Definitive Diagnosis And Risk Factors For Typhoid And Paratyphoid In The Endemic Area Of Yunnan Province, China

ObjectiveTo document definitive diagnosis of typhoid and paratyphoid at different level hospitals in the endemic area of Yunnan province, to find out real situation of typhoid and paratyphoid occurred.To identify risk factors of typhoid and paratyphoid in the endemic area of Yunnan province, provide information for control and prevention.Method1. Definitive diagnosis of typhoid and paratyphoidCross-section survey for definitive diagnosis of typhoid and paratyphoid was conducted at prefecture, county and township hospitals in5counties. The data related to laboratory test, reporting, diagnosis and treatment was collected with structured questionnaire in related departments. Situation analysis for definitive diagnosis was described by ratio, proportion.2. Risk factors for typhoid and paratyphoidA case-control survey township and community-based for risk factors of typhoid and paratyphoid was carried out in Mile county from June to October,2013.1case was matched to3healthy controls with residence village, community, class, age, gender and oecupation. Case was confirmed patient of typhoid and paratyphoid by blood culture from Mile county hospital. A face to face interview was given to control and case using structured questionnaire, x2or rank sum test was adopted for the univariate analysis of data, Cox regression was conducted for multivariate analysis of data.Result1. Definitive diagnosis of typhoid and paratyphoidThere were20study hospitals involved in the survey. Total of418cases of typhoid and paratyphoid was reported from the20study hospitals, the diagnosis of181reported cases met national diagnostic criteria for typhoid fever and paratyphoid fever. Coincidence rate between the reporting diagnosis and the last diagnosis in the case history was43.30%(181/418). The coincidence rate of the diagnosis at prefecture level hospitals, county level hospitals and township level hospitals were42.86%,47.02%,28.57%respectively. The coincidence rate for Honghe prefecture, Banna prefecture and Baoshan prefecture were53.39%,46.38%,20.35%separately with statistical difference.60.00%of typhoid and paratyphoid cases were diagnosed in outpatient clinic at different level hospitals. Laboratory tests related the diagnosis for typhoid and paratyphoid were conducted in20study hospitals. Blood routine examination could be done in the20study hospitals. classification of white blood cell could not be performed in township hospitals. Widal test had been conducted in19study hospitals using same band of reagent, application of glass’test accounts for70.00%. Blood culture could not be performed in all study township hospitals. Blood culture test could be done in all prefecture and county level study hospitals except one study hospital, using different band of culture bottles.The most of clinical doctors diagnosed the illness as typhoid fever and paratyphoid fever according to epidemiological history, clinical presentation and laboratory results. Few depended on individual clinical experience. Doctor’s proficiency in diagnosis of typhoid fever and paratyphoid fever is different.27.78%of the doctors considered that person bitten by the mosquito in recent30days should be epidemiological history of typhoid fever and paratyphoid fever infected; 24.07%of doctors thought that clinical symptoms of typhoid fever and paratyphoid should have cough, runny nose and expiratory dyspnea. Doctor’s proficiency in judge the results was also different,50.00%of doctors thought that the judgment standards of agglutinating antibody titer against O and H antigens were≥1:160and≥1:80, the doctors at township hospital gave more incorrect responses than the doctors at prefecture and county level hospitals.Cases history of172hospitalized patients of typhoid fever and paratyphoid fever was reviewed in Honghe prefecture, the data showed that113cases (account for65.70%) had been classified clinical cases as reporting cases, routine blood test was done for167patients; Widal test was conducted for156patients, positive rate of Widal test was27.56%; blood culture test was performed for119patients, positive rate of blood culture test was47.90%;153reported typhoid and paratyphoid case had fever, the symptoms and complications of them were summarized as following:headache (49.67%), malaise (37.91%), chills (30.07%), cough (27.45%), anorexia (24.84%), toxic myocarditis (14.38%), toxic hepatitis (12.42%), bronchitis and pneumonia (11.76%).37.79%of the patients were cured when they left the hospital. Only27.34%of the patients were put under quarantine in the hospital.94.19%of the patients got treatment of antibiotics.59.62%of patient was treated with antibiotics guided by results of drug sensitivity test.2. Risk factors for typhoid and paratyphoidThere were200people involved in the survey, including50cases and150controls. The gender, age, nationality, occupation were kept a balance between case and control (P>0.05).50patients with fever were confirmed as S. paratyphi A patients by blood culture, and associated with some symptoms such as headache, fatigue, chills, aching muscles.50patients were hospitalized. Their average hospital stay was (8.28±4.02) days.(1) Bivariate Analysis:In the comparison with controls, significantly associated risk factors for paratyphoid fever were eating breakfast outside in normal times, eating rice noodles and steamed rice sheet rolls recent2weeks, breakfast with fresh onion, eating lunch and supper outside in normal times, eating lunch and supper outside in normal times, having lunch and supper outside recent2weeks, consumption of iced drinks or having night snack recent2weeks.(2) Multivariate Analysis:Results of Cox regression analysis show that taking steamed rice sheet rolls for breakfast (OR=11.12.95%CI:1.39～88.75), breakfast with fresh onion (OR=15.55,95%CI:1.37～176.87). having lunch and supper outside recent2weeks (OR=5.68,95%CI:1.02～31.62) were factors for paratyphoid A in Mile county.ConclusionsThe coincidence rates of the diagnosis in Yunnan province were low as a whole, in township hospitals espcially. There was high incidence of typhoid and paratyphoid affirmed by blood culture in some areas of Yunnan province. In the comparison with prefecture and county level hospitals, township hospitals were at a disadvantage in terms of number of staff, professional title, personnel qualifications, working experience and equipments. The diagnosis and treatment of typhoid and paratyphoid lacked of standardization, course of the treatment for typhoid and paratyphoid was less than one of requirement. Isolation measures and discharge standard for patient of typhoid and paratyphoid was not taken strictly in some hospitals. A nearly one hundred proportion of enteric fever cases are caused by S. Paratyphoid A in some endemic areas. Dinning out. eating salad food and food with fresh seasonings were risk factors of paratyphoid fever in some areas of Yunnan province.