Typhoid fever (enteric fever) is an acute bacterial infection caused by Salmonella typhi. Typhoid fever is more prevalent in areas of poor sanitation and in places where there are unsafe water conditions. It is more commonly seen in India, South and Central America and Sub-Saharan Africa countries.
Globally 17-22 million cases of typhoid are present each year which leads to 200,000- 600,000 deaths per year.In India, the prevalence of typhoid in disease-endemic areas is approximately 1%. India has one of the highest burden of typhoid cases.Without right treatment, it may cause severe complications and in serious cases can even result in death.
Causes and risk factors
Typhoid fever is spread by consumption of food or water contaminated by the causative bacteria, Salmonella typhi.
A person infected with Salmonella typhi will pass the bacteria in his stools (excreta). If they have not washed their hands properly after going to the toilet and touch any food items, they can pass on the bacteria. Any person who eats this contaminated food may get the infection. Less frequently, the bacteria can also pass through the urine of infected person and they can contaminate food if hands are not washed properly after urination.
In places where sanitation is a problem, there can be mixing of sewage lines with drinking water leading to contamination with Salmonella.
The other ways of spread of typhoid fever include:
- Using a toilet that is contaminated with Salmonella bacteria and not washing hand properly before eating.
- Using contaminated seafood caught from water infected with the bacteria.
- Eating raw or improperly cooked vegetables grown using human waste as fertiliser.
- Through oral or anal sex with a carrier of Salmonella typhi bacteria.
When a person consumes any food or drinks contaminated with the Salmonella typhi, the bacteria multiply in the intestine. This causes symptoms such as diarrhoea, stomach pain, and fever. If untreated, the bacteria can then enter the bloodstream and spread to other parts of the body. If the infected organs are severely infected, this can cause serious complications.
Around 2-5% of those who suffer from typhoid, continue to carry the bacteria in their gall bladder (in the liver), even after the symptoms have resolved. The bacteria residing in the gall bladder can cause cholecystitis. They do not show any symptoms but continue to spread the bacteria in their faeces or urine.
- Age- Typhoid infection occurs in school-age children and young adults
- Sex- Males are more affected and females are the mostly the carriers
- Occupation – People who have strains of salmonella are at increased risk of acquiring the infection. Cooks being the carriers of infection, have a propensity for causing typhoid infections
- Socioeconomic condition- Usually it is a disease of the poor due to unsafe water and poor sanitation.
- Environmental factors- Peak incidences of infections occur through July to September
Typhoid bacilli are found in soil, milk, ice and food. Typhoid bacilli can survive for 7 days maximum but their lifespan is 48 hours only.
Symptoms and signs
The symptoms and signs of typhoid develop gradually over 1-3 weeks after exposure to the bacteria. The early symptoms can include:
- Fever (low grade progressing to high-grade)
- Diarrhoea or constipation
- Loss of appetite
- Weakness and tiredness
- Muscle aches
- Dry cough
- Pain in abdomen
- Abdominal swelling
- Skin rash
If proper treatment is not given, serious complications may develop. In severe disease, the patient can reach a state of confusion and exhaustion.
Diagnosis of typhoid fever is made by isolating S. typhi from blood, bone marrow or any site.
- Complete blood count (CBC) – may show increased white blood cells.
- A blood culture during the initial week of the fever may show growth of Salmonella typhi bacteria.
- Stool examination- As S. typhi is present in the acute stage of the disease, stool examination is done for its detection. Collection of stool samples should be done in a wide mouthed sterile bottle.
- Widal Test is used to detect H and O antigens of Salmonella typhi.
Other tests that may be done include ELISA urine test, fluorescent antibody test for typhoid bacteria, platelet count, stool culture, etc.
Treatment and prevention
- Hydration- Adequate hydration should be maintained either orally or if required, intravenously
- Nutrition- You should have appropriate nutrition for healthy recovery
- Antipyretics- Fever can be managed with the use of antipyretics
- Antibiotics- Typhoid fever can be treated effectively with a course of recommended antibiotics. You will be required to take these for 7 to 14 days.
Almost 90% of the patients can be managed at home. Hospital admission may be advised if you have serious symptoms like severe vomiting, diarrhoea or abdomen swelling.
Vaccines: There are two vaccines available. One is an injectable vaccine given as single dose at least one week before travel. The other is four capsules taken orally every other day. The vaccines are not 100% effective.
The other measures that can help in prevention include:
- Hand washing before preparing food or eating food and after using the toilet.
- Drinking only clean water.
- Avoiding raw fruits and vegetables.
- Eating well-cooked foods.
The most severe complication of typhoid fever is the development of a hole (perforation) in the intestine, which can cause the contents of the intestine to leak into the abdominal cavity. It may also result in internal bleeding. When this happens, symptoms such as severe abdominal pain, nausea, vomiting, fever, and sepsis (infection of the bloodstream) can develop. Typhoid fever is a life-threatening condition, which requires immediate treatment.
The less common complications include:
- Myocarditis – inflammation of the heart muscle
- Endocarditis- inflammation of the heart and valves
- Pancreatitis –inflammation of the pancreas
- Pneumonia – lung infection
- Kidney or bladder infections
- Meningitis – Infection and inflammation of the protective membranes covering the brain and spinal cord
- Psychiatric symptoms such as hallucinations, delirium and psychosis.
Rush to your physician if you have:
- Fever which is in a step ladder fever pattern -fever rises throughout the day and absent in the morning for many days continuously
- Severe nausea and vomiting
- Severe Pain Abdomen
- A headache persisting throughout the day
- Disorientation/ Dizziness
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- Kothari A, Pruthi A, Chugh TD. The Burden of Enteric Fever. J Infect Developing Countries 2008; 2(4): 253-259.
- NHS Choices. Health A-Z. Typhoid. Accessed at http://www.nhs.uk/Conditions/Typhoid-fever
- Medline Plus. Medical Encyclopedia- Typhoid fever. Accessed at https://www.nlm.nih.gov/medlineplus/ency/article/001332.htm