TYPHOID FEVER IN RETROSPECT


In 2000, typhoid fever caused an estimated 21.7 million illnesses and 217,000 deaths. It occurs most often in children and young adults between 5 and 19 years old. In 2013 it resulted in about 161,000 deaths – down from 181,000 in 1990. Infants, children, and adolescents in south-central and Southeast Asia experience the greatest burden of illness. Outbreaks of typhoid fever are also frequently reported from sub-Saharan Africa and countries in Southeast Asia. Historically, in the pre-antibiotic era, the case fatality rate of typhoid fever was 10–20%. Today, with prompt treatment, it is less than 1%. However, about 3-5% of individuals who are infected will develop a chronic infection in the gall bladder. Since S. Typhi is human-restricted, these chronic carriers become the crucial reservoir, which can persist for decades for further spread of the disease, further complicating the identification and treatment of the disease. Lately, the study of Typhi associated with a large outbreak and a carrier at the genome level provides new insights into the pathogenesis of the pathogen.

Brief History

In 430 BC, a plague, which some believe to have been typhoid fever, killed one-third of the population of Athens, including their leader Pericles. Following this disaster, the balance of power shifted from Athens to Sparta, ending the Golden Age of Pericles that had marked Athenian dominance in the Greek ancient world. The ancient historian Thucydides also contracted the disease, but he survived to write about the plague. His writings are the primary source on this outbreak, and modern academics and medical scientists consider epidemic typhus the most likely cause. In 2006, a study detected DNA sequences similar to those of the bacterium responsible for typhoid fever in dental pulp extracted from a burial pit dated to the time of the outbreak.


The cause of the plague has long been disputed and other scientists have disputed the findings, citing serious methodological flaws in the dental pulp-derived DNA study. The disease is most commonly transmitted through poor hygiene habits and public sanitation conditions; during the period in question related to Athens above, the whole population of Attica was besieged within the Long Walls and lived in tents.


Some historians believe that English colony of Jamestown, Virginia, died out from typhoid. Typhoid fever killed more than 6000 settlers in the New World between 1607 and 1624.


During the American Civil War, 81,360 Union soldiers died of typhoid or dysentery, far more than died of battle wounds. In the late 19th century, the typhoid fever mortality rate in Chicago averaged 65 per 100,000 people a year. The worst year was 1891, when the typhoid death rate was 174 per 100,000 people.


During the Spanish–American War, American troops were exposed to typhoid fever in stateside training camps and overseas, largely due to inadequate sanitation systems. The Surgeon General of the Army, George Miller Sternberg, suggested that the War Department create a Typhoid Fever Board. Major Walter Reed, Edward O. Shakespeare, and Victor C. Vaughan were appointed August 18, 1898, with Reed being designated the President of the Board. The Typhoid Board determined that during the war, more soldiers died from this disease than from yellow fever or from battle wounds. The Board promoted sanitary measures including latrine policy, disinfection, camp relocation, and water sterilization, but by far the most successful anti-typhoid method was vaccination, which became compulsory in June 1911 for all federal troops.


The most notorious carrier of typhoid fever, but by no means the most destructive, was Mary Mallon, also known as Typhoid Mary. In 1907, she became the first carrier in the United States to be identified and traced. She was a cook in New York who is closely associated with 53 cases and three deaths. Public health authorities told Mary to give up working as a cook or have her gall bladder removed, as she had a chronic infection that kept her active as a carrier of the disease. Mary quit her job, but returned later under a false name. She was detained and quarantined after another typhoid outbreak. She died of pneumonia after 26 years in quarantine.

Development of Vaccination

During the course of treatment of a typhoid outbreak in a local village in 1838, English country doctor William Budd realised the "poisons" involved in infectious diseases multiplied in the intestines of the sick, were present in their excretions, and could be transmitted to the healthy through their consumption of contaminated water. He proposed strict isolation or quarantine as a method for containing such outbreaks in the future. The medical and scientific communities did not identify the role of microorganisms in infectious disease until the work of Louis Pasteur.


In 1880, Karl Joseph Eberth described a bacillus that he suspected was the cause of typhoid. In 1884, pathologist Georg Theodor August Gaffky (1850–1918) confirmed Eberth's findings, and the organism was given names such as Eberth's bacillus, Eberthella typhi, and Gaffky-Eberth bacillus. Today, the bacillus that causes typhoid fever goes by the scientific name Salmonella enterica enterica, serovar Typhi.


The British bacteriologist Almroth Edward Wright first developed an effective typhoid vaccine at the Army Medical School in Netley, Hampshire. It was introduced in 1896 and used successfully by the British during the Boer War in South Africa. At that time, typhoid often killed more soldiers at war than were lost due to enemy combat. Wright further developed his vaccine at a newly opened research department at St Mary's Hospital Medical School in London from 1902, where he established a method for measuring protective substances (opsonin) in human blood.


Citing the example of the Second Boer War, during which many soldiers died from easily preventable diseases, Wright convinced the British Army that 10 million vaccines should be produced for the troops being sent to the Western Front, thereby saving up to half a million lives during World War I. The British Army was the only combatant at the outbreak of the war to have its troops fully immunized against the bacterium. For the first time, their casualties due to combat exceeded those from disease.


In 1909, Frederick F. Russell, a U.S. Army physician, adopted Wright's typhoid vaccine for use with the US Army, and two years later, his vaccination program became the first in which an entire army was immunized. It eliminated typhoid as a significant cause of morbidity and mortality in the U.S. military.


Most developed countries saw declining rates of typhoid fever throughout the first half of the 20th century due to vaccinations and advances in public sanitation and hygiene. In 1908, the chlorination of public drinking water was a significant step in the US in the control of typhoid fever. The first permanent disinfection of drinking water in the U.S. was made to the Jersey City, New Jersey, water supply. Credit for the decision to build the chlorination system has been given to John L. Leal. The chlorination facility was designed by George W. Fuller. In 1942 doctors introduced antibiotics in clinical practice, greatly reducing mortality. Today, the incidence of typhoid fever in developed countries is around five cases per million people per year.


A notable outbreak occurred in Aberdeen, Scotland, in 1964. This was due to contaminated tinned meat sold at the city's branch of the William Low chain of stores. No fatalities resulted.


In 2004–05 an outbreak in the Democratic Republic of Congo resulted in more than 42,000 cases and 214 deaths.

Treatments And Drugs

Antibiotic therapy is the only effective treatment for typhoid fever.


Commonly Prescribed Antibiotics
  • Ciprofloxacin (Cipro). Doctors often prescribe this for nonpregnant adults.

  • Ceftriaxone (Rocephin). This injectable antibiotic is an alternative for people who may not be candidates for ciprofloxacin, such as children.

These drugs can cause side effects, and long-term use can lead to the development of antibiotic-resistant strains of bacteria.


Other Treatments

Other treatments include:

  • Drinking fluids. This helps prevent the dehydration that results from a prolonged fever and diarrhea. If you're severely dehydrated, you may need to receive fluids through a vein (intravenously).

  • Surgery. If your intestines become perforated, you'll need surgery to repair the hole.

Typhoid Antibiotic Resistance

As with a number of other bacterial diseases, the problem of antibiotic resistance is impacting the choice of drugs available to typhoid sufferers. In recent years, typhoid has become resistant to trimethoprim-sulfamethoxazole and ampicillin.


Ciprofloxacin, one of the key medications for typhoid, is also suffering a similar fate. Some studies have found Salmonella typhimurium resistance rates to be around 35 percent.

Asymptomatic Carriers

Some individuals are asymptomatic carriers of typhoid, meaning that they harbour the bacteria but suffer no ill effects. As many as 1 in 6 people have the capacity to be a silent carrier.


These individuals are particularly dangerous within high-risk populations.


Mary Mallon, better known as "Typhoid Mary" (1869-1938), was the first known asymptomatic typhoid carrier in the U.S. During her career as a cook, Mary is thought to have infected at least 51 people, three of whom died.


Mary, an Irish immigrant, worked as a cook for a string of families, infecting numerous members of each household before moving on to work elsewhere.


Mallon was eventually tracked down and quarantined. In all, she spent the best part of three decades in forced isolation. She died aged 69, of pneumonia.

Prevent Infecting Others

If you're recovering from typhoid fever, these measures can help keep others safe:

  • Take your antibiotics. Follow your doctor's instructions for taking your antibiotics, and be sure to finish the entire prescription.

  • Wash your hands often. This is the single most important thing you can do to keep from spreading the infection to others. Use hot, soapy water and scrub thoroughly for at least 30 seconds, especially before eating and after using the toilet.

  • Avoid handling food. Avoid preparing food for others until your doctor says you're no longer contagious. If you work in the food service industry or a health care facility, you won't be allowed to return to work until tests show that you're no longer shedding typhoid bacteria.


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REFERENCE:

http://emedicine.medscape.com/article/231135-overview

http://www.webmd.com/a-to-z-guides/typhoid-fever#2

https://en.wikipedia.org/wiki/Typhoid_fever

http://www.medicalnewstoday.com/articles/156859.php

http://wwwnc.cdc.gov/travel/diseases/typhoid

http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/typhoid-paratyphoid-fever

http://www.nhs.uk/Conditions/Typhoid-fever/Pages/Introduction.aspx

http://www.mayoclinic.org/diseases-conditions/typhoid-fever/basics/symptoms/con-20028553

#TyphoidFever #TreatingTyphoidFever #TyphoidAntibioticResistance

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