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For the duration of this class, I will be studying Typhoid Fever.
Typhoid Fever is caused by Salmonella typhi.

https://wwwnc.cdc.gov/travel/diseases/typhoid#:~:text=Typhoid%20fever%20and%20paratyphoid%20fever%20cause%20similar%20symptoms.,flat%2C%20rose%2Dcolored%20spots.

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Typhoid Fever | Disease Directory | Travelers’ Health | CDC

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In 1880, the microbe behind Typhoid Fever was discovered by Karl Joseph Eberth, a German Pathologist, but many historians believe Typhoid Fever was what plagued Athens in 430 BC, wiping out 1/3 of the population, which is the earliest "known" occurrence.

Eberth was the first known person to attempt to identify the infectious agent, believing it was a part of the bacillus family (a bacterial family). 4 years later, Georg Gaffky confirmed that the agent was from the bacillus family, and named it Eberthella typhi, which has been changed since.

Typhoid Fever is a foodborne illness. Foodborne illnesses are defined as microbes or pathogens that cause disease by food or beverage contamination.

https://libguides.uml.edu/early_lowell/Typhoid_1890-1891
https://www.health.state.mn.us/diseases/foodborne/basics.html#:~:text=Foodborne%20illness%20is%20caused%20by,bacteria%2C%20viruses%2C%20and%20parasites.
https://www.news-medical.net/health/Typhoid-Fever-History.aspx

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LibGuides: The Town & the City: Lowell Before The Civil War: The 1890 - 1891 Typhoid Epidemic

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Part 10 - This section discusses the Typhoid epidemic of 1890 and 1891 in the City of Lowell. The effects on the residents of the city, the efforts to control it, and the work to identify the source of the outbreak and prevent future epidemics are chronic

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Early on in the disease's history, some historians believe that the disease started off in Athens, Greece in 430 BC, but it is more recently believed to have appeared during the colonization of Jamestown. Between the years of 1607 and 1624, almost the entire colony was wiped out. It is safe to say that the disease could have started on the european continent, and subsequently spread to the americas, as well as many other portions of the world during the time period where colonization was very prevalent.

There is no exact timeline for this disease, as it is believed to have been around since 430 BC. In 1838 an English doctor by the name of William Budd identified what he called at the time poison, and suggested isolation of individuals and excrement to help prevent the spread. It was not properly identified until 1880 and 1884 by Karl Joseph Ehberth and Georg Gaffky. A vaccine came out in 1896 and was given to military personnel. The disease does still spread today, but mainly in populations where access to clean water is not promised.

According to historians, if Typhoid Fever is responsible for the plague in Athens in 430 BC, about 1/3 of the population died as a result of the outbreak, and again for Jamestown between 1607 and 1624, it almost eliminated the colony by taking more than 6,000 lives. Currently per the CDC, it is estimated that around 200,000 deaths occur across the world each year as a result of typhoid fever, with about 11-21 million cases per year.

Since the origins of this disease is still rather unknown, here is a current map of areas where Typhoid Fever is prevalent.

https://www.cdc.gov/typhoid-fever/health-professional.html#:~:text=An%20estimated%2011%E2%80%9321%20million,fever%20occur%20worldwide%20each%20year.&text=In%20the%20United%20States%2C%20about,diagnosed%20with%20paratyphoid%20fever%20annually.
https://www.news-medical.net/health/Typhoid-Fever-History.aspx

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Virulence is defined as the severity or harmfulness of a disease or poison, per Oxford Languages.

When looking at that definition, and using the numbers gathered from the last post, (11-21 million cases and 200,000 deaths per year, per CDC), the disease in modern ages is not that virulent. It is only lethal if left untreated.

