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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