1. Public Health Operational Guidelines for Typhoid and Paratyphoid (Enteric Fever) Case Studies Typhoid and Paratyphoid Reference Group (TRPG) 10 th February 2012 Contact Person: Sarah.addiman@hpa.org.uk

2. 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

3. Outline of session Case Studies Part 2 1130 –1230 1015 - 1115 Scenario 1Maximum 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 hrsScenario 1Maximum of 20 mins for each scenario Utilise guidance and use the algorithms Record on the flip chart key points or issues 1150 hrsScenario 2 1210 hrs15-20 minute discussion with all groups Facilitated by Sooria

4. Scenarios

5. 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

6. Case Scenario 1: Public health risk assessment and management 1a) 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?

7. 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]

8. Case Scenario 2 (Part 1): Public health risk assessment and management 1a) 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?

9. 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?

10. 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?

11. 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?

12. 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

13. 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?

14. 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?

15. 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?

16. 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?

17. 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?

18. 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.

19. 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?

20. 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.

21. 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?

22. 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)?

23. Case Scenario 4c: Informal action: Formal action:

24. 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.

25. Case Scenario 5: Public health risk assessment and management 1a) 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?

26. 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

27. Case Scenario 6a: Public health risk assessment and management 1a) 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?

28. 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

29. Case Scenario 6b: Public health risk assessment and management 1a) 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?

30. 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

31. Case Scenario 7: Public health risk assessment and management 1a) 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?

32. Prepared by the secretariat on behalf of the Typhoid and Paratyphoid Reference Group TRPG Membership: