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									       TYPHOID FEVER
         WHAT IS TYPHOID FEVER?
Etiologic Agent:   Salmonella Serogroup Typhi.
Typhoid Fever is an acute illness associated with
fever caused by the Salmonella typhi bacteria. It can
also be caused by Salmonella paratyphi, a related
bacterium that usually causes a less severe illness.
Bacteria is deposited in water or onto food by a
human carrier or flies & are then spread to other
people in the area.




         NOTE THE TAIL & HEAD OF THE
           Salmonella typhi BACTERIA
    EXTRACT TAKEN ON THE 1ST DECEMBER 2009

                          1
This document has many sections which repeat itself,
especially the information concerning the carrier &
hygiene. This has been done because of the false
impression a person suffering from Typhoid can
develop “I feel okay now the disease is gone”. For
example, if they do not get tested they may think it is
another bout of Malaria. This is untrue as many people
who get a severe strain of Typhoid can be carriers for
12 months or more if not treated correctly.

WHERE IS TYPHOID FEVER LOCATED IN THE WORLD?




Typhoid fever is common in most Developing
Countries in the world. Industrialized regions such as
the United States, Canada, Western Europe, Australia,
& Japan are free of Typhoid, only tourists bring in the
disease back. Therefore, if you are travelling to the
developing world, you should consider taking pre-
cautions. Over the past 10 years, travellers from the
United States, Australiasia, Europe & to Asia, Africa,
& Latin America have been especially at risk.
                           2
YOU WILL NOTE THE SHADED RED AREAS ARE HIGH RISK
        AREAS TO CONTRACT TYPHOID FEVER




    Salmonella typhi DETECTED by blood test 1/12/09,
    photographs taken by Dr Ken Henry on the 1/12/09




NOTE ABOVE TEST SLIDE HAS TWO BLOOD SAMPLES, THE
TWO SPECIEMS ARE FROM THE SAME INFECTED PERSON.
THE RIGHT SAMPLE IS 100% STRONGER THAN THE LEFT
                           3
SAMPLE. THERE WAS A DROP OF IONIC SILVER PUT INTO
THE CONTAMINATED BLOOD IN THE LEFT SAMPLE.
           WHO CAN GET TYPHOID FEVER?
Anyone who swallows the bacteria can become ill & most
people will recover without specific treatment but can become
a potential carrier. A health check is essential to confirm
whether the bacteria has been eliminated from the body.
90% of typhoid fever reported in Developed Countries are
contracted whilst travelling abroad.

 FAMOUS PEOPLE IN THE PAST WHO HAVE CONTRACTED
                 TYPHOID FEVER
  •   Abigail Adams, second First Lady of the United States,
      wife of John Adams.
  •   Mary Mallon, more commonly known as Typhoid Mary
  •   Albert of Saxe-Coburg-Gotha, British prince consort,
      Queen Victoria's husband
  •   Edward VII, survived
  •   Princess Victoria of Hesse & by Rhine, survived
  •   Louisa May Alcott, author of Little Women records
      contracting it in Hospital Sketches
  •   Charles Darwin, naturalist, during his visit to Chile with
      HMS Beagle in 1835
  •   Eugenia Tadolini, a celebrated Italian soprano, who died of
      the disease in Paris in 1872.
  •   William Wallace Lincoln, third son of Abraham Lincoln, the
      16th President of the United States, & Mary Todd Lincoln,
      died of the disease on February 20, 1862.
  •   Wilbur Wright, one of the famous Wright Brothers. Died
      May 30, 1912.




                                 4
                  SIDE EFFECTS OF TYPHOID
BRAIN DAMAGE DUE TO LONG TERM HIGH TEMPERATURES
LIVER FAILURE      KIDNEY FAILURE
ENLARGED SPLEEN     LOW WHITE BLOOD CELL COUNT
DEATH              GALL BLADDER REMOVAL

              CLINICAL FEATURES OF TYPHOID




Typhoid fever has an insidious onset characterized by several
clinical features which reliably distinguish it from a variety of
other infectious diseases.
Symptoms in an unhealthy carrier usually develop 1–3 weeks
after exposure, & may be mild or severe.
They include:-
high fever,         enlarged spleen & liver
vomiting,           constipation in adults
chills,             diarrhoea in children
headache,           inability consume solid foods
malaise,            fibro myalgia & muscular pain
rose-coloured spots on the chest & stomach
A healthy carrier state may be followed by acute illness.
Diarrhoea & vomiting are not usually so severe. Confusion,

                                5
delirium, constipation, inability consume solid foods,
intestinal perforation, & death may occur in severe cases.
The etiologic agent may be recovered from the bloodstream or
bone marrow, stool or urine.

                 TREATMENT PROCEDURES
   ANTIBIOTICS                          BOWEL IRRIGATION
Typhoid fever can be treated with antibiotics. However,
Typhoid has now become resistant to most common
antibiotics & antimicrobials. Healthy Typhoid carriers should
be excluded from handling all food, including shopping &
especially in its preparation until they have been medically
cleared.
SEQUELAE
Without therapy, the illness may last for 2 to 4 weeks & death
rates can range between 12% & 30% in a highly contaminated
area with poor medical facilities to 2% - 7% in a low risk area.
This also varies from person to person & their current health
condition. For instance, if a person has HIV/AIDS the mortality
rate increases dramatically. The death rate of 2 in 100 people
has also increased to 1 in 10 people by no reliable treatment
being made available until it is too late.
TRANSMISSION
Sanitation & hygiene are the critical measures that can be
taken to prevent typhoid. Typhoid does not affect animals and
therefore transmission is only from human to human & one of
the great ape species.
Flying insects going into drop toilets & feeding on feces may
transfer the bacteria to food through poor hygiene habits &
public sanitation conditions. Public education campaigns are
encouraging people to THROUGHLY wash their hands after
defecating & before & after handling food to assist in
controlling spread of the disease. According to statistics from
the US Centre for Disease Control, chlorinated drinking water
                                6
has led to a dramatic decrease in the transmission of typhoid
fever in the U.S. Washing hands or food in contaminated water
will also spread the disease.




FLYING INSECTS FEEDING ON TYPHOID INFECTED FAECES
THE STANDARD HOUSE FLY CAN BE ONE OF THE BIGGEST
         CARRIERS FROM PIT TOILETS TO FOOD




 WATER FROM TYPHOID INFECTED PIT TOILETS & DRAINS
 CAN SEEP INTO THE UNDERGROUND WATER SUPPLY &
            CAUSE TYPHOID OUTBREAKS
A person may become an asymptomatic carrier of typhoid
fever, suffering no symptoms, but capable of infecting others.
                               7
According to the Centers for Disease Control approximately
5% of people who contract typhoid continue to carry the
disease after they recover. The most famous asymptomatic
carrier was Mary Mallon (commonly known as "Typhoid
Mary"), a young cook who was responsible for infecting at
least 53 people with typhoid, three of whom died from the
disease. Mallon was the first apparently perfectly healthy
person known to be the cause of an "epidemic". She was
locked away from the community for a number of years.
     PREVIOUS PATIENTS WERE ISOLATED FROM THE
        COMMUNITY TO CONTAIN TYPHOID FEVER
In the past many carriers of typhoid were locked into an
isolation ward never to be released in order to prevent further
typhoid cases. These people often deteriorated mentally,
driven mad by the conditions in which they lived. With modern
antibiotics there is no longer isolation of Typhoid infected
people unless it is a whole community.
As stated previously, the major method of contamination is by
the drinking water or eating food. Large epidemics are most
often related to faecal contamination of water supplies or
street vended foods. A chronic carrier state can excrete the
bacteria for more than 1 year.
About 8%-15% of patients become carriers of the bacteria after
the acute illness stage. Some patients suffer a very mild
illness that goes unrecognized. These patients can become
long-term carriers of the bacteria. The bacteria multiplies in
the gallbladder, bile ducts, or liver & passes into the bowel.
The bacteria can survive for months in water or dried sewage.
These chronic carriers may have no symptoms & can be the
source of new outbreaks of typhoid fever for many years.
Currently, the major problem is controlling the contaminated
products getting into the underground water supply.




                               8
  HOW DOES THE BACTERIA CAUSE ILLNESS, & HOW IS IT
                   DIAGNOSED?
After the ingestion of contaminated food or water, the
SalmonellaTyphi bacteria invade the small intestine and enter
the blood stream temporarily. The bacteria are carried by white
blood cells in the liver, spleen, & bone marrow. The bacteria
then multiply in the cells of these organs & re enter the
bloodstream.
Patients develop symptoms, including fever, when the
organism re-enters the bloodstream. Bacteria invade the
gallbladder, biliary system, and the lymphatic tissue of the
bowel. Here, they multiply in high numbers. The bacteria pass
into the intestinal tract & can be identified for diagnosis in
cultures from the stool tested in the laboratory. Stool cultures
are sensitive in the early & late stages of the disease but often
need to be supplemented with blood cultures to make the
definite diagnosis.
Rose coloured spots on the chest & stomach are common in
the early stages of the disease.




