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Typhoid Fever

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Typhoid fever is a disease commonly found in the tropics. Transmitted by a type of salmonella bacteria, this disease was once common worldwide, but has now disappeared from most developed countries. In fact, one of the most famous cases was a typhoid carrier who infected hundreds in the United States many years ago, gaining the name "Typhoid Mary" in the process.

Diagnosis

Diagnosis is achieved via isolation of the organisms from blood or feces. Bone marrow cultures may often helpful if antibiotic treatment has started, but this is appropriate only for SEVERE cases where diagnosis remains in doubt. Blood samples cultures establish a definitive diagnosis, but takes up to 3 days for a result.

Typhoid fever is a serious infection caused by spread by contaminated food or water and understandably is quite common in areas of poor sanitation. Although typhoid is common in cities and rural areas throughout Indonesia, it is commonly overdiagnosed. If diagnosis is made only based on the presence of typhoid antibodies, it may not be correct as antibodies be present due to previous exposure through infection or vaccination. Typhoid is cured with antibiotic treatment. Preventive vaccinations are available.

If you are told you have typhoid fever, you may have the illness but judicious inquiry should establish whether this is a firm diagnosis (typhoid bacteria isolated from your blood or stool samples) or an educated guess. Furthermore, while typhoid infection is usually accompanied by a fever, this is not always the case.

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 may progress to diarrhea, rashes, enlargement of the spleen and other complications.

Enteric fevers are caused by the salmonella bacteria S. paratyphi A, B (S. schottmülleri) and C (S. hirschfeldii). Salmonella are gram-negative bacteria, and their reservoir is persons chronically infected with the typhoid bacteria. Typhoid fever may be transmitted if carriers handle food or use a toilet without practicing proper hygiene. It may also occur if water supplies are contaminated by excreta or not properly treated. Flies may also carry the bacteria from feces onto food.

The patient's stools may be infectious for months, and the patient may become a carrier for life. 3% of patients with typhoid fever become carriers, with the rate increasing according to age and the presence of gallbladder disease. The convalescent carrier can pass bacilli in excretions 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, with the gallbladder and bile ducts being the source of infection. Typhoid has been transmitted congenitally, and newborn babies can be infected.

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

Symptoms and possible complications

Although typhoid fever is often called a diarrheal disease, some patients do not have diarrhea.

For the first week, victims typically symptoms associated with typhoid infection, which include:

  • Malaise and weakness
  • Continuous dull headache
  • Flue-like body aches and pain
  • Persistent high fever
  • Cough
  • Nose bleeds (rare)
  • Mild abdominal pain
  • Loss of apetite
  • Constipation
  • A fever
  • A slower than normal pulse
Without treatment, in the second week general symptoms become more severe. Abdominal pain increases and diarrhea may occur. On examination, the abdomen is usually distended and may be tender in the same area as the appendix, with the spleen often enlarged. A rash made up of pink/red spots lasting for a day or so may occur, especially on the chest and abdomen of some patients.

During the third week without treatment, symptoms progressively get worse and two serious complications may occur:

1. In severe cases, the bowel may perforate and develop a hole through to the peritoneal cavity. This causes sudden abdominal pain and a rapid worsening of the patient's condition with the added complication of severe bleeding or infection in the abdomen, which can be fatal.

2. Hemorrhaging 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).

Victims who survive these complications usually start to recover after the fourth week. In some cases, after about two weeks basic symptoms return, though usually not to the same degree.

In the case of fit, well-nourished people who have been immunized and/or treated effectively, mortality is rare.

Widal-Felix-Weil test

The Widal Test is specific for typhoid, but not especially reliable. Two sessions are required usually 10-14 days apart to establish diagnosis. Note that antibodies do not appear immediately, and if a test is done up to 24 hours after falling ill antibody levels will only reflect past infections or exposures.

Methods for control and prevention

There are two methods for controlling the typhoid bateria: killing the organism in the host's body and stop the spread of the organism. Choosing safe food and water will greatly reduce the risk of developing the disease.

Patients and carriers should not be allowed to handle food for others. Proper disposal of feces and a safe water supply are essential. Careful nursing of infectious cases is important, and staff must wash their hands carefully after caring for a patient. What this means for relatively isolated or crowded institutions such as rigs and remote sites is that:

1. All people involved in food handling/preparation should be screened via culturing stool samples, if feasible.

2. People in authority should oversee and enforce hygienic practices in kitchens and storage areas, particularly with practices such as:

  • Hand-washing after toilet use
  • Using clean flush toilets if possible
  • ALWAYS using soap and warm/hot water for hand washing
  • Keeping sick people out of the kitchen
All food for human consumption should be sourced from the most reliable and clean merchants. Meat should be freshly killed or immediately refrigerated. If frozen, it should be thawed and cooked immediately. Under no circumstances should meat, poultry, or seafood be prepared and then left at room temperature for extended periods or warmed over again. Vegetables are often fertilized with human excrement and should be sterilized before use in salads and any dish where they are not cooked for a minimum of 10 minutes.

Drinking, cooking and tooth-brushing water must be of the best possible quality. Water designated for washing and originating from an unknown supply should be boiled at a rolling boil for twenty minutes. The same standards of hygiene apply to food storage and dish/utensil cleaning.

Prophylaxis

The typhoid fever vaccine is usually given in a series of two subcutaneous injections given at four weekly intervals. The protection rate is effectively 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.

Live vaccine can also be 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 after any antibiotics effective against Salmonella are used. There are no data on its safety for pregnant women or children below 6 years of age. The oral form is at least as effective as (and in some cases is more effective than) the injectable vaccine.

Prevention is still better than treating typhoid, as taking the vaccine and instituting proper precautionary measures will be much more effective than dealing with a course of antibiotics in Indonesia.

Read related articles on gastroenteritis, travelers' diarrhea and food preparation tips.

Additional info on Typhoid Fever from the US Center for Disease Control
and this Yellow book information on Typhoid and Paratyphoid

 

If you have any further questions about medical concerns in Indonesia, see the Ask the Experts.

We trust this information will assist you in making correct choices regarding your health and welfare. However, it 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.

 

Housing and schooling information for expats in Indonesia expatriate website for Indonesia Indonesian language translation of article

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