CHAPTER ONE
1.0 INTRODUCTION
Salmonella Typhi Infection which is also known as Typhoid fever is a life
threatening Infection caused by the bacterium salmonella typhi.it is usually spread
through contaminated food or water WHO 2018)
Typhoid fever is a life threatening Infection caused by bacterium salmonella
Typhi.
Symptoms varies from mild to severe and usually begins 6 to 30 days after
exposure (Wikipedia 2023)
Improved living conditions, and the introduction of antibiotics resulted in a drastic
reduction of typhoid fever , morbidity and mortality in industrialized
countries.However the Infection continues to be a public health problem in many
developing area of Africa Eastern Mediterranean , South East Asia and Western
Pacific Regions .As of 2019 estimates , there are 9 million cases of Typhoid fever
annually , resulting in about 110,000 deaths per year WHO 2023)
Typhoid risk is higher in populations that lack Acess to safe water and adequate
sanitation , and children are at higher risk.
Symptoms of Typhoid Infection lives only in humans , the bacteria moves into the
blood stream and intestinal track, symptoms include prolonged high fever , fatigue,
headache , nausea , abdominal pain , constipation and diarrhea.some patients may
have rashes all over the body, some cases may lead to serious complications or
even death WH02023).
Typhoid fever can be treated with antibiotics .antimicrobial resistance is common
with likelihood of more complicated and expensive treatment.Even when
symptoms go away people may still be carrying Typhoid bacteria , meaning they
can spread it to others through sharing bacteria in their faeces .
It is important for people being treated for Typhoid fever to do the following
_take prescribed antibiotics for as long as the doctor as prescribed.
_wash their hands with soap and water after using the bathroom and avoid
preparing or serving food for people without washing of hands.
_Have their Doctor test to ensure that no Salmonella Typhi bacteria remain in their
body.WHO 2023
Prevention of Typhoid fever
Typhoid fever is common in places with poor sanitation and a lack of safe drinking
water , Acess to safe water and adequate sanitation, hygiene among food handlers
and typhoid vaccination are all effective in preventing Typhoid fever
(who.int/newsroom 2021)
_ensure food is properly cooked
_Avoid raw milk and products made from raw milk drink only pasteurized or
boiled milk
_when safety of drinking water is questionable boil it before drinking it.
_wash hands thoroughly and frequently using soap and water,in particular after
contact with pets or farm animals , or after visit to the toilet
_wash fruits and vegetables carefullyparticularly if they are eaten raw .(who/int
newsroom 2021).
WHO response to typhoid fever in October 2017 ,the strategic Advisory Group of
Experts on Immunization (SAGE ) which advises WHO on vaccine use,issued a
recommendation for the typhoid conjugate vaccine to be added to routine
childhood immunization programmes in Typhoid endemic countries.the strategic
Advisory Group of Experts also called for the introduction of typhoid conjugate
vaccine to be prioritized for countries with with the highest burden of typhoid
Infection ,or high levels of antibiotics resistance to salmonella Typhi.
As of March 2023 ,WHO has pre-qualified two conjugate vaccines for the
prevention of typhoid , Typhoid conjugate vaccine has longer -lasting immunity
than the older Typhoid vaccine and can be given as a single dose to children from
the age of 6 months .
In addition to decreasing the disease burden in endemic countries and saving lives,
wide spread use of Typhoid conjugate vaccine in affected countries is expected to
reduce the need for antibiotics for typhoid treatment , and slow the increase in
antibiotic resistance in salmonella Typhi (WHO2023
1.1 Background of the study
Typhoid fever is a systemic bacterial Infection caused by salmonella Typhi ,A
bacteria Infection of intestinal tract and blood stream continues to be a serious
public health problem. Typhoid fever and paratyphoid fever are gram negative
bacterium caused by salmonella enterica serovars (Typhi,s.Typhi )and salmonella
enterica serovars (paratyphi (s.paratyphi A,B and C
Typhoid and paratyphoid fever are together known as enteric fevers, whilst s.Typhi
and s.paratyphi And B Infection are restricted
to humans.
