Part 1 in the “Long-Term-Disaster Diseases” series.

by James Hubbard, MD, MPH

A doctor goes into this tent full of people who look deathly ill, some coughing. He comes out in about a minute and proclaims they all have typhus.

Good diagnostician. But is it realistic? Could you tell that quickly whether people have this disease? And how dangerous is it?

This scene is from the NBC television series Revolution, which is about how a bunch of people cope with life after the grid goes down—permanently. No electricity of any sort. It got me to thinking about typhus since an outbreak is a real possibility in a prolonged disaster situation. In fact, a couple of forms of it are not that uncommon in the United States right now. And in some other countries it’s much more widespread, especially Africa.

So, let’s start at the beginning. What is typhus?

Typhus Is Typhoid Fever, Right?

Wrong. Though they sound alike typhus, or typhus fever, is a different disease—similar symptoms but different in how you get it and what antibiotic you treat it with. I’ll go into typhoid in another post.

What Causes Typhus?

Typhus is caused by very small bacteria called rickettsia. We used to think of rickettsia as something in-between a virus and a bacterium, but now we class it with bacteria.

How Does Typhus Spread?
A mask won't help here. Just avoid the lice.

Covering your mouth won’t help here. Just avoid the lice. (Screen shot from “Revolution.”)

In Revolution, most of the people caring for the typhus victims are wearing masks. That’s not a bad idea in general when people are sick, but it won’t help with typhus because it’s not spread from person to person. Depending on the type, it can be spread by infected lice, mites, or fleas.

Well, Then, What Are the Types of Typhus?

1. Epidemic typhus

This is the killer, and the type that we’d fear in a prolonged disaster with crowds of people living under one roof. Epidemic typhus, also called jail fever, is currently rare in the U.S. I presume it’s the typhus in Revolution since the people are dying so fast.

How it spreads: Mainly body lice feces. A louse bites and feeds on the blood of an infected person, then catches a ride to another person and bites them to feed again. Not known for its good manners, the louse tends to defecate while feeding. The bite site itches, the person scratches, and the tiny bit of infected feces gets into their bloodstream.

Mortality and treatment: Depending on the patient’s underlying health, mortality rates range from 10 to 60 percent. Proper and early antibiotic usage can decrease that to the low single digits.

Where you’re most likely to get it: Somewhere with crowding and poor sanitary conditions (risk factors for body lice infestations). The lice like to live on clothes, especially coats, and just jump on the human to feed.

2. Endemic, or murine, typhus

How it spreads: Option 1: Fleas that feed on infected rodents, cats, and other animals. Humans are not the fleas’ food of choice, but given the chance, they’ll hop on and take a bite, spreading the disease they’ve ingested from other animals. Option 2: An infected animal’s feces. Say you stir up the dust and feces in some storage area and don’t wear a mask. You breathe in particles of the feces and you have the disease. Trust me, it happens a lot easier than you think.

Mortality rate: Endemic typhus usually causes less severe symptoms than the epidemic type. The death rate is 1 to 4 percent. With proper antibiotic treatment, it’s nil.

Where you’re most likely to get it: Endemic typhus is fairly common in some warmer regions of the U.S., especially in California and Texas.

Scrub typhus is a type of endemic typhus spread by mites. It’s the mildest typhus of all and seen mainly in the regions around the South Pacific.

What Are the Symptoms of Typhus (and Could That Revolution Doctor Really Be That Good?)

Back to that one-minute diagnosis I mentioned at the beginning. I guess it’s possible to recognize typhus that quickly if:

  • Some of the people had the typical typhus rash: spotty, red, or purplish; on the trunk and extremities; comes on usually a few days after other symptoms have developed.
  • They had a high fever of 103 to 105 F.
  • The doctor had a strong suspicion that typhus was likely—like perhaps the people getting sick were all living together and lice was a problem. (In Revolution, it looks like they all live in regular houses and do laundry, look clean, but hey, it’s a show.)

Here are some of the common symptoms of typhus the U.S. National Institutes of Health lists on their MedlinePlus website. Symptoms usually don’t start until about one to two weeks after you’re infected. The rash, then, takes an additional four or more days to develop.

Symptoms of epidemic typhus may include:

  • Chills
  • Confusion
  • Cough
  • Delirium
  • High fever (104 degrees Fahrenheit)
  • Joint pain (arthralgia)
  • Lights that appear very bright; light may hurt the eyes
  • Low blood pressure
  • Rash that begins on the chest and spreads to the rest of the body (except the palms of the hands and soles of the feet)
  • Severe headache
  • Severe muscle pain (myalgia)
  • Stupor

The early rash is a light rose color and fades when you press on it. Later, the rash becomes dull and red and does not fade. People with severe typhus may also develop small areas of bleeding into the skin (petechiae).

Source: NIH, MedlinePlus. Link added.

Epidemic typhus can also cause gangrene of the feet or hands.

Symptoms of murine or endemic typhus may include:

  • Abdominal pain
  • Backache
  • Dull red rash that begins on the middle of the body and spreads
  • Extremely high fever (105 – 106 degrees Fahrenheit), which may last up to 2 weeks
  • Hacking, dry cough
  • Headache
  • Joint and muscle pain
  • Nausea
  • Vomiting

Source: NIH, MedlinePlus.

How Is Typhus Treated?

Early use of antibiotics can do wonders. Examples are:

  • Doxycycline
  • Tetracycline
  • Azithromycin

Continue treatment for at least 72 hours after fever is gone.

Other treatment outside a medical facility is supportive. Keep the person hydrated with fluids (oral or IV if you’re trained), and give oxygen if available. Without antibiotics, the illness usually lasts about two weeks with several weeks to months of weakness to follow.

How Can You Prevent Typhus?

Prevention is essentially getting rid of the pests spreading the infection. Here’s what the NIH advises at MedlinePlus.

Measures to get rid of lice when an infection has been found include:

  • Bathing
  • Boiling clothes or avoiding infested clothing for at least 5 days (lice will die without feeding on blood)
  • Using insecticides (10% DDT, 1% malathion, or 1% permethrin)
    (Note from me: DDT is outlawed in the United States except in public health emergencies.)

Source: NIH, MedlinePlus.

Other tips include:

  • Cleaning out areas where pests can find food or nesting. (Wear a mask when cleaning dusty storage areas.)
  • Getting rid of pests with poison, traps, flea collars on pets, etc.


Have you ever had experience with typhus? Question number 2: Do you watch Revolution? 3: What’s your favorite postapocalyptic type show?