clinical picture:
Typhus abdominalis can occur worldwide. In Germany, this disease has been greatly reduced by hygienic measures, but even here occasionally flickering cases of the disease must be expected. This danger is mainly due to the introduction of typhoid fever by travellers.

Epidemiology
The causative agent of abdominal typhus occurs worldwide. More than 43 million diseases are reported every year, 200 of them in Germany. However, the number of unreported cases is likely to be high. The risk of infection varies from country to country, depending on the hygienic conditions.

It is highest in North and Central Africa, as well as in Mexico. In principle, all warm countries are particularly affected. More and more typhoid fever cases are being introduced into Germany from these regions.

For the traveler, the degree of risk depends on the standard of hygiene of the trip. Club trips and stays in international hotels are less dangerous. Trekking travelers are more frequently affected. Even when behaving carefully, the danger of infection cannot be excluded completely. One does rarely look behind the kitchen door of the restaurants.

Pathogens and infection
Salmonella typhi is a gram-negative stick with peritric flagellae. Infections occur almost exclusively orally. Sources are direct or indirect infection from person to person, contact with the sick and permanent elimination. Particular sources of danger are drinking water, milk, meat and other foodstuffs, e.g. potato salad, contaminated by typhoid faeces. If stored improperly, the pathogens multiply massively. Cooking kills the germs. This means that the main source of danger is raw, uncooked food, especially if it has been stored for a long time.

The duration of contagiousness varies. It remains until the stool and urine are completely sterile.

A special danger are permanent excretors, which can spread the disease under for many years. 5% of those who are ill or infected become permanent excluders and thus sources of infection for others.

In Germany, about 1,700 permanent dropouts are registered annually. The disease must be reported. All registrations are checked by the health authorities. During the period of elimination, activities in the food sector are prohibited. Thus the infection is even partially existence-threatening for special occupational groups.

Disease pattern
The incubation period is 3 to 60 days, usually from 10 to 14 days. The susceptibility to the disease depends on the general condition and exposure, but stomach acidity also plays an important role, which is why extreme gluttony should be avoided. The number of ingested salmonella seems to be a decisive factor in the onset of the disease, therefore the freshness of food preparation is a safety factor.

In contrast to other types of salmonella, the typhoid pathogen is overcoming the intestinal barrier, so that the infection affects the whole body. The onset of the disease is uncharacteristic, including dullness, headaches and a slow, stepped rise in fever. After the Prodromi, which are lasting for about one week, the so-called Continua with temperatures around 40°C starts for one to two weeks. There is a strong influence of the sensorium. Typical is the greyish-yellow coated “typhoid tongue”. Other signs are relative bradycardia, leukopenia (2,000 to 4,000), and a shift to the left. From the 10th day of illness, roseoles form on the abdominal skin. Spleen swelling, pea-like diarrhoea, hair loss, decubitus. If there are no complications, a gradual defevering begins in the 4th week after the morning fever remission. The convalescence is long lasting. Complications may include toxic circulatory failure, intestinal bleeding, intestinal ulcers, with possible intestinal perforation, peritonitis, pneumonia, myocarditis, splenic rupture, thrombosis, meningoencephalitis, cholangitis, cholecystitis and osteomyelitis. Therefore the disease must be classified as life-threatening. Of course, adventure travelers without appropriate medical care are particularly at risk.

Typhoid fever is therefore, especially in the early stages, not so much a disease of the intestine, but of the whole organism.

Laboratory diagnosis
During the first two weeks of the disease, the typhus disease is diagnosed by blood culture. From the end of the second week, bacteriological examinations of stool, bile and urine are carried out.

Preliminary serological tests can be performed after 24 to 48 hours with slide agglutination. The final result can be determined after 3 days at the earliest. The detection with the Gruber-Widal agglutination sample can be carried out at the earliest towards the end of the first week of the disease. The increase in titre is supporting the diagnosis.

