Conditions Typhoid and paratyphoid

Typhoid is an infectious disease caused by a subgroup of certain salmonella bacteria.

The bacteria are mainly transmitted by contaminated drinking water and food.

Good hygiene conditions in Germany mean that typhoid is extremely rare here. Most cases involve long-distance travelers who have been infected in high-risk areas in Asia.

There are two types of typhoid:

• Typhoid fever: also known as enteric fever or simply typhoid for short.
• Paratyphoid: this has similar symptoms to typhoid but is often less serious.

Typhoid must always be treated with suitable antibiotics as it can lead to life-threatening complications.

Typhoid and paratyphoid develop in a very similar way.

However, the incubation period, i.e. the period between a person becoming infected and symptoms appearing, differs.

The symptoms also differ greatly.

Typhoid symptoms

Typhoid has an incubation period of 3 to 60 days, although usually 8 to 14 days.

Typhoid starts with nonspecific symptoms such as a severe headache, body aches, and a slightly elevated temperature. However, within a few days, this temperature rises to 39 to 41 degrees Celsius.

A distinct feeling of illness then develops, frequently accompanied by:

• drowsiness and light-headedness
• stomach ache
• aching limbs
• constipation

The high temperature can last for up to three weeks.

The following typical symptoms can also arise:

• pea-soup-like diarrhea as the condition progresses
• bright red, pinhead-sized spots on the skin of the abdomen
• slowed heartbeat (bradycardia)

Paratyphoid symptoms

Paratyphoid typically has an incubation period of 1 to 10 days.

The symptoms are not very different from those with typhoid. Typical symptoms include:

• fever
• severe headache
• initially constipation, followed by diarrhea as the disease progresses
• nausea and vomiting
• stomach ache

Typhoid is caused by an infection with Salmonella enterica bacteria. There are two subgroups of these bacteria, which trigger either typhoid or paratyphoid:

• The bacteria in the subgroup Typhi cause typhoid fever, usually simply known as typhoid.
• The bacteria in the subgroup Paratyphi cause typhoid-like diseases, referred to by the collective term paratyphoid.

How is typhoid contracted?

The typhoid pathogens are excreted in the feces and urine of people infected and can therefore get into wastewater. Infection primarily occurs if food that has been contaminated by such wastewater is eaten. People can also get infected through contaminated drinking water, or from ice cubes or ice lollies made from it.

Person-to-person transmission is also possible, but very rare.

Typhoid and paratyphoid pathogens are found all over the world. Disease rates are particularly high in countries with poor sanitation, such as in some regions in Africa and Asia.

Number of cases in Germany

In Germany, between 50 and 100 cases of typhoid are reported every year. In addition, there are between 30 and 50 cases of paratyphoid fever per year.

In 2023, 79 people contracted typhoid and 38 people contracted paratyphoid. Most of these had become infected while traveling to Asia, especially to Pakistan or India.

Number of cases worldwide

The World Health Organization (WHO) estimates that 9 million people around the world develop typhoid every year and that up to 110,000 of these die as a result.

It is estimated that 3.4 million people contract a paratyphoid infection every year.

Typhoid typically has uncharacteristic symptoms in the initial phase followed by a persistently high temperature. These may be followed by complications, some of which are severe.

Patients who have not been treated with antibiotics often take longer to fully recover from the illness. Even if antibiotic treatment is delayed, there is a higher risk of the illness becoming severe and there being complications.

The illness can break out again following partial recovery. This can happen more than once.

With infants, typhoid is more severe and complications are more common.

Paratyphoid has a similar outlook to typhoid but is less serious.

What are the possible complications of typhoid?

If someone has a severe case of typhoid, life-threatening complications may occur:

• intestinal bleeding and perforation with peritonitis
• impaired consciousness
• gall bladder inflammation
• thromboembolism: blood clots break loose and move to another area of the body where they block a blood vessel.
• ostitis or osteomyelitis
• endocarditis (inflammation of the lining of the heart)
• meningitis

The most important measures for preventing typhoid include:

• taking care when consuming food if traveling in high-risk areas
• getting vaccinated against typhoid prior to traveling

Consuming food

Typhoid pathogens are usually transmitted through drinking water. In high-risk areas, you should avoid drinking tap water and skip ice cubes or ice lollies made from tap water whenever possible.

Uncooked or insufficiently heated food can also be contaminated with typhoid and paratyphoid pathogens. Such food includes green and delicatessen salads, seafood, unpeeled fruit or juices.

Recommended vaccinations

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

The Standing Committee on Vaccination (STIKO) recommends vaccination for:

• travel to South and Central Asia (e.g. Pakistan, India, Nepal, Afghanistan or 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. This applies if trekking or taking part in relief operations, for example, especially in the event of recent outbreaks and disasters.
• long-term stays in areas with increased cases of illness, especially where the accommodation is very basic.
• travel by people with a migration background to their countries of origin where there is an elevated risk

Two different vaccines are available: an injection (inactivated vaccine) or oral capsules (live vaccine).

Many health insurance funds cover the cost of travel vaccinations. People with health insurance should ideally contact their health insurance fund prior to vaccination to find out the applicable rules.

Injectable vaccine

The injectable vaccine (shot) is also available in combination with a vaccine against hepatitis A.

The injection uses an inactivated vaccine with dead bacteria and is administered into the muscle. Redness and swelling may develop at the injection site plus headaches, aching limbs, feelings of malaise or tiredness are possible.

The vaccine provides immune protection for up to three years, starting 14 days after administration. However, it does not offer full protection against infection. Nevertheless, the course of the disease is generally milder in vaccinated individuals. The vaccine does not protect against paratyphoid either. Therefore, even after vaccination, you should observe the precautions regarding eating and drinking when traveling.

Oral vaccine

The oral vaccine uses a live vaccine with attenuated bacteria. It is administered in the form of three capsules, with one taken every two days (primary immunization).

The capsules are well tolerated and give about 50 percent of those vaccinated protection for around 3 years. The live-attenuated vaccine also provides partial protection against paratyphoid B. Because the live-attenuated vaccine does not provide full protection from an infection, you should also comply with hygiene measures for food and drinking water.

Possible side effects of the vaccine include:

• nausea and/or vomiting
• stomach pain and headache
• fever
• rash
• diarrhea that occurs after the high temperature

Revaccination and boosters

People who have received the oral vaccine and are once again traveling to a high-risk area are advised to undergo full revaccination after one year. The injection vaccine should be repeated after 3 years in the event of renewed risk.

In the case of permanent residence in a high-risk area, the immunization should be boosted after three years regardless of the vaccine.

Typhoid and paratyphoid infections are often confused with flu infections or, if people have returned from tropical regions, malaria.

Blood count abnormalities can indicate typhoid and paratyphoid, but are not a reliable form of diagnosis.

A reliable diagnosis requires direct detection of the pathogens. To this end, a doctor will take a blood sample that can be used to grow a bacteria culture in a laboratory. In rare cases, bone marrow, urine or feces samples are taken.

The earlier typhoid is treated, the better the chances of recovery. The condition is treated with antibiotics.

The choice of active substance depends on the precise typhoid pathogen, which is determined in a laboratory, especially if people have returned from travels in Asia. Checks are also performed in advance to see if the antibiotic selected actually works.

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 also offer advice.