People with typhoid fever usually have a sustained fever as
high as 103 to 104 degrees Fahrenheit (39 to 40 degrees C).
Vaginal discharge (Candida or yeast overgrowth), chest
congestion & allergy conditions may develop in many
                                9
patients, thus giving the medical practitioner or support
people the wrong concept or incorrect diagnosis of the
disease. Abdominal pain, Fever & Headaches are also
common. Improvement occurs in the third & fourth week in
those without other complications, but if they stay ill they
need to have more intense medical treatment.
About 10% of patients have recurrent symptoms (relapse) after
feeling better for one to two weeks. Relapses are actually more
common in individuals treated previously with antibiotics.
A simple blood test followed by a faeces test will determine
whether you are positive & which antibiotic is more sensitive
or best suited to eliminate the strain of Typhoid Fever.
     INCIDENCE & TIMING OF VARIOUS MANIFESTATIONS OF
          UNTREATED TYPHOID FEVER See Document attached
Table of Symptom Levels
                           Incubation   Week 1        Week 2        Week 3     Week 4           Post

Systemic                                                                       Recovery phase   10-20% relapse;
                                                                               or death (15%    5-15% chronic
Stepladder fever pattern                Very common   Very common              of untreated     carriers;
or insidious onset fever                                                       cases)           long-term
                                                                                                neurologic
                                                                                                sequelae
Acute high fever                        Very rare
                                                                                                (extremely rare);
                                                                                                gallbladder
Chills                                  Almost all                                              cancer (RR=167;
                                                                                                carriers)
Rigors                                  Uncommon

Anorexia                                Almost all

Diaphoresis                             Very common

Neurological Disorders

Malaise                                 Almost all    Almost all    Typhoid
                                                                    state
Insomnia                                              Very          (common)
                                                      common

Confusion/delirium                      Common        Very
                                                      common

Psychosis                               Very rare     Common

Catatonia                               Very rare

Frontal headache                        Very common
(usually mild)

Meningeal signs                         Rare          Rare


                                                      10
Parkinsonism              Very rare

Ear, nose, and throat

Coated tongue, thrush &   Very common
Candida

Sore throat               Common

Pulmonary

Mild cough & runny nose   Common

Bronchitic cough &        Common
blocked nose every
morning

Rales                     Common

Pneumonia                 Rare (lobar)         Rare          Common

Cardiovascular

Varying blood pressure,   Rare                 Common
Dicrotic pulse

Myocarditis               Rare

Pericarditis              Extremely rareg


Thrombophlebitis                                             Very rare

Gastrointestinal

Constipation              Very common          Common


Diarrhea                  Rare                 Common (pea soup)

Bloating                  Very common


Diffuse mild abdominal    Very common
pain

Sharp right lower         Rare
quadrant pain

Gastrointestinal          Very rare; usually   Very common
hemorrhage                trace

intestinal perforation                                       Rare

Hepatosplenomegaly        Common

Jaundice                  Common

Gallbladder pain          Very rare

Urogenital

Urinary retention         Common

Hematuria                 Rare

Renal pain                Rare

                                               11
Musculoskeletal

Myalgias                  Very rare

Arthralgias               Very rare

Rheumatologic

Arthritis (large joint)   Extremely rare

Dermatologic

Rose spots                Common

Miscellaneous

Abscess (anywhere)          Extremely      rare      Extremely rare   Extremely rare




                                                  INTERVENTIONS
Public health interventions to prevent typhoid and paratyphoid
include:
*    health education about personal hygiene, especially
    regarding hand-washing after toilet use & before & after
    food preparation;
*    provision of a safe water supply;
*    proper sanitation systems;
*    EXCLUDE TYPHOID CARRIERS FROM ALL FOOD
    HANDLING & OTHER PEOPLE UNTIL APPROPRIATE
    TREATMENT HAS BEEN PROVIDED & FURTHER TESTING
    HAS BEEN CARRIED OUT TO CONFIRM THE PERSON IS
    NO LONGER A CARRIER.
    THE PIT TOILETS NEED TO BE PROPERLY SEALED
    AFTER USE.
CONTROL MEASURES
Control measures to combat typhoid include HEALTH
EDUCATION & AWARENESS & antibiotic treatment. A vaccine
is available, although it is not routinely recommended except
for those who will have exposure to contaminated food &
water in high-risk areas. The vaccine does not provide full
protection from infection. For those travelling to high-risk
areas, more potent vaccines are now available.
                                                          12
The incidence of typhoid fever in the United States has
markedly decreased since the early 1900s. Today, less than
500 cases are reported annually in the US., in people who
recently have travelled to endemic areas. This is in
comparison to the 1920s, when over 35,000 cases were
reported in the U.S &100,000 cases in Japan. This is still
common in Japan because of the lack of vaccinations.




      Death rates for typhoid fever in the U.S. 1906–1960

  ENVIRONMENTAL & PERSONAL SANITATION WILL
             REDUCE TYPHOID.
Mexico & South America are the most common areas for U.S.
citizens to contract typhoid fever. High risk areas in Africa are
Kenya & Uganda. Other countries such as India, Pakistan, &
Egypt are also known high-risk areas for developing Typhoid.
Worldwide, Typhoid Fever affects more than 21 million people
annually, with over 500,000 people dying of the disease.
              HOW IS TYPHOID FEVER SPREAD?
As stated previously, Salmonella S-typhi bacteria lives in the
intestines of infected persons & are found in the faeces &
urine of a person who is ill or who is a carrier of the bacteria (a
carrier has no symptoms of illness but continues to shed
bacteria). The bacteria may be found in & on food, water, un-
pasteurized milk or dairy products surfaces that have been
contaminated by hands because of poor hygiene with infected
faeces. The disease is spread by eating food contaminated

                                13
with the bacteria or by putting a contaminated object in one’s
mouth, eg. the skin of any fruit.
Salmonella Typhi can only survive in humans & one species of
Gorrillas. Persons with Typhoid Fever carry the bacteria in
their bloodstream & intestinal tract. In addition, a number of
persons, called carriers , recover from Typhoid Fever
physically but continue to carry the bacteria. Both ill persons
& carriers shed S. Typhi in their faeces (stool). It is the same
principal as Malaria.
Unless the parasite or bacteria is cleaned out of the system by
appropriate medical intervention the person can stay infected
for years if not for the rest of their life.
The concept of “I feel well so I do not have it anymore” can be
totally incorrect.
As stated previously, Typhoid fever is more common in areas
of the world where hygienic hand washing is less frequent and
water is likely to be contaminated with sewerage. If there are
OPEN PIT OR DROP toilets & Typhoid infected people are
using the drop or pit toilet then flies can be the carriers of the
bacteria. The drop or pit toilets faeces residue can or may get
into the underground water supply if the toilets are next to
water supply.




                                14
  CARRIERS, FOOD & WATER ARE # 1 SPREADERS OF THE
                             DISEASE
Most cases of typhoid fever human carriers are associated
with poor sanitary conditions & or poor personal hygiene.
Food can be contaminated with bacteria from the handling of
food from an infected person. Contaminated food looks &
smell is normal. The disease is spread when someone handles
food which was handled by an infected person who did not
carefully wash his or her hands after using the toilet or
changing a diaper from an infant who has been infected.
The carrier state, which occurs in 8% to15% of those infected,
can be treated with prolonged antibiotics. Often, the removal
of the gallbladder, the site of chronic infection, will cure the
carrier state. As stated earlier, all known or infected or
suspected carriers should be separated from all food handling
& preparation. This includes shopping for fresh food.
CAN TYPHOID FEVER BE TREATED?
Persons with diarrhoea or high fever should drink lots of
liquids to avoid dehydration. Consult your family doctor for
advice & treatment if you have symptoms of Typhoid Fever.
Typhoid fever is diagnosed by laboratory tests to determine
which prescription drugs is best to treat the bacteria.
HOW CAN TYPHOID FEVER BE PREVENTED?
PRACTICE GOOD PERSONAL HYGIENE.
Wash hands thoroughly with soap & water after using the
toilet, after handling animals, after handling raw meats, & fresh
vegetables or before preparing & eating food. Typhoid fever
can be prevented & can usually be treated with antibiotics. If
you are planning to travel outside the United States, Europe,
Canada or Australia you should know about Typhoid Fever &
what steps you can take to protect yourself.
PRACTICE BASIC FOOD SAFETY PRECAUTIONS.



                               15
Wash food in boiled water or peel all raw vegetables & fruits
before eating. Ensure the water for washing food has been
boiled.
Thoroughly cook all meats (meat, poultry & seafood). Prevent
contact of cooked foods with raw meats or poultry. Drink & eat
only pasteurized dairy products (milk, cheese, yogurt).
Unpasturized milk is a high carrier of Typhoid.
AVOID WATER THAT MIGHT BE CONTAMINATED.
Boil all water 3 times for consumption if you are Typhoid
designated area. If you cannot boil water the buy reliable
bottled water. Check to see if cap & label colour match or cap
has a plastic seal. Do not drink untreated surface water.
HOW CAN YOU AVOID TYPHOID FEVER?
Two basic actions can protect you from Typhoid Fever:
1. Avoid risky foods & drinks.
2. Get vaccinated against typhoid fever.
3. If you cannot boil it, cook it, peel it, then forget it.
It may surprise you, but watching what you eat and drink when
you travel is as important as being vaccinated. This is because
the vaccines are not completely effective. Avoiding risky foods
will also help protect you from other illnesses, including
travelers' diarrhea, cholera, dysentery, & hepatitis A.
AGAIN FOLLOW THESE RULES
IF YOU CANNOT BOIL IT, COOK IT, PEEL IT, THEN FORGET IT
Ask for drinks without ice unless the ice is made from bottled
or boiled water, but in developing countries it is rare that they
would take the time to boil the water to make ice. Best policy
is to no ice in drinks.
People in African assume the water or other drinks have ice in
it then every thing in & around the ice the bacteria will die. It is
just the opposite with Bacteria, most if not everything lives.
Also avoid icy poles & flavoured ices that may have been
made with local & contaminated water.