Therapy
The treatment is carried out with liquid and electrolyte substitutes, as well as with a high-calorie diet and general nursing measures. Toxic forms are being treated with Glucocorticosteroids. Cefotaxim and cotrimoxazole are used for specific pathogens. The treatment options are relatively good if therapy starts early. Toxic damage, that has already occurred, is usually no longer reversible. Thus about 20% of the patients die, often because the diagnosis is made too late.

Treatment must always be in-patient, which is a problem for tourists in many countries. This is another reason why prevention is of crucial importance.

Prophylaxis
The most important protection is an appropriate behavior. In endangered regions, only boiled and stewed dishes should be eaten as far as possible. Drinks must be boiled or packed in their original packaging. Ice cubes can also contain pathogens that can multiply.

Typhoid vaccination & vaccination indication
The typhoid vaccination should always be carried out, if there is a comparably high risk for the traveler due to this disease.
The indication for a typhoid vaccination depends on the following factors:

  • vom Reiseziel: Tropische oder subtropische Regionen; Regionen mit niedrigem Hygienestandard; Endemiegebiete oder Epidemiegebiete
  • von der Art des Reisens
  • from the destination: tropical or subtropical regions; low hygiene regions; endemic or epidemic areas
  • the type of the trip
  • Business travelers: They are often particularly at risk, as they are unable to pick out the restaurants themselves, when they receive invitations.
  • Trekking travelers under poor hygiene conditions
  • Adventure trips with visits to hotels or restaurants of lower categories
  • longer working stays in warm countries (G35 of the guidelines of the employers’ liability insurance association).
  • Vaccination is particularly important for children, as they usually do not take hygiene very seriously and often put everything in their mouths.

Nur relativ ist die Indikation zu stellen bei Pauschalreisen in guten Hotels oder Clubanlagen ohne intensiven Besuch des Landes. Dies gilt ebenso für Schiffsreisen. Bergsteiger und andere Reisende, die sich ausschließlich selbst versorgen, sind kaum gefährdet, wenn sie die elementaren Grundregeln der Nahrungsmittelhygiene beachten.Prinzipiell ist die Indikation bei der guten Verträglichkeit dieser Impfung eher großzügig zu stellen. Wir versuchen in unserer Impfpraxis beide Impfstoffe immer abwechselnd zu impfen, um einen höheren Schutzfaktor für die Typhusimpfung zu erreichen.

Only a relative indication is to be given for package holidays in good hotels or club facilities without intensive on-site visits to the country. This also applies to ship trips. Mountaineers and other self-sufficient travelers are rarely at risk, as long as they follow the basic rules of food hygiene.

In principle, the indication for the good tolerability of this vaccination is rather generous. In our vaccination practice we always try to vaccinate both vaccines alternately, in order to achieve a higher protection factor for the typhoid vaccination.

Vaccine
There are two highly effective and well tolerated vaccines currently approved in Germany:

The oral typhoid vaccine: A total of three tablets are taken at intervals of two days. The cold chain is to be considered. The capsules must be swallowed as a whole, which can restrict their use in small children. Even after own experiences, side effects are rare and limited mostly to lighter stomach intestine disturbances on the income days. For travelers, the duration of protection is 1 year, for stays in endemic areas up to three years. A simultaneous intake with mefloquine or antibiotics inhibits the effectiveness. Maintaining the cold chain is important. The capsules must be swallowed as a whole, according to the instructions, which sometimes causes difficulties.

The parenteral vaccine: This is administered as an injection. Its duration of protection is three years and it is approved for children aged 2 and over. Side effects are extremely rare and usually limited to mild irritations at the injection site. Parenteral vaccination is particularly important for children, who often have problems swallowing large tablets. For both vaccines there is no time gap to other vaccinations to be observed. The recommendations on the respective instructions for use apply.
Both vaccines protect against severe typhus abdominalis disease. They cannot prevent minor diarrhoeal diseases. Therefore, eating and drinking hygiene must be observed despite vaccination.