Controlling Spread of Typhoid Fever

Fluoroquinolones appear to be the drug of choice in adults. However, the recent emergence of resistance to fluoroquinolones prevents its indiscriminate use in primary care facilities. If a typhoid isolate is known to be sensitive to traditional first-line antibiotics, oral chloramphenicol, amoxicillin or trimethoprim-sulfoxazole (particularly in children) should be used in accordance with local antimicrobial sensitivity patterns. Short-term, high dose corticosteroid treatment, combined with specific antibiotics and supportive care, reduces mortality in critically ill patients.

A. Isolation and Quarantine Requirements

Hospital care is desirable during acute typhoid illness. All hospitalized patients should be on Standard Precautions. Use Contact Precautions for diapered or incontinent persons for duration of illness or to control institutional outbreaks.

Quarantine is not applicable.

B. Protection of Contacts of a Case

Administration of typhoid vaccine is of limited value for family, household and nursing contacts who have been or will be exposed to active cases. Vaccine should be considered for those exposed to carriers of typhoid.

C. Managing Special Situations

Contact the Center for Acute Disease Epidemiology (CADE) at (800) 362-2736 for consultation for persons identified as chronic carriers or who continue to have positive stool cultures after acute disease.

In the case of situations that are not covered below contact CADE at (800) 362-2736 for consultation.

Food Handlers

Note: Meat plant workers are considered food handlers.

Return to work should be after 3 consecutive negative stool cultures (and urine in patients with schistosomiasis) at least 24 hours apart and at least 48 hours after completion of antimicrobials.

Household members of people with a Typhoid Fever diagnosis must also have 3 consecutive negative stool cultures, as above, before a food handler is allowed to return to food handling duties.

Hand hygiene education must occur before return to work. Good hand hygiene must be practiced at all times.

Child Care/School

Since typhoid fever can be transmitted person-to-person through fecal-oral transmission, it is important to carefully follow up on cases in a child care setting. General recommendations for typhoid fever include:

• For staff or children 5 years of age and older who are fecally continent, 24 hours without a diarrheal stool is required before returning.
• For children younger than 5 years of age or individuals who are diapered or fecally incontinent, 3 consecutive negative stool cultures (and urine in patients with schistosomiasis) at least 24 hours apart and at least 48 hours after completion of antimicrobials are required before returning.
• Good hand hygiene must be practiced at all times.

Business

Since typhoid fever can be transmitted person–to-person through fecal-oral transmission, it is important to follow up carefully on each case.  General recommendations include:

• For staff (exception for food handlers), 24 hours without a diarrheal stool is recommended before returning to a business setting. 
• Staff with S. typhi in their stool who do not have diarrhea or vomiting and do not handle food may remain if proper hygienic practices are maintained.
• Good hand hygiene must be practiced at all times.

Health Care Provider

Return to work should be after 3 consecutive negative stool cultures (and urine in patients with schistosomiasis) at least 24 hours apart and at least 48 hours after completion of antimicrobials.  Good hand hygiene must be practiced at all times.

Reported Incidence Is Higher than Usual/Outbreak Suspected

Any case of typhoid fever is unusual in the U.S, so it is important to determine the source of infection and mode of transmission. Careful follow-up of cases to ensure proper isolation and identify “chronic carrier” status is important. Control of person-to-person transmission requires special emphasis on personal cleanliness and sanitary disposal of feces. Consult with the regional epidemiologist or CADE if assistance is needed. CADE can help determine a course of action to prevent further cases and can perform surveillance for cases that may cross jurisdictional lines.

D. Preventive Measures

Environmental Measures

Proper sanitation of public and private facilities is critical to prevent typhoid fever. Routine sanitation measures should include:

• Education of the public regarding proper handwashing, which includes providing suitable handwashing facilities in public places, especially in food service, child care, or health care settings.
• Proper disposal and treatment of human sewage. Latrines should be fly-proof and properly designed and situated.
• Public and private water supplies should be protected, purified, and chlorinated (as needed). Backflow prevention devices should be installed between potable water and non-potable water systems.
• Scrupulous cleanliness in food preparation and handling are important. Proper temperature maintenance of raw and cooked foods is critical, as well as avoiding cross contamination of raw meats and items already prepared to eat.
• All milk and milk products should be pasteurized before consumption.
• Limit the collection and marketing of shellfish to supplies from approved sources.

Education

To avoid possible exposures, recommend that people:

• Always wash their hands thoroughly with soap and water before eating or preparing food, after using the toilet, and after changing diapers. This is important for the entire household of a case as household members can become transient or long term carriers.
• Dispose of feces in a sanitary manner in all settings.
• Keep food that will be eaten raw, such as vegetables, from becoming contaminated by animal-derived food products.  Wash all foods that will be eaten raw before eating.
• Receive typhoid vaccination when traveling to endemic high-risk areas. Visit www.cdc.gov/travel/ for current information on endemic high-risk areas. The World Health Organization (WHO) also recommends that school-age children who live in such areas receive vaccination. An oral, live vaccine is available and usually consists of 3-4 doses.

In non-endemic areas there is no recommendation for vaccine except for those who are subject to unusual occupational exposures (e.g. clinical microbial technicians or household members of known carriers).

Iowa Dept. of Public Health, Revised  8/15