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Typhoid Fever
... NOT ALWAYS TYPHOID, NOT ALWAYS A FEVER!

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Typhoid fever is a disease commonly found in the tropics. Transmitted by a bacterium, this disease was once common world-wide, but has now disappeared from most (but not all) developed countries. In fact, one of the most famous cases of typhoid transmission by a typhoid carrier was in the United States many years ago, by a woman who infected hundreds, so gaining the name "Typhoid Mary."

Before discussing typhoid fever further, it bears pointing out that while the disease is undoubtedly common in areas of poor sanitation, it is often incorrectly diagnosed. If the diagnosis is made only from the presence of typhoid antibodies in the blood, it may not be correct: antibodies may be there from previous exposure through infection or vaccination and not from present infection.

If you are told you have typhoid fever, you may have the illness; but judicious inquiry should establish whether this is a firm diagnosis (i.e. typhoid bacteria have been isolated in blood or stool samples) or an educated guess. Furthermore, while typhoid infection usually presents with fever it does not always do so...

Typhoid or 'enteric' fever is an acute or sub-acute disease caused by the salmonella bacteria. At first it may cause malaise, fever, abdominal pain and constipation. If untreated it can progress to diarrhea, rash, enlargement of the spleen and other complications; usually, mild cases in the previously fit may cause only a non-specific illness and fever.

Enteric fevers are caused by Salmonella typhi, S. paratyphi A, S. paratyphi B (S, schottmülleri) and S. paratyphi C (S. hirschfeldii). Salmonella are gram-negative bacteria. Specifically typhoid fever is caused by infection with typhoid bacteria (Salmonella typhi). The reservoir is persons chronically infected by the typhoid bacteria. Typhoid fever can occur if such carriers handle food, or if they do not practice proper hygiene after using a toilet. It may also occur if the water supply is not safe from contamination by excreta or is not treated and sometimes flies may carry the bacteria from feces to food.

The stools of the patient are often infectious for weeks or months, and the patient may become a carrier for life. Three per cent of patients with typhoid fever become carriers and the rate increases with age and the prevalence of gallbladder disease. The convalescent carrier can pass bacilli in the excreta for up to six months after an attack of typhoid. The chronic fecal carrier outnumbers urinary carriers by ten to one and continues to pass bacilli intermittently for at least one year after infection. Women are carriers more frequently than men, the gallbladder and bile ducts being the source of infection.

An attack of the infection usually produces considerable personal immunity, but mainly to that particular salmonella strain.

S. typhi only affects man and the source of infection is another infected human being excreting bacilli in the feces, urine or other secretions. Typhoid has been transmitted congenitally i.e. newborn babies can be infected.

Symptoms and Signs, Course and Complications

(These are for untreated and non-immune / non-vaccinated patients)

For the first week the patient has the general symptoms and signs of infection with some special features. He has malaise, headache, pains all over and fever. He may have a cough, and rarely nose bleeds. He usually has mild abdominal pain and constipation. On examination, the patient has fever but the pulse may be slower than expected. Nothing else special is found.

During the second week without treatment the patient becomes worse. General symptoms and signs may be severe. Abdominal pain becomes more severe and diarrhea (generally not a feature of early typhoid) occurs. On examination the fever and slow pulse are still present, the abdomen is usually distended and may be tender especially in the right iliac fossa (same place as the appendix), and the spleen is often enlarged. A rash made up of red spots, each of which lasts for a day or so, may be seen, especially on the abdomen.

During the third week without treatment, the general and abdominal symptoms and signs become worse. During this third week two serious complications may occur.

1. The bowel may perforate (get a hole in it through to the peritoneal cavity). There is a sudden abdominal pain and rapid worsening of the patient's condition and the symptoms and signs of general peritonitis develop.

2. Hemorrhage may occur from the intestinal wall into the intestine. The patient may pass blood from the rectum, or simply become pale and shocked (and later pass blood).

The patient who survives these complications usually starts to recover quickly after the fourth week. However, in some cases, after about two weeks, there is a return of the symptoms and signs, though usually not as severe as before.

In the case of fit well-nourished people who have been immunized and / or treated effectively, this course with its attendant morbidity and mortality is fortunately rare.

