fever were reported in the United States (3). The first domestically acquired outbreak of typhoid fever in over a decade occurred in 2010. Twelve cases were identified, and illness was linked to consumption of imported frozen mamey fruit. Mamey from the same producer in Guatemala also was implicated in the previous domestic typhoid fever outbreak, which occurred in 1999 (4).



And finally, some advice for those planning a trip to areas where Typhoid Fever remains endemic, again from the CDC Typhoid FAQ.


How can you avoid typhoid fever?

Two basic actions can protect you from typhoid fever:

  1. Avoid risky foods and drinks.
  2. Get vaccinated against typhoid fever.

It may surprise you, but watching what you eat and drink when you travel is as important as being vaccinated. This is because the vaccines are not completely effective. Avoiding risky foods will also help protect you from other illnesses, including travelers' diarrhea, cholera, dysentery, and hepatitis A.


"Boil it, cook it, peel it, or forget it"
  • If you drink water, buy it bottled or bring it to a rolling boil for 1 minute before you drink it. Bottled carbonated water is safer than uncarbonated water.
  • Ask for drinks without ice unless the ice is made from bottled or boiled water. Avoid popsicles and flavored ices that may have been made with contaminated water.
  • Eat foods that have been thoroughly cooked and that are still hot and steaming.
  • Avoid raw vegetables and fruits that cannot be peeled. Vegetables like lettuce are easily contaminated and are very hard to wash well.
  • When you eat raw fruit or vegetables that can be peeled, peel them yourself. (Wash your hands with soap first.) Do not eat the peelings.
  • Avoid foods and beverages from street vendors. It is difficult for food to be kept clean on the street, and many travelers get sick from food bought from street vendors.

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