S.paratyphi has been reported to also affect a variety of animals.
Enteric fever remains Endemic in Africa , Asia and south America.infections seen
in Europe , Australia and North America are usually acquired abroad and imported
by travelers mostly from the Indian sub-continent , south East Asia and south
America ( infectious Diseases Fourth Edition 2017)
Estimates from the world Health Organization (WHO ) suggested there were
approximately 21million Infections , and 210,000 deaths caused by typhoid fever
in the year 2000
A revised estimate for 2010 suggested 27million cases of typhoid fever .
There is significant regional variability in the distribution and incidence of
s.paratyphi A in Asia and Africa .
A high proportion enteric fever in China ,India and Nepal (64%,24% and 33% )
respectively were caused by s.paratyphi A , whilst s.paratyphi A Infections have
only been reported from Africa .
Typhoid fever occurs via the feco-oral route , transmission by ingesting
contaminated water or food ,or through direct person to person contact , Bacteria
are shed in the stools during an acute Infection Typhoid epidemics are usually
water borne and caused by contaminated drinking water (infectious diseases fourth
Edition 2012)
1.2 AIM OF THE STUDY
To reduce the prevalence of Typhoid Infection in ILekun community through
preventive and curative measure
1.3 STATEMENT Of THE PROBLEM
It was observed during my community rural posting that a good number of people
were coming down with typhoid fever hence the need to investigate the mode of
transmission in the study area.
1.4 OBJECTIVE OF THE PROBLEM
1 to ascertain the prevalence of salmonella Typhi Infection in ILekun community
2 to identify the risk factors associated with the disease in the study area
3 to educate Ilekun inhabitants on preventive measures which will help reduce the
Infection to barest minimum.
1.5 RESEARCH QUESTIONS
1what is the level of knowledge on Typhoid fever
2 How can one prevent Typhoid fever Infection
3 what is the sign and symptoms of typhoid fever Infection
1.6 ASSUMPTIONS
It is generally believed that salmonella Typhi Infection is a seasonal Infection that
happens during the rainy season
2some people believe that salmonella Typhi cannot be cured with orthodox
medicine except the use of herbal preparations
3 some people believe that typhoid is caused by mosquitos
1.7 SIGNIFICANCE OF THE STUDY
This study is set out to investigate the prevalence and the mode of transmission of
Typhoid fever in ILekun community in Akure south local Government .it will also
ascertain the predisposing factors and ways by which it can be prevented in the
study area.it will be a useful piece among researchers on the same topic.
1.8 DEFINITION OF TERMS
PREVAlENCE: the total number of people in a population (both old and new
case )who have the disease at a given point in time (Salmonella Typhi (s.Typhi )are
bacteria that Infect the intestinal track and the blood stream.
INCUBATION PERIOD: this is the length of time elapsed between exposure to a
pathogenic organism and when symptoms or signs are apparent
SIGN :an objective indication of a disease disorder that is observed or detected by
a Doctor as opposed to a symptom which is noticed by the sufferer
SYMPTOMS :An indication of disease or disorder that is noticed by a person .
MODE OF TRANSMISSION
The route by which a pathogen causing communicable disease from one infected
host to another.
PREVENTION:the action of stopping something from happening or arising
CONTROL :A security mechanism ,policy or procedure that can counter system
attack , reduce risks and resolve vulnerabilities
ADULTS are matured human being who have fully developed between ages
18_35years
Complication: A condition resulting from a preceding disorder or from its
treatment.
COMMUNITY:this is a special group of any size whose members reside in
specific locality,share government and often have a common cultural and historical
heritage WHO 2018.
