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Typhoid fever

Introduction

Typhoid fever is an infection caused by bacteria that can spread throughout the body. 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, but not the same as, the bacteria that cause salmonella food poisoning.

Read more about the causes of typhoid fever.

Typhoid fever is very contagious. An infected person can pass the bacteria out of their body in their faeces when they have a bowel movement or, less commonly, when they urinate.

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

Who is affected by typhoid fever?

Due to 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.

Typhoid fever can be found throughout the developing world, particularly in South Asia and Southeast Asia.

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 Wales and England, with an estimated 350 cases occurring each year. Most of these people are thought to have developed the infection while visiting relatives in Bangladesh, India and Pakistan.

Typhoid symptoms

The initial symptoms of typhoid fever include:

  • a fever that gradually rises before settling at around 39–40C (103–104F)
  • abdominal pain
  • a dull headache

The symptoms continue to get worse. As the condition progresses, the risk of developing possibly fatal complications increases (see below).

Read more about the symptoms of typhoid fever.

Treating typhoid fever

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

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

Read more about treating typhoid fever.

Complications of typhoid fever

One in 10 people with untreated typhoid fever will develop one or more serious complications. Complications usually occur in the third week after symptoms start.

Complications can include internal bleeding or a section of the digestive system or bowel splitting open and causing widespread infection.

Read more about the complications of typhoid fever.

Typhoid fever vaccination

In Wales, two vaccines are available that provide limited protection against typhoid fever. Vaccination is recommended for anyone who is planning to travel to parts of the world where the typhoid is widespread (see below).

However, as the vaccines only provide limited protection, it is also important to follow some precautions when travelling, such as only drinking bottled water and not eating raw vegetables.

Read more about preventing typhoid fever.

Outlook

If typhoid fever is treated promptly with antibiotics, the outlook is very good. Less than 1 in 100 people will die as a result of a complication of the infection, and deaths from typhoid fever are now virtually unheard of in Wales.

If typhoid fever is not treated, the outlook is much worse. If complications occur, they are often fatal. People who survive complications of typhoid fever are often left with permanent physical or mental disabilities. 

High-risk countries

The countries with the highest rates of typhoid fever are:

  • Bangladesh
  • China
  • India
  • Indonesia
  • Laos
  • Nepal
  • Pakistan
  • Vietnam

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.

Find more information and advice about travel health.

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Symptoms

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

If typhoid fever is not treated, the symptoms will develop over four weeks, with new symptoms appearing each week. With treatment, the symptoms should quickly improve within three to five days.

The first week

Symptoms of typhoid fever during the first week of infection include:

  • a high temperature (fever) that can reach 39–40C (103–104F), which usually increases throughout the day before falling the following morning
  • abdominal pain
  • constipation or diarrhoea – adults tend to get constipation and children tend to get diarrhoea
  • vomiting – this usually affects children rather than adults
  • a dry cough
  • a dull headache that can be felt at the front of the head
  • severe mental confusion, such as not knowing where you are or what is going on around you
  • a skin rash made up of pink spots that are 1–4cm wide – there are usually fewer than five spots
  • a feeling of being increasingly very unwell

The second week

In the unlikely event that you do not get treatment, the symptoms above will become more severe in the second week.

You may also have:

  • a swollen abdomen
  • a slow heartbeat

The third week

During the third week, the symptoms of typhoid fever include:

  • loss of appetite
  • weight loss
  • physical exhaustion
  • bouts of foul-smelling, yellow–green, watery diarrhoea
  • severe swelling of the abdomen
  • rapid breathing
  • a deterioration of your mental state, such as severe confusion, apathy and, in some cases, psychosis (where a person is unable to tell the difference between reality and their imagination)

During the third week, 1 in 10 people will also develop serious complications, such as internal bleeding.

Read more about the complications of typhoid fever.

When to seek medical advice

It is recommended that you see your GP if you have a high temperature, particularly if you have recently returned from travelling abroad.

It is unlikely that a high temperature will be caused by typhoid fever, but will usually be caused by some sort of infection.

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.

Find more information and advice about travel health.

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Causes

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 faeces that contain the Salmonella typhi bacteria. If they do not wash their hands properly after going to toilet, they can contaminate any food they touch. If this is eaten by another person, they will also become infected.

Less commonly, the Salmonella typhi bacteria can spread after a person urinates. Again, if an infected person handles food without washing their hands properly after urinating, they can spread the infection on to someone else who eats the contaminated food.

