Typhoid Fever

Though typhoid fever is preventable and treatable disease around 90 lakh people fall sick and more than 1 lakh people die from typhoid worldwide¹.

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What is Typhoid Fever

It is a bacterial disease which causes the symptoms like headache, malaise, abdominal pain, nausea/ vomiting and constipation or diarrhea.

What causes Typhoid Fever

• Causative agent of Typhoid fever is a bacteria called ‘Salmonella’ ( S. typhi ).
• Milder but similar form of disease is also caused by salmonella paratyphi A,B and C. Typhoid and Paratyphoid fevers are collectively referred to Enteric fever.

• Most common mode of transmission of infection is Food and water contaminated with the bacteria

Who are at risk of Typhoid Fever

• In-access to safe drinking water and poor sanitation.
• Close contact with a person carrying salmonella bacteria
• Children are at greatest risk

Symptoms of Typhoid Fever

• usual symptoms:-
  • High grade fever ranging 103-104^oF
  • Generalized weakness
  • Stomach pain
  • Headache
  • loss of appetite
  • Diarrhea or constipation
• In the 2nd week, though rare, a faint rash called “ Rose spots” may be observed over the trunk of fair-skinned children which fades on pressure
• Severe cases may lead to complications like intestinal ulceration, intestinal perforation and even death.

Due to its Gastro Intestinal involvement Typhoid fever is also called Enteric fever.

Complications of Typhoid fever

• intestinal ulcers

• intestinal haemorrhage

• intestinal perforation

• circulatory collapse

Diagnosis of Typhoid Fever

various modalities include⁵:

1. Microbiological
   • Blood culture: Gold standard but early and widespread antibiotic use can reduces the sensitivity. it is also time consuming and takes at least 48 hours to get results.
   • Stool or urine culture- variable and lower sensitivity and therefore not used routinely.
   • Bone marrow culture- is more invasive and painful, therefore not performed routinely.
2. Molecular: PCR and Nested PCR have Promising sensitivity and specificity but availability and cost may be the issues. It may cost more than 7000 INR for the PCR testing at private setting in the India.
   • Nested PCR- is a modified PCR with 2 primer set and two successive PCR reactions, which increases sensitivity and specificity. ⁶The sensitivity of PCR on blood was found to be 100 per cent whereas the specificity was 76.9 per cent. The positive predictive value (PPV) of PCR was calculated to be 76.9 per cent with an accuracy of 86 per cent.
3. Serological
   • Widal : Athough inexpensive and rapid, it has some disadvantages. it is reliably interpreted, if there is a four-fold rise in the titer in two samples taken at an interval of minimum 7–10 days. Hence, a single reading of even 1:320 does not mean the child has typhoid (:IAP) Read more
   • Tubex, Typhidot and Typhidot-M: Are rapid diagnostic tests. Typhidot-M is better than Typhidot and has 73-95 per cent sensitivity and 68-95 per cent specificity but performance may not be robust in community settings as in Hospitals.
4. Others:- Urine antigen detection- has shown good sensitivity 65-95 per cent but it is in preliminary phase of evaluation.

Need of the hour is : good sensitive, specific and rapid test at an affordable price. The lack of adequate diagnostic testing means that this remains an active area of investigation.

Typhoid Treatment

At Home: Most cases can be managed at home with oral antibiotics

Hospital Admission: patient with persistent vomiting, severe diarrhea, not able to take orally, abdominal distension or with complications is admitted to hospital.

Drugs: Currently third generation cephalosporins (cefixime-oral and ceftriaxone-injectable) are first line of treatment

• Uncomplicated:
  • Drug of choice for uncomplicated enteric fever is oral Cefixime 20mg/kg/day but not to exceed 100-200mg BID for 14 days.
  • Second choice agent is Azithromycin 10-20mg/kg/day in children and 500mg to 1gram once a day in adults for 5-7 days.
  • Once culture sensitivity reports are available antibiotics can be modified.

• For complicated/ severe illness: I/V ceftriaxone or cefotaxime 100mg/kg/day are used. once able to take oral or complications are resolved , may be switched to oral cefixime to complete duration of 14 days.

Switch Drugs:

• once culture sensitive report is available and positive and shows that Quinolones are sensitive, therapy should be changed to ciprofloxacin 20 mg/kg/day in children and 500mg BID in adults to complete the duration of treatment. Quinolones offers advantage over others: faster fever subsidence and lower relapse rates as compare to ceftriaxone

• if C/S report shows Quinolones resistance, continue with same treatment.

• if culture is negative look for alternate diagnosis.

Prevention of Typhoid fever

Since Typhoid fever is common in places with poor sanitation and a lack of safe drinking water.

• Access to safe water and adequate sanitation,

• hygiene among food handlers and

• typhoid vaccination are effective in preventing typhoid fever.
• Foods and beverages from street vendors should be avoided
• Avoid raw vegetables and fruits that cannot be peeled. Vegetables like lettuce are easily contaminated and are very hard to wash well.

