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Public Health Operational Guidelines for Typhoid and Paratyphoid (Enteric Fever)
Case Studies
Typhoid and Paratyphoid Reference Group (TRPG)10th February 2012
Contact Person:Sarah.addiman@hpa.org.uk
Case study groups
•Split into 4/5 groups (colour coded dots on badges)
•Each group has a facilitator
•Group work divided into two sessions, each consisting of two/three cases studies
•Groups to:-
Nominate a chair and a note taker Utilise the new guidance to work through common scenarios Take the opportunity to systematically work through the scenarios utilising
the algorithms at every stage Discuss and agree on the recommended course of action for case and
contact management Record key discussion points/issues/questions as they arise on the flipchart Feed back to the main group discussion on particular issues which arose
during the group work
Outline of session
Case Studies Part 2 1130 –1230
1015 - 1115
Scenario 1 •Maximum of 20 mins for each scenario
•Utilise guidance and use the algorithms
•Record on the flip chart key points or issues
Scenario 2
Scenario 3
11.15-11.30 coffee
Case Studies Part 2 1130 –1230
1130 hrs Scenario 1 •Maximum of 20 mins for each scenario
•Utilise guidance and use the algorithms
•Record on the flip chart key points or issues1150 hrs Scenario 2
1210 hrs 15-20 minute discussion with all groups
Facilitated by Sooria
Scenarios
Case Scenario 1
Case
• 89 year old British born lady• Resident in a care home for 3 years• Has dementia and is doubly incontinent (wears pads: ‘managed’ incontinence)• S paratyphi B isolated from a stool specimen sent because of diarrhoea• No recent travel • On investigation, GP notes reveal microbiologically confirmed paratyphi infection in
1960
Contacts
• Large care home with catering and care staff from countries where paratyphoid is endemic
• All staff wear gloves when dealing with incontinence• Currently not aware of any staff with symptoms or diagnosed with paratyphoid• Other care home residents have occasionally had stools sent for clinical reasons but
none with S paratyphi identified
Case Scenario 1:
Public health risk assessment and management1a)
1b)
1c)
Q2. Consider if in risk group?
Action for case
Q3. Travel history?
Q4. Possible source identified?
Action for contacts
Other considerations?
ALGORITHMS
Q1a) is this a possible, probable or confirmed case of enteric fever?
1b) is the case symptomatic?
1c) is the case aware of anyone else with the
same symptoms
Q2.
Is the case in a risk group or do they
undertake risk activities?
Q3.
Is the infection likely to be travel-related?
Q4.
Does the initial risk assessment identify the
likely source of infection?
Case Scenario 2 (Part 1)
Case
• IT professional• Symptoms of typhoid, confirmed on blood culture• Returned from travel to an endemic area 28 days ago
Contacts
• Travelled with his girlfriend, who does not live with him • Lives with 3 other men in a flat share (does not want to reveal diagnosis to
household contacts). They normally cook for each other and one is a cook• Case volunteers in a religious temple where he may occasionally have to
undertake food-handling duties• Case does not know anyone who has had similar symptoms or who has travelled
recently apart from himself and his girlfriend
[Parts 2 and 3 on subsequent slides]
Case Scenario 2 (Part 1):
Public health risk assessment and management1a)
1b)
1c)
Q2. Consider if in risk group
Action for case
Q3. Travel history?
Action for contacts
Q4. Possible source identified
OTHER: see Parts 2 and 3 on the following slides…………
ALGORITHMS
Q1a) is this a possible, probable or confirmed case of enteric fever?
1b) is the case symptomatic?
1c) is the case aware of anyone else with the
same symptoms
Q2.
Is the case in a risk group or do they
undertake risk activities?
Q3.
Is the infection likely to be travel-related?
Q4.
Does the initial risk assessment identify the
likely source of infection?
Case Scenario 2 (Part 2)
SCENARIO Part 2
• Following the warn and inform letter, a member of the household subsequently develops symptoms and typhoid infection is microbiologically confirmed
• Onset: day 56 post the index case’s return from travel• Housemate is not a food handler
what further action to take?
ALGORITHMS
Q1a) is this a possible, probable or confirmed case of enteric fever?
1b) is the case symptomatic?
1c) is the case aware of anyone
else with the same symptoms
Q2.
Is the case in a risk group or do
they undertake risk activities?
Q3.
Is the infection likely to be travel-
related?