2.0CHAPTER TWO
Salmonella Typhi Infection which is also known as Typhoid fever is a life
threatening Infection caused by the bacterium salmonella Typhi .it is usually
spread through contaminated food or water (WHO2018
2.1 EpIDEMIOLOGY
WHO estimates the global Typhoid fever disease burden at a million cases
annually , resulting in 110,000 deaths per year (WHO2023
Typhoid risk is higher in population that lack Acess to safe water and adequate
sanitation , children are at highest risk WHo2023
Improved living conditions and the introduction of antibiotics results in drastic
reduction of Typhoid fever, morbidity and mortality in industrialized countries
In developing countries like Africa , Eastern , South East Asia , and Pacific regions
, however the disease continues to be a public health problem (WHO2018
Mode of transmission
Salmonella Typhi Infection (Typhoid fever is transmitted through the faeco-oral
transmission through the ingestion of contaminated food or water .the person
infected by the bacteria may eliminate it in their faeces and contaminate food and
water Clinic 2023)
INCUBATION PERIOD the incubation period ranges from 7_14days an average ,
but can range from 3 days to 2months
2.2PATHOPHYSIOLOGY
Once Typhoid fever cross the epithelial layer of the intestinal wall .they are then
quickly consumed by macrophages and transported to the aggregate of lymphoid
tissues in the small intestine (peyer's patches where the immune function of the
gut is most concentrated.the bacteria alters host cells ultimately, promotes the
survival and replication of s.typhi and s.paratyphi .the incubation period of a
Typhoid Infection is characterized by the replication and transfers of s.typhi and
s.paratyphi from the peyer's patches in the gastro intestinal tract through the
lymphatic system to the organs of the reticulo-endothelial system including the
lymph nodes, spleen ,bone marrow and liver ,once in the gallbladder s.typhi and
s.paratyphi are secreted back into the gastro-intestinal tract .this result in varying
degrees of necrosis and ulceration of peyer's patches which the clinical
manifestation is bleeding and perforation .the terminal Ileum is the most common
site of perforation, perforation has also been reported to occur anywhere from the
duodenum to the colon including the hall bladder and appendix (Cleveland 2023
STAGES OF SIGN AND SYMPTOMS
Ist week of illness
You can start having Typhoid symptoms anywhere from 5 to 14 days after coming
in contact with s.typhi , the first symptom is fever that gets higher over a few days
called ''stepwise ''since it gives up in steps .the bacteria is moving into your blood
in this stage
2nd week of illness
Around the second week of fever , the bacteria is multiplying in your peyer's
patches (part of your immune system that identifies harmful Invaders ) you will
start experiencing abdominal pain and other symptoms like diarrhea , or
constipation you might get small pink dots on your skin that looks like rash .
3rd week of illness
If not treated with antibiotics the bacteria can cause severe damages usually around
the third week after symptoms start .some people get serious complications like
internal bleeding , encephalitis (inflammation in the brain.
4th week of illness :stage 4 is when most people begin to recover , your higher
fever begins to come down .s.typhi can live in the gall bladder with causing
symptoms which means you may still be contagious even after you feel better
(Cleveland clinic 2023
CLINICAL PRESENTATION
The incubation period of Typhoid fever is 6-30days range ,the onset of illness is
insidous with gradually increase fatigue and
Clinical presentation : the incubation period of typhoid fever is 6_30 days range .the onset of illness is insidious with gradually
increase fatigue and a fever that increase daily from low grade to as high as 102F(38°c_40°c by the third to fourth day of illness ,
headache ,malaise ,and anorexia are nearly universal and abdominal pain, diarrhea or constipation is common.
Hepatosplenomegally can often be detected at later days .A transient muscular rash of rose_coloured spots can occasionally be
seen on the truck .fever is commonly lowest in the morning , reaching a peak in late afternoon or evening .the clinical
presentation is often confused with malaria if not treated .the Infection can last for month and finally kills.
2.3SEVERE SALMONELLA TYPHI INFECTION
The serious complications of typhoid fever generally occur after 28 weeks of illness and may include life_threatening intestinal
heamorrhage or perforation and almost all severe form of typhoid fever lead to death CDC 2018.
2.4Clinical Diagnosis:A diagnosis of Salmonella typhi Infection can be confirmed by analyzing samples of blood ,poo ,or
pee .these will be examined under a microscope for the Salmonella typhi bacteria that cause the condition.the bacteria are not
always detected the first time so you may need series of test .
