typhoid

Watch out for typhoid

Your Health
DR GITA MATHAI

Sanitation has never been an election issue. No political party has promised us cleaner cities or a healthier environment. Even after more than 60 years of independence the infrastructure cannot keep pace with the haphazard growth of cities. Slums have sprouted everywhere, garbage is piled up and sewage pipes are often clogged, open, aged or leaking. In many towns and villages the drainage is left open, or there is no sewage disposal at all. People still use open spaces for their ablutions.

Sewage contaminates our water supply. Epidemics of water borne diseases like typhoid (caused by the salmonella species of bacteria) occur during the rainy season. India has a very high incidence of typhoid, a fact mentioned prominently on travel advisories for tourists from other countries.

After the bacterium enters the body, there is an incubation period of 10-14 days, after which there is a feeling of malaise, followed by high spiking fever. In fair skinned individuals a red rash can be seen over the trunk and abdomen. The patient loses appetite. There may be abdominal pain and diarrhoea. In most fevers the heart rate increases approximately by 10 beats for every degree rise in temperature. There is a paradoxical effect in typhoid — slow pulse rate in the presence of high fever. The tongue is coated and white, with a central clear area like a streak of red. Lymph nodes, the liver and spleen become enlarged and can be felt.

Typhoid can be confirmed with blood tests. Some are non-specific but add to the index of suspicion. Unlike in the cases of other fevers, in typhoid the white blood cell count drops instead of rising. Laboratories often do a typhoid test called a “Widal test”. This is a non-specific test and can be positive in a variety of fevers. It is inconclusive if a single value is taken. For the diagnosis to be accurate a rising — doubling or tripling — of the titer (measurement of the amount of antibody in an organism) after a week has to be ascertained by two blood tests a week apart. No patient is really going to wait that long without treatment! The organism will grow in blood, stool and urine cultures. This also takes at least 48 hours.

There are newer more specific instant “card tests” for typhoid. When blood from the patient is placed on the card a positive result shows up as a red dot or a stripe.

If undiagnosed and untreated, typhoid complications set in during the third week. Infection can spread to the brain, lungs, bones and cause fatal complications like perforation in the intestines.

Untreated, fatality can be as high as 30 per cent. Relapses occur in 10 per cent of the people and 1-4 per cent go on to become chronic carriers of the bacteria. The organism gains a foothold in the gall bladder and remains there for the rest of the person’s life. Carriers remain apparently healthy but continue to excrete the bacteria in their stool. They are responsible for the spread of the disease.

In the 1900s an epidemic of typhoid in New York was traced to a healthy carrier, a cook called Mary. This resulted in the nickname “typhoid Mary”, a term used even today. “Typhoid Mary” now has actually become a generic term for a carrier of any dangerous disease, who is a health hazard because of a refusal to take appropriate precautions. It has also come into use as a term for a person who spreads computer viruses and malicious software.

Typhoid bacteria are killed by a variety of antibiotics. The older, more toxic drugs like chloromycetin are now seldom used and have been replaced by quinolones, cephalosporins and other groups of antibiotics with less side effects. Seven to ten days of treatment may be required. The duration of treatment, the intervals between doses and the quantity of drug given have to be adequate. Otherwise the organism becomes resistant to the medication.

Frequently, based on suspicion alone, any prolonged high spiking fever is labelled “typhoid”. Without confirmatory tests, the problem gets compounded.

Another problem is that often people discontinue medication once they feel better. Sometimes, impatient as the response and improvement are slower than anticipated, they “doctor shop” and switch medication. Medical shops also get into the act and dispense an illogical, inadequate, incomplete cocktail of antibiotics and other fever medication over the counter.

All this adds to drug resistance on the part of the organism, a failure to respond, spread of the disease and development of a carrier state.

With immunisation typhoid is preventable. The injection (a single shot) can be given after the age of two with a booster dose every three years. The oral vaccine consists of three capsules, to be taken once a day for three days. Protection lasts for two years.

Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in