                                 16
When you eat raw fruit that can be peeled, peel them yourself.
(Wash your hands with soap first). Do not eat the peelings.
When you finish peeling the fruit or vegetables wash your
hands again before eating.
Eat foods that have been thoroughly cooked & that are still hot
& steaming.
Avoid raw vegetables. Vegetables like lettuce & cabbage are
easily contaminated & are very hard to wash as well. In most
cases washing vegetables or fruit under tap water from the
local water supply may infect the vegetables or fruit.
Local town water is usually contaminated with the Typhoid
Bacteria in a Typhoid contaminated area. When an outbreak
occurs the local water supply is usually the first to become
contaminated.
As people from Kenya have stated recently, “There is no
Typhoid in the underground water supply, but we cannot
afford to run it because of the high fuel cost. The local water
supply is known to be contaminated”. This concept is a health
worry knowing people & especially students or children are
going to drink from the local water supply as there is nothing
else available. Even staff had bottled water available 3 staff
had symptoms of Typhoid. There are no facilities for boiling
water for students so contamination must take place.
Avoid foods and beverages from street vendors. It is difficult
for food to be kept clean on the street, & many travellers get
sick from food bought from street vendors.
If a person is having Headaches, Stomach pain, & Fever it is
best you assume he or she has a bacterial disease or Typhoid
Fever until otherwise disproved. The Typhoid ill person or the
carrier can spread the disease by touching food or having
body contact (hands). Food or water consumption is the
quickest way into the body for the disease to spread rapidly.
Drinking contaminated water, milk or other drinks which may
have been contaminated by Salmonella Typhi Bacteria.
                               17
Getting Vaccinated
If you are travelling to a country where typhoid is common,
you should consider being vaccinated against typhoid. Visit a
doctor or travel clinic to discuss your vaccination options.
Remember that you will need to complete your vaccination at
least 2 weeks before you travel so that the vaccine has time to
take effect. Typhoid vaccines lose effectiveness after several
years; if you were vaccinated in the past, check with your
doctor to see if it is time for a booster vaccination.
A vaccine for typhoid fever is available & is 75% reliable.
Taking antibiotics will not prevent typhoid fever; they only
help treat it.
     The chart below provides basic information on typhoid
        vaccines that are available in the United States.
                                                 Total time
                          Number of   Time       needed to   Minimum       Booster
Vaccine
             How given    doses       between    set aside   age for       needed
Name
                          necessary   doses      for         vaccination   every...
                                                 vaccination
Ty21a
(Vivotif
Berna,
              1 capsule
Swiss                         4         2 days    2 weeks       6 years       5 years
              by mouth
Serum and
Vaccine
Institute)


                             MEDICAL APPROACH
Drugs used to Eliminate the Typhoid Fever
14 day course of Offoxaun tablets
Caftriax Injection
Chloramphenicol (dangerous drug)
Ampicillin
Norflaoxacin
Nufloxib New formulae




                                           18
Diet must be void of Sugar &
additives as they can make the
condition worse.




              19
               REFERENCES & CASE STUDIES
References

Steinberg EB, Bishop RB, Dempsey AF, Hoekstra RM, Nelson
JM, Ackers
M, Calugar A, Mintz ED. Typhoid fever in travelers: who should
be targeted for prevention? Clinical Infectious Diseases. 2004;
39:186-191.
Crump JA, Luby SP, Mintz ED. The global burden of typhoid
fever. Bulletin
of WHO. 2004;84:346-353.
Olsen SJ, Bleasdale SC , Magnano AR , et al. Outbreaks of
typhoid fever in the United States, 1960-1999. Epidemiology
and Infection . 2003;130:13-21.
Ackers M, Puhr N, Tauxe R, Mintz E. Laboratory-based
surveillance of Salmonella Typhi infections in the United
States: antimicrobial resistance on the rise. JAMA 2000; 283:
2668-2673.
Mermin JH, Villar R, Carpenter C, et al. A massive epidemic of
multidrugresistant typhoid fever in Tajikistan associated with
consumption of municipal water. J Infect Dis 1999; 179: 1416-
1422.
Mermin JH, Townes JM, Gerber M, et al. Typhoid fever in the
United
States, 1985-1994: changing risks of international travel and
increasing antimicrobial resistance. Arch Intern Med 1998;
158: 633-638.
CDC. Typhoid immunization: recommendations of the
Advisory Committee on Immunization Practices. MMWR 1994;
43 (No. RR-14).




                              20
                         CASE STUDIES
Related Article: Typhoid Fever
The following Patient Discussions have not been medically
reviewed.
Comment from: Noemi, 45-54 Female (Patient)
I got Typhoid 15 years ago and it never came back until
around 5 years ago. It was low level, no fever, just very low
energy & headache. Now it is back. I got a blood test & it said I
have 1/160 Typhi H. I got on Cipro 1gr for 7 days but it came
back after two weeks. I took Cipro again for 10 days, same
dose. I finished the dose but still have a rash, at the end of the
day I start feeling bad, I lose energy, & I have itches under my
skin. I guess I have to take another antibiotic to clear this up,
but which one? 15 years ago, I was given the Ampicillin & that
seemed to clear it up well. Published: March 27 ::
Comment from: Indigo, 35-44 Female (Patient)
I contracted typhoid fever in 2005 while on vacation in Mexico.
The day of my return, I became violently ill. I had
uncontrollable diarrhea & vomiting.
My fever shot up to 104 degrees, & I was hospitalized where I
remained for seven days. I was packed on ice continually as
my fever shot to105. I suffered convulsions. The pain in my
body was so excruciating. I was put on a morphine drip, & I
have a high tolerance for pain. Blood tests showed minimal
kidney function & liver failure. Even after I was released, I
continued to have fevers of 104 and 105. I was disabled by this
illness for months. Published: February 20 ::
Comment from: Yucatan shadow, 45-54 Female (Patient)
I am in my 40's. I contracted Typhoid Fever about three years
ago by drinking contaminated water in Mexico after Hurricane
Wilma, it lasted for 8 months, I had a fever off and on & low
blood pressure, headaches and was lethargic. I would have
moments of severe heat inside my body, diarrhea & could not
eat food for up to 8 days at a time, normally only 3 days of no
eating, & this came in cycles, I was first diagnosed and treated
with homeopathy, it did not work, & then I was given
                                21
Chloramphenicol, it nearly killed me. I took it for 9 days, my
blood pressure was 70 over 40 & I had severe headaches. I
next went to a Doctor that performed colonics on me, 3
sessions, then to a doctor that uses Vibrational Herbal
Medicine, she had to treat me for the side effects of the drug
Chlor. it was a 2 month treatment of herbs, and a very clean
diet void of Sugar and additives, I then returned to the states &
had a disease specialist from India check me out, he did many
tests for damage from the drug, MRI, Cat scan, Bloodtests, etc,
& he said amazingly I had no permanent damage from the
drug, I did have a low white blood cell count & high allergy
counts. I have never fully recovered as I live in Mexico, I have
flair-ups of symptoms from time to time, once a month for
three months. I was getting nausea & diarrhea, & heat & chills
& not being able to eat for 2 days at a time, I went to Argentina
& started drinking Mate & my symptoms subsided, I still have
a low white blood cell count, stomach trouble off & on and
bladder & urination irritation & I have had eye irritation &
saggy skin & dark circles under my eyes since I was sick, so I
feel I have never truly recovered fromthis illness. Published:
January 22 ::
Comment from: LadyBond007::, 19-24 Female (Patient)
When I was 12 years old, I got typhoid fever. One day I
remember suddenly feeling as if the wind had been knocked
out of me. All my energy fled from my body, & I immediately
had to sit because I felt so weak. I told my parents I felt really
weird. Then that evening, I started to get a really high fever. It
was in the upper 100s. I continued with a high fever for weeks.
My body ached so much & was so sensitive from the high
fever that my mom couldn’t even touch me to brush my hair
because it hurt too much. I soon got on antibiotics, which
didn't make much of a difference. I often was vomiting the
medicine out, which was awful. Then the doctor gave me a
specific vaccination & within a few days from getting the
vaccination, I began to recover slowly and feel better.
Published: November 06:

                                22
Comment from: iluvnola, 2001, 45-54 Female
I had typhoid fever in 1972. Our family always received a
yearly vaccine. Initially, it was as if I had a small cold. The cold
did not dissipate. After a few weeks, went back to the doctor
who diagnosed me with severe bronchitis. That continued for
another 10 days. The extremely high fever hit all of sudden. At
that point I was on a different island that took 12 hours to get
home from. By the time I arrived home my fever was extremely
high, I could not remember what was said to me. All I wanted
to do was sleep. The doctor admitted me to the hospital. I had
alternating chills & feeling extremely hot for a week. I was
allergic for the first two lots of medication for treating typhoid
fever. I was given the 3rd line of dense medication which did
not work. They would give me an allergy shot 30 minutes prior
to the 1st line of defense medication. After two weeks of being
in the hospital I did not have a fever anymore. I was extremely
weak & fatigued for 3 months. I went to the US & started
working 40 hours a week & going to school 20 hours a week. 8
months after my initial typhoid fever illness, I became sick
again & had to have complete rest for 6 weeks. It took another
two years for my body to finally feel rested. My hair did not fall
out at the time of the typhoid fever but have been losing hair
on a daily basis since then.
                Author of this Document.
Information in this document has been gained from personal
experience, above references & information gained on the web sites
concerning Typhoid Fever.
Dr Kenneth Henry OMD
3 Mein Street, Scarborough, 4020, Queensland, Australia
Ph.   +61 432 046 551
Email Bus. Aust.:    baylineservices@optusnet.com.au
Email Bus. 2:        bayline_export_services@yahoo.com
Email International: kenhenry36@yahoo.com
Email NGO:           ken_projectafrica@yahoo.com
Internet downloads & Photographs by Ken Henry

                                 23
PREVALENCE OF TYHOID FEVER IN NYAHURURU DIVISION

             BY Boniface Wanjohi Wakiuru..