The virulence did change over time. Considering early plagues are believed to be Typhoid Fever, which effectively killed a large portion of the population, in comparison to today, where a simple antibiotic is able to treat the disease. So long as whomever is infected has access to medical care, Typhoid Fever is easily treatable.

https://www.cdc.gov/typhoid-fever/health-professional.html#:~:text=An%20estimated%2011%E2%80%9321%20million,fever%20occur%20worldwide%20each%20year.&text=In%20the%20United%20States%2C%20about,diagnosed%20with%20paratyphoid%20fever%20annually.
https://www.nhs.uk/conditions/typhoid-fever/#:~:text=If%20typhoid%20fever%20isn't%20treated%2C%20it's%20estimated%20that%20up,more%20about%20treating%20typhoid%20fever.

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Clinical Features

Typhoid fever and paratyphoid fever are bacteremic illnesses that have an insidious onset characterized by fever, headache, constipation or diarrhea, malaise, chills, and myalgias, with few clinical features that reliably distinguish them from a variety of other infectious diseases. Diarrhea may occur, and vomiting is not usually severe. A transient, maculopapular rash of rose-colored spots may be present on the trunk. Confusion, delirium, and intestinal perforation may occur in severe cases, typically after 2 to 3 weeks of illness. The incubation period for typhoid fever is typically 6 to 30 days, and 1 to 10 days for paratyphoid fever.

Diagnosis

Blood culture is the mainstay of diagnosis. Bone marrow cultures have sensitivity of 80% in some studies and can remain positive despite antibiotic therapy. Stool and urine cultures are positive less frequently. Multiple cultures are usually needed to identify the pathogen. Serologic tests, such as the Widal test, are not recommended because of the high rate of false positives.

Treatment

Typhoid fever and paratyphoid fever are treated with antibiotics.

Antimicrobial resistance in typhoid fever has been increasing. Most typhoid and paratyphoid fever infections diagnosed in the United States are caused by strains not susceptible to fluoroquinolones. Therefore, do not use fluoroquinolones for empiric treatment while awaiting susceptibility results. Patients who have traveled to Pakistan should be treated with azithromycin for uncomplicated suspected typhoid fever and carbapenems for severe or complicated disease. Treatment can be adjusted when culture and sensitivity results are available.

Etiologic Agent

U.S. estimates
An estimated 5,700 infections of Salmonella Typhi occur among people in the United States each year; an estimated 620 of these people are hospitalized. CDC has not made estimates for Salmonella Paratyphi.

Global estimates
An estimated 11-21 million cases of typhoid fever and 200,000 deaths occur worldwide each year. An estimated 5 million cases of paratyphoid fever occur worldwide each year.

Diagnosed cases
In the United States, about 350 patients are diagnosed with typhoid fever and 90 patients are diagnosed with paratyphoid fever annually. Most illnesses are in people who report recent travel to countries where the diseases are common, such as India, Bangladesh, and Pakistan. These cases do not account for people who do not seek medical care, who are not tested for either disease, or whose disease is not reported to CDC.

Sequelae

Without therapy, the illness can last for 3 to 4 weeks and death rates range between 12% and 30%. Relapse occurs in up to 10% of untreated patients approximately 1 to 3 weeks after recovering from the initial illness and is often milder than the initial illness. A chronic carrier state, in which stool or urine cultures for Salmonella Typhi remain positive for more than one year, occurs in up to 5% of infected people.

Transmission

Typhoid fever and paratyphoid fever are transmitted commonly through the consumption of drinking water or food contaminated with the feces of people who have typhoid fever or paratyphoid fever or of people who are chronic carriers of the responsible bacteria.

Risk Groups

Risk is very low in the United States, higher among international travelers, and highest among people living in places with poor sanitation and hygiene. Most typhoid fever and paratyphoid fever patients in the United States report international travel in the 30 days before their illness; most of these patients traveled to South Asia (e.g., India, Bangladesh, Pakistan).

Surveillance

CDC has conducted surveillance for typhoid fever since 1975 and paratyphoid fever since 2008. About 350 culture-confirmed cases of typhoid fever and 90 culture-confirmed cases of paratyphoid fever were reportedly annually to CDC's National Typhoid and Paratyphoid Fever Surveillance (NTPFS) system during 2008-2015. These cases do not account for people who do not seek medical care, who are not tested for either disease, or whose disease is not reported to CDC.

