What are typhoid and paratyphoid?
Typhoid fever is an infection caused by the bacterium (germ) Salmonella typhi. This can cause a serious illness which can be fatal if not treated rapidly with antibiotics. Paratyphoid is an infection which is similar but has milder symptoms. This is caused by the bacterium Salmonella paratyphi. (These bacteria are shortened to S. typhi and S. paratyphi for the remainder of this leaflet.)
Where are typhoid and paratyphoid most commonly found?
These bacteria are found most commonly in situations where good standards of hygiene are not maintained or cannot be maintained because of the lack of clean running water. According to the World Health Organization (WHO), typhoid and paratyphoid are now most commonly found in South East Asia and sub-Saharan Africa.
The most common infections in the UK have been among people who have visited friends and family in India, Pakistan and Bangladesh. Each year there are about 500 cases of typhoid in the UK in people returning from these areas. About half of these are in London.
How do you get these infections?
You get these infections by eating or drinking contaminated food or water. These bacteria are passed out in the faeces (stools) and urine of infected individuals. They can get into food and water because people who handle food (such as cooks or restaurant workers) do not know that they are infected. This is because they may have no symptoms or signs of the infection. Typhoid and paratyphoid are not passed on by animals. Humans are the only carriers of theses infections.
How do typhoid and paratyphoid make you ill?
The bacteria get into your body through the gut. They sit in your immune system (glands and lymph vessels) and multiply. They then enter the bloodstream and this is when most people experience symptoms of headache and fever. Through the bloodstream they enter the liver, spleen, gallbladder and bone marrow. Because bile from the gallbladder is normally squirted into the gut, the bowels then get infected again.
Symptoms of typhoid and paratyphoid
The incubation period (the time between getting the bacteria inside you, until the time you actually start to feel ill) depends on how much of the bacteria you have swallowed. It is usually between 7-14 days, but can be as short as three days, or as long as 30 days.
The illness usually lasts for three weeks, but may be longer in a small number of cases.
Symptoms vary from mild to severe and life-threatening.
About 1 in 300 people infected with typhoid may have a low-grade infection. They may not develop any significant symptoms, and then become carriers of the disease.
- Fever and headache are the most common symptoms. Typically, the temperature increases gradually day by day during the first week. People usually experience raised temperature mostly in the evenings.
- Rash (rose-coloured spots which lose their colour with pressure).
- Stomach pains.
- Loss of appetite.
- Diarrhoea – more common in children.
- Severe constipation – more common in adults.
- Nausea (feeling sick).
When to seek medical advice
Be aware if you or your child have travelled to an area known to have a high risk of typhoid infections, or have been in a situation where hygiene has been poor. If you experience headache, fever, tummy pains, cough or diarrhoea you should seek medical advice. This is even if you have been vaccinated against typhoid, as this does not guarantee 100% protection.
How are typhoid and paratyphoid diagnosed?
Your doctor will take note of where you travelled, the conditions you stayed in and what you did while you were there. He or she will listen to your symptoms, and examine you. These are all very important, as it is very difficult to find typhoid and paratyphoid in the body, even if you have these infections.
Tests your doctor may carry out
- Stool, blood and urine samples are sent to the laboratory for culture (in which the bacteria are helped to reproduce and be identified). This test may not identify about one third of cases of even whether the bacteria are there. It may also take some days for results to come back.
- Widal’s test – this is a blood test which checks for antibodies (proteins) which help to fight S. typhi or S. paratyphi. Again, however, this may miss about one third of cases.
- Bone marrow aspiration – this is when a needle is used to take sample of bone marrow fluid. A bone marrow sample is positive in 90% of cases if it is taken during the first week of the illness. It may be more difficult to find after that.
If your travel story and symptoms suggest that you have typhoid or paratyphoid, the doctor may start treatment before the results of the tests are available.
What are the treatments for typhoid and paratyphoid?
You may need to stay in hospital for these infections to be treated.
- Antibiotics: these should be started as soon as possible. They will reduce your chances of getting complications. They will also make you feel better in as short a time as possible. You should keep taking them until six consecutive negative stool and urine tests have been obtained.
- Have plenty to drink to prevent dehydration. Sometimes a drip where fluid is put directly into the vein is needed.
- Medication to lower your temperature may be needed.
Note: anyone looking after you must be particularly careful with hand washing and the disposal of faeces and urine.
How to wash your hands properly
Safe disposal of urine and faeces
Advice for people who work with food
Typhoid and paratyphoid are known to be easy to pass on, even after symptoms have stopped and you feel better.