     { Medical laboratory Nyahururu Private Hospital}

 TABLE OF CONTENTS
                                                    PAGE
ACKNOWLEDGEMENT…………….………………………………i
DEDICATION……………………………………….………………..ii
DECLARAION………………………………………………………..iii
ABSTRACT……………………………………………………….…..iv


CHAPTER ONE ……………………………………………………..1
1.0   INTRODUCTION……………………………………….……
….3
1.1   STATEMENT OF THE
PROBLEM……………………….......2

OBJECTIVES…………………………………………….…………...3

HYPOTHESIS…………………………………………..…..…………3

JUSTIFICATION…………………………………………....………. 3

LITERATURE REVIEW……………………………….....………….4

1.5 PATHOGENECITY OF SALMONELLA………………………7

TRANSMISSION………………….…………………………..…8

CLINICAL MANIFESTATION………………………………….8

LABORATORY DIAGNOSIS…………………..………………9

                            24
2.0 CULTURE…………………………………..……………………9

2.1 SEROLOGICAL TEST…………………………….…..……….10

PREVENTION………………………………………………….. 10

TREATMENT………………………………………………..…. 11

LIMITATIN OF STUDY……………………………………..… 12
CHAPTER TWO
3.0 METHODOLOGY………………………………………..…13

3.1 MATERIAL & REAGENT…………………………………13

3.2 SAMPLE COLLECTION…………………………….…..14

3.3 SPECIMEN ANALYSIS………………………...………..15

3.4 GRAM STAINING TECHNIQUE ………………………..18
3.5 BIOCHEMICAL TEST……………………………………19
3.6 ANTIMICROBIAL SENSITIVITY RESULT…………...22
CHAPTER THREE

4.0     DATA COLLECTION…………………………....……         24
4.1 DATA PRESENTATION AND
ANALYSIS……………..………………………….……                    25
4.2 DISCUSSION………………………………………… ..               34
4.3 CONCLUSION…………………………….……………                 37
4.4 RECOMMENDATIONS……… ………………….……               38
4.5 APPENDIX……………………… ……………….…….                39
4.6 REFERENCES………………………………………….                 42




                        25
ACKNOWLEDGEMENT
I am thankful to all people who have been of valuable
assistance during the period I have been writing this
project.

I am particularly grateful to Jeff Njogu Laboratory in charge
Nyahururu Private Hospital for producing large number of
valuable specimens, hospital records and the current
reference material required for this project.

Useful comments, un countable corrections, excellent
ideas, and suggestions were received from various people
and specific thanks go DR KEN.HENRY

FINALLY I thank my family for aberrance and support
throughout this challenging project which consumed a lot
of time.

DEDICATION
I dedicate this project work to my Mummy, my source of
inspiration, who guided me, loved me and encouraged me in
times of hardships Miss Jecinter Nyambura Mwangi.

ABSTRACT
This project work was carried out at Nyahururu division at
Nyahururu Private hospital. During THE PERIOD OF 2 AND
HALF MONTH, the study showed that a total of about 3000
parents were treated for salmonella and only 1300 patients
were diagnosed with the fever. If all patients had been Stool
tested the prevalence would have been higher. The Kenyan
Government Hospitals would have had a higher incidence
but because of funding issues the number of confirmed
cases would have much higher.

The prevalence of the positive tested cases was 43% as in
evidence (table 1a) of the study, the patients were grouped
according to their age differences. The grouping was as
                             26
follows; below 10 years, ;11-20 years,31-40 years and finally
above 50 years.

The most affected age group turned out to be those
between ages 21-30 years and the least affected are those
below 10 years. The mostly affected are known to reside in
those areas with low living standards with pit toilets, this
poses to them and thus are more susceptible to acquiring
the fever.

This information was gotten by interviews, questionnaires
and also through Hospital Records. The information gotten
has been presented in graphs and pie charts.

The specimen diagnosed were blood, stool and whereby
blood was diagnosed for widal tests and cultures. Widal
test was the mostly carried out.

G. Stain together with other (biochemical test) were used to
isolate salmonella e.g Urease, triple sugar ion (TSI,) motility
test and nitrate reduc

CHAPTER ONE
1.0 INTRODUCTION
Typhoid is disease of human beings, which is caused by the
bacteria of salmonella species. Salmonella is a gram
negative bacilli, aerobic and facultative anaerobe. It is
capable of growing in a wide of relatively simple media. It is
distinguish from other member of the enter bacteria by the
biochemical characteristics and antigenic characteristics.
Salmonella is transmitted through man to man without an
intermediate host. Infection is by ingesting salmonella in
food that has become contaminated from animal to human
intestinal sources directly or indirectly. The incidence of
the disease is a major health problem in most developing
countries.

                              27
The colonies of salmonella are ( 2-4mm) on diameter. Some
stains appear mucoid in the feacal specimens; a selective
medium is suitable for this isolation. In the agar the
colonies produces hydrogen sulphide whereby they form a
pink red colony which form black centers of about 3-5mm in
diameter.

Different strains of salmonella causes different diseases
e.g. enteric fever which is caused by S. typhi and S
paratyphi and finally the gastro enteritis (food poisoning
)which is caused by S typhimurium.

The test performed to identify salmonella typhi is known as
the widal test. It is the reaction that involves the
agglutination of typhoid bacilli when mixed with serum
(containing typhoid antibodies; the agglutinin) from an
individual with typhoid fever (J.P Hamley and L.M
Arescott).Most serotypes of the salmonella that causes
disease in human are in sub group I.

The serotype of salmonella enterica are sub –divided into
seven sub-groups. Typhoid is the most studied enteric
fever which is caused by salmonella typhi
Salmonella species has 3 main antigens;
Surface antigens Vi
Somatic antigens “O”
Flagella antigens ‘H’
The ‘Vi’ antigen interferes with agglutination of freshly
isolated organisms by “o” antigens. It is a polysaccharide
and heat labile. Heating or boiling destroys it.
The ‘o’ antigens are phosopholopids proteins
polysaccharide complexes. The antigenic specificity
resides in polysaccharides component. They are heat
stable and can withstand temperaturesl above 100oc for
several hours they also presents agglutination from O
antiserum.

                             28
The “H” antigen is a protein in nature and can be destroyed
by boiling for few minutes destruction can also occur from
exposure of alcohol. Exposing the organisim to foramalin
can do preparation.

1.1    STATEMENT OF THE PROBLEM
Typhoid fever has continued to cause death in Nyahururu
Division as the mortality rate is increasing day after the
other. This could be supported by the fact that most people
here are poor. Again the emergence of some strains
resistance to previously used antimicabials. Hence this
research seek to determine the cause of high mortality rate,
how to prevent it and solving it. Therefore these research
findings will be used to come up with ways of controlling
and managing this problem in future.

GENERAL OBJECTIVES
To determine the prevalence of typhoid fever
Specific objective
1. To identify the most affected ages of persons
2. To determine the sensitivity of the organism to different
antibiotics hence an appropriate cure
3. To propose relevant control measures
4. To identify the most affected estates among the area of
study
5. To determine isolation methods of salmonella in different
specimen
1.2    HYPOTHESIS
HA. The most affected people are those who live in low
hygienic areas and include all           ages
HO. The most affected people are not necessary from low
hygienic area and include specific ages
HA. Those who are affected are poor, and do not maintain
health environment.
HO –Those who are affected and poor and do not maintain
health environment.
HA – There is cure and all types of antibiotics may be used.
                            29
HO - There no cure and not all types of antibiotics may be
used

1.3   JUSTIFICATION
Nyahururu Division being a highly populated area in some
areas, water is polluted. This contributes to unsafe drinking
water, thus posing as great hazard to the residence with the
typhoid fever. In Nyahururu Division, more than half of the
samples tested turned out to be positive in some months.
This could be attributed to the poorly constructed drainage
system and increment of slums areas thus polluting the
environment and lowering the level of hygiene

1.4    LITRATURE REVIEW.
Typhoid fever was first discovered by Eberth in the year
1880. The organism was first cultured in 1884 by T. Smith
and D.E Salmon reported “the hog cholera of bacteria” and
the ‘swine Plaque’ subsequently the genus salmonella was
named in Salmon’s honor. Salmonella has a human medical
dimension (typhoid fever)
Typhoid fever and other Salmonella species were dealt with
adequately by Huck Step in 1962 who discovered 1300
typhoid cases collected from Kenya and Uganda in the
period 1954-1961.
Other Salmonella infections poisoning organism has been
distributed to S typhimurium although many other
serotypes of salmonella has been discovered at different
times(Muller 1974). Several conditions and symptoms are
the causes of typhoid fever. This include headache,
malaise, anoxea, toxaemia, low pulse rate ,enlarged spleen ,
abdominal discomfort with constipation or diarrhea. Some
times lead to mental confusion ‘rose spots’ rash on light
colored skin may be seen. Other complication of typhoid
include ,broncho- pneumonia, hemolytic anemia and
cholecystic.Other complications that occurs in children
those co infected with HIV, those with malignacy, sickle cell

                             30
disease, chronic schistosomiasis is bacteremia and
septicemia (Tropical africa. monicah -part 2)
Some important people involved in the discovery include.
1820      Bretuno and Charlie described pathological
changes due to the disease in lymphatic system.
1838      Gerhard differentiated in terms “typhoid” and
“typhus”
1880      Eberth saw the spleen and mesentic lymph codes
of patient who died
from typhoid.
1884      Gaffky isolated three salmonella typhi from cultures
1896      Guben discovered the phenomenon of
agglutination
1896      Femand George widal developed widal
agglutination Test for typhoid fever
1873      William Budd described the role of milk and water
in the transmission of typhoid fever.
The Kauffmann – white diagnostic scheme simplified by
Edwards and kauffman (1952) forms the basic of serotyping
of salmonella based on the identification of “O” and “H”
antigen. This is done by agglutination test with absorbed
sera.
The salmonella species were originally named after the
place of origin(S.Newport,S,S. Panama,S. Polna) after the
animal source [S.Gallnarum]after the discover[S.Thompson]
and after the name of the person from whom the first stain
was isolated (S. Scottmulleri) (Text book of microbiology, p.
charkaborty 1995)
About 3% of the patient who are affected with salmonellae
typhi and haven’t received treatment shed bacterial in their
stool.For more than a year some of those carries never
have symptoms of typhoid fever. Most of the estimated
2000 carrier in the United States are elderly women with
chronic fall gall bladder disease (Robert Berkau 1997)
A study in Roskidle country in Denmark in which featured
277 diarrhea patients, 68 being children below 15 years,

                             31
implicated salmorella species to have highest prevalence
(61%) (Peterson 1998)
In a study done in Nairobi, Kenya, amongst AIDS
patientswith chronic diarhoea[52
% were A.I.DS]35% of the patient yielded put active
pathogen in which salmonella typhimurim represented
about 13% (Mwachiri 1998)
Eggs are another widespread source of salmonellosis when
used In food such as cream cakes. In 1992 the CDC
reported on 38 cases associated with Caesar salad dressing
made of raw eggs. Researchers are coming to believe that
salmonella serotype infects the ovary of the hen and passes
into the egg before the shell forms (F. Microbiology Alcamo
5th edition)
In England ad Wales annual isolations of selected serotype
from man almost the trebled from 10251 to 2700 between
1981 and 1998. This dramatic increase was done largely to
the emergence of strains belonging to serotype Enteritidis,
which pleaked in 1997-1998 and continues to be most
frequently isolated serotype (M. Microbiology D.R.J
Greenwood, 6th edition)
Salmonella resists phagocytosis by macrophages by
growing within these macrophages hence becoming
distributed to various organs though the circulation and
produce local lesion in important sites(Mechanism of
Microbial desease – M. schaechter , G Madoff and D.
Shessinger)
Salmonella genus is a large group of enteric bacteria
closely related to Escherchiai Coli. Chronic salmonella
species infection is some times associated with
schistosomiasis, with bacteria growing with adult
schistosomers (Parasitology in focus; facts and Trends)

1.5   PATHOGENECITY OF SALMONELLA IN HUMAN
Salmonella are after pathogen to human who acquire the
disease through the oral route. There are transmitted from

                            32
annual product to human being. Diseases, which are
transmitted by typhoid, are divided into three ways;
• Enteric fever
• Septicemia
• Gastro enteritis

(a)     Enteric fever
It is a condition where the bacteria leaves the intestine and
enters the cells where multiplication occurs. These cells
enter the mesenteric lymph nodes where after a period of
multiplication, the bacilli invade the blood stream. The fever
incubation period is between 7-15 days, which is high
gradually. This duration last for about a few weeks after
the onset of the symptoms. Blood culture is usually
positive the 1st week of illness. Typhoid bacilli are most
easily isolated from feaces between 2nd and 3rd week of
illness and in urine the 3rd and 4th week of illness’

(b)   Septicemia
Following infection by the organism, there is early invasion
of blood stream, highly remittent fever, ordinarily without
gastro-intestinal manifestations. The incubation period is
very short. The organism can be recovered from blood or
exudates from focal lesions but rarely from feaces.

(c) Gastroenteritis
Infection is by ingesting salmonella or their toxins in food
that has become contaminated from animal or human
intestinal sources directly or indirectly. Its incubation
period is about 3-48 hours. Its onset is abrupt and after the
bacterium has entered the epithelial lining of the small
intestines it stimulates the release of inflammatory
cytokines. The symptoms include; vomiting,diarrhoea,
fever nausea and abdominal pain.



                             33
1.6     TRANSMISSION
Infection is transmitted by the faecal oral route through
contaminated food and water. When sufficient number of
bacilli passes into a gastric barrier, and reach the
duodenum, they increase in number the alkaline medium. In
the small intestine, the bacilli attach themselves on the
surface of the epithelial cells of the villi and pass through
them to the sub mucous coat, where they are phagocytosed
by neutrophils and macrophages. The virulent bacilli resist
intracellular killing and multiply within the cells. These cells
enter the mesenteric lymph node, where after a period of
multiplication the bacilli invade the blood stream via
thoracic duct and a transient bacteriaemias follows.
(primary bacteriaemia)

During primary bacteraemia the bacilli are able to live an
multiply in cells of MPS (Mononuclear Phagocytic System)
and by about 10th day the parasitised cells undergo necrosis
and the location pass into blood leading to secondary and
heavier bacteraemia which corresponds with the onset of
clinical illness at about 14th day after ingestion (infection)

1.7    CLINICAL MANIFESTATION
The incubation period varies with the size of the infecting
dose whereby the average is 5-15 days. In the 1st week the
patient present with headache, abdominal pain, nausea and
remittent fever. During the 2nd week the patient look toxic
apathetic, severe headache, diarrhoea (passage of blood
and mucus in feaces) and high temperature. There may
also be visible rose spot in invasive salmonellosis.in the
third week, the patient is still toxic and ill high fever and
confusion is also present. If the patient attains in the 4
week there is high fever with low pulse rate, mental
confusion and abdominal distension with convalescent
prolonged. These symptoms can be divided into general or
haemopoetic sign.

                              34
1.8    LABORATORY DIAGNOSIS.
For diagnosis, the specimen for the isolation of salmonella
include blood, faeces, urine and joint aspirates in the blood,
the organism can be detected the first 7-10 days of
infection. Blood cultures are positive for about 90% of
cases. The rate of isolation decrease after one week. In the
chronic salmonellosis; S. typhi is successfully isolated from
bone marrow than from blood.

In the feaces, the organisms are isolated from 40-50% of
patient, during the second week. This specimen is the
most useful from the diagnosis of food poisoning.
From the 2nd week of infection, it is possible to isolate
salmonella typhi from urine. Although bacteria’s are not
excreted continuously in urine and therefore several
specimen are to be cultured before the organism is isolated.
Pus or joint aspirate is collected in case of abscess or
arthritis.

2.0    CULTURE
The method of choice for isolation of causative agents of
the enteric fever is blood culture.
Since the number of bacteria present in the blood is scanty,
its preferred to inoculate two bottles of blood culture
medium having different media which are ideal for the
different groups of bacteria.5ml of blood is added to 50ml of
the medium in each bottle.

The community used set of blood culture media used
consist of glucose broth and bile broth. They are incubated
at 37 0c and subcultures (one done after one week) are
performed to detect almost all the positive cultures

2.1   SEROLOGICAL TEST
(a)   Widal Test


                             35
It is an agglutination test which detects presence of serum
agglutins (O & H) in the patent serum with typhoid and
paratyphoid fever.
Salmonella antibodies stants appearing in serum at the end
of 1st week and raises sharply during the third week.

(b)    Accu-chek S. typi antigens test
Is a rapid (10-15mins) immunochromatographic test for
detecting S. typhi antigen on feacel specimens The test is
sensitive and highly specific using two monoclonal
antibodies for S. typhi becomes present in the faeces.

(c) Elisa
This is a sensitive method of measuring antibodies against
the lip polysaccharides of salmonella, title of IGM antibody
corresponds fairly well with the widal ‘O’ in the detection of
porin by Elisa method is a useful for early sero-diagnosis of
typhoid fever (Rao .Jet al 1993)

2.2    PREVENTION
In the endemic continues, the deepest way of reducing the
enteric fever incidences is public health measures for clean
water supply, disposal of sewage and supervision of food
processing and handling must be taken . Infected poultry
meat and eggs should be thoughly cooked.

Carriers should also not be engaged in food preparations
and should also not be engaged in food preparation and
should observe strict personal hygiene.
Immunization can also be used to prevent typhoid fever.
Vaccines are indicated for those persons who travel or in
areas where typhoid fever is endemic.

Three types of vaccines are available
  i.  Killed whole cell vaccine
 ii.  Live oral (Tysia) typhoid vaccine
iii.  Purified Vi polysaccharide vaccine
                             36
Killed whole cell vaccines is associated with serious
adverse reaction, while live oral (Tysia) vaccine is a recent,
oral administration of live aviluent mutant stains of S. typhi
(Tysia). Purified Vi polysaccharides vaccine contains
purified Vi antigen which is injected intramuscularly and
gives immunity for 2-3 years with single injection.( Text
book of microbio/P Chadraborty.

