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Typhoid fever Content Supplied by NHS Choices
Introduction

Typhoid fever is a bacterial infection that can spread throughout the body, affecting many organs. Without prompt treatment, it can cause serious complications and can be fatal.

It's caused by a bacterium called Salmonella typhi, which is related to the bacteria that cause salmonella food poisoning.

Typhoid fever is highly contagious. An infected person can pass the bacteria out of their body in their stools (faeces) or, less commonly, in their urine.

If someone else eats food or drinks water that's been contaminated with a small amount of infected faeces or urine, they can become infected with the bacteria and develop typhoid fever.

Read more about the causes of typhoid fever.

Who's affected

Typhoid fever is most common in parts of the world that have poor sanitation and limited access to clean water (at the bottom of this page is a list of high-risk areas).

Worldwide, children 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. However, children with typhoid fever tend to have milder symptoms than adults.

Typhoid fever is uncommon in the UK, with an estimated 500 cases occurring each year. In most of these cases, the person developed the infection while visiting relatives in Bangladesh, India and Pakistan. However, you're also at risk of developing the infection if you visit Asia, Africa and South America.

Signs and symptoms of typhoid fever

Common symptoms of typhoid fever include:

If typhoid fever isn't treated, the symptoms will continue to get worse over the following weeks and the risk of developing potentially fatal complications will increase.

Read more about the symptoms of typhoid fever and the complications of typhoid fever.

How typhoid fever is treated

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

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

With prompt antibiotic treatment, most people will start to feel better within a few days and serious complications are very rare. Deaths from typhoid fever are now virtually unheard of in the UK.

If typhoid fever isn't treated, it's estimated that up to one in five people with the condition will die. Some of those who survive will have complications caused by the infection.

Read more about treating typhoid fever.

Typhoid fever vaccination

In the UK, two vaccines are available that can provide some protection against typhoid fever. These involve either having a single injection or taking three capsules over alternate days.

Vaccination is recommended for anyone planning to travel to parts of the world where typhoid fever is widespread (see below). It's particularly important if you're planning to live or work closely with local people.

However, as neither vaccine offers 100% protection, it's also important to follow some precautions when travelling. For example, you should only drink bottled or boiled water, and avoid foods that could potentially be contaminated.

Read more about the typhoid fever vaccination.

Symptoms of typhoid fever

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

With treatment, the symptoms of typhoid fever should quickly improve within three to five days.

If typhoid fever isn't treated, it will usually get worse over the course of a few weeks, and there's a significant risk of life-threatening complications of typhoid fever developing. Without treatment, it can take weeks, or even months, to fully recover and symptoms can return.

Common symptoms

Common symptoms of typhoid fever can include:

  • a high temperature, which can reach up to 39-40C (103-104F)
  • headache
  • muscle aches
  • stomach pain
  • feeling sick
  • loss of appetite
  • constipation or diarrhoea (adults tend to get constipation and children tend to get diarrhoea)
  • a rash made up of small pink spots on the trunk of the body
  • exhaustion
  • confusion, such as not knowing where you are or what's going on around you

Seeking medical advice

See your GP as soon as possible if you have symptoms of typhoid fever (even if you have been vaccinated against it), particularly if you have recently returned from travelling abroad.

It's unlikely that your symptoms will be caused by typhoid fever, but it's best to get them checked out, in case you need treatment.

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're visiting or, if you're feeling very ill, the local emergency services

The Foreign & Commonwealth Office (FCO) provides travel advice by country, and the contact details of all the British consulates and embassies in foreign countries.

Before you travel, it's a good idea to make a list of relevant contact details and telephone numbers, in case of an emergency.

Bacteria
Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and others are good for you.

Constipation
Constipation is when you pass stools less often than usual, or when you have difficulty going to the toilet because your stools are hard and small.

Diarrhoea
Diarrhoea is the passing of frequent watery stools when you go to the toilet.

Fever
A fever is when you have a high body temperature (over 38C or 100.4F).

Causes of typhoid fever

Typhoid fever is caused by a type of bacteria called Salmonella typhi.

This isn't the same bacteria that cause salmonella food poisoning, but the two are related.

How the infection spreads

The Salmonella typhi bacteria will be in the stools (poo) of an infected person after they've been to the toilet. If they don't wash their hands properly afterwards, they can contaminate any food they touch. Anyone else who eats this food may also become infected.

Less commonly, the Salmonella typhi bacteria can be passed out in an infected person's urine. Again, if an infected person handles food without washing their hands properly after urinating, they can spread the infection to someone else who eats the contaminated food.

In parts of the world with poor sanitation, infected human waste can contaminate the water supply. People who drink contaminated water or eat food washed in contaminated water can develop typhoid fever.

Other ways typhoid fever can be contracted include:

  • using a toilet contaminated with bacteria and touching your mouth before washing your hands
  • eating seafood from a water source contaminated by infected faeces or urine
  • eating raw vegetables that have been fertilised with human waste
  • contaminated milk products
  • having oral or anal sex with a person who's a carrier of Salmonella typhi bacteria

Carriers

Up to 1 in 20 people who survive typhoid fever without being treated will become carriers of the infection. This means the Salmonella typhi bacteria continue to live in the carrier's body and can be spread as normal in faeces or urine, but the carrier doesn't have any noticeable symptoms of the condition.

