Public Health England
Chartered Institute of Environmental Health
Full Text Guideline
Evidence Supporting the Recommendations
The working group made recommendations on the basis of the evidence obtained from the literature reviews, together with analysis of enhanced surveillance data, a review of clearance and screening schedules in use in other non-endemic areas, and expert consensus.
Implementation of the Guideline
Teaching Case Studies and Launch of the Guidelines
A collection of simulated case studies based on some common scenarios have been developed to support implementation of the new guidelines. These case studies were used in a launch event to familiarise practitioners with the guidelines. These case studies are available from the Health Protection Agency (HPA) Web site (see the "Availability of Companion Documents" field).
Foreign Language Translations
Staff Training/Competency Material
Benefits/Harms of Implementing the Guideline Recommendations
Appropriate public health management of typhoid and paratyphoid
Rating Scheme for the Strength of the Recommendations
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Searches of Unpublished Data
A literature review was undertaken in 2007/2008 around the public health management of enteric fever and was comprehensively updated in July 2011. The combined literature searches incorporated the following search terms: "typhoid" OR "paratyphoid" OR "enteric fever" OR "typhi" or "paratyphi". The first literature review searched PubMed for relevant English language articles from January 1980 onwards; the updated review was restricted to articles since 01 January 2008 to the date of the search on 27 July 2011 but did not use any language restrictions.
In addition to articles discussing public health management of enteric fever, the first literature review included narrative reviews of the global epidemiology of enteric fever, as well as papers covering aspects such as laboratory diagnostic methods and antibiotic resistance. Review of articles focused specifically on the public health management of enteric fever cases and contacts. For instance outbreak reports were considered for inclusion if relevant to public health management in non-endemic countries, but articles relating to laboratory diagnosis or clinical management were excluded. Reasons for exclusion were: not relevant to public health management. Many articles discussed epidemiology of typhoid fever globally or in endemic countries, or clinical management of cases only with no mention of public health actions. Papers reporting outbreaks from endemic countries were also excluded.
Additional papers, including grey literature, were identified through reference lists and discussion with members of the Typhoid and Paratyphoid Reference Group (TPRG). In addition, health protection and environmental health practitioners were asked to send publications, local audits, guidance, and case studies.
20 articles (case series, case reports, expert opinion papers) plus 17 outbreaks from non-endemic countries summarised in the text.
A Typhoid and Paratyphoid Reference Group was convened by the Health Protection Agency and the Chartered Institute of Environmental Health to revise guidelines for public health management of enteric fever.
The working group made recommendations on the basis of this evidence, together with analysis of enhanced surveillance data, a review of clearance and screening schedules in use in other non-endemic areas, and expert consensus.
A formal cost analysis was not performed and published cost analyses were not reviewed.
External Peer Review
Internal Peer Review
These guidelines were circulated for consultation in December 2011 across the Health Protection Agency (HPA)'s Health Protection Services, HPA Gastrointestinal Leads, and members of the Chartered Institute of Environmental Health (CIEH). All comments received were shared with Typhoid and Paratyphoid Reference Group (TPRG) members. The guidelines were approved by the HPA Gastrointestinal Programme Board and the CIEH Policy Development Board in January 2012.
Identifying Information and Availability
Balasegaram S, Potter AL, Grynszpan D, Barlow S, Behrens RH, Lighton L, Booth L, Inamdar L, Neal K, Nye K, Lawrence J, Jones J, Gray I, Tolley D, Lane C, Adak B, Cummins A, Addiman S, Typhoid and Paratyphoid Reference Group, Health Protection Agency. Guidelines for the public health management of typhoid and paratyphoid in England: practice guidelines from the National Typhoid and Paratyphoid Reference Group. J Infect. 2012 Sep;65(3):197-213. [59 references] PubMed
Not applicable: The guideline was not adapted from another source.
