Typhoid in Schenectady
Communicable diseases are one of the major concerns in public health, as it poses a significant threat to the population. The study of epidemiology allows nurses to understand the cause of the disease and helps determine the levels of prevention to be implemented in order to limit the spread of the disease (Lundy & Janes, 2016). The purpose of this paper is to: a) use an epidemiological model to identify the organism involved in the case study, as well as its pathology, etiology, diagnosis, and prognosis; b) describe the distribution of health events within Schenectady; c) identify the determinants affecting morbidity and mortality; d) determine the deterrents that exists within the affected population; e) calculate the outbreak’s incubation period; f) identify the individuals affected during endemic levels; g) provide a list of foods that were most susceptible to mass contamination; and h) determine the people involved in the food borne outbreak and analyze the possible cause of this occurrence.
Introduction
Typhoid fever is a systemic infection caused by the gram-negative organism Salmonella typhi. It is transmitted through fecal-oral or urine-oral route by either direct or indirect contact of the carrier’s or infected individual’s feces or urine. Humans are the only source of this organism. Ingestion of
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contaminated agents such as unpasteurized milk, raw shellfish, raw fruits, vegetables grown with night soil, or the presence of vectors such as flies, are considered to be modes of transmission as well. Incubation period of this organism ranges from 6 to 30 days, with the average being 2 weeks. Affected individuals develop fever, increasing fatigue, malaise, headache, anorexia, abdominal pain, diarrhea, constipation, or rose spots that are commonly manifested in the trunk. Differential diagnosis is warranted because typhoid fever exhibits the same signs and symptoms as appendicitis, cholecystitis, and malaria. Diagnostic procedures include obtaining a positive blood, urine, or fecal cultures. However, blood cultures are more definitive for early diagnosis since it takes about a week for urine and fecal cultures to be positive. The Centers for Disease Control and Prevention (2015) also indicated bone marrow cultures as a conclusive diagnostic test, which produces an estimate of 80% of the cases compared to 50% from single blood cultures. Serum agglutination tests also known as Widal test are considered unreliable but are still widely used in developing countries because it is inexpensive. Early recognition of the disease allows healthcare providers to provide prompt antibiotic treatment. Improvements of symptoms are evident within 2 to 4 weeks of antibiotic treatment and usually yield a good outcome. However, life-threatening complications such as intestinal hemorrhage or perforation might occur if typhoid is not treated within 2 to 3 weeks from the onset of illness (Heymann, 2014; Newton, Routh, & Mahon, 2015; Wain et al., 2015; Los Angeles County Department of Public Health, 2013 p. 1). An epidemiological triad for this disease is presented on Figure 1. Figure 1 Typhoid Fever Epidemiological Triad Distribution The population for the city of Schenectady was 90,000 in the year 1939. In June of the same year, thirteen cases of Typhoid fever were reported. The average incidence of the disease five years before the outbreak started was two cases per year. The incidence rate increased from 2/90,000 or 2 people per 100,000 to 13/90,000 or 14 people per 100,000 during the outbreak. Among the thirteen individuals who had developed typhoid fever, eleven were residents from the city and two were visiting out-of-state residents. Three of the thirteen individuals affected were teenagers (13 to 19 years old), two were young adults (20 to 35 years old), six were middle-aged adults (36 to 55 years old), and two were older adults (>55 years old). Gender distribution for the outbreak includes ten females and three males. Twelve of them ate the food provided from the Memorial Day service picnic hosted by the Methodist Church on May 30, while the other one ate the food his wife brought home from the picnic. There were also twenty-two other people who ate at the picnic but did not develop any signs and symptoms. Figure 2 shows the onset date of new cases and the number of people who were affected. Determinants The Typhoid outbreak in Schenectady is not just influenced by a single cause. Multiple factors such as age, sex, occupation, sewage system, water source, high-risk foods like dairy products, uncooked foods, meals away from home, and recent travel history should also be taken into account. Both men and women were affected in the outbreak. Only two individuals traveled outside of Schenectady before the outbreak started. The first individual visited Lebanon while the other individual traveled from Altaville. The occupation of individuals who were affected varied from students, housewives, teacher, and mechanic. The water source in the city was supervised by a sanitary engineer and had adequate sewage disposal. Based on the thirteen cases reported, the only common factor found was the food that was eaten at the Methodist Church picnic. There is a possibility that the foods served in the picnic might have been contaminated by a Salmonella typhi agent mentioned earlier in the Introduction Deterrents Prevention measures like good sanitation, proper hand washing, identification of carriers, and immunizations could have prevented or reduced the effects of the outbreak if it was practiced. Since typhoid fever is foodborne illness, it is important to educate the community about food preparation safety and proper hand washing, especially for the people handling the food. Proper food storage and temperature should also be observed to minimize the risk of contracting foodborne illnesses. Good personal hygiene such as washing hands after using the toilet, and keeping the fingernails clean and short are important to be implemented as well. Food handlers should be screened in order to identify the possibility of them being carriers, as carriers should be exempted from preparing food for the public. Identified carriers need to be supervised and educated in order to prevent an outbreak. Typhoid fever immunization should be administered to the people living in the same household as the carrier, the people who are at increased risk for exposure to the infectious bacteria, and the people who are traveling in an area where Typhoid fever is considered an endemic (Heymann, 2014; Newton, Routh, & Mahon, 2015). Incubation Period According to CDC (n.d.), incubation period is defined as a time of contact to the causative agent to the appearance of the first symptom.