Q4.
Does the initial risk assessment
identify the likely source of infection?
Case Scenario 2 (Part 3)
SCENARIO Part 3
• Index case found to still be positive, despite now being asymptomatic • Index case was compliant with antibiotics of appropriate sensitivity• No other members of household positive on screening
what further action to take?
ALGORITHMS
Q1a) is this a possible, probable or confirmed case of enteric fever?
1b) is the case symptomatic?
1c) is the case aware of anyone
else with the same symptoms
Q2.
Is the case in a risk group or do
they undertake risk activities?
Q3.
Is the infection likely to be travel-
related?
Q4.
Does the initial risk assessment
identify the likely source of infection?
Case Scenario 2 (Part 2 & 3):
Public health risk assessment and management
Part 2: For the newly identified case:
1a)
1b)
1c)
Q2. Consider if in risk group
Action for the new case
Q3. Travel history?
Q4. Likely source identified?.
Action for contacts
Part 3: Following on from index case’s positive sample:
Action for index case
ALGORITHMS
Q1a) is this a possible, probable or confirmed case of enteric fever?
1b) is the case symptomatic?
1c) is the case aware of anyone else with the
same symptoms
Q2.
Is the case in a risk group or do they
undertake risk activities?
Q3.
Is the infection likely to be travel-related?
Q4.
Does the initial risk assessment identify the
likely source of infection?
Case Scenario 3 (Part 1)
Case
• 8 year old child • Symptomatic, confirmed as having s.paratyphi in a blood culture. • No travel history • No previous history of enteric fever• No known contact with case or those with recent travel history or foreign visitors from
endemic areas • Limited social activity in two weeks prior to illness
Contacts
• Mother had fever onset 11 days after the onset of sons illness: referred to GP for investigation and clinical management.
• Mother is housewife
Case Scenario 3 (Part 1):
Public health risk assessment and management
1a)
1b)
1c)
Q2. Consider if in risk group.
Action for case:
Q3. Travel history?
Q4. Likely source identified?
Action for contacts:
OTHER: see Parts 2 and 3
ALGORITHMS
Q1a) is this a possible, probable or confirmed case of enteric fever?
1b) is the case symptomatic?
1c) is the case aware of anyone else with the
same symptoms
Q2.
Is the case in a risk group or do they
undertake risk activities?
Q3.
Is the infection likely to be travel-related?
Q4.
Does the initial risk assessment identify the
likely source of infection?
Case Scenario 3 (Part 2)
SCENARIO Part 2:
• Mother admitted to hospital overnight with her onset of symptoms commencing 11 days after the onset of symptoms in the index case (child)
• Her blood culture negative
• Her screening faecal sample taken by the EHO subsequently found to be positive
• Due to onset of symptoms for s.paratyphi, more likely to be a secondary case or carrier status
• Mother does not work, is at home during the day
what further action to take?
Case Scenario 3 (Part 2):
Public health risk assessment and management
PART 2: For the newly identified case:
1a)
1b)
1c)
Q2. Consider if in a risk group.
Action for case
Q3. Travel history?
Action for contacts
Q4. Likely source identified?
ALGORITHMS
Q1a) is this a possible, probable or confirmed case of enteric fever?
1b) is the case symptomatic?
1c) is the case aware of anyone else with the
same symptoms
Q2.
Is the case in a risk group or do they
undertake risk activities?
Q3.
Is the infection likely to be travel-related?
Q4.
Does the initial risk assessment identify the
likely source of infection?
Case Scenario 3 (Part 3)
SCENARIO Part 3
• On further investigation mother admitted to being a child minder due to commence looking after <1 year old the following week
• Performed the school run and after school care for three children 5, 8 and 10 years in her own home
• These children had been at the home when the index case (boy) and mother were symptomatic
what further action to take?
Case Scenario 3 (Part 3):
Public health risk assessment and management
Part 3: As a result of new information about risk group:
Q2. Consider if in risk group.
Action for case
Q3. Travel history?
Q4. Likely source identified?
Action for contacts
Other considerations?
ALGORITHMS
Q2.
Is the case in a risk group or do they undertake risk activities?
Q3.
Is the infection likely to be
travel-related?
Q4.
Does the initial risk assessment identify the likely
source of infection?
Case Scenario 4a
Case
• An individual had a typhoid like illness abroad whilst travelling in an endemic area. • He has since fully recovered and returned to the UK. • He is not in a risk group.
