Enteric fevers (Typhoid and Paratyphoid)

Key messages for primary care practitioners

Enteric fevers (typhoid and paratyphoid A or B) can affect any susceptible person regardless of age, sex, ethnicity or country of birth.
Enteric fevers can be serious illnesses, sometimes life threatening, and are largely preventable. There is a vaccine against typhoid.
Travellers visiting friends and relatives in a country that is endemic for enteric fever are at particularly high risk. The majority of the enteric fevers reported in the UK affect this group and they may not perceive that they are at risk and may therefore not seek pre-travel advice.
Primary care practitioners have an important role in prevention. They should opportunistically ask patients from, or with family links to, enteric fever endemic countries whether they will be travelling to visit friends or relations, and advise how and when travel advice should be sought. Travel advice should be offered according to national guidelines (see NaTHNaC [external link]).
Always ask about travel when a patient presents with a fever. Enteric fever (or other tropical infections) may need to be included in the differential diagnosis.
Enteric fevers are statutorily notifiable diseases. If you suspect and/or diagnose a case you should report this to your local proper officer (usually the Consultant in Communicable Disease Control at your local Health Protection Unit).

Background information

Testing and treatment

Prevention and control

Patient information (English only)

Patient information (English and other languages)

Other useful resources

References

Background information

Enteric fevers are caused by the bacteria Salmonella enterica var Typhi and Paratyphi A or B.
They are endemic in areas of the world where food and water hygiene are poor and/or where there is inadequate sanitation, usually in tropical and sub-tropical regions. The annual incidence of typhoid is estimated to be about 17 million cases worldwide [1].
In England, Wales and Northern Ireland, around 500 cases of enteric fever are reported annually through enhanced surveillance.
The majority of these cases are reported in travellers of Indian subcontinental ethnicity, who have acquired their infection in countries of their ethnic origin, associated with travelling to visit friends and relatives [2].
Enteric fevers are transmitted via the faecal-oral route. People become infected by consuming food or beverages that have been handled by an infected person or by drinking contaminated water. Good hygiene and proper sanitation prevent their spread [3,4].
The incubation period varies from one to six weeks depending upon how many bacteria are ingested, but is usually 7-14 days.
Classic typhoid fever is a serious disease and can be life-threatening unless treated promptly with antibiotics. It varies in severity and symptoms can include:
- fever which increases daily
- headache
- stomach pains
- altered bowel habit
- loss of appetite and nausea
- lassitude
- dry cough
- occasionally rash of flat, rose-coloured spots (at peak of fever after 7-10 days)
Presentation may be atypical in children with a high, swinging and persistent fever and sometimes absence of bowel symptoms.
Serious complications include intestinal bleeding/perforation and/or confusion or delirium.
The disease lasts several weeks and recovery takes some time.
Paratyphoid fever is clinically indistinguishable from typhoid fever.

Testing and treatment

In the UK enteric fevers are mainly managed by secondary care infectious disease specialists. If enteric fever is suspected, blood and faeces should be submitted for bacteriological culture and specialist advice sought on management from the local infectious disease department. Admission to hospital may be required depending on clinical presentation. Resistance to commonly used antibiotics is widespread, including amoxycillin, cotrimoxazole and chloramphenicol. Oral (or rarely, intravenous) fluoroqunolones are now the first line treatment in most areas. However, typhoid and paratyphoid A infections acquired in India and Pakistan are generally resistant to ciprofloxacin as well, and intravenous ceftriaxone is the empirical treatment of choice for such cases until susceptibilities are known [5]. Oral azithromycin may be a suitable alternative.

Prevention and control

Prevention of enteric fevers is predominantly associated with precautionary measures when travelling to endemic areas since the majority of cases are acquired abroad. Travellers visiting friends and relatives in their family country of origin are at particularly high risk.

Typhoid fever (but not paratyphoid) can be prevented by vaccination. Available vaccines offer 50-80% protection from typhoid fever. Travellers to endemic areas should be vaccinated with typhoid vaccine as well as ensuring they practise good food and water hygiene. More information about vaccines and about preventing food and waterborne infections is available from the National Travel Health Network and Centre [external link]:

NaTHNaC typhoid and paratyphoid information for health professionals [external link]

NaTHNaC prevention of food- and water-borne diseases information for health professionals [external link]

The primary care practitioner has a vital role to play in ensuring that those at risk of acquiring enteric fever receive adequate information about how to protect themselves and in prescribing vaccination as appropriate.

Enteric fevers are statutorily notifiable diseases. If you suspect and/or diagnose a case you should report this to your local proper officer (usually the Consultant in Communicable Disease Control at your local Health Protection Unit) for investigation and contact tracing as necessary. Affected patients should be advised about the necessity of maintaining good hygiene to prevent transmission to others in the UK.

Public health guidance on exclusion of affected individuals from work/school is available in the following documents:

Preventing person-to-person spread following gastrointestinal infections: guidelines for public health physicians and environmental health officers

Guidance on Infection Control in Schools and other Child Care Settings

Patient information (English only)

Patient UK leaflet on typhoid immunisation [external link]

Patient information (English and other languages)

HPA leaflet: Typhoid - Health Advice for travellers (English version)

Typhoid leaflet in Bengali (PDF, 110 KB)

Typhoid leaflet in Gujarati (PDF, 86 KB)

Typhoid leaflet in Punjabi (PDF, 83 KB)

Typhoid leaflet in Urdu (PDF, 599 KB)

Other useful resources

National Travel Health Network and Centre [external link] (NaTHNaC) - for country specific travel advice.

The Hospital for Tropical Diseases [external link] an NHS Hospital dedicated to the prevention, diagnosis and treatment of tropical diseases and travel related infections.

Liverpool School of Tropical Medicine [external link] this institution and the associated Tropical and Infectious Disease Unit in the Royal Liverpool University Hospital provide advice on prevention, diagnosis and management of tropical infections.

References

WHO: Water-related diseases - typhoid and paratyphoid enteric fevers [external link]
Health Protection Agency. Foreign travel associated illness - a focus on those visiting friends and relatives 2008 report
Health Protection Agency. Typhoid page
Health Protection Agency. Paratyphoid page
Parry CM, Beeching NJ. Treatment of enteric fever [external link] BMJ 2009;338:b1159