How the bacteria affect the body

After eating food or drinking fluid contaminated with the Salmonella typhi bacteria, the bacteria will move down into the digestive system, where they will quickly multiply. This triggers a high temperature, stomach pain and constipation or diarrhoea.

Left untreated, the bacteria can get into the bloodstream and spread to other areas of the body. This can cause the symptoms of typhoid fever to get worse during the weeks after infection.

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

Read more about the complications of typhoid fever.

Bacteria
Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and others are good for you.

Bone marrow
Bone marrow is the soft, spongy tissue in the centre of bones that produces blood cells.

Diarrhoea
Diarrhoea is the passing of frequent watery stools.

Stools
Stool (also known as faeces) is the solid waste matter that is passed from the body as a bowel movement.

Diagnosing typhoid fever

You should see your GP if you think you have typhoid fever, particularly if you've recently returned from travelling abroad.

Your GP will want to know whether you've travelled to parts of the world where the infection is present, or whether you've been in close contact with someone who's travelled to these areas.

Parts of the world where the infection is most common include the Indian subcontinent, Africa, South East Asia and South America.

Testing for typhoid fever

A diagnosis of typhoid fever can usually be confirmed by analysing samples of blood, stools or urine. These will be examined under a microscope for the Salmonella typhi bacteria that cause the condition.

The bacteria aren't 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 of diagnosing typhoid fever. However, getting the sample is both time-consuming and painful, so it's usually only used if other tests are inconclusive.

If typhoid fever is confirmed, other members of your household may also need to be tested, in case you've passed the infection on to them.

Bacteria
Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and others are good for you.

Fever
A fever is when you have a high body temperature (over 38C or 100.4F).

Stools
Stool (also known as faeces) is the solid waste matter that is passed from the body as a bowel movement.

Treating typhoid fever

Typhoid fever can usually be successfully treated with a course of antibiotic medication.

Most cases can be treated at home, but hospital admission may be required if the condition is severe.

Treatment at home

If typhoid fever is diagnosed in its early stages, a course of antibiotic tablets may be prescribed for you. Most people need to take these for 7 to 14 days.

Some strains of the Salmonella typhi bacteria that cause typhoid fever have developed a resistance to one or more types of antibiotics. This is increasingly becoming a problem with typhoid infections originating in South East Asia.

Any blood, stool or urine samples taken during your diagnosis will therefore usually be tested in a laboratory to determine which strain you're infected with, so you can be treated with an appropriate antibiotic.

Your symptoms should begin to improve within two to three days of taking antibiotics. However, it's very important you finish the course, to make sure the bacteria are completely removed from your body.

Make sure you rest, drink plenty of fluids and eat regular meals. You may find it easier to eat smaller meals more frequently, rather than three larger meals a day.

You should also maintain good standards of personal hygiene, such as regularly washing your hands with soap and warm water, to reduce the risk of spreading the infection to others.

Contact your GP as soon as possible if your symptoms get worse or if you develop new symptoms while being treated at home.

In a small number of cases, the symptoms or infection may reoccur. This is known as a relapse (see below).

Staying off work or school

Most people being treated for typhoid fever can return to work or school as soon as they start to feel better.

The exceptions to this are people who work with food and vulnerable people, such as children under five, the elderly and those in poor health.

In these cases, you or your child should only return to work or nursery after tests on three stool samples taken at 48-hour intervals have shown that the bacteria are no longer present.

Hospital treatment

Hospital admission is usually recommended if you have severe symptoms of typhoid fever, such as persistent vomiting, severe diarrhoea or a swollen stomach.

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

In hospital, you'll have antibiotic injections and you may also be given fluids and nutrients directly into a vein through an intravenous drip.

Surgery may be needed if you develop life-threatening complications of typhoid fever, such as internal bleeding or a section of your digestive system splitting. However, this is very rare in people being treated with antibiotics.

Most people respond well to hospital treatment and improve within three to five days. However, it may be several weeks until you're well enough to leave hospital.

Relapses

Some people who are treated for typhoid fever experience a relapse, which is when symptoms return. In these cases, the 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, you may have become a carrier of the typhoid infection, and you may need to have a further 28-day course of antibiotics to "flush out" the bacteria.

Until test results show that you're free of bacteria, avoid handling or preparing food. It's also very important that you wash your hands thoroughly after going to the toilet.

Antibiotics
Antibiotics are medicines that can be used to treat infections caused by micro-organisms, usually bacteria or fungi. Examples of antibiotics include amoxicillin, streptomycin and erythromycin.

Bacteria
Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and others are good for you.

Fever
A fever is when you have a high body temperature (over 38C or 100.4F).

Intravenous
Intravenous (IV) means the injection of blood, drugs or fluids into the bloodstream through a vein.

