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Typhoid fever

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Typhoid fever



Introduction 

Typhoid fever is a bacterial infection that can spread throughout the body, affecting many organs. Without prompt treatment, it can cause serious complications and can be fatal.

It is caused by a bacterium called Salmonella typhi, which is related to the bacteria that cause salmonella food poisoning.

Typhoid fever is highly contagious. An infected person can pass the bacteria out of their body in their stools (faeces) or, less commonly, in their urine.

If someone else eats food or drinks water that has been contaminated with a small amount of infected faeces or urine, they can become infected with the bacteria and develop typhoid fever.

Who is affected?

Because of the way the infection is spread, typhoid fever is most common in parts of the world that have poor levels of sanitation and limited access to clean water.

Children and younger adults are thought to be most at risk of developing typhoid fever. This may be because their immune system (the body's natural defence against infection and illness) is still developing.

Typhoid fever is uncommon in the UK, with an estimated 500 cases occurring each year. Most of these people are thought to have developed the infection while visiting relatives in Bangladesh, India and Pakistan.

Signs and symptoms of typhoid fever

Common symptoms of typhoid fever include:


a high temperature that can reach 39-40°C (103-104°F)

stomach pain

headache

constipation or diarrhoea


If the condition is not treated, the symptoms continue to get worse over the following weeks and the risk of developing potentially fatal complications increases.

Possible complications include internal bleeding, or a section of the digestive system or bowel splitting open and causing widespread infection.

How typhoid fever is treated

Typhoid fever requires prompt treatment with antibiotics. If diagnosed in its early stages, the condition is likely to be mild and can usually be treated at home with a 7 to 14-day course of antibiotic tablets.

More serious cases of typhoid fever usually require admission to hospital so antibiotic injections can be given.

With prompt antibiotic treatment, most people will start to feel better within a few days and serious complications are very rare. Deaths from typhoid fever are now virtually unheard of in the UK.

However, if typhoid fever is not treated, it's estimated that up to one in five people with the condition will die. Some of those who survive typhoid fever will have permanent physical or mental disabilities.

Typhoid fever vaccination

In the UK, two vaccines are available that can provide some protection against typhoid fever. These involve either having a single injection or taking three capsules over alternate days.

Vaccination is recommended for anyone who is planning to travel to parts of the world where the typhoid is widespread, particularly if you are planning to live or work closely with local people.

However, as neither vaccine offers 100% protection, it is also important to follow some precautions when travelling. For example, you should only drink bottled or boiled water and avoid foods that could potentially be contaminated.



Typhoid fever is caused by Salmonella typhi bacteria 

High-risk areas

The areas with the highest rates of typhoid fever are:


Africa

Central America

the Indian subcontinent

the Middle East

South America

South and South East Asia


When travelling to a foreign country, it is a good idea to make a list of relevant contact details and telephone numbers in case of an emergency.

For more information, see travel health and travel advice by country from the Foreign & Commonwealth Office (FCO).

Symptoms of typhoid fever 

The symptoms of typhoid fever usually develop one or two weeks after a person becomes infected with the Salmonella typhi bacteria.

With treatment, the symptoms of typhoid fever should quickly improve within three to five days.

If typhoid fever is not treated, the condition usually gets worse over a few weeks and there's a significant risk that life-threatening complications of typhoid fever may develop. Without treatment, it can take weeks – or even months – to fully recover, and symptoms can return.

Common symptoms

Common symptoms of typhoid fever can include:


a high temperature, which can reach up to 39-40°C (103-104°F)

headache

muscle aches

stomach pain

feeling sick

loss of appetite

constipation or diarrhoea (adults tend to get constipation and children tend to get diarrhoea)

a rash made up of small pink spots

exhaustion

confusion, such as not knowing where you are or what is going on around you


Seeking medical advice

You should see your GP as soon as possible if you have symptoms of typhoid fever (even if you have been vaccinated against it), particularly if you have recently returned from travelling abroad.

It is unlikely that your symptoms are caused by typhoid fever, but it's best to get them checked out in case you need treatment.

If you become ill while travelling abroad, you can get help by:


contacting a representative of the travel company you booked with

contacting your travel insurer

contacting the British consulate in the area you are visiting or, if you are feeling very ill, the local emergency services


The Foreign & Commonwealth Office (FCO) provides travel advice by country, and their website has the contact details of all the British consulates and embassies in foreign countries.

Before you travel, it is a good idea to make a list of relevant contact details and telephone numbers in case of an emergency.

Causes of typhoid fever 

Typhoid fever is caused by a type of bacteria called Salmonella typhi.

This is not the same type of bacteria that can cause salmonella food poisoning, but the two are related.