If you work with food, you should inform your employer if:
- You have, or are suspected of having, typhoid or paratyphoid.
- You have had it in the past.
- You have had a lot of contact with someone who has had typhoid or paratyphoid.
You should be excluded from food handling and food handling areas until you have been cleared to return to work by a medical professional.
If the person is confirmed as being infected or is a carrier of the bacteria, the exclusion period may take three months or more. This is to allow for treatment and confirmation of clearance of infection, through stool testing.
How long should someone with typhoid fever stay away from work, school or nursery?
Adults and children aged over five years who have good standards of personal hygiene can go back to work/school as soon as their illness is better, and they have no diarrhoea. (But see the section above if you work with food.)
People working with vulnerable groups such as the very young, elderly or those in poor health, should tell their employer of their illness. They must stay off work until tests show that the bacteria have cleared from stool specimens in three stool samples taken at weekly intervals.
Children aged under five years should stay away from nurseries, playgroups, etc, until tests show that the bacteria have cleared from stool specimens in three stool samples taken at weekly intervals.
What are the possible complications?
About 1 in 10 people with typhoid or paratyphoid infections have complications. These can occur at any time while you have the infection, even if you have a mild infection.
- The two most common complications are bleeding from, and rupture of, the bowel. These occur in about 2 in 100 cases. These may be life-threatening and may require a surgical operation.
- Infection of the heart muscle (toxic myocarditis) occurs in up to 1 in 20 cases. It is a significant cause of death in areas where typhoid and paratyphoid are commonly found.
- Infection of the nervous system can cause severe confusion, epileptic seizures and mental health disturbances.
- Liver and gallbladder infection may cause jaundice (yellowing of the skin) and severe abdominal pain.
- Pancreatitis (pancreas infection) is very rare. This can cause severe pain in the stomach or back, and indigestion.
- Kidney failure (in which the kidneys no longer clear toxins from the blood) is also uncommon.
Note: if you have any new symptoms, or feel worse while you are being treated for typhoid, you should contact your doctor as soon as possible.
What is the prognosis (outlook)?
Without antibiotics, about 1 in 5 people will die from a typhoid infection.
With treatment with antibiotics, most people make a full recovery but about 1 in 10 people have a recurrence of the illness (relapse). This usually happens a week after stopping the antibiotic but it can be much later. Another course of antibiotics will usually work if you have a relapse.
How can I prevent getting typhoid or paratyphoid?
1. Avoid getting typhoid and paratyphoid while you are abroad
It is very important to be careful of what you eat and drink and to wash your hands thoroughly after using the toilet, before eating and before preparing food:
- Only eat food that is freshly prepared, cooked and served piping hot, or fruit that you have peeled yourself, such as banana and mango.
- Only drink bottled or cooled boiled water.
- When drinking bottled water, ensure the seal is unbroken or choose sparkling water to ensure the bottle has not been refilled.
- Only drink pasteurised milk.
- Wash your hands frequently using soap and water or hand sanitiser.
- Wash your hands or use hand sanitiser before preparing food, eating or drinking, and after using the toilet.
- Use bottled or boiled water to brush your teeth. Do not use tap water.
You should avoid:
- Uncooked food such as salads.
- Raw or uncooked shellfish.
- Buffets (if you have to eat at a buffet, choose steaming hot dishes).
- Unpasteurised milk and cheese.
- Ice cubes (to keep drinks cold, put the container or glass on ice, do not put ice in your drinks).
- Tap water.
- Ice-cream products.
- Cold desserts in restaurants.
Remember: BOIL IT, COOK IT, PEEL IT OR FORGET IT!
Vaccination against typhoid is available free of charge on the NHS in the UK. People who should have the vaccine are:
- Travellers to countries where typhoid is common (South Asia, South East Asia, Middle East, Central and South America and Africa) – especially if staying with, or visiting, the local population
- Travellers to areas with frequent and/or prolonged exposure to conditions where sanitation and food hygiene are likely to be poor.
- Laboratory personnel who may handle S. typhi in the course of their work.
If you are going to travel to a country where typhoid is common, you should visit your practice nurse, GP or Travel Clinic at least two weeks before you are due to travel.
See separate leaflet called ‘Typhoid Immunisation’ for more information about typhoid vaccine. There is no vaccine against paratyphoid.
Health Advice for Travellers
Booklet from the Department of Health. You can get a free copy from main post offices.
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