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Public Health Operational Guidelines for Typhoid and Paratyphoid (Enteric Fever)
Case Studies with worked examples
Typhoid and Paratyphoid Reference Group (TRPG)February 2012
Contact Person:[email protected]
Major changes from previous guidance for the public health management of enteric fever
• Algorithms to aid comprehensive risk assessment of case, including likely source of infection and risk of onward transmission
• Emphasis on investigation of source of infection for cases unlikely to be travel acquired
• Simplified microbiological clearance schedules for cases/contacts• audit data shows declining rate of positives as number of samples increases • relatively low risk of onward transmission if exclusion and hygiene advice given
• Targeted co-traveller screening and utilisation of ‘Warn and Inform’ approach for other contacts, unless symptomatic
• Management of convalescent and chronic carriers
Case definitions
Possible case A person with a clinical history compatible with enteric fever and where the clinician suspects typhoid or
paratyphoid as the most likely diagnosis.
A person with clinical history of fever and malaise and /or gastrointestinal symptoms with an epidemiological link to a source of enteric fever, e.g. from “warn and inform” information.
A returning traveller reporting a diagnosis abroad with NO documented evidence of blood or faecal culture, or confirmation with serological testing alone.
Probable case
Local laboratory presumptive identification of Salmonella Typhi or Paratyphi on faecal or blood culture, with or without a clinically compatible history.
A returning traveller giving a clinical history compatible with enteric fever and with documentation of a positive blood/faecal culture and/or treatment for enteric fever overseas.
Confirmed case A person with S.Typhi or S. Paratyphi infection determined by the Health Protection Agency (HPA)
Laboratory of Gastrointestinal Pathogens, Salmonella Reference Unit (SRU).
A person with documented evidence from a recognised overseas reference laboratory.
Travel related case A case who develops symptoms of enteric fever within 28 days* of travel to an endemic region of the
world.
Algorithm 2.1 Question 1: Public health management of cases & contacts
Algorithm 2.1 Question 2: Public health management of cases & contacts
Algorithm 2.1 Question 3: Public health management of cases & contacts
Public health management of cases & contacts of non travel related cases
Algorithm 2.1Question 4:
Algorithm 2.2:
Public health management of cases with positive screening/clearance samples and those with previous documented history of enteric fever or identified through screening
SCENARIOS
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
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
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 1: worked example
Public health risk assessment and management1a) probable case of Paratyphi B, but need to be aware it may be an s.java
1b) diarrhoea (therefore exclude until 48 hours after symptoms)
1c) no-one else with similar symptoms
Q2. Consider if in Risk Group A? Potentially, BUT question to be asked is “is she at risk of passing the infection onto the other residents?” She is incontinent, but faeces is managed by staff who should have good personal hygiene / PPE. Hence case is not judged to have risk activities
Action for case: No clearance. Hygiene, Warn and Inform. Investigate other infective causes of diarrhoea e.g. norovirus, C. diff etc. At early stage, discuss with Consultant HPA Microbiologist.
Q3. No recent travel identified
Q4. Possible source identified. Previous documented history of enteric fever (need to check if same sub-type) therefore source of infection assumed to be long term carrier state.
Action for contacts: Care home screening not needed to find source unless risk assessment points to other potential sources i.e. staff recently returned from endemic area with contact with / symptoms of paratyphi
Other considerations: Algorithm 3.2 – Public Health Management of cases with positive screening/clearance samples. GP elected not to treat carrier state as no benefit to patient and could precipitate C. diff if prolonged high doses of antibiotics utilised. However, point for discussion as patient has current diarrhoea, and last treatment reported 1961 (antibiotic therapy changed since then).
• Situation managed with educational session held at the home about S paratyphi and infection control
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]
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):worked example
Public health risk assessment and management1a) Probable/Confirmed
1b) If yes exclude until 48 hours after last symptoms
1c) Not aware of anyone else with same symptoms
Q2. Consider if in Risk Group No professional risk group activities, but is involved in food handling duties.
Action for case: Advise not to handle food or cook for housemates (‘redeploy’). If food handling at temple is required regularly, consider taking three samples based on unofficial food handler status for a number of people i.e. theoretical spread could be to large numbers.
Q3. Travel within the 28 day period. However, as 28 days is upper limit of travel-acquired case definition, undertake further risk assessment to identify any other likely source.
Action for contacts: Girlfriend co traveller, 1 x screen. Warn and inform household contacts.
Q4. YES (travel). Therefore no further investigation as case does not know anyone who has had similar symptoms.
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 micro confirmation of typhoid
• 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 2):worked example
Public health risk assessment and managementPart 2: For the newly identified case:
1a) Probable (epidemiological link to confirmed case), subsequently confirmed
1b) Yes exclude until 48 hours after last symptoms
1c) Yes the index case
Q2. Consider if in Risk Group Not in a risk group or undertaking risk activities.
