Typhoid fever: symptoms, diagnosis, vaccination and treatment in Tashkent

How it is transmitted and why the topic is relevant for the region

The causative agent of typhoid fever lives only in humans - neither animals nor birds can tolerate it. This means that each new incidence can be traced back either to the patient or to a carrier who excretes bacteria in feces and urine, while remaining completely healthy. The route of transmission is water and food: contaminated water, ice from it, greens washed in it, dishes rinsed with such water.

The geography of the disease follows from this. Typhoid fever remains a problem where water supply and sewage systems are not completely separated, where network accidents occur, where water supply is intermittent and the pressure in the pipe periodically drops. Added to this is the street sale of prepared food and drinks, in which the seller does not have running water, and the dishes are washed in one basin. In the summer, a third factor is added - people drink more, buy drinks and ice on the street, and eat out more often.

• Drinking raw water from the tap, from a well, an aryk, or from bottles of unknown origin
• Ice added to the drink - it is almost never prepared from boiled water
• Greens, salads, fresh vegetables and fruits washed with contaminated water
• Ready-to-eat street food and drinks, especially where there are no facilities for washing hands and dishes
• Hand-touched homemade dairy products
• Contact in everyday life with a carrier - a relative, neighbor, catering worker, who himself does not know about his carrier status
• Flies as vectors from open latrines to food

Separately, it is worth mentioning the confusion in names, which occurs very often. Typhoid fever, typhus and relapsing fever are three completely different diseases with different pathogens and different modes of transmission. Typhus is carried by lice and has nothing to do with water or food. The word “typhoid” in their names remained from old medicine, where it denoted confusion during severe fever, and not a specific infection. This is important for practice: tests, treatment and prevention for these diseases do not overlap, and confusion leads to useless research.

Progression by week: why fever increases in steps

From infection to the first symptoms it usually takes from one to two weeks, sometimes up to three. The onset of typhoid fever is gradual, and this is its most important difference from most intestinal infections, which occur within a few hours. The classic description is a fever that rises in steps: each day the maximum temperature is slightly higher than yesterday, and by the end of the first week it reaches 39–40 and remains at this level.

1. Первая неделя: нарастающая слабость, головная боль, отсутствие аппетита, температура поднимается ступенчато; у взрослых чаще запор, чем понос; язык обложен налётом с чистыми красными краями.
2. Вторая неделя: температура держится высоко почти без суточных колебаний, появляется выраженная апатия и заторможенность, увеличиваются печень и селезёнка, живот вздут.
3. Восьмой-десятый день: на коже живота и нижней части груди появляется скудная сыпь — несколько бледно-розовых пятнышек, которые исчезают при надавливании; их бывает так мало, что их просто не замечают.
4. Третья неделя: период наибольшего риска осложнений со стороны кишечника, температура начинает медленно снижаться, силы на исходе.
5. Четвёртая неделя и далее: постепенное выздоровление, длительная слабость, у части людей — возврат лихорадки через одну-две недели после нормализации температуры.

Several signs help distinguish typhoid from influenza and other fevers. At high temperatures, the heart rate increases less than expected - this is a relative decrease in heart rate. There is no runny nose, sore throat or cough characteristic of respiratory infections. A person does not so much rush about from the heat as becomes indifferent, lethargic, answers in monosyllables and sleeps a lot. Finally, a key timing guideline: any fever that lasts longer than five days without a clear cause requires evaluation, not another antipyretic.

Complications of the third week: bleeding and perforation

The main danger of typhoid fever is not the fever itself, but what happens in the wall of the small intestine. The pathogen multiplies in accumulations of intestinal lymphoid tissue; by the third week, these areas become ulcerated, and it is then that the two most dangerous complications arise - intestinal bleeding and perforation of the intestinal wall. Both develop against the background of a fever that has already subsided, when both the patient and his relatives believe that the worst is over.

• Intestinal bleeding: increasing pallor, weakness, dizziness, black tarry stools, increased heart rate when the temperature drops
• Perforation of the intestine: sudden sharp pain in the abdomen, plank-like tension in the muscles of the abdominal wall, then an imaginary improvement and the development of peritonitis
• Infectious-toxic shock: drop in blood pressure, cold, moist skin, confusion
• Damage to the heart muscle, pneumonia, inflammation of the gallbladder
• Purulent lesions in bones and joints are a rare but possible long-term complication
• Relapse of the disease one to two weeks after the temperature returns to normal - usually milder than the first episode

From the mechanism of complications follow rules of behavior in the second or third week, which seem redundant until you understand their meaning. Bed rest is needed not because the person is weak, but because physical stress and straining increase the risk of perforation of the ulcerated intestinal wall. The food during this period is gentle, without coarse fiber, large pieces and anything that enhances peristalsis. Laxatives and cleansing enemas are contraindicated in the midst of illness. This is why typhoid fever in most cases is treated in a hospital: not so much for the sake of IVs, but for the sake of observation on those days when the condition can change in an hour.