CDC tracks changes in antimicrobial resistance among Salmonella causing typhoid fever and paratyphoid fever through the National Antimicrobial Resistance Monitoring System (NARMS).

Trends

Typhoid fever cases in the United States decreased slightly from 2008 through 2015. Since 2016, reported cases have increased slightly.

Challenges

Reduced susceptibility to fluoroquinolones (e.g., ciprofloxacin) and the emergence of multidrug resistance has complicated treatment of infections, especially those acquired in South Asia. There have been reports of sporadic ceftriaxone-resistant Salmonella Typhi infections and at least one documented outbreak. An outbreak of extensively drug-resistant typhoid fever in Pakistan is ongoing.

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Typhoid fever and paratyphoid fever are bacteremic illnesses that have an insidious onset characterized by fever, headache, constipation or diarrhea, malaise, chills, and myalgias, with few clinical features that reliably distinguish them from a variety of other infectious diseases. Diarrhea may occur, and vomiting is not usually severe.

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Initially, when they began to realize the disease was due to some microorganism, they began to look at sources. It was discovered it was passed through contaminated water, and if anyone fell ill they had to quarantine. 32 years after the identification of the bacteria, they were able to develop an immunization against Salmonella typhi, and antibiotics became available in 1948. Prior to the immunization, there was an outbreak in New York City, where they found a healthy carrier, Mary Mallon or commonly known as Typhoid Mary. Unfortunately, their treatment of her is deemed to be unethical, as many looked down upon her and she was forced into confinement for multiple years. This prompted for some type of way to handle the disease, as Typhoid began to quickly spread around the city.

The use of vaccines was the first way to combat Typhoid Fever in 1911. The use of vaccinations began in 1796, which was used to eradicate small pox. The same types of thinking aided researchers in their methods to combat typhoid via vaccination. Around 30 years later, researchers were able to create an antibiotic that was useful in treating typhoid fever. Antibiotics were first used in the 1890s, but the first true antibiotic, penicillin, was discovered in 1928.

The newest technology at the time was the development of the vaccine, followed by antibiotic technologies around 30 years later. No modern technology was used considering the timeline of when this disease developed.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959940/
https://www.acs.org/education/whatischemistry/landmarks/flemingpenicillin.html#:~:text=But%20it%20was%20not%20until,St.%20Mary's%20Hospital%20in%20London.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3336846/

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Abstract

Mary Mallon was born in 1869 in Ireland and emigrated to the US in 1884. She had worked in a variety of domestic positions for wealthy families prior to settling into her career as a cook. As a healthy carrier of Salmonella typhi her nickname of "Typhoid Mary" had become synonymous with the spread of disease, as many were infected due to her denial of being ill. She was forced into quarantine on two separate occasions on North Brother Island for a total of 26 years and died alone without friends, having evidently found consolation in her religion to which she gave her faith and loyalty.

Typhoid fever, Keywords: salmonella, Mary Mallon, carrier, New York

Isolating Salmonella

Long before the bacillus responsible for the disease was discovered in 1880, Karl Liebermeister had already assumed that the condition was due to a microorganism. He also tried, with his colleagues, to demonstrate that the spread of epidemic was related to drinking water contaminated by the excrement of patients with typhoid fever [ 1]. William Budd, a doctor in Bristol who was interested in cholera and in intestinal fevers, demonstrated in 1873, that typhoid fever could be transmitted by a specific toxin present in excrement and that the contamination of water by the feces of patients was responsible for that propagation. According to Budd, every case was related to another anterior case. A great number of doctors and scientists had tried to discover the nature of the microorganism responsible for the disease and had encountered great difficulty in isolating the bacillus. It was Karl Joseph Eberth, doctor and student of Rudolf Virchow, who in 1879 discovered the bacillus in the abdominal lymph nodes and the spleen. He had published his observations in 1880 and 1881. His discovery was then verified and confirmed by German and English bacteriologists, including Robert Koch [ 2]. The genus " Salmonella" was named after Daniel Elmer Salmon, an American veterinary pathologist, who was the administrator of the USDA research program, and thus the organism was named after him, despite the fact that a variety of scientists had contributed to the quest [ 3]. Salmonella thus became new scientific knowledge and therefore the contagion mechanisms, as well as the existence of healthy carriers were relatively in status nascendi [ 4].