DIAGNOSTIC LABORATORY TEST
A specimens:blood for culture must be taken repeatedly in enteric fever and septicemias,blood cultures are often positive in
the first week of Infection .urine culture may be positive after the second week .stool specimen also taken repeatedly in enteric
fever ,the stools yield positive results from the second or third week .A positive culture of duodenal drainage establishes the
presence of Salmonella in the biliary tracts in carriers.
B.Bacteriological methods: for isolation of Salmonella
Selective medium culture::the specimen placed on Salmonella shigella (as)ager ,Hektoen enteric ager or deoxycholate citrate
ager,which favours growth of Salmonella and shigella over other Enterobac teriace.
Enrichment cultures:the specimen( Usually stool ) also is put into selenite for tetrathionate broth both of which inhibit
replication of normal , intestinal bacteria and permit multiplication of Salmonella after incubation for 1_2days ,this is placed for
differential and selective media ,microscopy remains the gold standard for diagnosis of typhoid Infections in clinical practice
and research .
How microscope is a labour intensive which requires significant skills and time which causes therapeutic delays , the method of
blood samples now made possible with the introduction of AGGLUTINATION
TEST (WIDAL TEST
2.5 AGGLUTINATION TEST :widal test is agglutination test in which specific typhoid fever antibodies are detected by mixing the
patient's serum with kill bacterial suspension of Salmonella carrying specific O,H,AH and RH antigens and observed for clumping
. Antigen, Antibody main reaction .the main principle of widal test is that when you consume food contaminated with
Salmonella bacteria ,it enters your body in form of antigen after reaching your digestive system, your Immunity creates an
antibody against those antigens ,as a result .it will react with perspective antigen in the suspension and gives visible clumping
on the test slide or card.
Requirement for widal test
1fresh serum stored at 2.8°c,serum should be heated or inactivated.
2. Fresh serum stored
The complete kit containing live vials containing Salmonella antigen
S.Typhi_O antigen
S.Typhi _H antigen
S.paratyphi _AH antigen
S.paratyphi _BH antigen
3 widal test card or slide
4 widal positive controt
5 application stick
PROCEDURE FOR WIDAL TEST
1.clean the glass slide or testcard supplied in the kit well and make it dry .
2.label the circle (1,2,3,4,5 and 6 )in the test card as OH,AH,BH negative control and positive control
3.place a drop of undiluted test serum in each of the four labeled circle (1,2,3 and 4 ,i.e OH,AH, and BH and place a drop of
negative control serum in circle 5 and positive control serum in circle 6.
4.place a drop of antigen OH,AH, and BH in circle 1,2,3 ,4 respectively and no antigen in circle 5 and OH antigen in circle 6 .
5.mix the content of each with a separate wooden applicator stick and spread to full the whole area of the individual circle.
6.Rock the test card for a minute and observe for agglutination .if agglutination is visible within minute,proceed for quantitative
estimation of the titre of the antibody .
Quantitative slide test
_clean the test card and make it dry
_put o.005ml ,0.2ml ,0.02ml ,0.04ml and 0.08ml of undiluted serum in 1,3rd,4th and 5th circles respectively in the test card.
_add a drop of appropriate antigen suspension which showed agglutination in rapid slide test to each of the above circles.
_mix the contents of each circle with separate wooden application stick
_rock the slide slowly for minutes and observe for agglutination .
_the titre of the authority is the highest dilution of serum up to which there is clear agglutination of serum .
_repeat step to 6 with all the antigens which showed agglutination in rapid slide test.
The serum volumes in the quantitative slide test correspond approximately to the tube test is given below .
Table Here.
Result interpretation of widal test .
_Antibody titre greater than 1:8 is considered significant and usually suggests positive test for Salmonella Infection.
_low titres are often in normal individuals.
_a single positive is less significant than the rising antibody titre ,since rising titre is considered to be a definite evidence of
Infection (Gaurab 2018
Signs and symptoms
1Headache
2chills
3 loss of appetite
4stomach (abdominal pain
5fever
6''Rose spots "rash or faint pink spots usually on your chest or stomach.
