Davao Medical School Foundation Inc.

Medical Drive, Bajada, Davao City College of Medicine

EPIDEMIOLOGY (HYPOTHETICAL CASE PROBLEM)

Submitted to: Dr. Jesse Fabian, MD

Submitted by: Adlyn Bea A. Bernaldez Medicine II

July 8, 2013

Case Report
In the summer of April 2011, approximately 2500 individuals gathered to celebrate Governors Induction in the Province of South Cotabato. They were served with pork menudo, chicken adobo, rice and orange juice catered by a local carenderia. There has been an increased number of admission and hospitalization to local hospitals within 2 weeks after the assembly. A total of 1520 ICU patients progressed on to develop irreversible multi-system shock and expired while being hospitalized. Significant Widal reactions were present in 84.7% of cases. Blood and stool cultures were positive in the cases. WHO? Citizens of South Cotabato both male and female children, adults and elderly Gathered to celebrate Mayors Induction Municipal workers/ employees Random persons Majority of the people who died were between 6 to 60 years old. 2220 (89%) individuals experienced acute gastroenteritis and overwhelmed the Emergency Departments of 10 local hospitals 68% of 2220 were admitted to intensive care units. WHERE? South Cotabato, Philippines Local Gymnasium WHEN? April 2011 Sudden outbreak Last incident and isolation was 2005 Onset of symptoms occurred 1 to 3 weeks after exposure

TYPHOID FEVER
Etiology of Disease Salmonella typhi (2 - 5 microns) rod-shaped bacteria Gram-negative produces an endotoxin (which is typical of Gram negative organisms), as well as the Vi antigen, which increases virulence derived from the ancient Greek typhos, an ethereal smoke or cloud that was believed to cause disease and madness.

Natural History of Disease Incubation Period 13 weeks after exposure, and may be mild or severe Mode of transmission Oral transmission via food or beverages handled by an individual who chronically sheds the bacteria through stool or, less commonly, urine Hand-to-mouth transmission after using a contaminated toilet and neglecting hand hygiene Oral transmission via sewage-contaminated water or shellfish (especially in the developing world) Susceptibility and immunity All seasons, usually in summer Most cases in school-age children and young adults. both sexes equally susceptible. Signs and Symptoms FIRST WEEK: High fever 103 or 104 F (39.4 or 40 C) Malaise Headache Constipation (adults) or diarrhea (children) Rose-colored spots on the chest Enlarged spleen and liver Healthy carrier state may follow acute illness SECOND WEEK: Continuing high fever Either diarrhea that has the color and consistency of pea soup, or severe constipation Considerable weight loss Extremely distended abdomen THIRD WEEK: Become delirious Lie motionless and exhausted with your eyes half-closed in what's known as the typhoid state Life-threatening complications often develop at this time FOURTH WEEK: Improvement may come slowly during the fourth week COMPLICATIONS Intestinal bleeding or perforation sudden drop in blood pressure and shock followed by the appearance of blood in your stool severe abdominal pain, nausea, vomiting and bloodstream infection Risk Factors Genetic polymorphisms Environmental and behavioral eating food from street vendors

 living in the same household with someone who has new case of typhoid fever washing the hands inadequately sharing food from the same plate drinking unpurified water living in a household that does not have a toilet. Conditions that decrease stomach acidity stomach pH as low as 1.5. Antacids histamine-2 receptor antagonists (H2 blockers) proton pump inhibitors gastrectomy, and achlorhydria Epidemiology International Typhoid fever occurs worldwide, primarily in developing nations whose sanitary conditions are poor. Typhoid fever is endemic in Asia, Africa, Latin America, the Caribbean, and Oceania, but 80% of cases come from Bangladesh, China, India, Indonesia, Laos, Nepal, Pakistan, or Vietnam. Local In the Philippines alone, where the disease is endemic, the case fatality incidence in 2005 was 1.8 per 100,000 people Mortality and Morbidity Untreated typhoid fever is a life-threatening illness of several weeks' duration with long-term morbidity often involving the central nervous system. Age Most documented typhoid fever cases involve school-aged children and young adults. Treatment/ Management Antibiotic therapy is the only effective treatment for typhoid fever o Ciprofloxacin o Ceftriaxone Supportive therapy o Drinking fluids. This helps prevent the dehydration that results from a prolonged fever and diarrhea o Healthy diet. Non bulky, high-calorie meals help replace the nutrients patients lose when theyre sick Prevention and Control Strategies Vaccines against typhoid fever are available, but they're only partially effective One is injected in a single dose, and the other is given orally over a period of days Neither vaccine is 100 percent effective, and both require repeat immunizations as vaccine effectiveness diminishes over time Patient Teaching US Centers for Disease Control and Prevention dictum to "boil it, cook it, peel it, or forget it" is a good rule in any circumstance

Reference Articles http://www.cdc.gov/nczved/divisions/dfbmd/diseases/typhoid_fever/ http://www.who.int/topics/typhoid_fever/en/ http://emedicine.medscape.com/article/231135-followup#a2651 Typhoid Fever. Typhoid Fever Risk Factors. http://www.mayoclinic.com/health/typhoidfever/DS00538/DSECTION=risk-factors

Journals Comparison of Serological Test Kits for Diagnosis of Typhoid Fever in the Philippines http://jcm.asm.org/content/45/1/246.full Typhoid ulcer causing life-threatening bleeding from Dieulafoy's lesion of the ileum in a sevenyear-old child: a case report. http://www.jmedicalcasereports.com/content/4/1/171