The contagion

Mary Mallon was born in Ireland in 1869 and emigrated to the United States in 1883 or 1884. She was engaged in 1906 as a cook by Charles Henry Warren, a wealthy New York banker, who rented a residence to Oyster Bay on the north coast of Long Island for the summer. From 27 August to 3 September, 6 of the 11 people present in the house were suffering from typhoid fever. At this time, typhoid fever was still fatal in 10% of cases and mainly affected deprived people from large cities [ 5, 6].

The sanitary engineer, committed by the Warren family, George Sober, published the results of his investigation on the 15th of June 1907, in JAMA. Having believed initially that freshwater clams could be involved in these infections, he had hastily conducted his interrogation of the sick people and also of Mary who had presented a moderate form of typhoid [ 7]. Mary continued to host the bacteria, contaminating everything around her, a real threat for the surrounding environment. Although Sober initially feared that the soft clams were the culprits, this proved to be incorrect as not all of those stricken had eaten them. Finally Sober had solved the mystery and became the first author to describe a "healthy carrier" of Salmonella typhi in the United States. From March 1907, Sober started stalking Mary Mallon in Manhattan and he revealed that she was transmitting disease and death by her activity. His attempts to obtain samples of Mary's feces, urine and blood, earned him nothing but being chased by her. Sober reconstituted the puzzle by discovering that previously the cook had served in 8 families. Seven of them had experienced cases of typhoid. Twenty-two people presented signs of infection and some died [ 5, 6].

That year, about 3,000 New Yorkers had been infected by Salmonella typhi, and probably Mary was the main reason for the outbreak. Immunization against Salmonella typhi was not developed until 1911, and antibiotic treatment was not available until 1948 [ 4]. Thus, a dangerous source like Mary had to be restrained. Mary was then frequently accused of being the source of contact for hundreds of the ill. Sober, after enlisting the support of Dr. Biggs of the N.Y. Department of Health, persuaded Dr. Josephine Baker, who along with the police, was sent to bring Mary Mallon in for testing. Baker and the police were met by an uncooperative Mary, who eluded them for five hours. At the end she was forced to give samples. Mary's stool was positive for Salmonella typhi and thus she was transferred to North Brother Island to Riverside Hospital, where she was quarantined in a cottage [ 5].

In 1909, Mary unsuccessfully sued the health department. During her two-year period of confinement, she had 120/163 stool samples test positive. No one ever attempted to explain to Mary the significance of being a "carrier", instead they had offered to remove her gallbladder, something she had denied. She was unsuccessfully treated with Hexamethylenamin, laxatives, Urotropin, and brewer's yeast. In 1910, a new health commissioner vowed to free Mary and assist her with finding suitable employment as a domestic but not as a cook. Mary was released but never intended to abide by the agreement. She started working again in the cuisines of her unsuspecting employers, threatening public health once more [ 4].

As a cook of Sloane Maternity in Manhattan, she contaminated, in three months, at least 25 people, doctors, nurses and staff. Two of them died. She had managed to be hired as "Mary Brown" [ 8]. Since then she was stigmatized as "Typhoid Mary" () and she was the butt of jokes, cartoons, and eventually "Typhoid Mary" appeared in medical dictionaries, as a disease carrier. Mary was placed back on North Brother Island where she remained until her death. On Christmas morning, 1932, a man who came to deliver something to her found Mary on the floor of her bungalow, paralyzed. She had had a stroke of apoplexy and never walked again. Thereafter, for six years, she was taken care of in the "Riverside Hospital" (). She died in November 1938. Her body was hurried away and buried in a grave bought for the purpose at St. Raymond's Cemetery in Bronx. A post mortem revealed that she shed Salmonella typhi bacteria from her gallstones raising the issue of what would have happened if she had accepted the proposed operation. Some other researchers insisted that there was no autopsy and that this was another urban legend, whispered by the Health Center of Oyster Bay, in order to calm ethical reactions [ 5].