Diagnosis

By isolation of the organisms from blood or feces. (Bone marrow culture is often helpful if antibiotics have been started but this is only suggested for SEVERE cases where the diagnosis remains in doubt). Culturing the bacteria in blood samples is definitive (but takes 3 days to get a result). The white cell count is usually low, in contrast to the response in other types of bacterial infection; it is not raised unless a complication has developed when it may be high. Stool cultures may grow the organism but usually not in the first 10-14 days and hardly ever if the patient has had antibiotics, except if they go on to become carriers.

Diagnostic features:

Generalized symptoms and signs of infection
Slow pulse
Constipation at first, then diarrhea
Abdominal distention and tenderness
Persistence of temperature
Laboratory findings

As above, the white cell count is decreased (leucopenia). The erythrocyte sedimentation rate (ESR) is raised and the platelet count reduced. Serum liver enzymes are raised and the bilirubin is often above normal but not greatly so.

Widal-Felix-Weil Test

a.k.a. the "Widal Test": specific for typhoid but not especially reliable. Two sets are required usually 10-14 days apart (most patients do not want to wait that long for the diagnosis nor to come back when they are well) and titer (= antibody level) should rise 3-4 fold between sets to be diagnostic. NOTE that previous exposure and vaccination can produce high titers without active / acute infection.

Titer O (body): 0 (negative)

1/80 --> mild (suspected)

1/80 - 1/160 --> + (moderate)

1/160 - 1/320 --> ++ (severe)

Titer H (flagel): not specific

if H> 1/320 --> suspected

NOTE also that antibodies do not appear immediately; if a test is done 24 hours after falling ill there has been no time for antibodies to the present infection to develop, so any antibody level must reflect past infection.

Treatment of Typhoid Fever

Treatment with specific antibiotic treatment is generally effective but fever may persist for up to 5 days following start of treatment.

Control and Prevention

1. Kill the organism in the body of the host (reservoir) (patients and carriers)

2. Stop the means of spread of the organism

Patients and carriers should not be allowed to handle food for others. Proper disposal of feces is essential: safe water supply is essential. Careful nursing of cases which are infectious is important. Staff must wash their hands carefully after caring for a patient. What this means in institutions, rigs, and on sites is that:

1) all people involved in food handling/preparation should be screened if feasible. Screening is done by culturing stool samples taken on at least three separate occasions for 4-5 days and then checking them to see if the organism has been found growing.

Whether this is done or not, people in authority should oversee hygienic practices in the kitchen and storage areas, notably:

hand washing after the toilet
using clean flush toilets if possible
hand washing ALWAYS with soap
sick people out of the kitchen
all the obvious hygiene precautions.

All the food consumed should be sourced from the most reliable and clean, not the cheapest, merchant. Meat should be freshly killed and refrigerated. If frozen, it should be thawed and cooked immediately in sequence. Under no circumstances should meat, poultry, or seafood be prepared and the left for a few hours at room temperature or warmed over again; this is ideal to breed bacteria. Vegetables are often fertilized with human excrement and should be sterilized before use in salads and for any dish where they are not boiled for 10 minutes.

The drinking, cooking and tooth brushing water must be of the best possible quality i.e. bottled. Washing water for food utensils not from a known clean supply should ideally be boiled at a rolling boil for five-ten minutes. The same standards of hygiene must apply to food storage and dish / utensil cleaning and storage as in food preparation.

Prophylaxis

Parenteral vaccine

Typhoid fever vaccine is usually given in a series of two subcutaneous injections of 0.5 ml given at four weekly intervals. The protection rate is 70%.

Booster doses are recommended every 3 years in typhoid-endemic areas.

It should not be given to pregnant women and is contraindicated in those convalescent from serious illness.

Oral vaccine

Live vaccine is administered orally in the form of three capsules taken on days 1, 3 and 5, with booster doses after 3+ years.

It must not be administered until at least a week has elapsed since the patient has taken any antibiotics which are effective against Salmonella. There are no data on its safety in pregnancy or its efficacy in children below 6 years (and in any case the child must be old enough to be able to swallow the capsule intact).

The oral form is at least as effective as (and in some cases is more effective than) the injectable vaccine.

It should not be given to pregnant women and is contraindicated in those convalescent from serious illness.

* Even if vaccinated you can still get sick; prevention is better than cure.

We trust this information will assist you to make correct choices for your health and welfare. However it is not, and is not intended to be, a substitute for personalized advice from your medical advisor.

Our appreciation to Dr. Rene de Jongh of International SOS, An AEA Company who has contributed this article in response to a growing health threat faced by expatriates in Indonesia.

If you have medical-related questions about living in Indonesia to ask of medical professionals, see Ask the Experts.

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