The exposure to the contaminated food happened during the Memorial Day service celebration, which was May 30th. According to the case study, onset of symptoms occurred from June 5th to June 28th. Therefore, the incubation period from this case ranged from seven days to thirty days. According to Heymann (2014), the incubation period for Typhoid fever ranges from 3 days to over 60 days, with the usual range from eight to fourteen days. A graph of the incubation period is provided in Figure
2. May 30 (exposure to contaminated) to June 5 (first onset of symptoms) = 7 days May 30 (exposure to contaminated) to June 28 (last onset of symptoms) = 30 days Endemic Levels Endemic levels are the usual and steady occurrence of diseases for a number of years in a geographic area, while epidemic levels occur when diseases spread suddenly and rapidly in a particular time (Webber, 2012). Both the endemic and epidemic levels are useful in determining the rate of occurrences of Typhoid fever in this city. The endemic level of typhoid fever in Schenectady is considered low. On average, only two new cases per year had been reported from 1933 to 1937, and no case was reported in 1938, which was a year before the outbreak. In 1939, thirteen cases have been clinically diagnosed as typhoid fever. Visual representation of the Typhoid endemic levels can be found on Figure 3 and Table 1 identifies the thirteen people affected during the outbreak. Figure 3 Endemic Levels Table 1 Confirmed Typhoid cases Names of Individuals affected Potato Salad Macaroni Salad S. Christian Yes Yes F. Blair Unknown Unknown M. Dencher Yes No F. Howard Yes Yes T. Jones Yes Unknown E. Ostrander No Yes W. Thurber Yes No R. Kmiecziak Yes Yes D. Wagoner Yes Yes G. Wagoner Unknown Yes R. Wagoner Yes Yes A. Woods Yes Yes E. Vogel Yes Yes Foods Susceptible to Mass Contamination Foods that are most susceptible to mass contamination from the case study include the potato salad, macaroni salad, cabbage salad, and cakes. The case study indicated that 10 out of the 13 people who were infected with typhoid ate the potato salad, 9 out of the 13 ate the macaroni salad, and 1 out of the 13 was not sure if the potato or macaroni salad was eaten. Contamination of the potato and macaroni salad might have been due to the food preparation of a Salmonella typhi carrier who has poor personal hygiene, particularly hand washing after using the bathroom. Cabbage salads are usually prepared raw, which is a possible agent if the cabbage used was planted in night soil or watered with contaminated water. The cakes are also susceptible to mass contamination if unpasteurized milk was used as one of its ingredients. Hypothesis The individuals who prepared some of the foods for the Memorial Day service at Schenectady Methodist Church were Irene Pickett, Margaret Bennett, and Kenneth Rhinheardt. All of them had no previous histories of the typhoid fever but had tested positive based on their stool cultures, although they remained well overall. Irene Pickett had three positive stool cultures for three consecutive days but tested negative on June 23 and August 2. Kenneth Rhinheardt had one positive stool and had three negative stools after that. On the other hand, Margaret Bennett tested positive for eleven consecutive times from June 2 to October 4. Based on the information provided in the case study, the potato and macaroni salad most likely caused the outbreak, which was both prepared by Margaret Bennett. As what was discussed earlier, typhoid fever is transmitted through the fecal-oral or urine-oral route through direct or indirect exposure from contaminated agents, which in this case was the potato and macaroni salad. According to the Los Angeles County Public Health (2013), a chronic carrier is defined a person who does not have a history of the disease but has two positive urine or fecal cultures 48 hours apart. Based from this, the possibility of Margaret being a chronic carrier of Salmonella typhi is considered, and she might have caused the typhoid outbreak in the city of Schenectady.
Fever and chills are also common. At least two-thirds of patients complain of abdominal cramps. The duration of fever and diarrhea varies, but is usually 2 to 7 days”. S. typhimurium can cause many problems for consumers when there is an outbreak in products. Some of the more recent products that have been contaminated and pulled from store shelves are, cantaloupes, ground beef and poultry products, according to the CDC.
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The last time Typhus was recorded was by the British Troops during World War II. They had forty two cases of Typhus in 1942 and that was one year after the allied forces arrived. Then the year after that there was five hundred and eighty two cases of Typhus...
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The aim of this exploration is to investigate and examine one epidemic model and then attempt to apply it to a scenario and determine if it’s a realistic and accurate model.
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Sack D., Sack R., Nair G., and Siddique A. Cholera. 2004. Lancet, 363(9404), 223-233. Retrieved from: http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=4a213450-0d66-48ab-aee8-ba80898fa889%40sessionmgr12&vid=2&hid=121
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