Mary Mallon, the first known case of a healthy carrier in the United States, was proven responsible for the contamination of at least one hundred and twenty two people, including five dead [ 5].

Ethical issues

Much speculation remains regarding the treatment that Mary received at the hands of the Department of Health, City of New York. She was never fined, let alone confined. Instead of working with her, to make her realize she was a risk factor, the state quarantined her twice, making her a laboratory pet. Mary endured test after test and was only thinking of how she could cook again. She had become a victim of the health laws, of the press and above all of the cynical physicians, who had plenty of time to test but never had time to talk with the patient [ 9, 10].

Mary's case is a perfect example of how the Health Care system provokes social attitudes towards disease carriers, often associated with prejudice. This case highlighted the problematic nature of the subject and the need for an enhanced medical and legal-social treatment model aimed at improving the status of disease carriers and limiting their impact on society [ 9, 10]. Probably the answer to the rhetorical question "was Mary Mallon a symbol of the threat to individual liberty or a necessary sacrifice to public health?" is a single word, "balance". After all what Mary ever wanted was to be a good plain cook [ 11].

Concluding remarks

The history of Mary Mallon, declared "unclean" like a leper, may give us some moral lessons on how to protect the ill and how we can be protected from illness. Mary had refused the one operation which might have cured her. In later years she lost much of her bitterness and lived a fairly contented if necessarily restricted life. She evidently found consolation in her religion and she was then at perfect peace in the bosom of the church to which she gave the last years her faith and loyalty. By the time she died New York health officials had identified more than 400 other healthy carriers of Salmonella typhi, but no one else was forcibly confined or victimized as an "unwanted ill". Mary Mallon is always a reference when mentioning the compliance of the laws concerning public health issues. The state's pursuance and Mary's stubbornness gave her an awkward place in the history of Medicine.

Biography

Medical School, University of Athens, Athens, Greece

Footnotes

Conflict of Interest: None

References

Articles from Annals of Gastroenterology are provided here courtesy of The Hellenic Society of Gastroenterology

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Mary Mallon (1869-1938) and the history of typhoid fever

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Mary Mallon was born in 1869 in Ireland and emigrated to the US in 1884. She had worked in a variety of domestic positions for wealthy families prior to settling into her career as a cook. As a healthy carrier of Salmonella typhi her nickname of "Typhoid ...

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The most revealing aspect I learned about the disease I chose was that it is still a problem in many countries. Living in the United States means that typhoid is rare, and if you do encounter it, it is very treatable. Looking more into this disease made me realize that it is not eradicated or a disease of the past, and that many struggles with this disease.

What surprised me most about my disease was the treatment of Mary Mallon. I had always heard of typhoid mary, but learning about their treatment of her was really surprising and sad.

I feel like discussing the symptoms, or more so the medical aspects of the disease could be a part of the Padlet. After reading through many of the student introductions, I feel like many students enrolled in this course have plans to pursue medicine in some capacity, and I know for me personally, knowing in what ways disease affect people is interesting, as well as it expands on my knowledge of diseases.

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In 1907, a sanitary engineer named George Sober began investigating Mary Mallon, and wrote an article about a healthy carrier. Since there was no cure to typhoid fever, Sober enlisted the help of Dr. Biggs, who worked for the NY Department of Health, who then persuaded Dr. Josephine Baker, to deal with Mary. She was then locked into confinement for 2 years. Eventually, the vaccine was released and many countries began adopting the use of it. Unfortunately today, there are still many countries that face the dangers of typhoid fever, those being poor countries. As of 2010, the Coalition against Typhoid (CaT) was created in order to try and prevent typhoid that persists among vulnerable populations via many methods like advocacy, research, and education.

