Typhoid Fever

The typhoid bacteria enters your digestive system through contaminated food and thereafter multiplies within your body. This triggers the development of symptoms such as:

• Fever which ranges from 102⁰-104⁰F (38⁰-40⁰C)
• Stomach pain
• Cough
• Loss of appetite
• Constipation
• Diarrhoea

If left untreated at this stage, the symptoms worsen and you may experience:

• Fatigue
• Confusion
• Hallucinations (seeing or hearing something that is not there)
• Bleeding nose
• Attention deficit (difficulty in focusing or paying attention)
• Flat pink or rose-coloured spots (rose spots) or rashes on chest and abdomen (the area between the ribs and the pelvis).

Due to a stronger and developing immune system, children may show milder symptoms of typhoid infection than adults.

Causes of Typhoid Fever

Typhoid fever is caused by Salmonella typhi (a type of bacteria). The most common route of transmission is through the faecal-oral route. The infection can be passed on if the person's hands are contaminated and he/she is serving or cooking food for others.

Risk factors

Following are a few risk factors for typhoid fever:

• Contaminated food and water
  The most common cause of contracting this disease is by consuming food and water contaminated with Salmonella. Serving or eating raw fruits and vegetables which are not washed properly, eating food from a contaminated source, drinking contaminated water from an infected water supply may also cause infection.
   
• Poor hygiene
  You may also contract this disease by not washing hands properly after using an infected toilet and eating or feeding a child with the same hands. Thus infecting yourself and your child directly.
   
• Typhoid carriers
  People with a history of typhoid infection may unknowingly often carry typhoid bacteria in their stools and urine. Thus, they become a continuous source of infection. Contamination of food, water, and objects due to poor hygiene may transmit the disease from one person to another within the family as well as to other people. Infection can also occur from one person who has typhoid and is handling food items to others who are consuming it.
   
• Travelling
  Travelling to a high-risk area (with poor sanitation and limited access to clean water) or from a high-risk area to other parts of the world can also cause transmission of typhoid fever.
   
• Sexual contact
  Any kind of unprotected sex such as oral or anal sex with a carrier or infected person can cause its transmission to his/her partner.
   
• Stools
  Open dumping in fields contaminates soil, water supply and vegetation growing in that area with Salmonella. Transmission of the disease may occur when you consume food from areas where human waste is used as a fertilizer.
   
• Urine 
  Transmission via urine is less likely to happen but it is possible.

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• Stool test
  In this test, your stool sample is collected, cultured, and examined under a microscope (a device which is used to see organisms and substances which cannot be seen with the naked eye) for the presence of Salmonella typhi.
   
• Blood test
  In this test, your blood sample is drawn for CBC (complete blood count). In case of infection, the number of white blood cells will be elevated (high). A blood culture is also examined under the microscope to confirm typhoid infection. Your platelet count also goes down during an infection.
   
• Urine test
  However, it is less likely but there is a possibility for the affected person to pass bacteria in urine. Microscopic examination may reveal the presence of typhoid bacteria.
   
• Bone marrow test
  This test is done as a last resort because it is a very accurate test which is used when definite conclusions cannot be drawn from other tests. However, it is a painful and time-consuming process.

Other tests:

• ELISA-Ty (Enzyme-linked immunosorbent assay for Typhoid)
  It measures the serum levels of IgM and IgG antibodies (proteins of the immune system of the body which help in neutralizing foreign bodies or disease-causing microorganisms and their products) against typhoid bacteria.
   
• Indirect Fluorescent antibody test
  This is another serological test which is used as a rapid diagnostic test to confirm typhoid infection.

When any of the above tests confirm typhoid infection, your family members are also tested to check whether the transmission of infection has occurred within the family or not.

It is very important to get immediate medical help before the symptoms worsen. The usual course of treatment that you may go is described below:

• Oral antibiotics
  When you seek medical help and the diagnosis is made early, an oral course of antibiotics (medicines that act against microorganisms) for 7-14 days would be prescribed. Your symptoms may subside within 2-3 days of taking medication, but it is recommended that you do not stop taking antibiotics because it will help you remove the bacteria completely from your body. 
   
• Fluid replacement
  You are advised to take plenty of fluids to improve your dehydration (fluid loss from the body). Early diagnosis usually doesn’t require hospitalisation and the patient can be taken home to continue with the antibiotic course.
   
• Hospitalisation
  When your treatment is delayed for some reason or symptoms do not go away even after taking the full course of antibiotics, or the symptoms get worsened, the physician may advise hospitalisation in order to monitor your condition. If your condition becomes serious, antibiotic injections would be given. This will cause the antibiotic to act faster and help reduce the intensity of your symptoms. Fluid and electrolyte replacement is also done using intravenous (drips) route.
   
• Second Stool Test
  After complete treatment, a second stool test is done to confirm that you’re not passing typhoid bacteria in stools anymore. If the test is positive then you are considered as a carrier of typhoid bacteria. You will be given another 28-day course of oral antibiotics followed by a final stool test.
   
• Relapse
  In some cases, relapse (coming back of symptoms) occurs. It usually happens one week after completing your medication. The symptoms are mild and short-lived, however, a course of antibiotics is usually prescribed. However, in certain cases, the doctor specially asks the family members to keep a close check on the patient because relapse of typhoid makes the body weaker.

