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How serious?
Risk of death
Yes
Vaccine available?
Time to symptoms
Countries affected
Active outbreaks
Risk is highest in South Asia, Sub-Saharan Africa, and parts of Southeast Asia. Vaccination reduces risk by 50–80%. Practice food and water precautions. Seek medical care for persistent high fever (>38.5°C) lasting more than 3 days.
Systemic bacterial infection caused by Salmonella Typhi, transmitted via contaminated food and water. A major travel health risk in South Asia with ~11 million cases annually.
Symptoms | Frequency | Severity | Onset |
|---|---|---|---|
| Fever | 99% | Moderate | Early |
| Headache | 80% | Mild | Early |
| Malaise | 75% | Mild | Early |
| Chills | 55% | Mild | Early |
| Fatigue | 65% | Mild | Early |
| Loss of appetite | 70% | Mild | Early |
| Myalgia | 60% | Mild | Early |
| Bradycardia | 40% | Mild | Peak |
| Hepatomegaly | 55% | Mild | Peak |
| High fever | 97% | Severe | Peak |
| Maculopapular rash | 20% | Mild | Peak |
| Splenomegaly | 40% | Mild | Peak |
| Abdominal pain | 50% | Mild | Peak |
| Bloating | 30% | Mild | Peak |
| Constipation | 35% | Mild | Peak |
| Dehydration | 30% | Moderate | Peak |
| Diarrhea | 40% | Mild | Peak |
| Nausea | 25% | Mild | Peak |
| Vomiting | 20% | Mild | Peak |
| Dark urine | 15% | Mild | Peak |
| Confusion | 15% | Severe | Late |
| Weight loss | 30% | Moderate | Late |
| Bloody stool | 4% | Severe | Late |
Bacterial infection spread through contaminated food and water.
Typhoid fever is a life-threatening systemic infection caused by Salmonella enterica serovar Typhi, a gram-negative bacterium exclusive to humans. Transmission is fecal-oral — via contaminated water, food prepared by carriers, or direct contact. The bacterium invades intestinal epithelium, spreads to reticuloendothelial organs (liver, spleen, bone marrow, lymph nodes), and causes sustained bacteremia. Without treatment, case fatality is 10–30%; with appropriate antibiotics, <1%. Paratyphoid fever (S. Paratyphi A, B, C) causes a clinically similar but generally milder illness.
Seek emergency medical care immediately if:
Sustained high fever (>39°C) not responding to antipyretics
Sudden severe abdominal pain (possible intestinal perforation — surgical emergency)
Bloody or black tarry stools (intestinal hemorrhage)
Confusion, delirium, or altered consciousness
Signs of shock: rapid pulse, low blood pressure, cold clammy skin
Persistent vomiting with inability to maintain hydration
Most common signs and symptoms
Incubation: 6–30 days (typically 8–14). Classic presentation follows a stepwise pattern:
Week 1:
Gradual onset of sustained fever rising in a "staircase" pattern to 39–40°C
Frontal headache, malaise, and myalgia
Relative bradycardia (pulse-temperature dissociation — Faget sign)
Dry cough in ~30% of patients
Constipation (more common than diarrhea in adults initially)
Week 2:
Sustained high fever (40–41°C)
Rose spots: faint salmon-colored maculopapular lesions on trunk (seen in 5–30%, more visible on light skin)
Abdominal distension and tenderness
Hepatosplenomegaly
Diarrhea ("pea soup" stools) may develop
Confusion or delirium in severe cases ("typhoid state")
Week 3 (untreated):
Progressive weakness and weight loss
Risk of intestinal hemorrhage or perforation peaks
Complications may become life-threatening
Week 4+: Gradual defervescence if patient survives. 1–5% become chronic carriers (gallbladder colonization).
Knowing the symptoms is the first step to a quick response.
Typhoid fever can progress from mild to severe forms, potentially leading to intestinal perforation and death.
How this disease is identified
Definitive diagnosis requires isolation of S. Typhi:
Blood culture: Gold standard; positive in 40–80% during week 1 (sensitivity decreases with antibiotic use). Collect before antibiotics.