7.cough
8.muscle aches
9.Nausea ,commiting
10.Diarrhea or constipation.(Cleveland clinic medical professionals 2023).
2.6MANAGEMENT
Salmonella Typhi Infection (Typhoid fever )can be treated with antibiotics although increasing resistance to different types of
antibiotics is making treatment complicated .
A new typhoid conjugate vaccine with long lasting immunity was pre-qualified by W.H.O in December 2017 (WHO 2018
Salmonella Typhi Infection can be treated with antibiotics like 1ciprofloxacin(cipro either tab or infusion.
2.AZithromycin (Zithromax
3.ceftriaxone
Prevention and control
Salmonella Typhi Infection is common in places with poor sanitation and lack of safe drinking water.Acess to safe water and
adequate sanitation , hygiene among food handlers and typhoid vaccination are all effective in preventing Salmonella Typhi
Infection .
Two vaccines have been used for many years to protect people from typhoid fever .
_an injectable vaccine based on purified antigen for people aged over 2years .
_A live Attenuated oral vaccine in capsule formulation for people aged over 5years (WHO2018.
Examples of ways in which good hygiene and sanitation can be maintained include hand washing and ensuring drinking water
pipes are well separated from sewage pipes.
_Avoid drinking contaminated water by ensuring water is bottled or boiled and improved sanitation .
Public health measure : correctly diagnosing and treating cases , finding and treating carriers .
Health Education:Hand washing ,food safety practices (city med.co.za)2022 .
Complications of Salmonella Typhi Infection
Complications of Salmonella Typhi INFECTION
Complications caused by typhoid fever usually happens in people who haven't been treated with appropriate antibiotics . about
1in 10 people experience complications which usually develop during the 3rd week of Infection .the most common
complications in untreated typhoid fever are
_internal bleeding in the digestive system
_splitting (perforation )of a section of the digestive system or bowel which spreads the Infection to nearby tissue.
CHAPTER THREE
3.0RESEARCH METHODOLOGY
This chapter deals with methods used in carrying out this research work which entails the study design ,study area , sample
technique ,study population , sample size ,data collection ,study instrument ,Data Analysis and Ethical consideration.
3.1STUDY DESIGN
The nature of the study design used for the research work was retrospective study.
Retrospective study design is interested in looking back Ward and examine exposure to suspect the risk of Salmonella Typhi
Infection among the population of people taken from sample size.the merit of this method is that it is less expensive ,provides
quantitative data and enables one to obtain a great deal of information from variety of people.
3.2DTUDY AREA:this study was conducted in ILekun community which is located in Akure south local Government Area of ondo
state
PopULATION: population of11,150.
Tribe: the main tribe in ILEKUN community include AKURE indigenes ,yorubas ,igbos and Hausas ,idoma ethnic group.
Major occupation:their major occupation Include civil service, trading and farming
Health institution:there is bone basic Health centre providing primary health care services for the people within this
geographical Area.
RELIGiON:the religion practiced in Ilekun community are Christianity ,Islamic ,and Traditional religion.
Commerce :their major occupation is trading and farming.
3.3 STUDY POPULATION
This study is carried e in ILekun community.
3.4 SAMPLE SIZE:A total number of one hundred and Fifteen (115 sample were selected for this research study.
3.5.SAMPLE TECHNIQUE
A simple random technique was used as it gives everyone an equal chance of being selected.
3.6STUDY INSTRUMENT
A structured questionaire was designed which was rectified by the supervisor before distribution .it was administered to both
literate and non -literate respondents.
3.6DATA COLLECTION METHODS
Structured questionaires and oral interview were used for data collection ,the questionaires were personally
administered ,while oral interview was conducted for the non_literate .
Respondents : Relevant existing health records were looked into .
3.7DATA ANALYSIS
The collected and collated data was analysed using statistical method of frequency table and simple percentage .
3.8ETHICAL CONSIDERATION
Informed consent was sought from officers in charge of the health facility ,the respondents and community leader ,they were
all assured of confidentiality of information.
