Vacation Vaccinations Quiz: Typhoid Mary and the Taj Mahal

January 19, 2016

A family of 4 plans a vacation to India; typhoid vaccination is needed. Who can receive it? When? And is the pill or injection indicated?

[[{"type":"media","view_mode":"media_crop","fid":"45086","attributes":{"alt":"","class":"media-image media-image-right","height":"320","id":"media_crop_1350336344574","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5108","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©filmlandscape/Shutterstock.com ","typeof":"foaf:Image","width":"237"}}]]As you enter the exam room in mid-May, an involuntary smile pops up on your face as you see the 4 family members awaiting your arrival. As a family practice physician, caring for the entire family is what you are all about. You check the nurse’s intake note and see that the family will be traveling home to India in August for a two-week visit with family in both urban and rural areas with a stop by the Taj Mahal. The parents immigrated to the US shortly before the birth of their first child, now 12-years-old. His younger brother is 10. They want to talk to you about the need for any vaccinations or medications. This will be the children's first trip out of the US. Everyone's vaccines are up to date per the ACIP recommendations except for influenza which none of the family has ever received.

You begin by saying everyone should be vaccinated against typhoid fever and the 10-year-old gets excited and tells you they just talked about Typhoid Mary in his social studies class. He gives you a two-minute rundown on her. She was a cook who worked for multiple families and as many as 50 persons may have died from typhoid caught from her. He said he didn't like shots but he would get one to prevent typhoid fever.

Let's see if you are as smart as a fifth grader.

What city is most closely linked to Typhoid Mary?

A. London       

B. Bombay

C. New York City

D. Boston

Please click here for answer, details, and next question.

[[{"type":"media","view_mode":"media_crop","fid":"45088","attributes":{"alt":"","class":"media-image media-image-right","height":"250","id":"media_crop_9601972222920","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5109","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©pisaphtography/Shutterstock.com ","typeof":"foaf:Image","width":"172"}}]]Answer: C. New York City

George A. Soper, a typhoid fever researcher, was hired by a family in 1907 to look into the outbreak in their house in New York City. He looked at other outbreaks in households between 1900 and 1907 and recognized a common theme:  an Irish cook was hired and shortly thereafter the infections began. While she always denied ever having the disease or being the cause, this Irish cook named Mary Mallon would move on to another family once illness broke out. Soper published his findings in the Journal of the American Medical Assocation since an asymptomatic carrier of typhoid had never been described. NYC placed her in quarantine against her will from 1907 to 1910. She was released when she promised never again to work as a cook and to engage in careful hand washing practice. She became a laundress, a job not paying as well as cook. She changed her name and again became a cook. For the next five years she worked in a number of establishments with typhoid outbreaks in all of them. She was again arrested in 1915 and lived the rest of her life until 1938 in quarantine.

Back to our family; you tell the relieved 10-year-old that the vaccine comes in pill form as well as a shot. The pill is a live attenuated vaccine given in 4 doses on an every-other-day schedule. The shot is a single injection. Everyone decides they want the pills. Relevant details of medical history include: Mom is 16 weeks pregnant; the 12-year-old is on tetracycline for his acne; Dad is on high-dose Flovent for his asthma, and the 10-year-old can't swallow pills but is willing to chew them up like he does with some other medicines. The 12-year-old absolutely refuses to stop his tetracycline even for a few days since he is afraid his acne will flare.

Who can receive the oral attenuated live virus vaccine?

A. Only Dad

B. Mom and Dad

C. Mom, Dad, and the 10-year-old

D. Dad and the 10-year-old

E. No one, all will need the inactivated vaccine given by injection

F. Everyone except Mom

Please click here for answer and discussion.

Answer: B is the best answer, but one could make a good argument that A is also correct.

Live vaccines are contraindicated in immunocompromised persons but even high-dose Flovent does not put Dad at risk, so he can receive the live vaccine. One is always hesitant to give a pregnant woman a live vaccine and no good data exist on the use of either form of typhoid vaccine in pregnancy. The V.I.S sheet and product package insert do not list pregnancy as a contraindication to either the injection or the pill. This is a situation where the provider and patient have to decide if the risk of disease to mom and fetus outweighs the potential risk of recieiving the vaccine.

Antibiotics may interfere with the replication of the live typhoid virus in the gut, so the 12-year-old will need to receive the shot. The rule is that antibiotics needs to be stopped for 3 days before and after each of the 4 pills that are given on an every-other-day schedule. The capsule is enteric coated so should not be chewed.

We'll move on inVacation Vaccinations: Quiz Part 2 to look at the need for the influenza vaccine in our family vacaction scenario.

 

Sources

World Health Organization. International travel and health. Typhoid fever, vaccine.  (This WHO page looks at the different recommendations for the oral typhoid vaccine in Europe and Canada.)

This is Soper's article on Typhoid Mary for you history buffs.

Soper GA. The Curious Career of Typhoid Mary.* Bull N Y Acad Med. 1939 Oct;15(10):698–712.  *Read May 10, 1939 before the Section of Historical and Cultural Medicine. (This is Soper's article on Typhoid Mary for you history buffs--free full text.)