Recent Challenges in typhoid treatment
Medical investigators have encountered certain strains of typhoid bacteria with reduced susceptibility and increased resistance to antibiotics like fluoroquinolones (e.g. Ciprofloxacin). Multi-drug resistant bacteria (bacteria which are resistant to a lot of antibiotics which were previously very effective in treatment)  have also been noted to be emerging recently. Hence, the responsibility of prevention from infection lies a lot more in our own hands than in the hands of the doctors. Needless to say, maintaining hygiene and sanitation is the best preventive measure to this disease.

Self-Care

• First of all doctors advice complete bed rest at home during the initial days.
• As the body is weak and is susceptible to different infections, it is highly recommended to take fluids regularly such as coconut water, juices, lassi, glucose water, etc.
• Take lighter digestible meals such as rice, fruit custards, etc between short intervals rather than taking heavy meals three times a day.
• Do not eat food rich in fat, such as ghee, milk, etc. You are also advised to maintain good personal hygiene.
• Most people can get back to work or school as soon as they start feeling better, however, people who handle food, work with children below five years of age or with elderly are advised to stay off work or school till their stool test comes out to be negative.

Typhoid and paratyphoid fever are collectively known as enteric fever. This is a common infectious disease which is caused by different strains of Salmonella enterica (a type of bacteria) namely Typhi, Paratyphi A, B, and C. Initially it affects your digestive system, but if left untreated this condition takes a serious turn and the bacteria spread to different organs of your body. If treatment is not received in time, it may also lead to serious complications which can be fatal.

If your condition is not diagnosed and treated early, serious complications can occur and you may suffer from internal bleeding (hemorrhage) from the digestive system, bowel perforation, sepsis, multiple organ failure, and death.

• Internal bleeding
  When typhoid bacteria start growing rapidly and release toxins, it starts eroding the intestinal wall. This eventually leads to internal bleeding. Your symptoms may include fatigue, difficulty in breathing, pale skin (anemic appearance due to blood loss), irregular heartbeat, blood in vomit, dark/black tarry stools due to internal bleeding. and You may require a blood transfusion to replace the lost blood if your internal bleeding lasts for a long duration. You are also required to undergo a surgery at the site of bleeding to prevent any further blood loss.
   
• Perforation
  Bowel perforation is a very serious complication of untreated typhoid fever. Prolonged accumulation of bacteria and continuous secretion of their toxins eventually lead to a perforation in the intestinal wall. After perforation, the bacteria start growing in the adjacent lining of the abdomen (peritoneum). The peritoneum is a sterile (free of germs or infection) organ. The growth of S. typhi causes inflammation (swelling) and infection of the peritoneum (peritonitis), which is a medical emergency characterised by sudden and sharp abdominal pain.
   
• Sepsis
  Bacteria can spread through the bloodstream soon after the episode of peritonitis leading to a condition called sepsis.
   
• Multiple organ failure
  If bacteria spread to different parts of the body such as lymph nodes (part of the immune system which helps in removing toxins and harmful infectious substances from the body), gallbladder, liver, spleen, etc. it can lead to multiple organ failure. At this stage, patients condition becomes very critical.
   
• Death
  There is a remote possibility and with the advancement of medical science the chances are very less, but it is in an unfortunate event. When the infection becomes extensive and the patient stops responding to all sorts of treatment strategies, a fatal outcome is very likely in certain extreme cases. Hence typhoid never to be taken very lightly immediate commencement of treatment is the best way to deal with typhoid fever.

Vaccination:

Different types of vaccinations are available for prevention against typhoid fever. These include:

• Oral vaccine
  This is available both as a liquid suspension and enteric-coated capsules. Three doses of the vaccine are given on alternate days, followed by a yearly booster dose for next three years. It shouldn’t be used in pregnant women. The capsule/sachet vaccine should be given with safe drinking water.
• Vi vaccine
  This is an injectable vaccine which is given as a single dose either subcutaneously (below the skin) or intramuscularly (in the shoulder or hip muscle). Revaccination should be done every three years.

These vaccinations fall short in providing a long-term protection and protection of young children who are below two years of age.

For infants, vaccination is now done between 9 to 12 months of age, thanks to the recently launched fourth-generation vaccine that provides protection against typhoid for ten years.

Travellers going to high typhoid risk areas (south and southeast Asia, Indian subcontinent, Africa, South America etc) should get themselves vaccinated before they start travelling.

During a typhoid disease outbreak, the entire community should be vaccinated in order to prevent further spread of the disease to those who have not been infected yet.

Precautions:

It is a known fact that a dirty environment is a home for diseases. Hence, we hereby provide you with a list of things that you can do to prevent typhoid and many other infections:

• Always drink sealed, bottled water or boiled water (boil for 1 minute).
• Avoid using ice in your drinks until the ice has been made from bottled water.
• Do not eat flavoured ice or popsicles from street vendors or from suspected sellers who do not use clean water.
• Do not eat raw vegetables or fruits without washing them.
• If you are travelling, keep a soap to wash your hands before eating and after using a toilet. Always wash and peel fruits and vegetables that you buy on your way before consuming them. Avoid buying food from street vendors and roadside stalls. Do not eat green leafy vegetables on your way because it is difficult to wash them. Keep a hand sanitizer in case you can’t find clean water to wash hands, however, it is highly recommended that you always try and wash hands.
• Maintain personal hygiene and sanitation and teach the same to your children.
• Always thoroughly cook your meals and only eat steaming hot food outside.