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

Other ways that typhoid fever can be contracted include:

  • using a toilet that has been contaminated with bacteria and touching your mouth before washing your hands
  • eating shellfish or similar seafood that from a water source that has been contaminated by infected faeces or urine 
  • having oral or anal sex with a person who is a carrier of Salmonella typhi bacteria (see below)

Carriers

If typhoid fever is not treated, an estimated 1 in 20 people who survive the infection will become carriers of the condition. This means that the Salmonella typhi bacteria continue to live in their bladder, and they can still spread typhoid fever in their faeces or urine. However, carriers of typhoid fever do not have any symptoms themselves.

The effects of typhoid fever

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

If the person is not treated, the bacteria will spread into the bloodstream, intestines, liver and bone marrow. The spread of bacteria out of the bowel causes the symptoms to get worse during the second and third weeks of the infection.

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

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Diagnosis

If you develop symptoms that suggest you may have typhoid fever, your GP will want to know whether:

  • 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

See the introduction for a list of countries that are most commonly affected.

Testing for Salmonella typhi

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

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 is usually recommended that other members of your household are also tested in case you have passed the infection to them.

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Treatment

Treatment at home

If typhoid fever is diagnosed in its early stages, usually during the first week, a course of antibiotic tablets may be prescribed for you. Most people require a 7- to 14-day course of antibiotics.

Some strains of the Salmonella typhi bacteria have developed a resistance to one or more types of antibiotics. Therefore, you may be prescribed a combination of different antibiotics, depending on where in the world the infection is thought to have originated.

Your symptoms should begin to improve within two to three days of taking antibiotics, but it is very important that you finish the complete course so that your symptoms do not reoccur.

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.

Hospital treatment

Hospital admission is usually recommended if you have:

  • persistent vomiting
  • severe diarrhoea
  • a swollen abdomen

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

You will be given antibiotic injections and you may also be attached to an intravenous drip so that you can be given fluids and nutrients.

Surgery may also be required to correct any life-threatening complications that develop, such as internal bleeding or if a section of the digestive system splits. However, this is very rare in people being treated with antibiotics.

Read more about complications of typhoid fever.

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.

Relapse

Around 1 in 20 people who are treated for typhoid fever experience a relapse, when symptoms return. 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 means that you are a carrier of typhoid fever and you will 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 toilet.

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Complications

Complications caused by typhoid fever usually only occur in people who have not been treated with antibiotics.

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

The two most common complications that can occur in untreated typhoid fever are:

  • internal bleeding in the digestive system
  • perforation (splitting) 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 it 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

blood transfusion may be required to replace any 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 because 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 and, if it is not treated, 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 to get rid of the infection. Surgery will then be used to seal the hole in your stomach wall.

Read more about treating peritonitis.

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Prevention

Vaccination

Vaccination is recommended if you are travelling to parts of the world where typhoid fever is present, particularly if you are planning to work or live with local people.

Parts of the world that are most affected by typhoid fever are:

  • South Asia
  • Southeast Asia
  • Africa
  • the Middle East
  • Central and South America

In Wales, most people who get typhoid fever have visited India, Pakistan and Bangladesh. Therefore, it is particularly important that you are vaccinated if you are visiting these countries.

Some GP surgeries vaccinate against typhoid fever free of charge on the NHS, so it’s worth checking with your GP first.

Alternatively, vaccinations are available from private travel clinics for around £25.

Choosing a vaccine

Two vaccines are available for typhoid fever in the UK:

  • VI vaccine – this is thought to be 75% effective against typhoid fever in the first year after vaccination
  • Ty21a vaccine – this is thought to be 50–60% effective against thyroid fever in the first year after vaccination

While the VI vaccine is more effective, some people prefer to have the Ty21a vaccine because it is available as a tablet, while the VI vaccine is given by injection.

However, 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.

The protective effect of the VI vaccine will last for around three years, after which a follow-up booster vaccination will be required. The Ty21a vaccine will last for around one year before a booster shot is required.

Advice for travellers

Vaccinations do not provide complete protection against typhoid fever so it is important to take some basic precautions when travelling in countries where typhoid fever is present. For example:

  • Only drink bottled water from a bottle that is properly sealed.
  • Don't buy ice cream, ice cubes or fruit juice from street vendors.
  • Don't eat raw vegetables, peeled fruit, shellfish or salads.
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