How the infection spreads

When someone with the infection has a bowel movement, they may pass stools (faeces) that contain the Salmonella typhi bacteria. If they do not wash their hands properly after going to the toilet, they can contaminate any food they touch. If this is eaten by another person, they may also become infected.

Less commonly, the Salmonella typhi bacteria can be passed out in an infected person's urine. Again, if an infected person handles food without washing their hands properly after urinating, they can spread the infection to someone else who eats the contaminated food.

In parts of the world with poor levels of sanitation, infected human waste can contaminate the water supply. People who drink contaminated water or eat food washed in contaminated water can develop typhoid fever.

Other ways typhoid fever can be contracted include:


using a toilet contaminated with bacteria and touching your mouth before washing your hands

eating seafood from a water source contaminated by infected faeces or urine 

having oral or anal sex with a person who is a carrier of Salmonella typhi bacteria


Carriers

Up to 1 in every 20 people who survive typhoid fever without being treated will become carriers of the infection. This means the Salmonella typhi bacteria continue to live in the carrier's body and can be spread as normal in faeces or urine, but the carrier doesn't have any noticeable symptoms of the condition.

How the bacteria affect the body

After a person eats or drinks food or liquid contaminated with the Salmonella typhi bacteria, the bacteria will move down into their digestive system. The bacteria will then quickly multiply, triggering the initial symptoms such as a high temperature, stomach pain and constipation or diarrhoea.

If the person is not treated, the bacteria can get into the bloodstream, which means they can spread to other areas of the body. The spread of bacteria out of the digestive system can cause the symptoms of typhoid fever to get worse during the weeks after infection.

If the organs and tissue become damaged as a result of the infection, it can cause serious complications, such as internal bleeding or a section of the bowel splitting open.

Diagnosing typhoid fever 

You should see your GP if you think you have typhoid fever, particularly if you have recently returned from travelling abroad.

To help diagnose the condition, your GP will want to know if:


you have travelled to parts of the world where the infection is present

you have been in close contact with someone who has travelled to these areas


Parts of the world where the infection is most common include Africa, the Indian subcontinent, Southeast Asia and South America.

Testing for typhoid fever

A diagnosis of typhoid fever can usually be confirmed by analysing samples of blood, stools or urine and examining them under a microscope for the Salmonella typhi bacteria that cause the condition.

The bacteria are not always detected the first time, so you may need to have a series of tests.

Testing a sample of bone marrow is a more accurate way to diagnose typhoid fever. However, getting the sample is both time consuming and painful, so it is usually only used if other tests are inconclusive.

If testing confirms that you have typhoid fever, it may be recommended that other members of your household are also tested in case you have passed the infection to them.

Treating typhoid fever 

Typhoid fever can usually be successfully treated with a course of antibiotic medication.

In most cases, you can be treated at home, but hospital admission may be required if the condition is severe.

Treatment at home

If typhoid fever is diagnosed in its early stages, a course of antibiotic tablets may be prescribed for you. Most people need to take these for 7 to 14 days.

Some strains of the Salmonella typhi bacteria that cause typhoid fever have developed a resistance to one or more types of antibiotics. This is increasingly becoming a problem in typhoid infections originating in Southeast Asia.

Any blood, stool or urine samples taken during your diagnosis will therefore usually be tested in a laboratory to determine which strain you are infected with so you can be treated with an appropriate antibiotic.

Your symptoms should begin to improve within two to three days of taking antibiotics, but it is very important that you finish the course to help ensure the bacteria are completely removed from your body.

Make sure that you rest, drink plenty of fluids and eat regular meals. You may be able to tolerate eating smaller, more frequent meals rather than three larger meals a day.

You should also take care to practice good personal hygiene, such as regularly washing your hands with soap and warm water, to reduce the risk of spreading the infection to others.

Contact your GP as soon as possible if your symptoms get worse or if you develop new symptoms while being treated at home.

In a small number of cases, the symptoms or infection may recur. This is known as a relapse.

Staying off school or work

Most people being treated for typhoid fever can return to work or school as soon as they start to feel better.

The exceptions to this are people who work with food and vulnerable people, such as children under five, the elderly and those in poor health.

In these cases, you should only return to work or nursery after tests on three stool samples taken at 48 hour intervals have shown that the bacteria are no longer present.

Hospital treatment

Hospital admission is usually recommended if you have severe symptoms, such as persistent vomiting, severe diarrhoea or a swollen stomach.

As a precaution, young children who develop typhoid fever may be admitted to hospital.

In hospital, you will be given antibiotic injections and may also be given fluids and nutrients directly into a vein thorugh an intravenous drip.

Surgery may be required if you develop any life-threatening complications, such as internal bleeding or a section of your digestive system splitting. However, this is very rare in people being treated with antibiotics. 

Most people respond well to hospital treatment and improve within three to five days. However, it may be several weeks until you are well enough to leave hospital.