Action for the new case: Warn and inform
Q3. No travel to an endemic area.
Q4. YES likely source identified. Housemate who has travelled - secondary household transmission has occurred hence there is a defined group to be screened.
Action for contacts: As this case is a contact of a travel related case within the last 56 days, identify other members of the contact group where secondary transmission may be possible from that source (i.e. household contacts) and screen them all with 1x sample. Only exclude if symptomatic.
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
• Through screening, index case found to be still 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 3):worked example
Part 3: Following on from index case’s positive sample:
• No further action with contacts, as all have been given warn and inform and have been screened x1
• Case asymptomatic but still has occasional food handling duties in temple.
• Hence consider repeat treatment and further clearance.
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 onset of illness in the child: referred to GP for investigation and clinical management.
• Mother is housewife
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):worked example
Public health risk assessment and management
1a) Confirmed case
1b) Yes exclude until 48 hours after last symptoms
1c) No known contact with anyone else with same symptoms
Q2. Consider if in Risk Group. Not in risk group
Action for case: Exclude until 48 hours after last symptom, hygiene advice, warn and inform case and contacts.
Q3. No travel to an endemic area
Q4. No likely source identified. Although mother had fever onset within 11 days of child, so could be a carrier, or a secondary contact, or both mother and child had same food source
Action for contacts: All household contacts screened (x1) and food trawling questionnaire and activity history collated
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 onset of symptoms commencing 11 days after the onset of symptoms in the index case
• Blood culture negative
• 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?
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):worked example
Public health risk assessment and management
PART 2: For the newly identified case:
1a) possible and then confirmed
1b) yes therefore should have been excluded whilst symptomatic
1c) Yes the child (‘index’ case)
Q2. Consider if in Risk Group. Not in risk group
Action for case: warn and inform
Q3. No travel to an endemic area
Action for contacts: warn and inform
Q4. Likely source identified. Known household contact of confirmed UK acquired case, whose source of infection is yet to be confirmed. Suspected secondary transmission based on date of onset: undertake wider risk assessment.
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?
ALGORITHM
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): worked example
Public health risk assessment and managementPart 3: As a result of new information about risk group:
Q2. Consider if in Risk Group. YES, as she is a child minder and was working when symptomatic and whilst index case symptomatic.
Action for case: 3x clearance samples. Exclude from food handling after school. Warn and inform parents of children. Baby, who will require feeding, not to be placed with the family until 3 x clear negatives from mother.
Q3. No travel. Therefore assessed to unlikely to be a travel-related case
Q4. Likely source identified. No evidence of documented infection in the past. Possibly a secondary case from son. Further possible risk of secondary transmission as case handles food and drink after school and children being cared for in a household with two symptomatic cases. More importantly at this stage cannot rule out secondary transmission from index to mother and therefore possibility of other secondary cases and the possibility that one of the children being cared for is the source of infection,
Action for contacts: Screening of childminding work-related contacts undertaken.
Other considerations:
• Known household contact of confirmed UK acquired case ?secondary case, ? carrier, ?unlikely common source (as date of onset in 2nd case 11 days after onset in index case).
• Investigation dependent on outcome of food and social history questionnaire and samples from wider contacts screened. This will also inform the need for an Outbreak Control Team.
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.
ALGORITHM
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 4a:worked example
Public health risk assessment and management
1a) possible case, so GP to take sample and give hygiene advice
1b) Not symptomatic, and not in a risk group
1c) No symptomatic contacts
Q2. Consider if in Risk Group: Case not in a risk group
Action for case: Warn and inform only; no clearance samples
Q3. Yes likely to be travel related.
Action for contacts: No co-travellers. Household contacts need to be ‘warned and informed’ regardless of their risk group.
Part 2: If sample comes back positive for typhoid, no further action is necessary beyond warning and informing as the case is asymptomatic.
Part 3: As the patient is not in a risk group and is asymptomatic we would not treat him. No further action.
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 (part 1)
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.
ALGORITHM
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 (part 1):worked example
Public health risk assessment and management
1a) Possible case, so GP to take sample and give hygiene advice
1b) Not symptomatic, so do not exclude (even though he is in risk group)
1c) No symptomatic contacts
If sample returns as positive: manage as probable/confirmed case
Q2. Consider if in Risk Group: Case is in a risk group
Action for case: If confirmed as typhoid, case should be excluded/redeployed. He was not excluded previously as asymptomatic and was only a possible case. However now need to exclude him, ensure 3x negative clearance samples prior to going back to work, and conduct a risk assessment to see if he was symptomatic in workplace and if there is need to warn and inform at work.
Q3. Likely to be travel related: Yes
Action for contacts: No co-travellers. Household contacts need to be ‘warned and informed’ regardless of their risk group. May need to warn and inform workplace, depending on risk assessment.