In 1907, there wasn't a prominent initiative to combat the spread of typhoid, rather just trying to eliminate Mary from interacting with the population. In modern times, we now have CaT, which has partnered with the Typhoid Vaccine Acceleration Consortium, which aims to attack typhoid on a global level, mainly in underserved populations.

In 1907, leadership was rather harsh and unethical to Mary, unfortunately due to the lack of knowledge of the disease coupled with no cure for it. Overall, the disease is well contained in more affluent countries, but still poses a risk to others. If financial boundaries were not an issue for the countries most at risk, leadership would definitely have a more feasible way of treating it.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6405271/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959940/

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Typhoid is not a disease of the past; it is a disease of the poor. In communities with access to clean water and improved sanitation, typhoid is rare. But in the many areas of the world where these are dreams, not even luxuries, the threat of typhoid persists. Coupled with the growing threat of antibiotic-resistant strains, this disease of the poor is becoming increasingly difficult to treat. There is an urgent public health need to expand preventive measures that can slow the development of drug resistance and reduce the impact of typhoid.

Despite resulting in 12 million cases and >128 000 deaths globally each year, typhoid, a bacterial infection caused by Salmonella enterica subspecies enterica serovar Typhi, has remained low on the global public health agenda since the 1940s when the disease became a rarity in developed countries [ 1, 2]. As noted in The Lancet in 2012, "whoever invented the phrase 'out of sight, out of mind' must have been thinking of typhoid fever" [ 3]. Efforts to prevent and control typhoid emerged more than a century ago, yet attention and prioritization of the disease have since diminished, leaving poor communities in South Asia and sub-Saharan Africa to bear the brunt of the morbidity and mortality of typhoid [ 3].

Launching the Coalition Against Typhoid

Combating a disease that keeps such a low profile presents an inherent challenge. One global strategy that has been employed to redirect funds and research efforts to the overlooked health problems facing low- and middle-income countries like typhoid is the creation of coalitions [ 4]. Coalitions act as conveners of a specific health issue by providing a forum to the many sectors that have a stake in the issue to take a stand together by advocating for funding, mobilizing resources for research, sharing knowledge, and fostering capacity development. With a shared vision, coalitions can improve effectiveness and efficiency by strengthening partnerships and consolidating valuable resources to collaborate on research and implementation issues, share success stories, and convey viewpoints to global health and development decision makers [ 4].

To raise the profile of typhoid on the global health agenda, the Coalition against Typhoid (CaT), with support from the Bill & Melinda Gates Foundation, was created in 2010 with the mission of preventing typhoid among vulnerable populations through research, education, and advocacy. CaT acts as a catalyst in the global health and development community and supports prevention and control interventions by coordinating partnerships, convening decision makers, and advocating for sustainable solutions to typhoid, including access to clean water and vaccines for vulnerable populations.

Coalition Structure

CaT is made up of individual members-people who share the common goal to prevent typhoid. Over the course of 8 years of work, CaT recruited >1000 members across different sectors including health; engineering; water, sanitation, and hygiene; and human rights. Prior to 2016, CaT consisted of organizational members. However, with multiple disease priorities fighting for one organization's attention and with staff turnover at organizations, this model was not effective. By broadening membership to individuals, CaT was able to garner multiple champions from within one organization, as well as individual members from organizations without a specific mandate for typhoid control. This broad membership base enables CaT to raise awareness among members of the global health and development community not previously active in typhoid prevention.

An important factor in CaT's success is that the membership reflects the population that typhoid impacts most. While CaT members come from >75 countries all over the world, the majority of members are based in regions that bear the disease burden of typhoid. Thirty-five percent of CaT members are based in South or Southeast Asia and 23% are based in Africa. CaT ensures it is responsive to this diverse membership through a multistakeholder steering committee. Additionally, CaT receives member feedback through the CaT website and in-person side events, and by making outreach calls to members to tailor activities to benefit its membership.

