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S. Typhi Investigation Chattanooga, TN 2009

This case study examines a typhoid fever outbreak in Chattanooga, Tennessee in 2009, highlighting the epidemiology, transmission, symptoms, and investigation results. Lessons learned and recommendations for future outbreaks are also discussed.

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S. Typhi Investigation Chattanooga, TN 2009

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  1. S. Typhi InvestigationChattanooga, TN 2009 Chattanooga-Hamilton County Epidemiology Department

  2. S. Typhior Typhoid Fever • Gram-negative bacilli • Humans only reservoir • Contaminated food/water or person to person • Incubation 7-14 days (range 3-60) • Fever, abd. pain, malaise • (diarrhea, rash, hepato/splenomegaly) • Potentially fatal Image courtesy of the Centers for Disease Control and Prevention

  3. Epidemiology & Surveillance • Worldwide incidence highest in: • South & East Asia • Africa • Central & South America • 22 million cases with 200,000 deaths per year • ~ 1% of adults may become chronic carriers

  4. Source: PHLIS Surveillance Data, 2006

  5. TN Incidence, 2005 - 2010 • 15 cases – MSR 5, CHR 5, NDR 2, MCR 1, SER 1, SUL 1 • Median age 23, female 8, male 7 • 10 cases associated with foreign travel • 14 cases hospitalized, 0 deaths

  6. CHR Outbreak 2009 • 3 cases April 28 – June 3 • Children ages 2-6 • Fever, abdominal pain, h/a, diarrhea (2) • No recent travel history • Worked with 6 household contacts, 20 school contacts

  7. Case A • 4-19 2 y/o child with fever, abdominal pain, diarrhea • 4-20 appendectomy • 4-23 stool specimen collected • 4-28 salmonella + stool • 5-5 serotype S. typhi+ • No obvious exposures identified

  8. Case B • 5-12 2 y/o child with fever, abdominal pain, vomiting, diarrhea • 5-16 blood culture + S. typhi • 5-16 to 5-19 hospitalized and treated • No obvious exposures • No connection to case A??

  9. Case C • 5-17 6 y/o child with fever, chills, headache sibling of case A • 5-29 stool + salmonella • 6-3 serotype S. typhi

  10. Contact Investigation • Initial interviews did not reveal a connection • 5-26 home visits with interpreter to Case A & Case B • Mothers of the cases are sisters • No illness except in sibling • 3 adults in each household, deny recent travel • All agreed to submit clinical specimens

  11. Contact Investigation • Case C attended kindergarten while ill • 18 of 20 school contacts were interviewed for illness • All received a certified letter by mail • 1 child evaluated for febrile illness

  12. Medical Provider Communication

  13. Media avoidance on a Friday afternoon was unsuccessful!

  14. Investigation Results • PFGE pattern of the cases revealed a rare serotype not seen since 2007 • 6 adult contacts tested negative for salmonella in stool and negative IgM in blood • 2 adult males tested + for antibody to S. typhi Vi antigen • Carriers were treated to eradicate S. typhi • No contacts in high risk occupations

  15. Case/Carrier Relationships

  16. Conclusions & Lessons Learned • Consider chronic carrier in cases with no travel hx or association with others who have traveled • Epi links are hard to find initially • Utilizing interpreter with similar culture may yield better results • Although no recent travel was identified, most foreign born are not vaccinated prior to travel • Providers do not normally include typhoid in differential diagnosis if no travel identified

  17. Thank you

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