Typhoid

Typhoid is an infectious disease caused by Salmonella serotype Typhi bacteria (Salmonella enterica, serotype Typhi). The name typhoid comes from ancient Greek and roughly translates as dizziness or a “foggy” state of mind, i.e., an impairment in a person’s general state caused mainly by high fever.

The bacteria are mainly transmitted by contaminated water and food, but can also be transmitted through a smear infection (i.e., contact with contaminated surfaces). Good hygiene conditions in Germany mean that the disease is not very common here. Most cases are in long-distance travelers who have been infected in high-risk areas in Asia. The countries with the highest risk of infection are Pakistan, India and Nepal. However, there is also a risk of typhoid infections in other countries, e.g. in Africa and South America. Travelers should therefore seek advice from travel medics before their trip.

There are two types of typhoid – typhoid fever/enteric fever (commonly referred to simply as typhoid) and paratyphoid fever (commonly referred to simply as paratyphoid). Para means “similar”. This disease has symptoms that are similar to typhoid, but it is less serious. 

Typhoid must always be treated with antibiotics, as the disease can lead to serious complications.

The incubation time, i.e., the time between contracting an infection and developing the disease, can be anywhere from 3 to 60 days, but is usually between 8 and 14 days. 

Both types of typhoid (typhoid fever and paratyphoid) differ in terms of symptoms and the course of the disease.

Typhoid (typhoid fever) symptoms

Typhoid begins with uncharacteristic symptoms such as headache, aching limbs and a slightly high temperature, which can reach up to 39 to 41 degrees within 2 to 3 days.

Other typical symptoms in this first phase are:

• drowsiness and light-headedness
• abdominal pain
• aching limbs
• constipation

In the second phase, the high temperature continues (for up to 3 weeks).

The following symptoms also occur:

• diarrhea with an appearance similar to pea soup
• light red, pinhead-sized patches of skin on the stomach
• slowed heartbeat (bradycardia)

If the typhoid infection is not treated with antibiotics, other very serious complications can arise.

Paratyphoid symptoms

The period between getting infected and the outbreak of the disease (incubation period) is 1 to 10 days.

In addition to a high temperature of 39 degrees, the typical symptoms of paratyphoid are gastrointestinal in nature:

• diarrhea
• nausea
• vomiting
• abdominal pain

Typhoid is caused by bacteria. There are two types of typhoid bacteria that each cause a specific typhoid disease:

• Salmonella serotype Typhi bacteria cause what is known as typhoid fever, often also referred to as typhoid for short. Typhoid fever is by far the more dangerous form of the two typhoid diseases.
• Paratyphi bacteria cause typhoid-like diseases, referred to by the collective term paratyphoid. The symptoms of paratyphoid are similar to those of typhoid, but the disease is less severe.

The bacteria are passed on through the feces of infected people. People are mainly infected through drinking water and food contaminated with wastewater. The germs then enter into the body through drinking or eating. Person-to-person infection is also possible, but very rare.

The likelihood of people who live in Germany getting typhoid is extremely low.

People who travel to high-risk areas for typhoid, such as India, Pakistan and Nepal in particular, are at greater risk of infection – especially if they are not careful about the food they eat.

Therefore, before traveling to high-risk areas, people are strongly advised to:

• get vaccinated
• pay particular attention to hygiene when consuming food in high-risk areas

Typhoid and paratyphoid pathogens are found all over the world. In Germany, between 50 and 100 cases of typhoid are reported every year. 

Spread of typhoid (typhoid fever) worldwide

The World Health Organisation (WHO) estimates that 11 to 21 million people around the world develop typhoid every year. Between 128,000 and 161,000 infected people die of the infection.

Spread of paratyphoid worldwide

It is estimated that 5.5 million people contract a paratyphoid infection every year. Disease rates are particularly high in countries with poor sanitation, e.g. in Africa, South America and Southeast Asia. These countries experience repeated outbreaks and epidemics.

Spread of typhoid (typhoid fever) in Germany

Typhoid is no longer very common in Germany Significant improvement in sanitation has led to the number typhoid cases reducing by a factor of about 100 since 1951. While in 1951, there were still around 10.5 typhoid infections per 100,000 inhabitants, this had dropped to 0.07 infections per 100,000 inhabitants in 2018.

