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1 Oct., 138 An Epidemic of Typhoid Fever Attributed to Salad Contaminated by a Chronic Typhoid Carrier PAUL A. LEMBCKE, M.D., AND PAUL VON HAESSELER, M.D. State Department of Health, Albany, N. Y. EACH of 3 cases of typhoid fever reported during the third week of June, 137, in individuals rather widely separated as to residence was investigated independently by the health agency * in whose jurisdiction the case occurred. The New York State Department of Health was notified of the occurrence and result of investigation of each case. Study of the reports revealed the common factor that all 3 individuals had attended a luncheon served on Memorial Day by a fraternal organization in Schenectady. An immediate survey of recent admissions to Schenectady hospitals was undertaken and disclosed additional cases of illness characterized by continued fever which were suspected of being typhoid fever, the diagnosis of which was subsequently confirmed by laboratory evidence. Both individuals had attended the luncheon on Memorial Day. The almost simultaneous occurrence of cases of typhoid fever in residents or visitors to Schenectady was a definitely unusual prevalence of the disease, the average annual number of cases in Schenectady for being. The fact that all had at- *Schenectady City Department of Health, New York State Department of Health District Office, and AMassachusetts State Department of Health. tended the Memorial Day luncheon strongly suggested an etiological relationship of some factor connected with the luncheon. A detailed investigation was undertaken jointly by the Schenectady City Department of Health and the New York State Department of Health. CLINICAL INVESTIGATION The names and addresses of persons who attended the luncheon were obtained, and each individual was visited by a member of the medical staff of the State Department of Health. In all, 33 persons attended the luncheon and were discovered who did not attend but who ate food brought home from this function. All but of the 3 were interviewed. If the questioning revealed symptoms suspicious of typhoid fever, 3 fecal specimens and one or more of blood were obtained for laboratory examination. In the absence of symptoms a single fecal specimen was secured. Three fecal specimens were obtained from all persons known to have supplied or prepared food for the luncheon. During the investigation new cases were reported and hitherto unknown cases were discovered, making 13 cases among those who attended the luncheon. The Widal was positive in all 13 cases. [11]

2 One patient died before a fecal specimen was obtained; typhoid bacilli were isolated from the feces of of the 1 cases from whom specimens were secured. Typhoid bacilli were cultured from the blood of one patient who had negative fecal cultures. Of the total number, were residents of Schenectady and were non-residents. In addition to the 13 clinical cases, subclinical cases or passive typhoid carriers were detected. A positive Widal and positive fecal cultures were obtained from both individuals, although there was no history of previous typhoid fever and neither exhibited the symptoms nor physical signs of the disease. That the carrier condition in these two was of temporary duration was demonstrated by repeated bacteriological studies. A positive Widal was reported in one individual who gave no history of previous typhoid fever or vaccine and who suffered no symptoms of the disease; repeated fecal cultures were negative. With the exception of this person, positive Widal tests were not found in other than the clinical cases and temporary passive carriers of typhoid bacilli. None of the individuals interviewed had ever received typhoid vaccine. Two gave a history of previous typhoid fever; neither became ill and the laboratory examinations were negative. CLINICAL CHARACTERISTICS The clinical course was prolonged and severe in 6 cases, and 1 death occurred; a girl aged 16 years. The other cases were relatively mild; in fact, TYPHOID CARRIER Vol were not recognized prior to the epidemiological investigation as having typhoid fever. In addition to these 13 clinically recognizable infections, there were the sub-clinical cases or temporary passive carriers, and the 1 individual with a positive Widal, who have been described above. Three of the 13 cases became chronic carriers, women, aged, 3, and 6, respectively. Each has been found to excrete typhoid bacilli in the feces over a period of more than a year following the illness. INCUBATION PERIOD The interval between the luncheon and the onset of symptoms varied from to 8 days. The peak incidence was reached on the 7th day, when cases occurred; the median case fell on the th day. The chronological distribution of cases is shown in Table I. FOOD SOURCE Detailed information was obtained as to the various foods eaten by each individual who attended the luncheon. Table II lists the foods, and shows the consumption of each type by the 1 infected and by the 17 who did not show evidence of infection. Potato salad, macaroni salad, buttered rolls, and coffee were the only foods eaten by more than of the patients. Of the home prepared foods, persons each supplied one dish of potato salad; 1 person provided two dishes of potato salad, and 1 of macaroni salad; cakes were contributed by different persons; 1 person supplied cabbage Il Inciubation Period of 13 Clinical Cases of Typhoid Fever Occurring Among Persons Having a Single Exposuire to Food Contaminated by a Chronic Typhoid Carrier of Days Following the Luncheoni Total of Cases

