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Typhoid fever

Introduction

Typhoid fever, also know as enteric fever, is a serious infection that is caused by the bacterium Salmonella typhi. The disease is transmitted from human to human and is spread by eating food or drinking water that is contaminated with typhoid bacteria.

Each year, around 150 to 200 cases of typhoid are reported in the UK. However, worldwide, there are 13 to 17 million cases with an estimated 600,000 deaths.

Typhoid fever is a common problem in developing countries, such as India, Africa and South America, where food hygiene and sanitation standards may not be as high as in developed countries. In these countries, typhoid sometimes causes epidemics. Therefore, if you are visiting a developing country, it is advisable to have a typhoid vaccination.

Salmonella typhi belongs to the salmonella group which, as well as causing typhoid fever, also causes mild diseases such as food poisoning. Paratyphoid fever, caused by Salmonella enteritidis paratyphi A, B or C, is a similar infection to typhoid fever but is less severe.

Causes

Typhoid fever can be caused in three main ways:

  • if contaminated sewage gets into the supply of drinking water,
  • if an infected person handles food without washing their hands properly, and
  • if bacteria is transferred to food by flies feeding on infected stools (faeces). 

Typhoid bacteria are released in the urine and stools of infected people. If an infected person does not wash their hands properly before handling food, the disease may be spread to anyone who eats the food.

Once ingested (taken into your body), the bacteria multiply in your blood stream, causing the first signs of disease in the form of fever. The bacterium is then absorbed into your digestive tract, bone marrow, liver and bile ducts. In the second stage of the infection, the bacterium enters the small intestine causing violent diarrhoea symptoms to begin.

The typhoid bacterium can survive refrigeration, freezing and drying so ensuring high standards of food hygiene and personal hygiene is paramount. Water supplies are often infected and even ice can transmit the disease. Shellfish may be contaminated by sewage containing infected stools and in the past, contaminated tinned meat products have caused typhoid epidemics in Britain.

Someone who has typhoid fever is most contagious during the first week of the illness. The patient should therefore be isolated during this time, if possible. As well as a person with the disease being infectious, typhoid can also be caught from a carrier. A carrier is someone who still has typhoid bacteria in their system after they have recovered from the disease.

Carriers do not show symptoms of the disease but can spread it via their stools. Approximately 5% of people carry the bacteria for a year or more. It is therefore vital that a carrier of typhoid does not have an occupation that involves handling food. Treatment is available for carriers of typhoid. The disease can be eradicated in 4-6 weeks using antibiotic treatment.

Symptoms

Typhoid can vary in severity depending on how much bacteria has been ingested. The symptoms can be mild and last up to a week, or they can be more severe and cause a major illness lasting up to two months. The time between catching the disease and showing symptoms (the incubation period) is normally 1-3 weeks. For typhoid fever, there are two distinct phases of symptoms.

First phase

The first symptoms of typhoid fever are headache and fever. Your temperature will rise gradually to 39 C to 40 C (103 F to 104 F). This is followed by a loss of appetite, joint pain, sweating, a sore throat and a general feeling of being unwell. You are likely to experience constipation and stomach pains and may have a rash of flat, rose-coloured spots. Occasionally, early symptoms will also include; coughing, nosebleeds and painful urination. Children with typhoid fever often vomit and have diarrhoea. The first phase usually lasts about a week.

Second phase

During the second stage of the disease, your fever will continue and, if not treated, will get worse. Your pulse may become weak and your heartbeat may slow. You will feel extremely tired and may become confused and delusional. Your initial constipation will change to diarrhoea and your stools may contain blood. Your liver and spleen may enlarge, so that they can be felt on either side, just below the ribs. Your abdomen (stomach) will feel tender and painful.

Usually, in treated cases of typhoid fever, it is not until the fourth or fifth week that your temperature returns to normal and your general condition slowly starts to improve. However, if left untreated, typhoid fever can be fatal. If you do not have treatment, you will continue to have a fever for several months and may develop complications, such as peritonitis which results from perforation of the gut wall.

Between 10-30% of people who have typhoid and are not treated, die. Those most at risk are the elderly, very young children and people who are malnourished.

Diagnosis

Typhoid fever is usually diagnosed by conducting tests on a patients stools, blood or urine. If the typhoid bacterium is detected, a correct diagnosis can be made.

The symptoms of typhoid can be similar to those of malaria, so this should be ruled out as soon as possible. Typhoid fever is mainly caught abroad, so it is useful for your doctor to know your recent travel history.

Treatment

As typhoid fever can be fatal, early diagnosis and treatment is crucial. In developed countries, antibiotics such as ampicillin and chloramphenicol are often used to treat the infection.

You may need to be admitted to hospital, if you are infected with the typhoid bacterium while abroad. If you are unable to eat, due to gastrointestinal (stomach and gut) problems, you may be given an intravenous drip. In severe cases of typhoid fever, corticosteroids (steroids) may be needed to reduce the inflammation of your brain.

If you are admitted to hospital, you will be cared for in isolation and your family members stools may be examined to see if they are carrying the disease. While undergoing treatment, maintaining good general hygiene is important as bacteria may continue to be present in your body.

People with typhoid fever, who are treated with antibiotics, usually improve within 2-3 days and death is extremely rare. However, if you have had the infection, you may still be carrying the bacteria in your system. Therefore, if you have been treated for typhoid abroad, you should have your stools examined when you return.

If your job involves handling food, you should stay off work until at least two stool samples are clear of the bacterium.

Complications

Typhoid fever can lead to complications, particularly if it is not quickly diagnosed and treated. Complications that can occur include; intestinal bleeding, peritonitis (when the contents of your intestine infect the abdominal cavity), severe haemorrhages (internal bleeding), liver infection, gall bladder infection, blood infection, urinary tract infection and liver and kidney failure.

Perforations or bleeding from the intestine can occur if typhoid is untreated. If you experience severe pain this may mean that your bowel has perforated (torn), causing peritonitis. The perforations may heal themselves, but if there is widespread peritonitis or severe bleeding, an operation may be necessary as well as a broad range of antibiotics to fight the different types of bacteria that spread into your peritoneal cavity (the space within the abdomen that contains the intestines, stomach and liver).

Prevention

A vaccination against typhoid was first developed over a hundred years ago, in 1898. Since then, vaccines have improved significantly and are much less likely to cause side effects. The vaccine works by telling your body to make antibodies against typhoid bacteria, so that you can fight off the illness if you become infected.

If you are travelling to a country where standards of food and water hygiene may be poor, such as those in Asia, Africa and South America, you should have a typhoid vaccination. It is particularly important to have the vaccination if you are backpacking, travelling on local transport and staying in basic accommodation.

There are several forms of vaccine that protect against Salmonella typhi. The Typherix or Typhim Vi injections are the ones most commonly used. You need to have an injection at least two weeks before visiting a high risk country, in order to allow immunity to develop. There is also an oral vaccine called Vivotif. However, an injection is easier to administer, only requires a single dose and lasts for three years. After this time, a booster dose is recommended for those still at risk.

The typhoid vaccination is available on the NHS. However, you may only be able to get a free vaccination from your GP or practice nurse, so it is best to get it done before you travel. GPs can refuse to give the vaccine if they have chosen to opt out of the vaccination and immunisation additional service. You therefore need to visit your GP surgery to check that your GP is able to provide you with a vaccine.

Selected Links

  • Medical Advisory Services for Travellers Abroad (MASTA) - (MASTA)
    http://www.masta.org/
    The Medical Advisory Services for Travellers Abroad (MASTA) was set up in 1984 at the London School of Hygiene and Tropical Medicine and aims to raise the awareness of health issues associated with travel. The website provides information about minimise health risks, immunisations, antimalarial drugs, travel vaccines, and other aspects of international travel.
  • Travel advice - (Foreign and Commonwealth Office (FCO))
    http://www.fco.gov.uk/
  • Travel Health UK - (Travel Health UK)
    http://www.travelhealth.co.uk/
    This web site provides General Travel Health Topics including information on Diseases, Vaccinations{ NHS guidelines WHO guidelines Travel Clinics} Books and Essential Travel Items and Online Resources for Health Professionals. Also there is an advice section including the evaluation of the risk of Deep Vein Thrombosis and air travel.
  • Travel information - (Fit for travel)
    http://www.fitfortravel.nhs.uk
  • Health information for overseas travel - (Department of health (Stationery Office))
    http://www.archive.official-documents.co.uk/document/doh/hinfo/
    Health information for overseas travel
  • Travel Health - Disease Map - (BBCi)
    http://news.bbc.co.uk/1/shared/spl/hi/health/03/travel_health/jab_map/html/default.stm
    Travel Health - Disease Map

Last updated on 27 June 2007 04:48 PM

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