Transcript Jan Dulay - web.biosci.utexas.edu

Mentors:
Marilyn Felkner, DrPH
Infectious Disease Control Unit
Texas Department of State Health Services
Jeff Taylor, MPH
Infectious Disease Control Unit
Texas Department of State Health Services
INTRODUCTION

Also know as:
› Endemic typhus
› Flea-borne typhus

Zoonotic rickettsial disease

Caused by:
› Rickettsia typhi
› Rickettsia felis

Rat flea
› Xenopsylla
cheopis

Rats
› Rattus rattus
› R. norvegicus
Photo from: Emer. Inf. Dis.

Cat flea
› Ctenocephalides
felis

Opossum
› Didelphis virginiana

New Reservoirs:
›
›
›
›
›
›
cats
house
mice
skunks
dogs
raccoons
Photo from: Emer. Inf. Dis.
Symptom
Boostrom1
%
Fergie2
%
Fever
100
100
Rash
27
80
Headache
56
77
Myalgia
22
57
Malaise
44
57
Chills
N/A
33
Thrombocytopenia
N/A
N/A
Hepatospenomegaly
N/A
N/A
It is confused with…
 Typical fever
 Viral illness
 Urinary tract infection
 Respiratory illness
 Gastroenteritis






Leptospirosis
Brucellosis
Occult bacteremia
Infectious
mononucleosis
Kawasaki disease
Bacterial meningitis
Laboratory Diagnosis

Serology
› Indirect Fluorescent
Antibody test (IFA)
› Latex Agglutination
Test (LA)
› Complement
Fixation Test

Direct Fluorescent
Antibody Test
Treatment:




Doxycycline
Tetracycline
Chloramphenicol
Supportive care
Bexar
Murine Typhus
in Texas
Nueces
Hidalgo
Cameron
Year
Number of cases


History of cases in the 1930s1940s
Geographic proximity to
Nueces County

Temperature- rarely gets
below 45°F

Opossums and cats

Urban-suburban; urban-rural
interfaces
Occurs worldwide
 Reasons:

› Misdiagnosis
› Lack of confirmatory lab results
› Physicians’ lack of knowledge
 Reportable condition
 How to report
› Belief that murine typhus is not a public
health concern

To assess the under-reporting of murine
typhus in Bexar County
METHODS
Design Survey
Locate Physicians in San Antonio
Family Practice, Infectious Disease, Internal Medicine, and
Pediatrics
Create Website
Buy Domain Name
Distribute Survey
Collect and Analyze Responses


9 questions
Questions asked:
› Patients with fevers
›
›
›
›
›
›
of unknown origin
Symptoms
Risk factors
Laboratory tests
Location of where
specimens are sent
Treatment
Reporting
Pics of Mr. Wes, Mrs.
Tabony, Mr.
McElwain

Physicians in San Antonio
› Family Practice
› Infectious Disease
› Internal Medicine
› Pediatrics

Retrieved list of physicians from the
Texas Medical Board

1174 surveys were sent
by US mail!
Responses could be
sent back by mail, fax,
or website

