Epidemiologic Notes and Reports Typhoid Fever -- Michigan

During October and November 1981, 18 cases of typhoid fever were diagnosed in Jackson, Michigan, among 310 United Way volunteers who consumed a luncheon served at a community banquet hall on October 8, 1981. Although no specific food could be incriminated, a probable chronic carrier of Salmonella typhi was identified among the food handlers who prepared the luncheon.

Dates of onset ranged from October 12 to November 11, 1981 (Figure 1), for an incubation period of 4 to 33 days (mean = 13.5). Older individuals tended to have shorter incubation periods. The attack rate was 5.8%. Sixteen of the 18 cases were confirmed by blood and/or stool culture. All isolates of S. typhi were phage type E((1)) and were sensitive to chloramphenicol, ampicillin, and trimethoprim-sulfamethoxazole.

All patients experienced fever (mean temperature 103.3 F (39.6 C)), fatigue, and headache, and most had chills, sweats, and anorexia; 39% reported diarrhea, and 33% had constipation. There were four relapses (rate = 22%) of which only one was symptomatic. No instances of gastrointestinal hemorrhage or perforation were reported. There were no deaths and no evidence of secondary transmission.

Self-administered questionnaires asking about foods eaten at the luncheon and subsequent illness were distributed to all attendees; 289 (93%) returned completed questionnaires. Food histories of the 16 culture-confirmed cases were compared with those of asymptomatic controls. Univariate testing did not identify any single food associated with illness. Multivariate logistic regression analysis (using different control groups and different weighting of responses and carried out in forward and backward stepwise fashion) also failed to incriminate any food item.

A probable chronic carrier of S. typhi was identified among the food handlers. This individual, an asymptomatic 68-year-old female with previously undiagnosed cholelithiasis, had participated in the preparation of all or most of the foods served. S. typhi of the same phage type and antimicrobial-sensitivity pattern as that obtained from cases was isolated from her rectal swab and all her stool specimens; the serum Vi antibody titer was 20. She subsequently underwent cholecystectomy in combination with high-dose amoxicillin therapy. Culture of the gallstone after antimicrobial therapy and all follow-up stool cultures have been negative. Reported by D Ray, MPH, D Tribby, DVM, Jackson County Health Dept, J Eyster, PhD, S Coopes, W Hall, MD, H McGee, MPH, E Renshaw Jr, PhD, G Winter, N Hayner, MD, State Epidemiologist, Michigan Dept of Public Health; Field Services Div, Epidemiology Program Office, Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The incidence of typhoid fever in the United States has decreased dramatically over the past 50 years (1). About 350-600 cases have been reported annually since 1965 when the incidence rate stabilized. The majority of cases in the United States are now acquired overseas (2), the most common source countries being Mexico (50%) and India (15%).

Typhoid outbreaks, especially in communities, have occurred only rarely in the United States in recent years (3); contamination of food and water by a previously unrecognized chronic carrier is usually responsible. The carrier state is now rare in the United States, although its exact prevalence is unknown. Routine stool culturing of food handlers is considered unjustified (4).

Multivariate regression analysis can be useful in identifying the vehicle or vehicles in a food-borne outbreak. In this outbreak, however, the technique was not successful because of 1) the small number of cases, 2) minimal variation in food-consumption patterns resulting from the limited menu, and 3) unreliable food histories due to the extended period between transmission and the administration of the questionnaire.

References

1. CDC. Annual Summary 1980. MMWR 1981;29:12-7.

2. CDC, unpublished data.

3. Ryder RW, Blake PA. Typhoid fever in the United States, 1975 and 1976. J Infect Dis 1979;139:124-6.

4. Pan American Health Organization. Health examination of foodhandlers. Epidemiological Bulletin 1980;1:9-10.

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