Coalition Impact

CaT has successfully raised the profile of typhoid and is continuing to advance prevention and control efforts. Both in person and digitally, CaT has engaged and mobilized researchers, scientists, and advocates to coordinate efforts in the fight against typhoid and deliver results. CaT has convened the community through a biennial CaT conference with growing participation, disseminated data and news through a website and newsletter with increasing readership, and advocated through social media and a blog reaching a diverse audience [ 5]. CaT's work has grown even more important throughout the last year when it joined forces with the Typhoid Vaccine Acceleration Consortium (TyVAC). Together CaT and TyVAC implemented the "Take on Typhoid" campaign to disseminate the latest evidence to global and national decision makers. Take on Typhoid has focused attention on typhoid as the new typhoid conjugate vaccine (TCV) was prequalified and recommended by the World Health Organization (WHO) and Gavi, the Vaccine Alliance opened a funding window for eligible countries to receive support for TCV introduction. After 8 years of work, the conversation around typhoid is no longer whether and how to stop it, but rather when and where [ 6].

Convening the Community

Every 2 years, CaT hosts the only international conference on typhoid and other invasive salmonelloses. Participants attend with the aim of disseminating new data, sharing and promoting best practices for prevention and control, fostering partnerships across sectors and regions, and equipping colleagues with tools to contribute to national, regional, and global advocacy efforts. The 10th and most recent International Conference on Typhoid and Other Invasive Salmonelloses took place in Kampala, Uganda, in April 2017 and featured conversations on topics including disease burden, antimicrobial resistance, updates on the vaccine pipeline from manufacturers, and discussions of global policy from public sector representatives [ 7]. The conference was attended by a diverse audience of >250 participants from 38 countries, primarily from Africa and Asia. Along with plenary and symposia sessions, the scientific agenda included 95 original poster abstracts, a 120% increase from the Ninth International Conference on Typhoid and Other Invasive Salmonelloses.

The research, evidence, and ideas shared in Kampala helped provide a foundation for global action against typhoid. With a new TCV developed in 2017, the time was ripe for renewed global interest in updating policies for typhoid prevention and control. In October 2017 the WHO's Strategic Advisory Group of Experts Typhoid Working Group reviewed select evidence presented at the conference, including data sets from surveillance projects like the Surveillance of Enteric Fever in Asia Project, in updating recommendations for typhoid vaccination [ 8]. Additionally, results from the conference survey, administered at the conference and receiving a 66% response rate, illustrated the success of the conference. The majority of participants reported leaving with renewed excitement and energy toward the goal of reducing the global typhoid burden. They also went home with new ideas. Eighty-eight percent of respondents said they would implement techniques learned at this conference in their practice or work, and 86% agreed that they learned something from another region that could be applied in their own. The next International Conference on Typhoid and Other Invasive Salmonelloses will take place in March 2019 in Vietnam. However, between the international conferences, the energy and enthusiasm of the typhoid community need regular encouragement to sustain member mobilization. CaT continues to build momentum by regularly bringing together CaT members at global venues such as the American Society for Tropical Medicine and Hygiene annual meeting and similar fora.

Website and Newsletter

Disseminating data and facilitating knowledge sharing are important avenues to keep a community informed and to reach decision makers with actionable evidence. Since CaT joined forces with TyVAC to maximize advocacy and communications efforts, the partnership has harnessed multiple communications channels to help bring attention to typhoid and raise awareness of prevention and control efforts. The Take on Typhoid website consolidates several resources for use by advocates when meeting with decision makers, including news on outbreaks and the increasing danger of antimicrobial resistance, information on the TCV, and the latest research. The website was also an important tool to disseminate groundbreaking policy decisions. When the first TCV (Typbar-TCV) achieved WHO prequalification and the WHO recommended its use, CaT issued press releases on the website. The press releases facilitated the placement of stories about these policy decisions in >40 news outlets [ 9].