Contacts
• He did not travel with anyone• There are some household contacts, but no-one has symptoms
Part 2:
What actions would be taken if a stool sample comes back as positive for typhoid?
Part 3:
What action would be taken if the case reports having antibiotics to treat his infection whilst overseas? He is unsure of the name of the antibiotics.
Case Scenario 4a:
Public health risk assessment and management
1a)
1b)
1c)
Q2. Consider if in risk group:
Action for case
Q3. Travel related?
Action for contacts
.
Q4. Likely source identified
Part 2:.
Part 3:
ALGORITHMS
Q1a) is this a possible, probable or
confirmed case of enteric fever?
1b) is the case symptomatic?
1c) is the case aware of anyone else with the same symptoms
Q2.
Is the case in a risk group or do they undertake risk
activities?
Q3.
Is the infection likely to be travel-related?
Q4.
Does the initial risk assessment identify the likely source of
infection?
Case Scenario 4b
Case
• An individual had a typhoid like illness abroad whilst travelling in an endemic area. • He has since fully recovered and returned to the UK.
• He is in a risk group. Works in a restaurant.
Contacts
• He did not travel with anyone• There are some household contacts, but no-one has symptoms
Part 2:
What actions would be taken if a stool sample comes back as positive for typhoid?
Part 3:
What action would be taken if the case reports having antibiotics to treat his infection whilst overseas? He is unsure of the name of the antibiotics.
Case Scenario 4b:
Public health risk assessment and management
1a)
1b)
1c)
If sample returns as positive:
Q2. Consider if in risk group:
Action for case:
Q3. Travel related:
Action for contacts:
OTHER:
ALGORITHMS
Q1a) is this a possible, probable or
confirmed case of enteric fever?
1b) is the case symptomatic?
1c) is the case aware of anyone else with the same symptoms
Q2.
Is the case in a risk group or do they undertake risk
activities?
Q3.
Is the infection likely to be travel-related?
Q4.
Does the initial risk assessment identify the likely source of
infection?
Case Scenario 4c
Work risk assessment
• Risk assessment performed at the restaurant by the environmental health team.• Restaurant is in a different Borough to where the case resides.• Decision taken that the case cannot be redeployed and will require exclusion
Part 4: Who will exclude the case?
How will the process be managed (formally and informally)?
Case Scenario 4c:
Informal action:
Formal action:
Case Scenario 5
Case
• Trainee cook returns from travel to an endemic area 28 days ago with ongoing symptoms of typhoid.
• Presents to GP, and a blood culture confirms typhoid. • He has been cooking at a local restaurant, including whilst symptomatic.
Contacts
• Case lives with 12 other men in a halls of residence: kitchen and bathroom facilities are shared
• Case does not want to reveal his diagnosis to his household contacts but advises that some of his friends are also working in the catering industry.
• He has been regularly cooking for his friends, 3 of which live in the halls of residence but 4 of which often dine with him but live in other residences.
• He also stays with his family at weekends who live elsewhere. • Not aware of anyone else who has similar symptoms.
Case Scenario 5:
Public health risk assessment and management1a)
1b)
1c)
Q2. Consider if in risk group:
Action for case
Q3. Likely to be travel related:
Action for contacts
Q4. Likely source identified?
ALGORITHMS
Q1a) is this a possible, probable or
confirmed case of enteric fever?
1b) is the case symptomatic?
1c) is the case aware of anyone else with the same symptoms
Q2.
Is the case in a risk group or do they undertake risk
activities?
Q3.
Is the infection likely to be travel-related?
Q4.
Does the initial risk assessment identify the likely source of
infection?
Case Scenario 6a
Case
• Confirmed typhoid in a individual who travelled within 28 days of onset.
• Works as a surgeon, and operates on immuno-compromised patients
• He was at work whilst symptomatic
• Occupational Health at the hospital where he works insists he should be excluded but he insists he can be redeployed doing admin duties.
Contacts
• Unclear from initial notification whether he travelled alone
Case Scenario 6a:
Public health risk assessment and management1a)
1b)
1c)
Q2. Consider if in risk group:
Action for case
Q3. Likely to be travel related?
Action for contacts
Q4. Likely source identified?
ALGORITHMS
Q1a) is this a possible, probable or confirmed case of enteric fever?
1b) is the case symptomatic?
1c) is the case aware of anyone else with the
same symptoms
Q2.
Is the case in a risk group or do they
undertake risk activities?
Q3.
Is the infection likely to be travel-related?
Q4.
Does the initial risk assessment identify the
likely source of infection?
Case Scenario 6b
Case
• Confirmed typhoid in a individual who travelled within 28 days of onset.
• Case works as a nursery nurse and was at work whilst symptomatic
• Nursery nurse role involves handling food for small children.
Contacts
• Unclear from initial notification whether she travelled alone
Case Scenario 6b:
Public health risk assessment and management1a)
1b)
1c)
Q2. Consider if in risk group:
Action for case
Q3. Likely to be travel related:
Action for contacts
Q4. Likely source identified?
ALGORITHMS
Q1a) is this a possible, probable or confirmed case of enteric fever?
1b) is the case symptomatic?
1c) is the case aware of anyone else with the
same symptoms
Q2.
Is the case in a risk group or do they
undertake risk activities?
Q3.
Is the infection likely to be travel-related?
Q4.
Does the initial risk assessment identify the
likely source of infection?
Case Scenario 7
Case
• 30 year old man, unemployed and sometimes homeless• Confirmed typhoid, acute symptoms• Lived in an endemic area for number of years prior to entry to UK 7 years ago.
No travel abroad since.• Does not admit previous history of enteric fever• Heavy drinker of alcohol, spends most of time on street corners drinking and has
developed renal failure.• Eats mainly take-away (although some query regarding this, as he is known to be
destitute).• Not compliant with outpatient treatment
Contacts
• Has stayed in several locations including homeless hostel but minimal contact with hostel residents
• No known other cases linked to hostel• Difficult to identify any contacts let alone those with a travel history
Case Scenario 7:
Public health risk assessment and management1a)
1b)
1c)
Q2. Consider if in risk group
.
Action for case
Q3.Travel history
Action for contacts
Q4. Possible source identified
Other considerations?
ALGORITHMS
Q1a) is this a possible, probable or confirmed case of enteric fever?
1b) is the case symptomatic?
1c) is the case aware of anyone else with the
same symptoms
Q2.
Is the case in a risk group or do they
undertake risk activities?
Q3.
Is the infection likely to be travel-related?
Q4.
Does the initial risk assessment identify the
likely source of infection?
Prepared by the secretariat on behalf of the Typhoid and Paratyphoid Reference Group
Amelia Cummins - Consultant in Communicable Disease Control, Essex HPU, HPA
Amy Potter (Secretariat) - Public Health Specialty Registrar, NENCLHPU/ South East Regional Epidemiology Unit, HPA
Bob Adak - Head of Gastrointestinal Infections, Gastrointestinal Emerging and Zoonotic Infections Department, HPA
Chris Lane - Head of Salmonella Surveillance, Gastrointestinal Emerging and Zoonotic Infections Department, HPA
Dave Tolley - Environmental Health Commercial and Corporate Health & Safety Service Manager, London Borough of Tower Hamlets
Delphine Grynszpan (Secretariat) - Consultant in Communicable Disease Control, NW London, HPA
Ian Gray - Principal Policy Officer, Chartered Institute of Environmental Health
Jane Jones - Consultant Epidemiologist, Travel and Migrant Health Section, HPA
Joanne Lawrence - Surveillance Scientist, Travel and Migrant Health Section, HPA
Kathy Nye - Consultant Microbiologist and National Clincal lead for Gastrointestinal infections for HPA Microbiology services, HPA
Keith Neal - Consultant in Health Protection, East Midlands HPU, HPA
Leena Inamdar - Consultant in Communicable Disease Control/Regional Epidemiologist, Yorkshire & the Humber HPU, HPA
Linda Booth - Consultant in Communicable Disease Control, Hampshire & Isle of Wight HPU, HPA
Lorraine Lighton - Consultant in Communicable Disease Control, Greater Manchester, HPU, HPA
Sarah Addiman (Secretariat) - Nurse Consultant, NENC London HPU, HPA
Sooria Balasegaram (Chair) - Regional Epidemiologist, South East Regional Epidemiology Unit, HPA
Ron Behrens - Infectious Disease Consultant, London School of Hygiene & Tropical Medicine, and University College London, Hospital for Tropical Diseases
Steve Barlow - Team Leader, Food and Environmental Safety, Wolverhampton City Council
TRPG Membership: