Salmonella Disease with a Health Management Perspective

Abstract

Salmonella infections represent a significant global health challenge, primarily due to their transmission through contaminated food and water, which affects individuals across all demographics. Salmonella spp., which are Gram-negative, rod-shaped pathogens, are responsible for various illnesses, ranging from gastroenteritis to more severe conditions such as typhoid fever. The prevalence of Salmonella infections exhibits global variability, significantly influenced by factors such as sanitation standards, food handling practices, and the robustness of public health infrastructure. Diagnosis typically involves culture analysis of stool, blood, or tissue samples, with treatment options complicated by increasing antibiotic resistance. Prevention and control measures emphasize food safety, public health education, and stringent hygiene practices. The chapter further elaborates on the significance of a multidisciplinary approach in health management to combat Salmonella infections effectively, including enhancing food safety inspections, expanding education programs, and improving laboratory capacities for infection control. The challenges of managing Salmonella are compounded by the pathogen’s ability to cause outbreaks, the growing issue of antimicrobial resistance, and the necessity for effective health policies and regulations to reduce infection risks.

1. Introduction

Infections resulting from the ingestion of contaminated food and water present a significant health issue, impacting individuals across all age groups. The primary contributory factors to this public health challenge are the consumption of foods and water supplemented with pathogenic microorganisms, including bacteria, viruses, and parasites [1]. In the field of health management, the management of infectious diseases, especially those caused by foodborne pathogens, is a critical issue that requires careful attention. In this context, the prevention and detection of Salmonella infections constitute a key public issue worldwide. This chapter provides a comprehensive overview of the etiology, epidemiology, and strategies of Salmonella in the field of health management [2]. The prevalence and severity of these infections vary depending on geographical location, socioeconomic conditions, and public health infrastructure. In developing countries, inadequate sanitation and limited supplies of clean drinking water lead to a higher prevalence of Salmonella infections, while in developed countries, deficiencies in food handling and preparation are a major risk factor [3]. In this context, prevention, detection, and control of these infections are of great importance for health management professionals.

Salmonella infections are usually diagnosed by culture analysis of stool, blood, or infected tissue samples. Laboratory tests are vital for identifying the causative agent and selecting suitable treatment methods without resorting to inhalation [4]. Nowadays, increasing antibiotic resistance is another factor complicating the treatment of infections. Therefore, preventing antimicrobial resistance is a priority for health management. The prevention and control of Salmonella infections covers a broad spectrum, starting from individual hygiene practices to the implementation of food safety standards and public health education. By implementing these multilayered approaches, health management professionals play an important role in reducing infection rates. This process requires effective collaboration between the food industry, public health authorities, and consumers. Furthermore, the development and implementation of health policies and regulations are critical for reducing the risk of infection [2, 3].

From a health management perspective, taking a proactive approach in the fight against Salmonella is vital in preventing the spread of the disease and protecting public health. This includes not only treating existing infections but also developing strategies to prevent future outbreaks [5]. These strategies include strengthening food safety inspections, expanding public health education programs and building enhanced laboratory capacities for infection control. This study aimed to address in depth the complex nature of Salmonella infections and the challenges faced in managing these infections. It is intended to provide an in-depth resource for health management professionals, policy makers, specialists in infectious diseases and microbiology, public health workers, and all other interested individuals seeking information in this area.

2. Salmonella disease

Salmonella infections hold significant implications for global public health, particularly within underdeveloped nations [6]. It can cause epidemics. The rise of this disease due to inadequate hygiene standards and limited regulatory controls further increases concerns [7]. The most important factors affecting prevalence factors include providing clean drinking water, safe wastewater removal, and access to clean food and climatic conditions [8, 9]. Transmission occurs via the fecal-oral route. There are numerous animal species associated with Salmonella infections. Among these, especially poultry, sheep, goats, cattle, horses, pigs, reptiles, wild birds, rodents, and domestic pets are notable. Additionally, infected humans can serve as sources of transmission, especially contaminated with feces consumption of water and foods (egg yolk, mayonnaise, milk, cream, vegetables and fruits, ice cream, etc.) for illness. High levels of Salmonella spp. ingested orally overcome the acidity of the stomach and reach the small intestine, where pathogenic Salmonella adhere to the intestinal epithelium and continue to live and multiply and spread. The infection first manifests as intestinal inflammation (gastroenteritis) [10, 11]. It lasts from 2 to 7 days, and its severity can vary. In some cases, the bacteria causing diarrhea can enter the bloodstream, leading to sepsis, which necessitates prompt and effective antimicrobial treatment. However, sepsis rarely occurs [2]. For disease to manifest in healthy individuals, a microbial load ranging between 10⁵ and 10¹⁰ organisms is typically necessary. This threshold may be lower in young children, elderly individuals, and individuals with immunodeficiency. Factors such as the number of bacteria, virulence attributes, host age, and host immune conditions play pivotal roles in disease pathogenesis [6, 12].

Salmonella spp., are Gram-negative, rod-shaped bacterial pathogens belonging to the Enterobacteriaceae family. This bacterium is motile, unencapsulated, generally aerobic and facultatively anaerobic, and can reproduce [6]. When there is only one pathogen (blood, cerebrospinal fluid, etc.), it can grow on blood agar, chocolate agar, but when mixed flora is present (feces, etc.), it can only be produced on selective media such as SS agar and bismuth sulfate agar. Salmonella spp., which are divided into two taxonomic families as Salmonella enterica and Salmonella bongori, have different serogroups according to their somatic (O) antigen. Different serotypes have been defined based on virulence (Vi) antigen and flagellar (H) antigen [13]. More than 2600 Salmonella serovars have been identified. These serovars are categorized into typhoidal and non-typhoidal types. Typhoidal serovars exhibit high adaptation to the human host and are exclusively transmissible through human-to-human contact, causing potentially life-threatening syndromes such as typhoid or paratyphoid fever. Most cases in Europe are considered imported and typically involve individuals returning from endemic countries. Non-typhoidal serovars, on the other hand, are recognized as zoonotic agents capable of transmission from animals and foods to humans. They are commonly found in the environment and can contaminate water and food sources [14].

2.1 Salmonella epidemiology

Salmonella is one of the top three bacteria that causes food-associated enteritis [15]. In addition, enteric fever, acute enteritis, bacteremia, and invasive infections can lead to different infection patterns, such as asymptomatic carriage [6]. In 2010, the Foodborne Disease Burden Epidemiology Reference Group (FERG) of the World Health Organization (WHO) documented that Salmonella resulted in approximately 180 million cases of illness and contributed to 298,496 fatalities [16, 17, 18, 19].

Globally, non-typhoidal Salmonella (NTS) is responsible for approximately 94 million cases of gastroenteritis annually, resulting in approximately 155,000 deaths. Data from the SalmSurv surveillance network, supported by the World Health Organization for foodborne illnesses, indicate that S. enteritidis and S. typhimurium are implicated in about 80% of these human infections. [20, 21]. Currently, within the European Union (EU), Salmonella enteritidis, S. typhimurium, and its monophasic variant are recognized as the primary serovars accountable for human disease. Salmonella enteritis was most common in 2019 with 32,010 cases (61.6%); in 2020 with 21,203 cases (63.1%); and in 2021 with 23,634 cases (64.6%) [14]. Both pathogens affect both humans and animals [22]. While many serovars are non-pathogenic to animals, they pose a significant pathogenic risk to humans.

From January to October of 2023, a total of 335 instances connected to this epidemic were documented across 14 countries within the European Union (EU) and the European Economic Area (EEA), in addition to the United Kingdom (UK) and the United States (US). Between the start of January and late October 2023, across 14 EU/EEA countries, the United Kingdom, and the United States, there have been 335 confirmed cases of Salmonella Enteritidis ST11, categorized into three microbiological groups, affecting individuals of various ages. A significant portion of the cases reported eating chicken products, notably chicken kebabs, prior to falling ill. There were nine hospitalizations in three nations and one fatality in Austria, emphasizing the ability of the outbreak to cause serious, sometimes lethal, illness [23].

Salmonella disease has recently garnered attention due to its diverse modes of transmission, notably through the consumption of pork or dry dog food. Additionally, there has been a recent focus on Charcuterie meats as potential sources of Salmonella contamination [24]. In terms of foodborne transmission, outbreaks within the EU have provided compelling evidence that various foods serve as carriers. For example, eggs and egg products were implicated in 39 outbreaks, mixed foods in 24, bakery products in 15, pig meat and related items in 14, and vegetables, juices, and their derivatives in 11 outbreaks. Additionally, raw milk and dairy products made with raw milk, seafood products, and processed foods such as sweets and chocolate have also been identified as sources of foodborne outbreaks in the EU [14]. Understanding the various transmission routes of Salmonella is essential for effective epidemiological management. Such insights underscore the importance of comprehensive surveillance and control measures to mitigate the risk of Salmonella outbreaks associated with diverse food sources.

2.2 Salmonella disease risk factors

Salmonella infections can originate from diverse food sources including meats like chicken and turkey, dairy products, and even some processed foods. Animal-derived raw products tend to have a higher risk of contamination, particularly uncooked meats, eggs, milk, and shellfish. Ensuring food safety involves preventing contamination throughout the production process and implementing control measures at critical points to secure access to safe food for consumption [1]. While various animal-derived foods are recognized as potential sources of Salmonella spp. infections, pork specifically has gained attention as a high-risk vector. A risk assessment model focusing on the pork supply chain indicates the incidence rate of salmonellosis from pork consumption in China, highlighting distinct rates for males and females [25]. The model’s sensitivity analysis pinpoints critical factors impacting the risk associated with pork, such as display temperature, display duration, and the concentration of Salmonella spp. present in pork at retail points [25]. Apart from animal products, there is another way of contamination that should not be ignored. Multidrug-resistant and highly virulent strains of Salmonella are found in the small-scale production and distribution networks of leafy green vegetables. Multidrug-resistant strains of Salmonella spp. were detected in 92.4% of the samples collected from the water-plant-food nexus [7]. Recent multistate outbreaks of Salmonella have been associated with a variety of food items that are not traditionally linked to the pathogen. Investigations have connected cases of illness to products such as flour, peanut butter, salami sticks, onions, prepackaged salads, peaches, and ground turkey. These incidents underscore the importance of vigilance across a broad spectrum of foodstuffs to prevent contamination and subsequent Salmonella infections [24].

People, notably young children under the age of five, elderly adults over 65, and those with compromised immune systems due to certain health conditions—like diabetes, liver or kidney diseases, and cancer—or as a result of their medical treatments, are at an elevated risk for experiencing severe infections caused by Salmonella. It is crucial for these vulnerable groups to practice heightened food safety precautions [24]. Immune system suppression poses a risk for salmonellosis. Cancer, systemic lupus erythematosus, sickle cell anemia, and human immunodeficiency virus (HIV) infection have been reported as risk factors for invasive salmonellosis. Salmonella spp. stands out as a significant pathogen causing foodborne illnesses that pose a risk to human health. However, the transmission of this bacterium is not limited to food; it can also spread through contaminated water, environmental contact, interpersonal interactions, and animals, including pets and those found in petting zoos, farms, fairs, and educational settings. The occurrence of Salmonella infection typically increases in the summer months of June, July, and August, in contrast to winter, which shows seasonal differences [26].

2.3 Salmonella disease signs and symptoms

S. enterica has different clinical characteristics according to its defined serotypes. The most important of these clinical pictures are food-related enteritis, bacteremia and localized organ infections, enteric fever (typhoid fever) and asymptomatic carriage [13]. While salmonellosis generally resolves on its own within a week, fatalities have been documented, particularly among susceptible demographic groups. These groups include very young individuals, elderly individuals, and individuals with compromised immune systems, highlighting the need for heightened vigilance and care in managing the disease within these populations [27]. The length and intensity of the illness can vary depending on the specific bacterial strains involved, the quantity of bacteria present, and the immune response of the host. This variation underscores the importance of considering both pathogen and host factors in understanding and managing the disease [28]. The disease presents with different clinical features [6].

2.3.1 Acute enteritis

Salmonellosis is frequently identified by symptoms resembling stomach flu or gastroenteritis. Gastroenteritis and food poisoning due to Salmonella sometimes occur as sporadic cases, and sometimes as outbreaks in places where public meals are held, such as hospitals, schools, dormitory canteens, and restaurants [10].

Symptoms of this condition include nausea, vomiting, abdominal pain, and diarrhea that may be bloody, along with headaches and fever. Prolonged symptoms can lead to dehydration, a concern, particularly for vulnerable groups such as infants and elderly individuals. This emphasizes the need for prompt and appropriate hydration and medical intervention in affected individuals. It develops on average 6–72 hours (average 24 hours) after consumption of food contaminated with S. enteritidis, S. choleraesuis, and S. typhimurium. It may also be accompanied by muscle pain and weakness. It may cause mesenteric lymphadenitis, which can cause severe abdominal pain that can be confused with acute appendicitis [8, 9, 29].

2.3.2 Bacteremia and localized organ infections

S. typhi, S. typhimurium, S. choleraesuis, S. enteritidis, S. paratyphi A, B, and C, and S. Heidelberg have the ability to cause bacteremia by passing into the bloodstream. Although the frequency of transient bacteremia resulting from Salmonella gastroenteritis is not clearly known, it is thought to be approximately 1–5%. This rate increases in the neonatal period and in conditions such as HIV infection and sickle cell anemia [30, 31].

In some cases, signs of sepsis (fever, chills, sweating, myalgia, loss of appetite, and weight loss), as well as findings associated with focal suppurative infection such as meningitis and osteomyelitis, may be detected [8, 13].

2.3.3 Enteric fever (typhoid fever)

S. typhi is primarily associated with enteric fever, a condition that may also be caused by S. paratyphi A, B, and C, though less frequently. The illness is marked by symptoms such as fever, loss of appetite, headaches, fatigue, muscle pain, and constipation, in addition to other nonspecific symptoms. In severe cases where the infection leads to septicemia or meningitis, it poses a fatal risk, underscoring the severity of these bacterial infections and the importance of timely diagnosis and treatment [18]. The process of diagnosis solely through clinical manifestations presents difficulties, owing to the symptomatic resemblance with various infections that are widespread in endemic regions. These include viral (such as dengue and influenza), parasitic (such as malaria, typhus, and leishmaniasis), and bacterial (such as brucellosis and tuberculosis) diseases. This overlap in symptomatology underscores the necessity for comprehensive diagnostic approaches to accurately identify the underlying cause of the patient’s symptoms [31]. Microorganisms are taken via the fecal-oral route approximately 10–14 days after fever, fatigue, loss of appetite, dry cough, and abdominal pain begin. The incubation duration may vary between 3 and 30 days depending on the inoculum amount, bacterial virulence, age, and host characteristics, such as the immune response and vaccination history. The clinical manifestations of S. paratyphi A, B, and C have a milder clinical picture. It causes paratyphoid fever [13].

On physical examination, relative bradycardia can be detected depending on the severity of fever. Maculopapular rashes (rose spot) may occur in 7–10 days of the disease, lasting for 2–3 days, usually by palpation of the abdomen. The spleen is softly and sensitively palpated in the first 2 weeks of the disease. Patients with a toxic appearance (dull facial expression, rusty tongue, and foul mouth odor) are detected [29, 31]. Normochromic normocytic anemia, leukopenia, and neutropenia may be detected. Thrombocytopenia, coagulation abnormalities, and hypofibrinogenemia can be observed in cases of DIC development [6].

According to US data, the frequency of non-typhoid Salmonella (NTS) infections has increased sixfold in the last 40 years. The reason for this is the rapid growth of the ready-made food industry rapid growth, disruption of flora as a result of improper use of antibiotics, and the increase of immune deficiency in the population. Due to increasing HIV infection, malnutrition, and poor hygiene conditions, non-typhoidal Salmonella (NTS) have emerged as a leading cause of mortality and morbidity among children in Africa [9].

2.3.4 Asymptomatic carriage

Enteric fever or salmonella gastroenteritis can result in the continuation of Salmonella shedding through feces for a duration of up to 5 weeks. Individuals who persist in shedding Salmonella after 1 year are considered asymptomatic chronic carriers. The likelihood of becoming a carrier is notably higher in individuals with gallbladder stones, those under the age of five, women, elderly individuals, and patients with gastrointestinal tract cancers. Moreover, in patients suffering from tuberculosis of the urinary system or Schistosoma infection, the excretion of Salmonella in urine may also be observed [8]. The existence of Mary Mallon, a healthy carrier, has made this disease more recognizable [32].

2.4 Diagnosis of Salmonella disease

The diagnosis of Salmonella infection is accomplished through a careful assessment of patients’ clinical symptoms and the application of microbiological tests. This process typically involves culture analysis of samples of blood, feces, or other body fluids that may be infected. A rapid and accurate diagnosis is critical for determining appropriate treatment approaches and reducing potential risks to public health.

2.4.1 Diagnosis of Salmonella enteritis

A common cause of food-associated bacterial diarrhea is Salmonella infection. During stool examination, leukocytes and erythrocytes are detected. In rare cases, it is necessary to perform rectoscopy for differential diagnosis. In these patients, macroscopic mucosal edema, hyperemia, mucosal fragility, and bleeding foci can be observed. Definitive diagnosis is made by producing the agent. S. enteritidis and S. typhimurium are the most frequently produced agents. In blood and suppurative infections, aspirate liquid culture and Gram staining must be done [8, 13]. For the causes of invasive diarrhea (such as Shigella, Yersinia enterocolitica, Clostridium difficile, and enterohemorrhagic E. coli) and acute appendicitis, intestinal perforation should be considered in the differential diagnosis [8, 9].

2.4.2 Diagnosis of enteric fever

For the definitive diagnosis of enteric fever, laboratory testing is essential. Despite the recognized significance of enteric fever for over a century, the search for a single “ideal” laboratory diagnostic biomarker has yet to yield a universally accepted solution. Diagnostic tests should be performed when the fever is ≥38°C and lasts ≥3 days [4, 33].

Definitive diagnosis is made by testing the causative agent in blood, bone marrow, feces, or duodenal liquid culture. For diagnosing enteric fever, in addition to the use of blood and bone marrow for bacterial culture, additional biological materials such as rose spots, duodenal bile, stool, and urine might be cultured to detect Salmonella. Culturing from rose spots, although noninvasive and offering approximately 60% sensitivity, is less frequently applicable as these spots appear in only 1–30% of enteric fever cases, indicating the necessity for a broad approach in sample collection for effective disease identification [34]. The detection of nucleic acids employs polymerase chain reaction (PCR) techniques to amplify serovar-specific DNA of Salmonella for diagnostic purposes. This method’s significant advantage lies in its swift processing time. PCR is particularly beneficial as it is capable of identifying DNA from Salmonella, whether the bacteria are alive, dead, or both, thereby offering a versatile and efficient diagnostic tool [33]. Serological detection of S. enterica serovars utilizes the Kauffman-White classification, although its specificity for diagnosing enteric fever is not perfect due to antigen commonality among different serovars. Despite this, serological tests are simple and rapid, making them crucial for prompt disease management in resource-limited endemic regions. The Gruber-Widal test is a prevalent serological method in such settings, detecting agglutination of bacterial antigens by specific antisera. For enhanced accuracy, it is advised to conduct the test twice, once during the acute phase and again during convalescence, seeking a fourfold increase in antibody titers for a positive result [31, 35, 36]. However, it should not be forgotten that chronic liver disease, infection with other Gram-negative agents or hypogammaglobulinemia, can result in false negatives; in disseminated tuberculosis and malaria, false positive can be detected [13]. The diagnosis of bacteremia and localized organ infections is similar to that of enteric fever. In addition, the radiological appearance specific to the involved organ and bacteriological growth in that organ is also detected [13].

2.4.3 Diagnosis of asymptomatic carriage

Long-term asymptomatic carriage, exceeding 1 year, is rare. Considering that transient excretion following infection is frequent, whereas prolonged asymptomatic carriage is infrequent, and the absence of substantiated evidence endorsing antibiotic treatment for chronic carriers, conducting follow-up stool cultures for the impacted children and their relatives is deemed unnecessary [6]. In some cases, however, it may be recommended to collect three consecutive stool samples at least one month apart after completion of antibiotic therapy [11]. Although outbreaks of typhoid fever that occur in underdeveloped countries are usually linked to contaminated water, the most common mode of serotype typhi transmission in the United States is the asymptomatic carrier [37]. Diagnosis is usually made with stool samples examined consecutively. Chronic carrier screening commonly utilizes the Vi antigen [33, 38].

2.5 Salmonella disease treatment

Treatment of Salmonella infection often varies depending on the severity of the disease and the general health status of the affected individual. Mild cases may often require no specific treatment, and symptomatic treatment with adequate hydration may often be sufficient. However, severe or high-risk patients may require antibiotic therapy and supportive care in hospital.

2.5.1 Salmonella enteritis treatment

Dehydration and electrolyte irregularity are recommended for rapid evaluation. For treatment, usually oral or IV rehydration and correction of electrolytes is sufficient. Antibiotic treatment in asymptomatic chronic illness is not recommended because it increases the carrier rate. However, for three-month-old babies, elderly individuals, and people in high-risk groups (patients with immunodeficiency, HIV, chemotherapy, who use immunosuppressive drugs and have sickle cell anemia patients) should be used empirical treatment due to the risk of bacteremia. Third-generation cephalosporins and ciprofloxacin may be preferred for empirical treatment [13, 39]. Multiple multidrug-resistant (MDR) Salmonella spp. are being isolated at increasing rates. Therefore, according to culture and antibiotic sensitivity testing, appropriate antibiotic treatment should be continued [31, 40].

2.5.2 Treatment of bacteremia and localized organ infections

The third generation cephalosporin treatment for bacteremia thought to be due to NTS should be preferred. Ciprofloxacin, ceftriaxone, and cefotaxime are first option, and cefixime and azithromycin are used as alternatives. Chloramphenicol, ampicillin, and trimethoprim/sulfamethoxazole are used only if susceptibility is detected. Cephalosporin, quinolone, and azithromycin combination is available in severe cases [13]. If there is resistance to all first and second choice drugs, carbapenem and tigecycline can be used [40, 41].

The prescribed duration for antibiotic therapy varies depending on the condition being treated: 14 days for bacteremia, 4–6 weeks for acute osteomyelitis, and a minimum of 4 weeks for meningitis. While some research suggests a 2-month treatment period for uncomplicated osteomyelitis, a duration of at least 3 months is advised for chronic or complex infections. The decision to discontinue antibiotic therapy should be based on the observed therapeutic response. Additionally, it is imperative to conduct clinical studies to ascertain the optimal duration of treatment for these conditions [8, 42, 43].

2.5.3 Treatment of enteric fever

Early diagnosis and treatment of typhoid is important. Patients should be given rest, adequate fluid, and electrolyte support. Paracetamol or ibuprofen may be given as antipyretic treatment. Nutrition should be continued, unless intestinal complications develop the patient with soft, light, easily digestible foods. Usually within 3days after starting antibiotic treatment, the fever begins to drop, and the patient starts to feel better. Adequate treatment takes an average of 2–3 weeks. Although treatment is needed, 1–4% of patients relapse within the second week [6].

2.5.4 Treatment of asymptomatic carriage

High-dose ampicillin for 6 weeks or treatment with a fluoroquinolone for 4 weeks is implemented. Cholecystectomy is recommended for people with gallstones whose decolonization cannot be achieved with this treatment. Treatment with ampicillin is recommended for 10 days before the operation and 4 weeks after the operation. Chronic carriers in the food industry are not recommended for public health purposes [8, 13].

2.6 New diagnosis, treatment approaches, and vaccines

The scientific community is actively engaged in the search for new acute biomarkers specifically tailored to enteric fever, with the goal of distinguishing these cases from other infectious diseases. The quest for ideal biomarkers for enteric fever, which are yet to be validated clearly, continues. The absence of an animal model that fully mirrors the infection lifecycle of typhoidal Salmonella strains poses a significant obstacle in understanding the disease pathogenesis and in the search for new biomarkers. There is a critical need for biomarkers that are detectable early in the infection, can reveal resistance to treatment, and accurately identify acute cases from subclinical infections or chronic carriers, especially in regions where the disease is endemic [33].

The ELISA technique and a method known as the TPTest, which evaluates IgA levels against the membrane components of S. typhi and S. paratyphi using ALS samples, have demonstrated a specificity range of 78–97% and a sensitivity of 100% in identifying the bacteria. This indicates a high level of accuracy in detecting these pathogens, demonstrating the potential of these methods for diagnosing infections caused by these Salmonella serovars [44, 45]. The TPTest offers a significant advantage by being able to distinguish between the acute phase of infection and the convalescent phase. This capability renders it a critical diagnostic tool within endemic regions for accurately diagnosing the disease status of individuals [46]. Further enhancements to these biomarkers could enable their advancement into point-of-care (POC) compatible rapid diagnostic tools, offering a more immediate and accessible option for disease detection.

While traditional culture-based methods for diagnosing enteric fever show high specificity, they are limited by their sensitivity and extended processing times. PCR techniques offer quicker results but require specialized skills and equipment. Serological tests, such as the Widal test, are rapid and suitable for point-of-care use in endemic regions, though their specificity and sensitivity are moderate. Efforts to identify distinctive bacterial and host biomarkers for enteric fever, aiming to differentiate between the stages of infection, have led to high-throughput studies. However, no single biomarker has yet been identified as ideal due to insufficient data [33]. Advanced technologies like proteomics, transcriptomics, and metabolomics, despite their potential, advanced technologies such as proteomics, transcriptomics, and metabolomics are often not feasible in endemic areas due to infrastructure limitations. Consequently, there is an urgent requirement for the development of more cost-effective, simpler methods or the adaptation of these advanced technologies into more accessible forms. The primary challenge in diagnosing S. typhi and S. paratyphiinfections in such regions lies in the need for diagnostic solutions that are both affordable and user-friendly. Furthermore, future research should also focus on devising diagnostic methods capable of identifying healthy or asymptomatic carriers of these pathogens, despite the complexities involved in this endeavor [33].

The initial development of typhoid vaccines dates back to the late 19th century. There are various vaccines developed for this purpose, but none of them provide long-term protection, and also not 100% effective and protective antibody levels can be achieved with annual booster doses every 3–5 years. Two vaccines licensed in the United States are accessible for Salmonella typhi: an oral attenuated live virus vaccine and an injectable polysaccharide vaccine. The Vi-polysaccharide typhoid vaccine is administered to adults over 2 years of age via a single intramuscular dose. The effect continues for 3 years, and its effectiveness is 70–80%. The Ty21a vaccine is an oral live typhoid vaccine. It is recommended that three doses be administered 2 days apart. Antibiotics should not be taken, 7 days before and after vaccination. It is not recommended for children under 6 years old or pregnant and for those with primary immunodeficiency or who are receiving immunosuppressive medication. This vaccine provides protection for 5 years, and its effectiveness is 67–82%. The conjugated forms of the Vi typhoid vaccine and tetanus vaccine are produced in India. This vaccine (Typbar-TCV) can also be used at 9 months of age [43, 44]. The FDA does not recommend the typhoid vaccine for routine immunization of individuals in the United States [47].

2.7 Protection

Salmonella infections are an important public health issue that should not be neglected. A significant portion of patients have this infection severe enough to require hospital inpatient treatment. Salmonella species cause epidemics and epidemics may cause economic losses. This situation reveals the importance of minimizing losses due to the disease, preventing the disease, and taking these prevention measures [10, 48].

All Salmonella infections can be prevented only by breakage in the fecal-oral chain. For this purpose, hand washing is the first step. Local administrators are responsible for providing infrastructure services and provide clean domestic water and food to people and animals. Another important issue is preventing contamination with animal feces during cutting and storage of all products, effective cooking, and pasteurization. In short, clean food consumption is required [10, 13, 48]. Food contaminated with Salmonella or other harmful germs usually looks, tastes, and smells normally. Therefore, it is important to know how to prevent infection. The use of pets by the veterinarian regularly makes the pets healthy. When a pet is healthy, household is also protected [24]. Risky people, such as employees in laboratory, who has household exposure to a chronic Salmonella typhi carrier, living in endemic areas and who travel to these regions for more than 2 weeks, can also be protected from typhoid with the S. typhi vaccine [49, 50].

3. Health management and food safety

The global impact of foodborne diseases is significant, affecting nearly one in ten individuals annually and resulting in the loss of 33 million healthy life years. These diseases disproportionately affect young children, with diarrheal diseases being the most prevalent outcome of consuming unsafe food. Annually, 550 million people are afflicted, including 220 million children under the age of five. Among the leading causes of diarrheal diseases worldwide, Salmonella ranks as one of the top four pathogens [51].

In this context, the magnitude of the burden of foodborne diseases has become an important focus of governments and health policy makers. Therefore, ensuring food safety is not only an ongoing problem from a historical perspective but also a critical public health priority today.

Food safety has been an important issue throughout history in terms of its impact on human health. Since the beginning of recorded history, unsafe food consumption has been a threat to human health. Many of the food security challenges we face today are not new but have historical roots. On a global scale, governments are developing and implementing various strategies to maximize the security of the food supply. However, in both developed and developing countries, the emergence of foodborne diseases remains a major public health challenge. Five key points have been identified for safer food. These are as follows [52]:

• It should be kept clean

• Raw and cooked foods should be separated

• It should be cooked well

• Store food at safe temperatures

• Use safe water and raw materials

4. Conclusions

Salmonella infection poses a significant public health challenge, as this bacterial disease is one of the most common causes of food poisoning and can affect millions of people worldwide. Salmonella is a major foodborne pathogen and can cause gastroenteritis, typhoid fever, and paratyphoid fever, particularly through contaminated water and food. The severity of Salmonella infections can range from mild cases of gastroenteritis to life-threatening systemic diseases, increasing the impact of the infection on public health [6, 9, 15]. Prevention and control of disease due to this bacterium is possible through effective food safety practices, public health surveillance, and public awareness efforts. Early diagnosis and treatment of Salmonella infections are vital to protect public health and reduce the burden of foodborne illness. Therefore, reducing the burden of Salmonella infections on public health is possible not only through individual and societal measures but also through proactive and holistic approaches of health systems. In this context, controlling the infection and preventing its spread should be at the center of health management strategies, and coordination of multidisciplinary efforts in this field should be a priority. Salmonella is a complex and multilayered problem in terms of health management.

The etiology, epidemiology, and health system impact of Salmonella infections emphasize the need for a comprehensive and multidisciplinary approach to the management of this disease [53]. Prevention, early diagnosis, and effective treatment of infections are vital to protect public health and utilize health resources effectively. In the fight against Salmonella, strict enforcement of food safety and hygiene standards plays a fundamental role in preventing the spread of the disease. This requires continuous awareness raising and supervision at the food production and processing stages, in consumers’ food preparation and storage practices, and in public health education programs. Furthermore, the development and implementation of health policies and regulations are critical in the prevention and control of these infections [2, 9, 53].

One of the biggest challenges in the diagnosis and treatment of Salmonella infections is antibiotic resistance. This is a growing problem worldwide and requires the development of new strategies for the management and treatment of infections [54]. Health management professionals need to play a leading role in the fight against antimicrobial resistance and promote research and innovation in this field. Furthermore, rapid and accurate diagnosis of infections increases the effectiveness of infection control programs and reduces the burden on health systems. From a health management perspective, another important factor in combating Salmonella infections is public health education. Informing the public about how infections are transmitted, prevention and control are critical steps in preventing the spread of these diseases. Health management professionals should develop effective communication strategies to disseminate this information and raise public awareness.

In conclusion, the management of Salmonella disease requires constant attention and innovation in the field of health management. It is important to recognize the complexity of Salmonella infections and the importance of health management of these infections. Health management professionals, policy makers, and public health workers should continuously strive for effective prevention, diagnosis, and treatment of this disease and keep abreast of evolving knowledge in this field. This approach will contribute to the protection of both individual and public health and help prevent future Salmonella outbreaks. Within the scope of this study, certain recommendations were developed. These recommendations are as follows:

• It is important to strengthen international cooperation to enhance global monitoring of Salmonella and data sharing. This can contribute to a better understanding of disease patterns and prevent disease spread.

• Organizing community-wide awareness-raising and education programs on food safety can increase individuals’ awareness of safe food consumption.

• International food safety standards should be effectively implemented in food production, processing, distribution, and consumption stages.

• Increasing the use of existing vaccines against Salmonella and investing in research and development on vaccine development, diagnostic methods, and treatment approaches will be an important step in the fight against the disease.

• Adopting multidisciplinary approaches to solving food safety problems can produce effective solutions by combining the knowledge and experience of different disciplines.

• Continuous review and improvement of hygiene and sanitation standards in food businesses can reduce the risk of transmission of pathogens such as Salmonella.

• Establishing improved monitoring and reporting systems for the early detection of foodborne diseases is vital to prevent the spread of disease.

• Improving labeling and information practices for consumers can help people make more informed decisions about their food choices.

• Harmonizing safety standards in the international food trade can limit the international spread of foodborne diseases.

• Increasing the frequency and scope of food safety inspections is an important factor in reducing risks in food businesses.

• Encouraging innovations in food processing technologies can enable safer processing and storage of food.

• Strictly controlling the use of antibiotics in the production of animal products can help prevent antibiotic resistance and thus control resistant pathogens such as Salmonella.

Conflict of interest

The authors declare no conflict of interest.

Thanks

We would like to thank all the authors and the editorial team involved in the preparation of this resource.