3 AMERICAN JOURNAL OF PUBLIC HEALTH 11 Oct., 138 e- Type of Food Macaroni Salad Potato Salad 1 Buttered Rolls 13 Coffee Baked Beans Summer Sausage Pickles Cabbage Salad Spiced Ham White Cake Chocolate Cake TABLE II Infection According to Foods Eaten at Luncheon Fifteen Infected Persons A Not _ Doubtful 1 1 ERating Seventeen Persons Not Infected Not Doubtfe 1 -. Known to Have Eaten Infected 1 13 Infection Rate Among Those O 33 salad; a dish of baked beans was furnished by another, and a jar of pickles was provided by one. The remaining articles-tinned evaporated milk, coffee, sugar, butter, rolls, and cold sliced meats-were purchased from various stores in Schenectady. Serving spoons were placed in the dishes contributed and each guest helped himself. The only food prepared at the church was the rolls, which were buttered just before the luncheon. Of the women who did this,, all of whom were well at the time, subsequently developed typhoid fever; the th gave no history of previous typhoid fever; her Widal was negative; and 3 fecal cultures on successive days were negative. Four of the 1 persons who prepared food at home developed typhoid fever subsequent to the luncheon. The date of onset could be fixed with a considerable degree of certainty in eachfirst symptoms appeared from to days after the luncheon. Two of the 6 persons who prepared food and who did not contract typhoid fever gave a history of previous typhoid fever; 3 or more negative fecal cultures were obtained from each. Of the who prepared food but did not develop the disease and who gave no history of previous typhoid fever, 3 each submitted 3 or more negative fecal specimens. B. typhosus was isolated from the feces of the remaining individual on 1 different occasions over 3 months following the luncheon. The individual with positive fecal cultures, M. T., a woman 6 years of age, denied having had clinically recognized typhoid fever at any time.* She recalled, however, that about years previously, her sister suffered from a disease which was probably typhoid fever, and that, although she was living in the same household, she herself did not become ill. For the past 1 or 1 years, M. T. had suffered symptoms which might be ascribed to chronic cholecystitis. She had never had children, her occupation had never involved the preparation of food for others, and there was no history of her ever having given rise to a case of typhoid fever previous to this epidemic. Despite the finding of typhoid bacilli in many fecal specimens submitted at intervals over 3 months, and a negative Widal reaction on the 3rd day following the luncheon, the possibility that * Twenty per cent of known chronic typhoid carriers in New York State deny previous history of typhoid fever.

