Public Health Operational Guidelines for Typhoid and Paratyphoid (Enteric Fever) Case Studies...

Public Health Operational Guidelines for Typhoid and Paratyphoid (Enteric Fever)

Case Studies

Typhoid and Paratyphoid Reference Group (TRPG)10th February 2012

Contact Person:[email protected]

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):


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




same symptoms

Q2.



Q3.


Q4.




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



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?


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


ALGORITHMS



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)


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




same symptoms

Q2.



Q3.


Q4.




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



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




same symptoms

Q2.



Q3.


Q4.




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




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


ALGORITHMS




same symptoms

Q2.



Q3.


Q4.




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




Part 3: As a result of new information about risk group:

Q2. Consider if in risk group.

Action for case

Q3. Travel history?


Action for contacts


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:


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?


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.


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:


1a)

1b)

1c)

If sample returns as positive:


Action for case:

Q3. Travel related:

Action for contacts:

OTHER:

ALGORITHMS





Q2.


activities?

Q3.


Q4.


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:


1b)

1c)


Action for case

Q3. Likely to be travel related:

Action for contacts


ALGORITHMS





Q2.


activities?

Q3.


Q4.


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:


1b)

1c)


Action for case

Q3. Likely to be travel related?

Action for contacts


ALGORITHMS




same symptoms

Q2.



Q3.


Q4.



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:


1b)

1c)


Action for case

Q3. Likely to be travel related:

Action for contacts


ALGORITHMS




same symptoms

Q2.



Q3.


Q4.



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:


1b)

1c)


.

Action for case

Q3.Travel history

Action for contacts

Q4. Possible source identified


ALGORITHMS




same symptoms

Q2.



Q3.


Q4.



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:

Public Health Operational Guidelines for Typhoid and Paratyphoid (Enteric Fever) Case Studies...

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