Diagnosis: why the Vidal reaction does not make a diagnosis

Confirmation of the diagnosis is based on the isolation of the pathogen, and not on antibodies. This is a fundamental point, because in many laboratories, by inertia, they offer a serological test, known as the Widal reaction, and its result is often perceived as the final answer. In fact, it gives false positive results - after a past infection, after vaccination, with other fevers - and false negative ones in the first week, when antibodies have not yet been developed.

1. Посев крови — main метод; максимальная вероятность вырастить возбудителя приходится на первую неделю болезни, до начала антибиотиков.
2. Посев кала и мочи — информативнее со второй-третьей недели, а также используются для выявления носительства.
3. Посев содержимого костного мозга — самый чувствительный метод, сохраняющий информативность даже после начала лечения; применяется в сложных случаях.
4. ПЦР — быстрый метод, доступность и трактовка результата обсуждаются с врачом.
5. Общий анализ крови — характерно отсутствие роста лейкоцитов, что нетипично для большинства бактериальных инфекций, и исчезновение эозинофилов.
6. Биохимия, УЗИ органов брюшной полости — оценка печени, селезёнки, желчного пузыря и осложнений.

This leads to a simple rule of thumb: you need to donate blood for culture before the first antibiotic tablet. Self-medication for an unclear fever deprives the doctor of the main tool - after the start of therapy, the pathogen usually cannot be grown, and treatment must be done blindly and, in addition, without data on sensitivity, which is critical with modern resistance. The second rule concerns blood volume: cultures are taken in sufficient quantities and, if possible, repeated, because the concentration of bacteria in the blood is low, and a single test gives a negative result more often than is commonly thought.

Treatment and resistance of the pathogen

Typhoid fever is an infection for which an antibiotic is required: without treatment, the disease lasts four to six weeks and has a high incidence of complications. But the choice of drug has become dramatically more complicated over the past decades. The pathogen acquired resistance, first to the classical drugs with which it had been treated since the middle of the last century, then to the next generation of drugs, and in a number of regions strains appeared that were resistant to almost all available groups. Therefore, treatment is prescribed by a doctor taking into account the culture result and data on regional resistance, and treatment started at random often turns out to be ineffective.

• Hospitalization is indicated in most cases due to the risk of complications and the need for isolation
• Antibacterial therapy is long-term, the course is not interrupted when the temperature normalizes
• The temperature does not drop immediately: even with the right drug, it takes an average of 3–5 days, and this is not a sign of ineffectiveness
• Fluid replenishment, electrolyte correction, in severe cases - intensive care
• Strict bed rest and gentle nutrition during the period of intestinal ulceration
• Watching stool and pulse as early signs of bleeding
• After discharge - control cultures to exclude the formation of carriers

A separate topic is relapses. In some patients, the fever returns one to two weeks after the temperature normalizes. Typically, a recurrent episode is milder and shorter, but requires resumption of treatment, so observation does not end with the day of discharge. Another task of the recovery period is to identify the emerging carrier state: if, three months after the illness, bacteria continue to be released, the issue is resolved separately, and it is approached especially carefully in people with gallstones and in those whose work is related to cooking, teaching or treating people.

Vaccination, water and carriage

Prevention of typhoid fever consists of two parts: what can be done once, and what has to be done daily. Vaccination belongs to the first part. It is recommended for people traveling to regions with high incidence rates, workers whose activities are related to water supply and food, family members of an identified carrier, as well as for epidemic indications. Protection is not absolute and not lifelong: its duration is limited to a few years, after which repeated administration is required. That is why vaccination does not replace caution with water, but complements it.

• Drink only boiled or known safe bottled water, especially during the hot season and after water supply accidents
• Do not use ice in drinks outside the home if you do not know what kind of water it is made from.
• Wash fruits, vegetables and herbs with safe water; when traveling, give preference to what you can clean yourself
• There is hot and freshly prepared food; avoid food sitting on the counter
• Wash your hands with soap before eating and after using the toilet - the mode of transmission here is the same as for all intestinal infections
• Do not share utensils and towels with a person who has had an intestinal infection
• Undergo an examination when applying for employment in the food industry and do not treat it as a formality

Carriage deserves a separate discussion, because it is what maintains the existence of the disease. After suffering from typhoid fever, in about one to five people out of a hundred, bacteria continue to live in the gallbladder and are released for months and years. The carrier is not sick and has no complaints, and can only be detected by research. Older women and people with gallstone disease form carriers more often. When identified, the issue is resolved individually: there are treatment options, there are restrictions on working with products and people. Hiding such a result is pointless and dangerous - history knows of cases when one undetected carrier in the kitchen became the cause of dozens of diseases.