Complications of typhoid fever

Complications caused by typhoid fever usually only occur in people who haven't been treated with appropriate antibiotics or who weren't treated straight away.

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

The two most common complications in untreated typhoid fever are:

  • internal bleeding in the digestive system
  • splitting (perforation) 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 isn't life-threatening, but 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

A blood transfusion may be required to replace 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 the tissue of the peritoneum is usually sterile (germ-free). Unlike other parts of the body, such as the skin, the peritoneum doesn't have an inbuilt defence mechanism for fighting infection.

In peritonitis, the infection can rapidly spread into the blood (sepsis), before spreading to other organs. This carries the risk of multiple organ failure. If it isn't treated properly, it may result in death. The most common symptom of peritonitis is sudden abdominal pain that gets progressively worse.

If you have peritonitis, you'll be admitted to hospital, where you'll be treated with antibiotic injections. Surgery will then be used to seal the hole in your intestinal wall.

Read more about treating peritonitis.

Typhoid fever vaccination

Vaccination against typhoid fever is recommended if you're travelling to parts of the world where the condition is common.

High-risk areas

Typhoid is found throughout the world, but it's more likely to occur in areas where there's poor sanitation and hygiene. High-risk areas include:

  • the Indian subcontinent
  • Africa
  • South and South East Asia
  • South America
  • the Middle East
  • Europe
  • Central America

Vaccination is strongly recommended if you're going to be staying or working with local people, or if you're going to be staying for prolonged periods in areas where sanitation and food hygiene are likely to be poor.

In the UK, most people who get typhoid fever develop it while visiting India, Pakistan or Bangladesh. It's therefore particularly important that you're vaccinated if you're visiting these countries.

Vaccination against typhoid fever is usually free on the NHS from GP surgeries. Private travel clinics also offer the vaccine for about 30.

Choosing a typhoid vaccine

In the UK, the two main vaccines available to prevent typhoid fever are:

  • Vi vaccine - given as a single injection
  • Ty21a vaccine - given as three capsules to take on alternate days

Combined typhoid and hepatitis A injections are also available for people aged 15 or older. Protection against hepatitis A lasts one year and protection against typhoid lasts three years.

The vaccines work by stimulating your body to create antibodies (infection-fighting proteins) that prevent you getting ill if you become infected with the typhoid bacteria.

It's important to remember that none of the typhoid vaccines are 100% effective, and you should always take precautions when eating food and drinking water abroad (see the advice below about this).

The Vi vaccine is generally more effective than the Ty21a vaccine, but some people prefer to have the Ty21a vaccine because it doesn't require an injection.

As the Ty21a vaccine contains a live sample of Salmonella typhi bacteria, it isn't suitable for people with a weakened immune system, such as people with HIV or those receiving certain types of treatment, such as chemotherapy. It also isn't usually recommended for children under six, whereas children can have the Vi vaccine from two years of age.

The typhoid vaccine should ideally be given at least one month before you travel, although if necessary it can be given closer to your travel date.

Booster vaccinations are recommended every three years if you continue to be at risk of infection with typhoid bacteria.

Side effects of typhoid fever vaccine

After having the typhoid fever vaccine, some people have temporary soreness, redness, swelling or hardness at the injection site.

About 1 in every 100 people experience a high temperature (fever) of 38C (100.4F) or above. Less common side effects include:

Severe reactions are rare for both typhoid vaccines.

Read more about routine NHS vaccinations.

'I was lucky to survive without long-term problems'

Dominic Aguiar developed typhoid during a trip to India. He says it was lack of planning that caused the infection.

"It was my own fault really," says the London schoolteacher. "I've been visiting southern India, where I've got family, for years without ever bothering with the typhoid vaccine. The last trip, during the Christmas holidays, was more ambitious, as it included a visit to Delhi. If I'd thought about it or consulted an expert, I could have had the vaccination."

Dominic doesn't know exactly where he was infected with typhoid fever, but it was almost certainly during a stay in a Delhi hotel. By the time he got back to London two weeks later, he was already ill, vomiting and with diarrhoea and a fever that came and went.

"I got home and lay on the couch for a month feeling the worst I've ever been in my whole life. I was sharing a flat with a couple and I was on my own all day while they were out at work. I had the sweats and no appetite at all and probably lost about 10kg in weight."

Initially, Dominic thought it was a case of food poisoning. "I was prescribed antibiotics by my GP, but I couldn't hold down anything I swallowed, including the tablets. It was quite frightening, but I was just too ill to do anything about it. I finally went to a hospital casualty department and they took a stool sample. I had to wait for three or four days for the result. When I was diagnosed with typhoid, I was really shocked."

Once Dominic was put on antibiotics, the typhoid cleared up and he didn't have to spend time in hospital.

"Because I'd already travelled to India several times, I didn't think about typhoid. I knew I was travelling in areas where typhoid is a risk for tourists, but for some reason I assumed I would be safe. I haven't been back to India, so haven't organised a vaccination yet. I feel lucky to have survived without long-term problems."

 
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