Relapses

Some people who are treated for typhoid fever experience a relapse, which is when symptoms return. In these cases, the symptoms usually return around a week after antibiotic treatment has finished.

The second time around, symptoms are usually milder and last for a shorter amount of time than the original illness, but further treatment with antibiotics is usually recommended. See your GP as soon as possible if your symptoms return after treatment.

Long-term carriers

After your symptoms have passed, you should have another stool test to check if there are still Salmonella typhi bacteria in your faeces. If there are, it may mean you have become a potentially long-term (chronic) carrier of the typhoid infection, and you may need to have a further 28-day course of antibiotics to "flush out" the bacteria.

Until test results show that you are free of bacteria, avoid handling or preparing food. It is also very important that you wash your hands thoroughly after going to the toilet.

Complications of typhoid fever 

Complications caused by typhoid fever usually only occur in people who have not been treated with appropriate antibiotics, or who have had delayed treatment.

In such cases, about 1 in 10 people experience complications, which usually develop during the third week of infection.

The two most common complications in untreated typhoid fever are:


internal bleeding in the digestive system

splitting (perforation) of a section of the digestive system or bowel, which spreads the infection to nearby tissue


These are described in more detail below.

Internal bleeding

Most internal bleeding that occurs in typhoid fever is not life threatening, but can make you feel very unwell.

Symptoms include:


feeling tired all the time

breathlessness

pale skin

irregular heartbeat

vomiting blood

passing stools that are very dark or tar-like


A blood transfusion may be required to replace lost blood, and surgery can be used to repair the site of the bleeding.

Perforation

Perforation is potentially a very serious complication. This is because bacteria that live in your digestive system can move into your stomach and infect the lining of your abdomen (the peritoneum). This is known as peritonitis.

Peritonitis is a medical emergency, as the tissue of the peritoneum is usually sterile and germ-free. Unlike other parts of the body, such as the skin, the peritoneum does not have an inbuilt defence mechanism for fighting infection.

In cases of peritonitis, an infection can rapidly spread into the blood (sepsis) before spreading to other organs. This carries the risk of multiple organ failure. If it is not treated aggressively, it may result in death. The most common symptom of peritonitis is sudden abdominal pain that gets progressively worse.

Peritonitis requires admission to hospital, where you will be treated with injections of antibiotics. Surgery will then be used to seal the hole in your intestinal wall.

Typhoid fever vaccination 

Vaccination against typhoid fever is recommended if you are travelling to parts of the world where the condition is common.

High-risk areas

Typhoid is found throughout the world, but is more likely to occur in areas where there is poor sanitation and hygiene. High-risk areas include:


Africa

Central America

the Indian subcontinent

the Middle East

South America

South and Southeast Asia


In particular, vaccination is recommended for those who will be staying or working with local people, and those who will have frequent or prolonged exposure to conditions where sanitation and food hygiene are likely to be poor.

In the UK, most people who get typhoid fever have visited India, Pakistan and Bangladesh. It is therefore especially important that you are vaccinated if you are visiting these countries.

Vaccination against typhoid fever is usually free of charge from GP surgeries on the. Alternatively, you can have it done at a private travel clinic from around £25.

Choosing a vaccine

Two main vaccines are available for typhoid fever in the UK:


Vi vaccine – given as a single injection

Ty21a vaccine – given as three capsules to take on alternate days


There are also combined typhoid and hepatitis A injections available for people aged 15 to 16 or older.

No vaccine offers 100% protection against typhoid fever, but the Vi vaccine is generally more effective than the Ty21a vaccine. However, some people prefer to have the Ty21a vaccine because it does not require an injection.

As the Ty21a vaccine contains a live sample of Salmonella typhi bacteria, it is not suitable for people who have a weakened immune system (the body's natural defence against infection and illness), such as people with HIV. It is also not usually recommended for children under six, whereas children can have the Vi vaccine from two years of age.

Ideally, the typhoid vaccine should be given at least one month before you travel, but, if necessary, it can be given closer to your travel date.

Booster vaccinations are recommended every three years if you continue to be at risk of infection.

Side effects

After having the typhoid fever vaccine, some people experience temporary soreness, redness, swelling or hardness at the injection site. About 1 in every 100 people experience a high temperature (fever) of 38ºC (100.4ºF). Less common side effects include:


abdominal pain

headache

feeling sick

diarrhoea


Severe reactions are rare.

Advice for travellers

Whether you have been vaccinated against typhoid or not, it is important to take basic precautions when travelling in countries where typhoid fever is present. For example:


only drink water that has been recently boiled, or drink from a bottle that is properly sealed

avoid ice cream and don't have ice in your drinks

avoid uncooked fruits and vegetables unless you have washed them in safe water or peeled them yourself

avoid shellfish, seafood or salads

Typhoid fever