OTHER:
• If any clearance samples come back positive, use algorithm 2.2.• Part 3: Case is likely to need to be re-treated as he is in a risk group and is still excreting
typhoid despite reported treatment overseas. In the absence of details regarding initial treatment, assume the first course was with appropriate antibiotics (check sensitivities).
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(part 2)
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?
Case Scenario 4b (part 2):worked example
Informal Action
• Request food handler not to go to work
• Can pay compensation
• Consent form to notify Food Business Operator
• Complies with Data Protection Act 1998 to notify FBO even if consent is refused
• Food handler can still be prevented from working – Food handlers: Fitness to Work guidance (Annex II Chapter VII paragraph 2 of Regulation 852/2004
Case Scenario 4b (part 2):worked example
Formal exclusion – Part 2A Order• Local Authority can apply to JP to deal with a threat to human health• Local Authority to agree action amongst themselves – Order/Monitoring/Samples• Must give notice to the person• JP to make conditions to reduce or remove the risk• JP can order compensation – Local Authority required to pay this if made a condition• Order can last up to 28 days• Follow through to clearance – agree conditions on order utilise Health Protection
Regulations 2010 Toolkit
http://www.cieh.org/WorkArea/showcontent.aspx?id=37814
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.
ALGORITHM
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 5:worked example
Public health risk assessment and management1a) probable/confirmed case
1b) yes, case is symptomatic
1c) no, unaware of anyone else with similar symptoms
Q2. Consider if in Risk Group: Yes food handler
Action for case Advise not to handle food or cook for housemates. If it is possible for him to stop cooking and perform front of house duties in the restaurant then exclude him purely from food handling, rather than work.
Q3. Likely to be travel related: Yes, although travel is at the very end of the 28 day period.
Action for contacts:
• Identify fellow travellers for screening. • Warn and inform other relevant contacts who did not travel:• An assessment of shared living arrangements would suggest that ‘other contacts’ should be restricted to
the 3 who regularly eat with him who share the residence, the 4 that live elsewhere and his family. • As he was symptomatic at work, risk asses shared facilities at restaurant and provide warn and inform
information, but no screening required.
Q4. Likely source identified: Likely travel-related, especially because he does not know anyone who has had similar symptoms or who has travelled recently. Therefore no further investigation.
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
ALGORITHM
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:worked example
Public health risk assessment and management1a) Confirmed
1b) Yes, symptomatic
1c) Unknown
Q2. Consider if in Risk Group: Yes healthcare worker
Action for case: They will require 3x clearance samples, and should be excluded from risk activities until clearance is ensured. However, as hygiene facilities good in hospital, and the surgeon would have been scrubbed up, no further risk assessment of work place is necessary.
Q3. Likely to be travel related: Yes
Action for contacts
• Identify fellow travellers for screening• Warn and inform household contacts
Q4. Likely source identified Yes – likely to be travel related
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
ALGORITHM
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:worked example
Public health risk assessment and management1a) Confirmed
1b) Yes, symptomatic
1c) Unknown
Q2. Consider if in Risk Group: Yes
Action for case: Will require 3x clearance samples, and should be excluded from risk activities until clearance is ensured. This would include exclusion from food duties, or redeployment.
Q3. Likely to be travel related: Yes
Action for contacts:
• Identify fellow travellers for screening• Warn and inform household contacts• Risk assessment regarding hygiene arrangements at the nursery. It may be assessed as
appropriate to warn and inform parents of those children who she looked after whilst symptomatic.
Q4. Likely source identified: Yes likely to be travel related
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
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: worked example
Public health risk assessment and management1a) confirmed case of typhoid
1b) yes the case is symptomatic
1c) no social links identified
Q2. Consider if in Risk Group A. Highlights need for professional judgement: although theoretically meets the definition (and therefore 3x clearance). Does he pose a risk to others? As minimal contact with hostel residence and no social links identified, it is unlikely. Therefore he is not in a risk group.
Action for case: Exclusion, Hygiene, Warn and inform.
Q3. No recent travel identified. No previous history of typhoid like illness, no other links to other cases identified. Difficult to identify any contacts let alone those with a travel history. Hostel details identified, no other cases known to be linked to hostel.
Action for contacts: None sampled (given the throughput of the hostel, and the inability to ascertain close contacts).
Q4. No possible source identified.
ACTION: Repeat risk assessment, add eating establishments and hostels as ‘contexts’ in HP Zone, in case of future cases.
Other considerations: Re-treat? No, as it is not practically possible, and questionable public health benefits. Also unlikely compliance with outpatient/inpatient treatment. Therefore: Warn and inform, and if symptomatic should see GP/key worker. Engage key worker/significant other who does work with case, may be outreach worker etc. Flag for GP and hospital notes.
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:
