Some diseases that aren’t a big problem in the most industrialized nations now could become a problem during a long-term disaster. This is the second in a series of posts I’m writing about such diseases. See part one, on typhus, here.

What Is Typhoid Fever?by James Hubbard, MD, MPH

We don’t hear much about typhoid fever in the United States. To most of us, it’s a mysterious disease that we know is serious, but we’re not sure what it looks like. Is it even really a fever?

We need to be able to recognize it, though, because in certain conditions during a long-term disaster, it could spread rapidly. And proper early treatment dramatically lowers your risk of dying from it.

Where Is Typhoid Fever Most Common?

Make no mistake, typhoid fever is still a problem worldwide. In fact, over 20 million people get it each year, mostly in Africa, Latin America, and Asia. India has a particularly high incidence.

The only things that keep typhoid fever from becoming a problem in countries like the U.S. are our good sanitation and relatively uncrowded conditions. Even then, around 400 people come down with it here every year, mostly those who were infected in another country and brought it back.

If someone were to bring typhoid fever back in time for a long-term disaster situation, we could have an outbreak.

Typhoid Mary, or Why to Finish Your Antibiotics

About 3 percent or so of people who get typhoid fever still carry the bacteria in their stool long after they’re well. In fact, some may have such a light disease they never know they had it at all.

So begins the saga of Typhoid Mary.

In 1906, Mary Mallon was a cook for a family renting a summer house in New York. Several family members came down with typhoid fever. The owner of the house, thinking he needed to find the cause and get rid of it if he ever expected to rent the house again, started looking into it. Apparently everything checked out clean, so he started looking into Mary’s history.

It turns out that several of her old employers had come down with typhoid fever while she was the cook. Mary denied ever having typhoid fever herself.

After reportedly much protest, Mary was brought in for stool samples. Salmonella typhi, the bacteria that causes typhoid fever, was found in them.

Mary was what we now call an asymptomatic carrier, or just a carrier. This is not that uncommon in infectious diseases. Hepatitis comes to mind.

Despite being banned from working as a cook for life, she apparently continued and infected several more families.

So how do you not become like Mary? If you get typhoid fever, take your antibiotics until they’re gone, not just until symptoms subside. But even then, some people remain carriers and have to have a more complex treatment to try to get rid of it. Of course a stool specimen culture, if available, will make sure it’s gone.

What Is Typhoid Fever?

Typhoid fever does involve a high fever, yes, along with other symptoms. The disease is also known as enteric fever—an appropriately descriptive name. Enteric means “related to the intestine,” and the intestine is where some of typhoid fever’s most serious problems occur.

The bacterium that causes it, Salmonella typhi, is carried in the feces. So typhoid fever is spread via feces. For example, say an infected person doesn’t wash their hands after going to the bathroom and leaves bacteria on a doorknob. Other people touch the doorknob and touch their face; the bacteria enter through their mouth, and you have an outbreak.

With antibiotics and support, such as fluids to avoid dehydration, the death rate is around 0.2 percent. Without these it can be as high as 20 percent.

When to Suspect Typhoid Fever

Many of the symptoms of typhoid fever are pretty generic. They could point to a variety of illnesses. So if you think you might have it, ideally, you go to the hospital, and stool cultures reveal the bacteria.

Without a bacterial culture, you might strongly suspect someone has typhoid fever if both of these things are true:

  1. The person has a high fever, abdominal discomfort, and a rash composed of a few red spots on the trunk.
  2. You think the disease is going around (someone else has it and there are crowded conditions, bad water sanitation, etc.).

Initial symptoms usually start a week or two after being infected and can include:

  • Fever of 103–104 F orally and the headache and muscle aches that go with it
  • Abdominal pain and bloating
  • Constipation (more common in adults) or diarrhea (more common in children)
  • No appetite
  • Dry cough
  • Rash—nonraised pink spots (you don’t always get these; if you do, they’re usually only a few and are gone in a few days)
How Does Typhoid Fever Progress?

If the correct antibiotics are started within a few days of the onset of symptoms, you usually begin getting better in a few days and are feeling pretty good within a week or two.

If you don’t have antibiotics, things get more hairy.

As typhoid fever progresses, symptoms become more specific to this disease, so you can more easily tell that someone has it.

During the second week, in addition to having the initial symptoms listed above, you’ve lost a noticeable amount of weight, but at the same time, your abdomen has become distended (bloated).

Another differentiating factor during this second week is a slow pulse. Normally with fever and pain, your pulse rate is going to increase to 90–100ish. With typhoid fever, it may run around 60 or below.

During the third week is when things really get bad. People often develop what’s called the typhoid state—becoming delirious (agitated, seeing things, irrational)—or lie motionless with eyes half-closed. Organs begin to shut down; the heart can become inflamed. There can be intestinal bleeding or even holes all the way through the intestine (a very bad sign).

If you’ve survived into the fourth week, you start getting better, but it takes many months to recuperate.

How Do You Treat Typhoid Fever?

If you can get expert treatment, the doctor will test antibiotics on a specimen of your stool to see which drug works best. Right now one of the antibiotics in the fluoroquinolone class (ciprofloxacin, etc.) is often chosen. But in a growing number of cases, the bacterium is resistant to that.

If no expert care is available but you have antibiotics, ciprofloxacin would be a good choice. Azithromycin would be a second choice.

If you don’t have antibiotics the treatment is just support with fluids the best you can.

How Do You Prevent Typhoid Fever?

To prevent typhoid fever, just like you would any other disease transmitted by the fecal-oral route:

  • Wash your hands regularly.
  • Only drink bottled or properly disinfected water.
  • Don’t eat raw fruit or vegetables unless you peel them yourself with a disinfected knife.
  • Eat foods thoroughly cooked and still freshly hot and steaming. (That’s your best bet that any bacteria has been killed with the heat.)

There is a vaccine you can take a couple or more weeks before traveling to a high-risk area.

What about you? Do you know of anyone who has experience with typhoid fever?


Image: The New York American, 1909.