Main messages

Enteric fevers (typhoid and paratyphoid A, B or C) 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.

A vaccine against typhoid fever is available.

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, so:

• opportunistically ask patients from, or with family links to, enteric fever endemic countries whether they are travelling to visit friends or relations
• advise how and when to seek travel health advice
• offer travel advice according to national guidelines

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 or diagnose a case, you must report this to your local proper officer, usually the consultant in Communicable Disease Control at your local health protection team (HPT).

Background

Enteric fevers are caused by the bacteria:

• Salmonella enterica serovar Typhi (typhoid)
• Salmonella enterica serovar Paratyphi A, B and C (paratyphoid)

They are endemic in areas of the world where food and water hygiene are poor, usually in tropical and sub-tropical regions.

Worldwide, there are an estimated 14 million cases of typhoid in 2017.

In England, Wales and Northern Ireland, around 300 to 520 cases of enteric fever are reported annually through enhanced surveillance.

The majority of these cases are reported in people who have travelled to visit friends and relatives in countries of their ethnic origin, predominantly the Indian sub-continent.

Transmission

Enteric fevers are transmitted via the faecal-oral route. People can become infected by:

• consuming food or beverages that have been handled by an infected person or that a fly has landed on
• drinking contaminated water
• eating shellfish harvested from contaminated water

The spread of enteric fevers is prevented by good hygiene and proper sanitation.

Symptoms

The incubation period varies from 1 to 3 weeks depending, for example, upon how many bacteria are ingested. Paratyphoid has a significantly shorter incubation period, usually 1 to 10 days. Paratyphoid B may have a shorter incubation period of 4 to 5 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 to 10 days)

Children may have an atypical presentation with a high, swinging and persistent fever and sometimes absence of bowel symptoms. Children are also disproportionately affected by typhoid fever, with peak incidence worldwide occurring in those aged 5 to 15 years of age.

Serious complications include intestinal bleeding or perforation, and/or confusion.

The disease lasts several weeks, and recovery takes some time.

Paratyphoid fever is clinically similar to typhoid fever, although it is typically milder.

Testing and treatment

In the UK, enteric fevers are mainly managed by secondary care infectious disease specialists.

If you suspect enteric fever:

• submit blood and faeces for bacteriological culture
• seek specialist advice 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
• chloramphenicol

Oral (or rarely, intravenous) fluoroquinolones 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.

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 a country that is endemic for enteric fever are at particularly high risk. Areas with the highest rates of typhoid fever are the Indian subcontinent, Africa, South and Southeast Asia and South America.

Vaccination can prevent typhoid fever, but not paratyphoid. The typhoid vaccine should ideally be given at least 1 month before travel, although if necessary it can be given closer to the travel date. Booster vaccinations are recommended every 3 years if the individual continues to be at risk of infection with typhoid bacteria.

Travellers to endemic areas should:

• be vaccinated with typhoid vaccine
• ensure they practice good food and water hygiene

The British Infection Association have produced guidelines for the diagnosis and management of enteric fever in England.

Operational guidance from Public Health England (now UK Health Security Agency) and the Chartered Institute of Environmental Health has been produced to support public health practitioners in identifying the sources of typhoid or paratyphoid (enteric fever) infection.

The National Travel Health Network and Centre (NaTHNaC) has produced guidance for health professionals on typhoid and paratyphoid and the prevention of food- and water-borne diseases.

The primary care practitioner plays a vital role ensuring 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 team (HPT), for investigation and contact tracing as necessary.

Advise affected patients about maintaining good hygiene to prevent transmission to others in the UK.

Public health guidance on the exclusion of affected individuals from work or school is available, including advice on the public health management of gastro-intestinal infections and infection prevention and control in schools and other childcare settings.

Resources

Public Health England has produced Typhoid: health advice for travellers guidance, available in English, Bengali, Gujarati, Punjabi and Urdu.

The Green Book provides information on typhoid immunisation.