Health Protection Agency/Chartered Institute of Environmental Health
National Typhoid and Paratyphoid Reference Group
Typhoid and Paratyphoid Reference Group Membership: Amelia Cummins, Consultant in Communicable Disease Control, Essex HPU, HPA; Amy Potter (Secretariat), Public Health Specialty Registrar, North East and North Central London Health Protection Unit (HPU)/South East Regional Epidemiology Unit, HPA; Bob Adak, Head of Gastrointestinal Infections, Gastrointestinal Emerging and Zoonotic Infections Department, HPA; Chris Lane, Head of Salmonella Surveillance, Gastrointestinal Emerging and Zoonotic Infections Department, HPA; Dave Tolley, Environmental Health Commercial and Corporate Health and Safety Service Manager, London Borough of Tower Hamlets; Delphine Grynszpan (Secretariat), Consultant in Communicable Disease Control, North West London HPU, HPA; Ian Gray, Principal Policy Officer, Chartered Institute of Environmental Health; Jane Jones, Consultant Epidemiologist, Travel and Migrant Health Section, HPA; Joanne Lawrence, Surveillance Scientist, Travel and Migrant Health Section, HPA; Kathy Nye, Consultant Microbiologist and Clinical lead for Gastrointestinal infections for HPA Microbiology services, HPA; Keith Neal, Consultant in Health Protection, East Midlands HPU, HPA; Leena Inamdar, Consultant in Communicable Disease Control/Regional Epidemiologist, Yorkshire & the Humber HPU, HPA; Linda Booth Consultant in Communicable Disease Control, Hampshire and Isle of Wight HPU, HPA; Lorraine Lighton, Consultant in Communicable Disease Control, Greater Manchester HPU, HPA; Ron Behrens, Tropical Medicine Consultant, London School of Hygiene and Tropical Medicine, & Hospital for Tropical Diseases; Sarah Addiman (Secretariat), Nurse Consultant, North East and North Central London HPU, HPA; Sooria Balasegaram (Chair), Regional Epidemiologist, South East Regional Epidemiology Unit, HPA; Steve Barlow (Team Leader), Food and Environmental Safety, Wolverhampton City Council
This is the current release of the guideline.
Electronic copies: Available from the Journal of Infection Web site.
The following are available:
- Public health operational guidelines for typhoid and paratyphoid (enteric fever). A joint policy from the Health Protection Agency and the Chartered Institute of Environmental Health. Full guidance document. 2012 Jan 1. 30 p. Electronic copies: Available in Portable Document Format (PDF) from the Health Protection Agency (HPA) Web site.
- Public health operational guidelines for typhoid and paratyphoid (enteric fever). Case studies with worked examples. PowerPoint presentation. 2012 Feb. 40 p. Electronic copies: Available from the HPA Web site.
- Public health operational guidelines for typhoid and paratyphoid (enteric fever). Case studies. PowerPoint presentation. 2012 Feb 10. 32 p. Electronic copies: Available from the HPA Web site.
- Enhanced surveillance of enteric fever. Electronic copies: Available from the HPA Web site.
- Enhanced surveillance of enteric fever questionnaire (ESQ). 2012 Sept 9. 8 p. Electronic copies: Available from the HPA Web site.
- Template letter and factsheet for contacts of a case of enteric fever. Electronic copies: Available from the HPA Web site.
The following available:
- Typhoid. Health advice for travellers. Factsheet. Electronic copies: Available in Portable Document Format (PDF) from the Health Protection Agency (HPA) Web site. Also available in Bengali, Gujarati, Punjabi, and Urdu languages from the HPA Web site.
Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.
This NGC summary was completed by ECRI Institute on April 1, 2013.
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
Typhoid and paratyphoid (enteric fever)
Note: Advice on clinical management and treatment is outside the scope of this guidance.
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Public Health Departments
To present the new guidelines for the public health management of enteric fever in England and the rationale for the recommendations
Patients with possible, probable, confirmed or travel-related cases of enteric fever
- Confirmation of diagnosis: culture of organism from blood or faeces
- General principles to reduce risk of transmission
- Warn and inform approach
- Advice about hygiene
- Public health management of probable and confirmed cases: determining if case is in a risk group or undertakes risk activities
- Investigation of source of infection: determining if infection is travel-related or United Kingdom (UK)-acquired
- Management of contacts
- Screening contacts
- Warning and informing all contacts identified
- Management of carriers
- Individual risk assessment
- Warning and informing contacts
- Consideration of treatment/re-treatment if public health risk
- Outbreak of typhoid or paratyphoid
- Risk for transmission of typhoid or paratyphoid
- Timing of development of symptoms
Table 1. Summary of New Guidelines and Rationale for Recommendations
|Area of Guidance||Detail of Guidance||Rationale|
|A. Public Health Case Definitions|
|Possible case|| || |
|Probable case|| |
|Confirmed case|| |
|Travel-related case|| || |
|Contact||Definitions for contacts expanded to include: ||Action taken for contacts should depend on: |
|Carriers|| || |
|Risk groups|| || |
|Area of Guidance||Detail of Guidance||Rationale and Discussion|
| ||Use Algorithm 1: Question 1 in the original guideline document to determine whether the case is POSSIBLE, PROBABLE, or CONFIRMED|
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| || |
| ||If infection is likely to be travel-related: || |
|If infection is unlikely to be travel-related: || |
| || |
| ||If case's infection is likely to be travel-related: || |
|If case's infection is unlikely to be travel-related: |
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The original guideline includes the following clinical algorithms:
- Public health management of cases and contacts
- Public health management of those who continue to excrete S. typhi or paratyphi
Institute of Medicine (IOM) National Healthcare Quality Report Categories
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