2.3    TREATMENT.
Chloramphenical is the antibiotic of choice since its
introduction in 1948 although dangerous. Adults dose is
500mg every 4 hours. Ant microbial therapy with ampicilin
or trimethoprim sulfamethorazole gives encouraging
results.

Ciproflaxacin is also effective against salmonellae
cholecystectomy is indicated in those who do not show
response toAnti bacterial also Norfloxacin ..

2.4   LIMITATION OF STUDY
Limited time to carry out the research i.e. to obtain and
collect adequate data for analysis.

Lack of funds for writing, fare (traveling) field expenditure,
compiling and binding relevant materials.e.g computers and
camera.

Some patients were not willing to co-operate which could
lead to inaccurate information gotten
Language barrier. This created inaccurate data, as different
people could not understand i.e. face to face became a
problem.




                              37
CHAPTER TWO
3.0   METHODOLOGY

3.1   MATERIAL AND REAGENTS

A.     REAGENTS
• Neutral red
• Crystal violet
• Lugoils iodine
• Acetone
• Phenol led
• Oil immersion

B. APPARATUS
• Bunsen burner and wire loop
• Microscope and microscope slider and cover slips
• Measuring cylinder
• Petridishes
• Sterile specimen bottle
• Tourniquet and application stick
• Forceps
• Grease pencil;

C. EQUIPMENT
• Hot air oven
• Refrigerator
• Incubator
• Autoclave
D.    MEDIA
• Deoxycholate Citrate Agar (D.C.A)
• Triple Sugar Ion media
• Selenite broth.
•
3.2   SAMPLE COLLECTION
Samples include
                           38
    • Stool
    • Blood
    • Urine

    URINE COLLECTION
    The patients were given sterile dry, a wide mouth leak proof
    container, where they were supposed to put urine inside.
    The container was labeled with the name of patients, date
    and the time of collection of the urine specimen .

    BLOOD
    Blood was collected before ant microbial treatment was
    administered and at the time when patients transfer time
    began to rise. Organisms were most detected during the
    first 10 days of infection. Two different times of diagnosis,
    specimen was collected i.e. at the onset of the symptom and
    decline of fever

    METHOD
•     To locate a suitable vein a pressure cuff was used to
    dilate the veins
•     Skin was cleaned thoroughly using a wet swat dropped in
    70% alcohol
•     Using a sterile syringe and size gauge needle 5mls of
    blood was withdrawn
•     Then 3 mls of the blood was dispensed into the culture
    bottle containing thioglycholate broth. The remaining blood
    was put into anticoagulants bottle for serological test at
    room temperature to clot
•     The top of the alcohol was wiped using ethanol swab and
    tape to cover the bottle completely. Blood was gently mixed
    to avoid cloths as clot could facilitate bacteria.
•     Using the grease pencil, label the bottles with name of
    patient, number, date and time of collection.
•     The bottle was incubated at 35-37 0c for up to 2 weeks sub
    cultured after 48 hours.
                                39
    FEACAL SPECIMEN
    This was collected during the convalescent stages second
    week.
    Method
•     The patent was given a clean dry disinfectant free bedpan
    or polypot to pass the specimen into it. A portion is put on a
    clean container
•     The specimen was labeled, the patient name, number,
    date and time of collection
•     Physical appearance of the stool (specimen) was noted
    whether formed, semi formed or formed, a thick suspension
    of it was made in about a thick suspension of it was made in
    about 1ml of sterile peptone water and then inoculated
•     D.C.A is used or salmonella-shigella agar and latter
    culture
•     Examine for growth next day


    3.3 SPECIMENT ANALYSIS

    STOOL PROCESSING TO ISOLATE SALNELLA FROM
    OTHER
                ORGANIZASMS

                STOOL PROCESSING

    Alkaline peptone water      SELENITE F


       TCBS
    Suspected of cholera
                  SUB- CULTURE
                                         MACCONKEY




                                 40
               LF           NLF                                  LF




                                                 SAL -positive

    OXIDASE
                                     TSI



                                               SHIGELA-
             PSEUDO negative                   negative
                                              Positive
PSEUD


           UREASE



SAL / SHIGELA           PROTEUS positive

MOTILITY SHIGELA negative


           SALMONELLA positive

WIDAL TEST
During the course of the disease, the body responded to
antigenic stimulation by producing antibodies whose titres
rose slowly in early stages to a maximum and then fell
slowly till it was detectable. In endemic areas, antibody titre
was as high as it1:160 was detectable in normal individuals.
Antibodies to salmonella organism were detected in patent
serum from the second week after the onset of infection
Principle
                              41
       It is the test that involves the agglutination of typhoid bacilli
       when mixed with (serum containing antibodies the
       agglutinin) from an individual with the typhoid fever. I.e.
       when the anti salmonella antibodies present in the patient
       serum reacts with antigen suspension to produce
       agglutination, which indicates a positive test. No
       agglutination the test is negative.
       Procedure
   •      All reagents were bough to room temperature before the
       test was done.
   •      A drop of isotonic saline was placed on each of the two-
       reaction circle.
   •      One drop of the positive control pipette on the next two
       reaction circles each at a time
   •      20 micro liters of the patient serum to be tested was
       placed on the two remaining reaction circles each at a time.
   •      A drop of antigen suspens ‘O’ and ‘H’ was added to all the
       above reactions circle “O” to the top circles and H to lower
       circles.
   •      Then the content is mixed in each circle with a separate
       stick.
   •      The content was placed in a mechanical shaker and
       locked gently observing for agglutination macroscopically
  •       Agglutination was check against back ground under light
3.3            Gram stain
       Primary dye (crystal violet) stains the organism purplish.
       Action of mordant (lugols iodine) is employed. The stain is
       decolorized and counter stained. Those organisms which
       resist decolorization hence retain primary dye are said to be
       Gram positive while others like salmonella which were
       decolorized hence taking the co lour of the counter stain
       pinkish are Gram negative
       Procedure
  i.      A clean glass slide was taken and a smear was made
 ii.      The smear was air dry and then heat fixed
iii.      The smear was flooded with crystal violet for 30-60
       seconds
                                     42
 iv.    The stain was then washed using distilled water
  v.    Then lugol’s iodine was flood for about 60 seconds
 vi.    The stain was then washed and then flooded with
      acetone, which is used to decolorize the smear. It takes 10-
      30 seconds
vii.    Heat it again with center stain (neutral red) for 30-60 and
      then wipe the excess stain at the back of the slide using a
      cotton wool. Air dry
viii.   Observe the slide using oil immersion (x100) objective
      Results
      Gram-negative bacteria – dark red
      Gram-positive bacteria -dark purple

 3.4          BIOCHEMICAL TESTS
       A.                 Urease test
       Principle
       It enables the ability of the organism to produce urease
       enzyme, after breaking down urea to give ammonia and
       carbon dioxide gas. Ammonia and carbon dioxide gas are
       released; when released; ammonia makes the medium
       alkaline, which is shown by the change of colour to pink
       red.
       Procedure
   •          Have the medium ready i.e. Christensen’s modified
       urea broth
   •          Then sterilized the wire loop using a Bunsen burner
   •          Then using this sterile wire loop, pick a colony of the
       test organism and inoculate in the medium i.e. Christensen
       modified urea broth.
   •          Incubated at 35 oc –37oc in water bath
   •          Then observe for the growth; i.e.. This is seen when
       the media changes to pink red colour.

       Results
       The medium remained un charged since salmonella species
       don’t produce the enzyme urease which breaks urea to
       ammonia and carbon dioxide.
                                    43
 B.      NITRATE REDUCTION TEST
 Principle
 Chemolithotropic bacteria that get energy through chemical
 oxidation obtain the use of in organic compounds as
 electron donor and carbon dioxide as their primary source
 and many chemolitholithotophs (bacteria that requires in
 organic compound serves as a source of carbon dioxide
 and energy) are able to use nitrates as a terminal election
 acceptor during anaerobic respiration.
 Procedure
  •     The tubes was labeled correctly
  •     Using a septic condition the was inoculated with the
  test organism
  •     It was latter incubated at 35oc for 24 hours
  •     Then the presence of growth or absence was
  observed
  •     A Durham tube was observed for the presence of any
  gas
  •     0.5ml of sulfanilic acid and 0.5 ml napthylamine
  solution added to each of the culture tube and mixed.
  Results
  A red color was observed.
  Conclusion
  Salmonella species present because the produces nitrate
  that turns the medium red in colour