4 Vol. 8 TYPHOID CARRIER M. T. was not a typhoid carrier prior to the luncheon but had developed sub-clinical typhoid and the carrier condition subsequent to the luncheon might be raised were it not for the epidemiological evidence incriminating her Ȯn the evening of May 3, M. T. peeled and boiled potatoes which were set aside until the following day. Early in the morning of the day of the luncheon, the potatoes prepared the previous evening, and a dish of macaroni boiled the same morning, were cut up, celery and a prepared mayonnaise dressing were added, and the ingredients stirred and mixed with the fingers. Two dishes of potato salad and one of macaroni salad were set aside for several hours at room temperature, and shortly before noon taken to the church parlors to be served at the luncheon. A small amount of each salad was left at home for the evening meal. This was the only macaroni salad served at the luncheon. Eleven of the 1 persons known to have been infected (either clinical cases or passive carriers) gave a definite history of having eaten this salad; one other patient stated she had probably eaten it. Two of the four dishes of potato salad were prepared by M. T. Twelve of the 1 infected persons stated definitely they had eaten potato salad, and others stated they had probably eaten of it. Altogether, 1 of the 1 gave a definite history of having eaten potato salad or macaroni salad, or both; the remaining patient felt it was very probable she had eaten of both. At the conclusion of the luncheon, some of the potato salad prepared by M. T. remained, was taken home by one of the women present, and served to her son and niece. The son developed typhoid fever on June, but the niece was apparently not affected. 11 A young man who rented a room in the home of M. T. attended the luncheon but denied having eaten either potato or macaroni salad, preferring baked beans, as did the majority of men attending. However, in the evening of the day of the luncheon, he ate in the home of M. T. a portion of the salads which had been left at home since morning. On the basis of a positive blood agglutination test and the presence of typhoid bacilli in a fecal specimen submitted July, he has been considered a temporary passive typhoid carrier; several fecal cultures subsequent to that of July have been negative. The remainder of the salad left at home was eaten by M. T. and her husband. The latter suffered from " grippe " and vague intestinal symptoms for or 3 days about weeks after the meal; fecal culture was negative 3 days later, and the Widal test, made days after the meal, was negative. The fact that macaroni salad prepared by M. T. was eaten by at least 1 of the typhoid fever patients; that potato salad was eaten by at least of the 13, and that M. T. prepared two of the four dishes of potato salad; that 1 and probably all 13 of the patients ate potato salad, macaroni salad, or both; that of the patients ate M. T.'s salad elsewhere than at the luncheon; and that repeated fecal cultures submitted by M. T. over 3 months have contained typhoid bacilli makes it extremely probable that, even in the absence of a history of previous typhoid fever, she was a chronic typhoid carrier and the source of the outbreak. The vehicle of infection was potato salad and macaroni salad prepared by the carrier. SUMMARY AND CONCLUSIONS 1. Three cases of typhoid fever in individuals rather widely separated as to resi-

5 116 AMERICAN JOURNAL OF PUBLIC HEALTH Oct.) 138 dence were reported by 3 different health departments to the New York State Department of Health. Prompt reporting, followed by epidemiological investigation, made possible the early recognition of an outbreak of typhoid fever and the institution of steps to detect the source and prevent its spread. The importance of prompt reporting by physicians and health officers of what may seem to be individual and apparently isolated cases is illustrated by this outbreak.. Thirteen clinical cases of typhoid fever were found to have occurred among 3 persons who had eaten food prepared for a community meal to which articles were contributed by 1 different persons. 3. In addition to the 13 clinical cases, temporary passive carriers of typhoid bacilli were detected by routine laboratory examination. An additional person was found to have a positive Widal in the absence of symptoms and history of typhoid fever or yaccine; fecal cultures were negative.. Three of the clinical cases were found to have passed from the acute stage into the chronic typhoid carrier condition. All 3 continue to excrete typhoid bacilli for more than a year after the onset of typhoid fever.. No secondary cases occurred as a result of the epidemic. 6. Detailed epidemiological studies identified the vehicle of infection as macaroni and potato salads, and the source as a previously unrecognized chronic fecal typhoid carrier. Yellow Fever in Brazil AS to the general situation in regard to yellow fever in South America the observations of the last 3 months show in a striking way the importance of jungle fever as a public hygienic problem of the first order. An enormous area covering parts of the States of Minas Geraes and Rio-de-Janeiro have been infected during this year (138). The value of viscerotomy has been again shown. All of the early cases of the present epidemic have been discovered by viscerotomy, although many of the physicians of this region were familiar with the literature concerning jungle fever. The present outbreak in the States of Minas Geraes, Rio-de-Janeiro, and Sao Paulo have been associated as have been those in recent years in Brazil with a high mortality in howler monkeys. This observation has been confirmed by the discovery of dead monkeys in the forest. The result of many thousands of protection tests with the serum of wild animals begun in 13, confirm the opinion that the various varieties of monkeys are the most important vertebrates in the dissemination of the jungle virus. The collection of insects in the many infected zones also confirm the idea that several species of mosquitoes are the active vectors of the virus when most of the human cases are produced. However, it has not yet been possible to determine the method by which the virus is concerned from season to season in the south of Brazil where each vear a number of months pass without a single human case being observed.-f. L. Soper, Month. Bull., Office International d'hygiene Publique, June, 138, p. 1.

6 This article has been cited by: 1. G A Silver. 1. Paul Anthony Lembcke, MD, MPH: a pioneer in medical care evaluation. American Journal of Public Health 8:3, [Citation] [PDF] [PDF Plus]

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