www.typhussurvey.org

90 follow up phone
calls to Infectious
Disease and Pediatrics

Microsoft Excel
 Epi Info

RESULTS
Participants
Responses
No. (%)
Total Physicians
1174 (100%)
Wrong Address
23 (2.0%)
Total Responses
100 (8.7%)
% of Respondents
75
9
4
Response Method
12
Specialty
Percentage
of Physicians
Female
38%
Male
62%
N= 1174
N= 100
Number of Responses
35%
26%
19%
20%
Age Group
0%
Number of responses
15%
20%
0%
19%
20%
Age groups
26%
35%
1) a fever with a temperature greater than
101°F (38.3°C)
2) continuous or intermittent for at least 3
weeks with no known cause
3) diagnosis cannot be obtained even after 1
week of inpatient investigation
Patient with
Fever of
Unknown
Origin
0
1-20
>20
Total
62
35
3
100
Number of Physicians
82%
14%
3%
Number of Differential Diagnosis
1%
62
38
31
7
Did not consider
murine typhus
FUO Seen
Considered
murine typhus
Symptoms and tests
All Responding
Physicians
No. (%)
47 (47%)
Physicians who
considered MT
No. (%)
15 (83%)
Headache
43 (43%)
10 (56%)
Fever
42 (42%)
10 (56%)
Rash
42 (42%)
9 (50%)
Chills
39 (39%)
10 (56%)
Myalgia
38 (38%)
8 (44%)
Liver Function Test
23 (23%)
5 (28%)
Thrombocytopenia
27 (27%)
4 (22%)
Don’t Know
33 (33%)
1 (6%)
100 (100%)
18 (100%)
Fever with Rash
No. Respondents:
Out of the 38 doctors who had patients
with a fever of unknown origin, 18
(47.4%) did not know the proper
symptoms of murine typhus:
 Responded don’t know, fever with rash
only, or no fever

Number of Respondents
41%
31%
29%
Specialty
Risk factor
No (%)
All respondents
No. (%) Total=100
Physicians who
considered MT
No (%) Total= 18
Rodents present
52 (52%)
Fleas (presence and history)
49 (49%)
9 (50%)
Wild animals/Opossums
present
Dogs present
27 (27%)
6 (33.3%)
18 (18%)
3 (16.7%)
Cats present
27 (27%)
5 (27.8%)
Foreign travel within 14 days
of onset
Recent exposure to outdoors
26 (26%)
5 (27.8%)
31 (31%)
9 (50%)
Don’t know
29 (29%)
1 (5.6%)
None of the Above
1 (1%)
0 (0%)
Total Responses:
100 (100%)
18 (100%)
12 (66.7%)
All responding
physicians
No. (%)
Physicians
10
who suspect
murine typhus
40
No. (%)
R. typhi
Antibody Test
36 (36%)
4 (22%)
Rickettsia Panel
28 (28%)
4 (22%)
Would Never
Order Lab Tests
3 (3%)
1 (5%)
40 (40%)
10 (56%)
100 (100%)
18 (100%)
Don’t Know
Total
Respondents:
Number of Responses
52%
29%
19%
Specialties
Number of Responses
52%
28%
20%
Specialty
Seen FUO or Dx MT
Responses
Total
No. (%)
Notify
63 (63%)
Do not
notify
14 (14 %)
Do not
know
23 (23%)
Total Respondents
100 (100%)
Barriers to Reporting
Total
No. (%)
Lack of confirmatory
lab results
8 (57%)
Did not know it is a notifiable
condition
Not considered a public health
concern
10 (71%)
Don’t know where to report
5 (36%)
Don’t know how to report
8 (57%)
Total Respondents:
3 (21%)
14 (100%)
Indications of
Underreporting
Fever with Rash are only
indication
Total Frequency
No. (%)
5 (5%)
Don’t know signs and
symptoms
Don’t know treatment
regimen
Don’t know risk factors
33 (33%)
Don’t know lab tests ordered
40 (40%)
Don’t know what lab to send
lab tests
31 (31%)
Would never order lab tests
3 (3%)
Total Respondents:
25 (25%)
29 (29%)
100 (100%)
CONCLUSIONS
There is potential under-reporting of
murine typhus in Bexar County but
additional data would be required to
confirm these findings.
 Design an intervention that would target
multiple physician specialties.

Biggest limitation- low response rate
 Respondents contacted by phone may
have used a handbook to answer the
questions
 List of physicians was not updated
 List did not incorporate the
subspecialties of physicians

More research in finding the best way to
contact physicians (either through mail,
phone, or web)
 Find effective ways to update physicians
about reportable diseases

Texas Department of State Health Services
 Marilyn Felkner
 Jeff Taylor
 Mike McElwain
 Mike Gilliam
 Laura Taboney
 Wes Hodgson
 Dawn Hesalroad
 Sky Newsome
At UT Austin
 Leanne Field
 Nancy Elder
 Diane Kneeland
Centers for Disease Control and
Prevention
Office of Workforce and Career
Development