    RAPID APIZ SCREENING TEST
    It is a test used for the screening of salmonella from the
    patient using smooth colony seen in the XLD agar plate.
    The results were latter read after three hours.
    Procedure
 (i) A drop of distilled water was added to cupules A&B
    copula A has enzymes substance and cupule B has
    peptone culture
(ii) An application stick was used and a smooth colony was
    removed from the XLD plate and inoculated in the cupule
    A and B
                               44
(iii) They were later incubated at 37oc for two hours
(iv) A cupule A was observed for any change in colour for
     formation of a yellow and blue green. It signifies that the
     organism was not salmonella
 (v) One drop of fast violent B solution was added to cupule A
     OBSERVATION
     A red colour formed after three minutes signifys the
     organism was salmonella typhi
     MOTILITY TEST
     The motility test medium has agar concentration of 0.4%
     or less, to allow free spread of organisms.
     Inoculation are made on the stab medium by a single stab
     Then they are incubated overnight.
     Results
     Movements are seen away from the stab line or a hazy
     appearance throughout the medium.
     E     TRIPLE SUGAR IRON
     Used to separate organism of the family enterobacteal.
     Principle
     TSI has the ability to catabolise glucose, lactose or
     sucrose and to liberate sulphide from ferrous ammonium
     sulphate or sodium thiosulphate. It contain 1% Glucose
     Concentration, 1%of lactose,1% of sucrose concentration
     a P.H indicator phenol to detect acid production through
     carbohydrates fermentation. A yellow buff indicates acid
     formation. The slant remains red (alkaline because of
     limited acid formation). A gas formation is noted by
     accumulation of the gas at the bottom of the agar (cracks).
      A yellow butt formation (H2S) is indicated by blackening of
     the agar. Red butt and slant indicates no of the sugars
     were fermented and no gas produced.
     Procedure
     •     Label all tubes (slant tubes). Use one tube as your
     control.
     •     Use aseptic techniques to streak the slant the slant
     with the appropriate bacteria from plate(colony) and cover
     the top using a cotton wool
                               45
•     Then incubate the tube at 37oc over night and
observe for the colonial growth. (i.e. changes in Buff and
slant)
•     The tubes are latter incubated again to observe the
blackening for 7 days. All the slant cultures were
examined for colour changes on slant and buff.
•     Indicates motile organism
Conclusion
If the test is positive, it could be signifying salmonella
(salmonella is motile)
3.5 Ant microbial sensitivity results
Procedure
Molten Mueller Hinton Agar was poured into sterile
petridishes. Agar was allowed to set for 20-30 minutes.
The plate was slightly inoculated with the test organism
using a sterile cotton wool swab.
The plate was then allowed to dry and ascetically the
sensisitivity testing dishes were placed onto the plate. The
plate was inoculated at 37oc for 18-24 hours. After that,
you observe for inhibition zones. This inhibition zones are
measured using calipers which was latter compared with
the zone size interpretation chart.

Results
Salmonella species showed sensitivity to trimethoprim,
tecyline, chloramphenical, norflaxacin, contrimoxazoles
and sulphamethoxazole
The table below illustrates below various antibiotics in
relation to their sensitivity to salmonella.
Antibiotic               Potency          Remarks
Cortimoxazole            300ug            Highly
                                          sensitive
Chloramphenicol          30ug             Highly
                                          sensitive
Norflacin                100ug            Sensitive
Ciproflaxacin            100ug            Sensitive

                           46
   Tetracycline           30ug              Sensitive
   Gentamycin             25ug              Resistant
   Nitrofurantion         300ug             Resistant




     CHAPTER THREE
4.0 DATA COLLECTION
     The following are the methods used to collect data for the
     research
(i)           Interview
     Patients and their caretakers who attend the hospital for
     treatment were interviewed. Here the information was
     gotten face to face in dialogue with the patients. This was
     meant to support the questionnaires for the uniformity of
     the data
(ii)          Questionnaires
     When patients reached the reception in the hospital,
     standardized, simple questions were sent or given to
     patient to give information by answering them. This will
     be done by co-operation of the other hospital staff. Old
     and illiterate patients will be guided and assisted in
     putting down the information.
         (iii)    Hospital records
      By the great assistance of the senior laboratory
     technologist, then, laboratory records of previous
                               47
infection by typhoid fever were obtained. These records
gave the collect and additional information required as it
also involved the titre of the antibodies (concentration of
the disease in the body. Again the nurse in charge of the
hospital represented the records of the entire patient in
in-patient services as a result of typhoid fever. This
record included even drugs used, the management of the
patients and the during by which the patient stayed in the
hospital for treatment.


4.1 DATA PRESENTATION AND ANALYSIS
Table Ia
Age (years)         Positive    Negative   Percentage
                    Cases       Cases       Positive    Negative
                t




                f




    Under               46          80          1.5%        2.6%
    10
    years
    11-20               54          170         1.8%        5.7%

                4
    21-30               540         490         18%         16.3%



    31-40               300         488         10%         16.3%


                               48
    41-50            300         204     10%        6.8%

                4
    Above            60          238     2%         7.9%
    50

    Total            3000        1300    1670       44.3%

The above table 1a displays the distribution of infection
per age limits. It shows the No. Of patient diagnosed with
typhoid fever starting from the month of may up to
September.
(a) Calculation of positive cases
         Under 10 years 46 x 100 = 1.5%
                         3000
    11-12 years = 54       x 100 = 1.8%
                     3000
    21-30 years = 540        x 100 = 18%
                      3000
    31-40 years = 788        x 100 = 10%
                       3000
    41-50 years = 500        x 100 = 10%
                       3000
    Above 50 years = 60          x 100 = 2%
                          3000
(b) Calculation of negative cases
    Under10 years = 80         x 100 = 2.6%
                        3000
    11-20 years = 170        x 100 = 5.7%
                      3000
    21-30 years = 490        x 100 = 16.3%
                      3000
    31-40 years = 488        x 100 = 16.3%
                      3000
    41-50 years = 204        x 100 = 6.8%
                      3000
    Above 50 years = 238          x 100 = 7.9%
                           3000

                            49
Chart I
The bar graph (figure 1a) below shows the relationship
between the numbers of patient testifies in their relevant
age groups and those infected with salmonella typhi
  No. of patients   600
                    500
                    400
                    300
                    200
                    100
                      0
                          5-10.   15-20. 25-30. 31-40. 41-50. Above
                                                               50
                                         Age in years

                                       Positive   Negative

KEY
    Positive cases
    Negative cases
Scale: Horizontal Axis; Double bar represents 5 years
    Vertical Axis; One unit represents 100 patients




Chart II
The pie chart below (figure 1b) illustrates t he relationship
in the number of positive and negative case diagnosed in
Nyahururu Private Hospital in a period of five months




                                                        50
              160o                                  Negative cases
                                        200 o       Positive cases




    Negative cases 200.4 = 200o
    Positive cases = 160o
Fig 1b calculation
Negative cases = (1670 x 360 )= 200o 3000
positive case = (1300 x 360 = 159.48o%
                 3000 = 160o
  Table
                   Under10         11-                               21-30   3
  Years            years           20
  Mid              5.5             15.5                              25.5    3
  years
  Positive         1.5%            18%                               18%     1
  cases
  negative         2.6%            5.7%                              16.3%   1


Chart three
The line graph below (fig /c) shows the relation between
the percentage of positive cases and negative cases in
relation to their ages.
              20

              15
 Positive %




                                                     Positive case
              10
                                                     Negative case
              5

              0
                     1   2    3   4     5       6
                             Mid Ages


Mid Ages
                                                        51
Scale; horizontal 1 unit represent 5.5% years
    Vertical 1 unit represents 2% positive cases

Table 1c
The below table shows the distribution of positive and
negative cases in various estates of study.
Estate            Positive      Negative       total
Kiamaina          12            90             210
Site Core         6             20             26
Kibathi           50            60             110
Ma-hipo           60            25             85
Site phase I      4             10             14
Site Phase II     7             12             19
Ngomongo          61            40             101
Chemichemi        40            30             70
Augustine         36            40             76
Total             384           327            711




Chart iv
                            140
  Potive & Negative Cases




                            120
                            100
                             80                           Positive
                             60                           Negative
                             40
                             20
                              0
                                 ic o
                                Si na




                                   Si I



                               A emi
                                        ne
                                M thi
                                 K re


                                        po



                            Ch mo i
                               go te i
                              em ng
                                      te
                                     io
                                     ai




                                    sti
                                     hi
                                      a


                                    Si




                                    h
                                   ib
                                   te
                                  m




                                  ia




                                 gu
                                ia
                            K




                             N




                                  Affected Estates




                                                     52
The table 1d below shows the total number of specimen
tested for salmonella and their outcome
Sample        No. of      No. Of      Total
              positiv     negati      tested
              es          ve
Blood         1200        1500        2700
for
widal
Blood         64          90          154
for
culture
Stool         35          70          105
for
culture
Urine         1           10          11
for
culture
total         1300        1670        3000


The graph below (figure 1e) shows samples collected in
relation ship to their total number.
            1600
            1400
            1200
            1000
  Samples




            800
            600
            400
            200
              0
                   Widal   Blood        Stool     Urine
                           culture     Culture   culture
                                Test Done


KEY
Widal Test                                 Negative
                                       Positive
                                            53
Blood Culture                             negative
                          Positive

Stool culture                             Negative
                          Positive

Urine culture                 Negative
                          Positive
Chart V (fig 1f)
The pie chart below shows the relationship of different
test used in diagnosis of typhoid



                          Widal
                          Blood culture
                          Stool Culture
                          Urine culture




Blood for widal =    2,700    x 360 = 324o
                    3000
Blood culture = 154       x 360 = 18.48o
                  3000
Stool for culture = 110       x 360 = 13.62o
                    3000
Urine for culture = 11      x 360 = 3.90
                  3000




The graph show the monthly a analysis of the patient
found infected in relation to the number of months.
                            54
             600
             500




  Patients
             400                                               Positive
             300
             200                                               Negative
             100
               0




                          ne




                                            t
                                ly
                    ay




                                                           r
                                        us



                                                       be
                               Ju
                         Ju
                   M




                                        g


                                                       m
                                     Au



                                                  te
                                                   p
                                                Se
                               Months


Key 1unit on vertical axis represent 50 patients
    2 units on horizontal axis represent 1 month
4.2 DISCUSSION
In Nyahururu Private Hospital, so many patients attended
the hospital for various types of diagnosis; as the hospital
offered so many test and diagnosis. In addition, the
number of patients who attended the hospital for
salmonella testing for a period of 5 months totaled to
about three thousand patients. Resulting from this
number, only 13 patients turned out to be positive i.e.
infected with enteric fever.

