TYPHOID FEVER IN BARROW?

I recently received a fax from State Epidemiology in Anchorage, letting me know that a physician’s assistant at the hospital here in Barrow had faxed in a required report on a patient she admitted who she believed had typhoid fever.  Several family members had acute symptoms and were being tested also.  Health care providers as well as pilots and ship captains are required by law to report any suspicion or knowledge of a person with a communicable infectious disease.  The report was surprising since typhoid fever is found in tropical countries, is rare in the United States and non-existent in Barrow, Alaska.  I was asked to interview the suspected cases, write a report and fax it back to Epidemiology who keep track of all occurrences of these sorts of diseases in the State of Alaska and assist in preventing their spreading. 

After pulling each of the persons’ charts and running and reviewing health histories on them from our shared data base with the hospital, I was able to determine that they’d been seen and that blood culture tests were pending.  Two of the sick people were hospitalized and I wasn’t able to interview them.  I reached one at their home who was not covered by insurance, so chose to be treated with strong IV antibiotics as an outpatient.  My heart went out to him as he patiently answered my questions, confirming acute upper and lower GI symptoms, fever, and headache.   He and five other family members had traveled to a Pacific island country for a month where they stayed and shared in many events which included homemade food.  A cyclone struck the country last year causing much flooding and contamination of food and water sources.  A cousin there had recently been diagnosed with typhoid fever and they had all had casual contact with him, not imagining that several of them would contract it and bring it back to Barrow. 

The annual 4^th of July festival was the following week and in the course of my interview, I learned that the family usually had a booth where they prepared and sold food.  Typhoid fever is spread by eating food or fluids that has been contaminated with infected fecal matter, so I was naturally concerned that it not be spread to anyone else in the community through the family preparing and selling food.  I gained his agreement that he would not assist this year, even if symptom free and planned to talk with the other family members as soon as possible.  Three negative stool samples, each a month apart, the first one taken a month after symptom onset, is required in order for a person who has tested positive for salmonella typhi or has had symptoms, before they are considered cleared of the disease and no longer a carrier.  Timing wouldn’t allow for this to happen before July 4th, so it was important that he and anyone with symptoms not participate.  For an asymptomatic person in the same household, stool samples need to be collected 24 hours apart and both be negative before a person can prepare and sell food to the public or be in contact with unpackaged food in a public setting.

Because of hospitalization and the seriousness of the other family members’ conditions, I wasn’t able to talk directly to them, but reached the physician’s assistant who was very helpful in filling me in on the status of their health, pending tests, and medications they were receiving.  They were being given IV boluses of Cephtrioxone, a strong antibiotic four times a day, as well as Ondansetron, an anti-nausea medication and Ibuprofen for pain relief.  She also informed them about requirements of not serving food in public.  I admire this PA very much, having heard positive things about her and knowing that she has a very sharp mind and the tenacity of a good detective.  Someone without these qualities might have missed asking about recent travel, could have passed their symptoms off as that of a virus or treated them with a less aggressive antibiotic.  Her skills could very well have saved their lives and also prevented the spread of typhoid fever in Barrow.

I had emailed my supervisors with udpates on the status of the investigation throughout the day and was very grateful to have finished writing up the report for Epidemiolgy within 32 hours of receiving the fax.  With nine months passed since beginning work here, it feels good to be in the flow of knowing who to contact for information, what to ask during an interview and how to coordinate with other health care providers in Barrow.  I was grateful too that the intinerating nurse from Fairbanks offered to take my case load for the better part of two days so that I could focus on the investigation.       

7/14/13 - I’m just finishing up this post on my way back from a wonderful six days with my family in Washington.  While there, I received a stream of emails from Barrow and Anchorage keeping me in the loop about two additional confirmed cases of typhoid fever in Barrow.  I’m impressed reading about the collaboration between the State of Alaska Epidemiology nurse, the Public Health nurse practitioner, the Public Health nurse, the physician’s assistant at the hospital and the Deputy Director of Community Health.  They’re working in concert with each other to collect information and lab specimens, treat and continue to educate about the crucial importance of hand, household and food preparation hygiene and the importance of not preparing any food for others in the community.  Lab tests that will be taken over the next several months will need to show no indication of the disease. 

The State Epidemiology nurse is also concerned about family members who traveled from other countries and parts of the United States for the gathering in Samoa.  The Barrow Public Health Clinic has been asked to contact its counterparts in other communities to let them know of the possibility of positive cases there.

It’s nice to be still on vacation and only reading about the work being done this time.  It will be interesting being a part of following up with the lab testing though.  I’m hoping, along with all of my colleagues, that there are no more incidents. 

7/18/13 - I’ve been back in Barrow now for just under a week and arrived in time to take part in continuing the investigation.  It’s been an intense week of interviews, conference calls between a State of Alaska Epidemiology physician, a number of Epidemiology nurses; the physician’s assistant, Infectious Disease Nurse and Director of Nursing from our local hospital; as well as five nurses from the Health and Public Departments here.  As many nurses will tell you, these are the interesting aspects of nursing and working in collaboration with others is very fulfilling and inspiring.  The late nights of charting, not so much = )

Because of our already daunting work load and because a symptomatic individual wasn’t agreeable to complying with waiting before preparing and selling food to the public, the Director of Community Health lobbied with State Epidemiology for help.  A nurse from Anchorage arrived yesterday morning and assisted us with the many tasks that still needed to be accomplished--meetings with family members to educate and  insist on compliance with the weight of the Department of Environmental Conservation and the State of Alaska Section of Epidemiology.  It felt reassuring to have someone with her authority here to help ensure public safety. 

We were also grateful for her presence when meeting with family members’ employers, educating and strategizing about alternatives to being involved in food handling, taking time off of work and how to help so that no one will suffer a large financial set back.  She coordinated specimen collections and will Gold Streak them to the lab in Anchorage. 

It’s been an interesting week.  I’m glad it’s almost Friday, but wouldn’t consider trading all that I’m learning on the job for a slower pace.  Even on my late, tired and slower than normal bike rides or walks home, I’m thinking how much I love the work I do here and how grateful I am for this opportunity.