In 2018, 58 people were reported to be ill with typhoid in Germany, and most of these had been infected during travel Asia. In 2019, there was an increase after people had stayed in Pakistan. In addition, typhoid pathogens that are resistant, i.e., insensitive, to commonly used antibiotics, were registered in Germany for the first time.

Spread of paratyphoid in Germany

In 2018, there were 29 cases of paratyphoid. Over 90% of people who became ill had been infected during a long-distance trip. The most common countries were India, Thailand, Cambodia and Pakistan.

The disease typically initially has two phases. These may be followed by complications, some of which are severe.

Outlook for typhoid (typhoid fever)

If someone has a severe case of typhoid, they may experience the following complications:

• intestinal bleeding and perforation with peritonitis
• cholecystitis
• blot clot (thromboembolism)
• ostitis or osteomyelitis
• endocarditis
• meningitis

Patients who have not been treated with antibiotics take a long time to recover from the illness completely. If a patient fails to make a full recovery, the illness can break out again (relapse). This can happen more than once.

With babies, the illness is more severe and there are more often complications.

How paratyphoid develops

The course of paratyphoid is similar to that of typhoid, but milder. The illness lasts 4 to 10 days.

The main ways to prevent typhoid are:

• Taking care when consuming food if traveling in typhoid high-risk areas
• Getting vaccinated before departure

Consuming food

Typhoid pathogens are usually transmitted through drinking water. In high-risk areas, tap water and ice made with it for beverages should be avoided if possible. Raw food and food that is not cooked thoroughly – such as green and delicatessen salads, seafood, unpeeled fruit or juices – can also be contaminated with typhoid and paratyphoid pathogens. 

Vaccination

People are strongly advised to get vaccinated before traveling to high-risk areas for typhoid in Asia, South America and North Africa – especially if the living conditions are going to be basic in the destination country. Travel medics can provide comprehensive information and advice about this.

The Standing Committee on Vaccination (STIKO) at the Robert Koch Institute recommends vaccination for:

• Travel to South Asia (Pakistan, India, Nepal, Afghanistan, Bangladesh) – regardless of travel style.
• Travel to all areas of Asia, Africa, Central and South America where there are increased cases of illness and low hygiene standards if the travel, living or working conditions there are going to be very basic (for example, if trekking or taking part in relief operations). This is the case in particular if the destination country is experiencing outbreaks or disasters at the time of travel.
• Long-term stays in areas with increased cases of illness, especially where the accommodation is very basic.

Two different vaccines are available – an injection or tablets to be taken orally. The cost is approximately 30 euros. The injectable vaccine (shot) is also available in combination with a vaccine against hepatitis A.

It is injected into the muscle. It provides vaccine protection for up to 3 years from the seventh day after vaccination in about 60% of adults and children (over 2 years of age). A booster may be required after 3 years.

There may be redness and swelling at the injection site, accompanied by fever, shivering, headache and aching limbs or tiredness.

The capsules are based on a live vaccine with attenuated bacteria and are taken 3 times every 2 days. The tablets are well tolerated and give about 60% of those vaccinated protection for at least one year. A booster is required after 3 years and an earlier repeat vaccination is recommended for more frequent travel to high-risk areas.

The tablets may have side effects, such as gastrointestinal symptoms with vomiting, abdominal pain and diarrhea, and also headache and fever.

Typhoid and paratyphoid infections are often confused with flu-like illnesses or malaria when people return from travel to tropical regions.

Blood count abnormalities indicate typhoid and paratyphoid infections, but are not a reliable form of diagnosis. A reliable diagnosis requires direct detection of the typhoid bacteria directly. This is done using blood samples – or, less commonly, samples of bone marrow, urine or stool, which are used to grow a bacterial culture in the laboratory.

The earlier the treatment is given, the better the chances of recovery. The patient is treated with an appropriate antibiotic to target the bacteria directly. The choice of a suitable antibiotic depends on the exact typhoid pathogen that is detected using laboratory tests.

If you would like to get vaccinated against typhoid or are concerned that you may have typhoid, it’s best to contact a tropical medicine practice. Some university hospitals have special tropical medicine departments that offer advice.