After the analysis of the patient, chart 1 shows the age
bracket of 21-30 years as the most affected one by the
diseases. This age group is composed of young people
with low income i.e. unemployed and casual workers who
cant afford living standards in better estates and end up
in poor, shanty, unhygienic slums and feed on cheap dirty
food from the “kibanda” due to their financial status
For the children with age bracket of below 10 years, they
are minimal incidence of the disease. This is due to the
fact that out of the research, most of the children here are
below 5 years this contributing about 64% of the aged
bracket of (below 10years). These ages of children are
catered for by there parents and the chances of getting to
the hazard are low. Their diet is properly prepared and
water source maintained as very clean. Again children

                                        55
are suspended to dirty activities, objects and other
hygienic practices.
Chart I and II shows the relationship Number of positive
and negative case, which were diagnosed. Positive cases
reduced compared to negative cases i.e positive case
acquired an area angle of 160 o compared to negative
case of 200o. r was result of the fact that; only typhoid
fever was my interest of study i.e. compared to negative
cases patient (200o) could be occurred by other diseases
e.g. cholera, malaria, gastric ulcers, brucella and other
different types of diseases. Hence, typhoid fever, showed
that it was the most common disease in the area; as
compared to the diseases. This could be attributed by
poor sanitation, where people do not boil their drinking
water, the drainage and severage system were not
properly efficient. The above conditions lead to high
salmonella infection in the area
In the table 1c: chart iv shows the variation in infection
rates in different estates. Clean and less populated
estates like site phace I WAS THE LEAST affected estate.
This is because this estate are meant for rich people,
where their level of living is high, they are educated and
they have access to clean water from the Municipal
Councils which is sterilized and therefore bacteria free.
Their compounds are highly maintained up to the
standards
In contrast Kiamaina, a neighbors estates of site phase,
showed the highest number of infected people. The area
was very poor favoring the breeding of many bacteria’s in
addition, the latrines kept an overflowing thus
discharging waste all over, favoring the better site for
breeding of flies which act as a vector of transmitting the
diseases. Kiamaina was a place where by all risk factors
of salmonella infection was prevalent. They is no clear
bacteria free, piped water. Their source of water is from
dirty nearby springs. That is a great hazard.

                           56
On the side of rainfall, the rain season in Nyahururu start
on May and ends on October the 1st season. With rainfalls
taking its peak on the month of July. During the month of
July so many people was infected with the disease. This
was lead by overflowing, stagnant water and dirty water
flowing all over. Especially in the estate of Kiamaina
which topography is flat. In addition, the drainage system
in the area busted due to excess water latrines
overflowing all over thus attracting the chances of
acquiring the fever.
After doing sensitivity test; results showed that some
antibiotics were sensitive. This included norflaxacin,
ciproflaxin, trimethoprim, tetracycline, ampicilin,
fluorequinolones, cortrimoxazole and chloramphenical.
Some were resistant like nitrofurantion and gentamycin.



4.3 Conclusion
Since Nyahururu division has come to be known for its
prevalence of typhoid fever, the most of the patients who
attended the hospital were sent in the Laboratory
requesting for salmonella testing especially most of
teenagers coming form Kiamaina village estate;
Water was the greatest source of infection as it was used
in preparing food, drinking, washing and also for other
uses at home. Also it was gotten from Ngare-mano River
and its springs, which passes through many estates
where it is contaminated when flowing.
Culture and ant microbial sensitivity test is the most
accurate method of diagnosis of salmonella organism.
Other methods are serology test and Elisa.
Macconkey agar and deoxychocolate agar are the best
media for colonial study and Muller Mueller Hinton agar is
the best for sensitivity test
The best antibiotics in the treatment of salmonella fever
are contimoxazole and chlorampenenicol.
                          57
On the Government side, public health, officer are very
reluctant on the surveillance of general sanitation in the
food handling areas e.g. hotels. They have been taking
long to carry out check up in places of health e.g. hotels,
bars and butcheries. To add to this, Municipal Councils
should also ensure that waste from houses is collected at
least once a week. In stool Microscopic examination is
difficult to distinguish between salmonella species
presence or other bacteria hence culture biochemical test
and serology has to be carried out.



4.4 RECOMMENDATIONS
After the analysis was done, the relevant sources of
infections were pin pointed and measures were
highlighted to try to curb the infections.
The infections were found out to be with the taking dirty
food contaminated water where the bacteria of salmonella
species survive well. These victims should be considered
highly infectious hence they should be avoided in any
food handling dirty. Thus the government, Municipal
Council and other non-governmental organization should
select a specific source of clean and bacteria free water.
Competent employee should be employed to treat and
supply clean water safe for household work.
Pit latrines and compost pit should be constructed in very
strategic point to ensure that the flow is not directed to
the water sources. The sewages and factory effluents
should be treated to kill the micro-organism present.
Offer community health education through seminars,
chief Baraza to the public to alert them on such
infections. I.e. the symptom of the disease, mode of
transmission and the way of preventing the diseases.
Food handlers and dairy men should undergo thorough
medical check up according to public health acts and
being insured with Medical certificate annually.
                           58
Radon typhoid check up should be performed to detect
any symptom less infection and is determined in endemic
areas
Health workers and other public authorities should work
together to ensure proper sanitation to prevent
contamination of water resources.

4.5 APPENDIX I

PREPARATION OF REAGENT

1. CRYSTAL VIOLET FOR GRAM STAIN
Formula to make- one liter
Crystal violet- 20grams
Ammonium oxalate-0.9grams
Absolute ethanol- 95 mls
Distilled water - 1 liter
  i.Weigh crystal violet
 ii.Add absolute ethanol and mix completely
iii.Weigh ammonium oxalate and dissolve in about 200
    mls of distilled water. Add to stain and make up to 1
    liter with distilled water, and mix well.
iv.Label the bottle and store at room temperature
    2. LUGOL’S IODINE
    Formula to make 1 liter
    Potassium iodine- 20 grams
    Iodine-     10grams
    Distil water 1 liter
  i.Weigh potassium iodide and transfer to clean brown to
    hold 1 liter
 ii.Add about 250 mls of water and mix until the
    potassium iodide is completely dissolved
iii.Weigh the iodine and add potassium iodide s
iv.Make up to one liter with distil water and mix
 v.Label the bottle and store in dark place away form light


                           59
APPENDIX II
FORMULA AND PREPARATIONS OF MEDIA’S
MACCONKEY AGAR
Components
Sodium taurocholate – 5g
Water            1 litre
Agar             20g
Peptone      20g
Neutral red solution 2% in 50% ethanol – 3.5 ml
Lactose 10% aqueous solution – 100 ml
Preparation
Dissolve the peptone and taurocholate in the water by
heating. Add the sugar and dissolve it in the steamer or
autoclave. Clear by filtration. Adjust the P.H to 7.5 add
the lactose and the neutral red. Which should be well
shaken before use and mix. Heat in the autoclave with
free steam 100oc for 1 hour and then at 115oc for 15
minutes
Pour into plates
PEPTONE WATER
Components
Sodium chloride 5mg
Distilled water 100ml
Peptone      10ml

Preparations
  i. Dissolve in steamers
 ii. Adjust the reaction to P.H 7.5
iii. Filter through a filter paper
iv. Autoclave for 15 minutes
 v. Label and store
  SELENITE F. BROTH
  Requirement
  Peptone      5g
  Distilled water 1000ml
                           60
Mannitol         4gm
Sodium and seletone- 4gms
Disodium hydrogen phosphate- 10g
Mode of preparation
• Dissolve the other in distilled water
• Sterilize by auto clearing for 15 minutes at 121oc
• Distribute in 10ml under screw capped bottle and steam
for 30 minutes

THIOGLYCOLLATE BROTH
Yeast extract powder 5.0 gms
Tryptone            15.0gms
Sodium thioglycollate    5.5 gm

  Dissolve all the ingredients and dispense in 500ml
amount in bottles with screw caps
•    Sterilize by auto caving at 121oc for 15 minutes
•    Let it cool and tighten the bottle caps
•    Label the bottles date of preparation and the media
inside
APPENDIX III
TSI- Triple sugar ion
D.C.A- Deoxy chocolate agar
N.L.F- Non – Lactose Fomenter
L.F Lactose Fermenter
Ab Antibody
+VE POSITIVE
-VE NEGATIVE

4.5 REFERENCES
1. Alcamo- F. Microbiology 5th edition
2. D.R.J. Green Wood- Medical Microbiology 6th edition
3. E. N. Effiviy-Medical Micro Biology in Topics year
1995
4. GOrdon Cook Etai-Topical disease 20th Edition
5. G.Madoff, D. Schlessinger and M. Schaechter,
Mechanism of Microbial
                          61
6. Monicah Cheesbrough: Laboratory Practice in
Tropical Countries
7. P. Charkraborty- Text Book of Microbiology 1995
8. Rapheal S. Stanely- Linches Medical Laboratory
Technology 4th edition.




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