Typhoid Vaccine in India

The Indian academy of Pediatrics recommends typhoid vaccine to all children from 9 months onward.

There are two vaccines to prevent typhoid:

• One is an un-conjugated polysaccharide vaccine given as a single dose and remain effective for at least 3 years. But it cannot be administered below 2 years of age.
• Other is much improved Typhoid conjugated vaccine (TVC) which is again given as a single dose. this vaccine can be given to young infants 6 months onwards.

Who should receive the Vaccine

Typhoid vaccine may be offered to all who have suffered from typhoid because natural infection does not give long-term protection. TCV vaccine is licensed for use, till 45 years of age¹¹.

The vaccine may be given as early as 4–6 weeks after recovery.

Can Vaccine fully protect me from Typhoid

well exactly not.

Different person’s body reacts differently to vaccines. vaccines cannot offer 100% protection from any disease. That is why typhoid might occur in children even after vaccination.

Paratyphoid fever which is very similar to typhoid fever might occur in children as the vaccines protect only against typhoid and not paratyphoid fever

Typhoid Vaccine cost in India

cost of Typhoid vaccine in India cost around ₹ 1500- 2000 ($ 18-25)

Typhoid in US and world

In the United States each year, about 425 people are diagnosed with typhoid fever and about 125 people are diagnosed with paratyphoid fever each year. Most of these people travelled internationally. 

Travelers to Eastern and Southern Asia (especially India, and Bangladesh, Pakistan), Africa, the Caribbean, Central and South America, and the Middle East are at increased risk for typhoid and paratyphoid fever¹¹

Typhoid vaccine in US

Routine typhoid vaccination is not recommended in the United States, but typhoid vaccine is recommended for:

• Travelers to parts of the world where typhoid is common. (NOTE: typhoid vaccine is not 100% effective and is not a substitute for being careful about what you eat or drink.)
• People in close contact with a typhoid carrier.
• Laboratory workers who work with Salmonella typhi bacteria

Inactivated typhoid vaccine is administered as an injection (shot). It may be given to people 2 years and older. One dose is recommended at least 2 weeks before travel. Repeated doses are recommended every 2 years for people who remain at risk.

Live typhoid vaccine is administered orally (by mouth). It may be given to people 6 years and older. One capsule is taken every other day, for a total of 4 capsules. The last dose should be taken at least 1 week before travel. Each capsule should be swallowed whole (not chewed) about an hour before meals with cold or lukewarm water. A booster vaccine is needed every 5 years for people who remain at risk. Important: live typhoid vaccine capsules must be stored in a refrigerator (not frozen

Typhoid Vaccine side effects

Generally, it is a safe vaccine. Side effects of the vaccine may include fever, pain and swelling at the site of the injection¹¹ ,which cab be seen with all vaccines.

FAQ

Why Typhoid repeats

Typhoid fever is known to re-occur in 5–10% of patients known as relapse. It usually occurs 2–3 weeks after the resolution which is usually milder¹⁰.

An attack of typhoid fever does not provide long lasting immunity from a future episode of the same illness. An episode of typhoid fever usually means that the child lives in an environment in which further exposure to infection is likely. There is also the possibility that early treatment would have reduced the full force of immunity from developing⁹

Relapse typhoid fever should be treated with the same antibiotics with proper dose and duration.

How to Recover from Typhoid weakness

• Children should be offered balanced, easily digestible diet during typhoid fever and following recovery.

• Properly cooked non-vegetarian food can be consumed during typhoid fever

• Undercooked food, raw vegetables or contaminated milk and dairy products should not be consumed.

Is Typhoid Contagious

Yes, it is highly contagious. patient shed bacteria in feces and less frequently in urine. If someone else eats food or drinks water that’s been contaminated with a small amount of infected feces or urine, they can become infected with the bacteria and develop typhoid fever.

Does Mosquitoes spread Typhoid

No typhoid is not transmitted by the mosquitoes bite, houseflies can spread though. they act as carrier of bacteria causing typhoid.

Is Typhoid common in India

Yes, Typhoid is endemic in India.

Typhoid Fever pattern

Stepladder pattern, that is steady increase in intensity and frequency of fever is classically seen in the typhoid fever.

Can Typhoid cause death

Yes, if untreated, the illness can last for 3 to 4 weeks and death rates range between 12% and 30%.

Can a Typhoid patient take bath

Yes, one can take the bath but make sure that water is comfortable to your body neither too warm nor too cold.

Typhus vs Typhoid

Typhoid is transmitted faecal-orally as we discussed here, while Typhus is primarily transmitted through insect or mite bites on the skin. both are completely different diseases.

 references:

“stepladder” rise in fever and toxicity is rarely seen.:

1. WHO -World Health Organisation
2. CDC
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11. https://wwwnc.cdc.gov/travel/diseases/typhoid
12. https://iapindia.org/pdf/vaccine-information/TYPHOID-VACCINE.pdf
13. J Infect Dis. 2021 Nov 15; 224(Suppl 5): S475–S483.Published online 2021 Nov 23. doi: 10.1093/infdis/jiab187