The website also serves as a continuing resource for advocates, researchers, and policy makers, with fact sheets, infographics, and message maps, many of which are tailored by country or region. While national decisions around vaccine introduction are encompassed within numerous complicated socioeconomic and political realities, translating data around disease burden and cost-effectiveness of vaccine introduction can help inform policy decisions. The website is also regarded as a starting point for new researchers entering the field of typhoid, paratyphoid, or nontyphoidal Salmonella research for the first time. Of the 14 856 unique website visitors during September 2017-July 2018, 89% were new to the site. The Take on Typhoid knowledge exchange newsletter, meanwhile, informs a broader audience on a bimonthly basis of research, outbreaks, news stories, and vaccine updates. CaT members actively contribute to the newsletter by submitting articles to be featured. The newsletter is another integral tool for disseminating news on TCV development. Keeping members informed and connected was vital leading up to the WHO and Gavi's policy decisions on the TCV in 2017 and 2018.

Social Media and Blog

As with many diseases, the challenge in typhoid advocacy has been less about accumulating evidence than it has been about communicating that evidence in a clear and impactful way. CaT and TyVAC publish the Take on Typhoid blog to communicate important issues such as drug resistance, integrated approaches to prevention and control, and the new TCV vaccine to a broad audience. Beyond translating data into more easily understood blog posts, CaT works to put a face on a statistic to bring attention to and inspire action on an issue. When advocates speak of typhoid, they want decision makers to not only remember the numbers and rates, but also know the names and faces they represent. To shine a light on the human face of typhoid, CaT launched the "Stories of Typhoid" blog series in May 2016. This popular series features some of the 12 million individuals, mostly children, who suffer from typhoid every year. It has profiled families touched by typhoid in endemic countries including India, Bangladesh, Kenya, Malawi, Uganda, Pakistan, and Nepal. These stories explore the linkages between socioeconomic status, environment, and disease, illustrating how typhoid is interconnected with poverty, education, access to information, and natural disasters. The series has inspired CaT members to submit their own stories, as well as some they have come across in the field. Readership of the Take on Typhoid blog spans the globe, with readers visiting the website most often from India, Pakistan, Nepal, Nigeria, the United States, and the United Kingdom. The diversity of readership illustrates the wide dissemination of messaging about typhoid that helps raise visibility of the disease.

Reaching out to a less technical audience is an important aspect to increase awareness and interest in preventing typhoid. Take on Typhoid is active on digital social media platforms to interact with a broader audience across sectors and rapidly share information and resources. When TCV prequalification was announced by the WHO, the Take on Typhoid social media plan quickly rallied people from all corners of the typhoid community around a single topic and hashtag, receiving >16 000 Twitter impressions. The participation of well-known thought leaders from the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance lent credibility to the fight against typhoid, and signaled high-level support for TCV introduction through their social media support. Social media allows Take on Typhoid a far-reaching platform to stay connected and engaged, drive followers to resources on the website, and encourage participation and action across communities.

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The Coalition Against Typhoid: Mobilizing a Community for a Global Fight

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Typhoid became a low priority on the global public health agenda when it was largely eliminated from developed countries in the 1940s. However, communities in South Asia and sub-Saharan Africa continue to bear the brunt of the disease burden. One strategy ...

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When the outbreak happened initially in the US, there was societal typecasting of the disease, for example Mary Mallon. She was socially rejected, considering there was no cure for the disease. Today, there is not much societal or sociological impact brought on by the disease. As mentioned previously, this disease is only prevalent in what are considered to be third world countries. Societal outlooks on this disease do disrupt those who are afflicted with typhoid, as well as their families.

In the US, as a cure rolled out there was less of a stigma around the disease. This is not the same in some countries, as there is still a stigma surrounding the disease due to increase antimicrobial resistance, as well as contaminated water sources.

Society learned the importance of proper sanitation. Always washing your hands, treating foods, as well as many other common practices used in the food industry today. Not to mention sanitation in regards to drinking water and plumbing. Unfortunately for those in an area where plumbing and clean drinking water is not readily available, typhoid exists, which is why we see it in certain regions of the world.

https://pubmed.ncbi.nlm.nih.gov/28973415/
https://www.coalitionagainsttyphoid.org/the-issues/typhoid-and-wash/#:~:text=Proper%20hygiene,in%20the%20prevention%20of%20typhoid.