Bone marrow culture: Most sensitive (80–95%); positive even after antibiotic exposure. Reserved for difficult cases.
Stool/urine culture: Positive from week 2 onward; useful for carrier detection
Widal test: Detects anti-O and anti-H agglutinins; widely available but poor sensitivity/specificity — NOT recommended as sole diagnostic
Typhidot/TUBEX (IgM rapid tests): Sensitivity 60–85%; useful in resource-limited settings for presumptive diagnosis
CBC: Leukopenia (not leukocytosis) is typical; thrombocytopenia in severe cases; elevated LFTs
Drug susceptibility testing is essential — multidrug-resistant (MDR) and extensively drug-resistant (XDR) typhoid is a growing global threat.
Available treatment methods
Antibiotic therapy (definitive treatment):
Uncomplicated (drug-susceptible): Fluoroquinolones — ciprofloxacin 500 mg BID × 7–14 days (first-line where susceptible); azithromycin 1 g day 1 then 500 mg × 5–7 days (WHO preferred for uncomplicated)
MDR typhoid: Azithromycin or cephalosporins (ceftriaxone 2 g IV daily × 10–14 days)
XDR typhoid (ceftriaxone-resistant): Azithromycin + carbapenems (meropenem); prevalent in Pakistan (Punjab/Sindh — ongoing XDR outbreak since 2016)
Severe/complicated: Ceftriaxone 2 g IV daily + dexamethasone 3 mg/kg then 1 mg/kg q6h × 48h (reduces mortality in severe typhoid with delirium per Hoffman 1984 study)
Supportive care:
Oral or IV rehydration
Antipyretics (avoid aspirin — bleeding risk)
Surgical consultation for suspected intestinal perforation
Follow-up stool cultures to confirm clearance and detect carriers
Most cases are effectively treated with early diagnosis.
How to protect yourself
Vaccination:
Vi polysaccharide (injectable — Typhim Vi): Single IM dose ≥2 weeks before travel; ~55–72% efficacy; revaccinate every 3 years if ongoing exposure. Age ≥2 years.
Ty21a (oral — Vivotif): 4 capsules on alternate days; ~50–67% efficacy; revaccinate every 5 years. Avoid with concurrent antibiotics/antimalarials (mefloquine). Requires refrigeration.
Typhoid conjugate vaccine (TCV — Typbar-TCV): WHO-prequalified 2018; single dose from 6 months; ~82% efficacy (TyVAC trial). Recommended by WHO for routine immunization in endemic countries.
Vaccination does NOT replace food/water precautions — efficacy is 50–80%, not absolute.
Food and water hygiene:
"Boil it, cook it, peel it, or forget it"
Avoid street food, raw salads, unpasteurized dairy, ice in drinks
Drink bottled/boiled water; use water purification tablets as backup
Preparation is the best protection.
Risk to travelers:
Very high risk: India (especially subcontinental), Pakistan (XDR), Bangladesh, Nepal
High risk: Indonesia, Philippines, Sub-Saharan Africa, Egypt
Vaccinate before ALL travel to South Asia — even short business trips carry risk
Typhoid vaccine provides only 50–80% protection — food/water hygiene is ESSENTIAL alongside vaccination
Carry oral rehydration salts and consider azithromycin as standby treatment (pre-discuss with travel clinic)
If visiting Pakistan: be aware of XDR typhoid — azithromycin is the only reliable oral option
Travelers who develop sustained fever (>38°C for >3 days) after returning from South Asia should report travel history and request blood cultures
Post-travel: seek medical evaluation for fever within 60 days of return from endemic areas
Statistics and geographic data
WHO estimates 11–21 million cases and 128,000–161,000 deaths annually (2019 GBD data). Highest incidence in South and Southeast Asia:
South Asia: India, Pakistan, Bangladesh, Nepal — incidence >100/100,000 per year; XDR typhoid spreading in Pakistan since 2016
Sub-Saharan Africa: Growing recognition of high burden; TCV introduction underway
SE Asia: Indonesia, Philippines, Vietnam — moderate incidence
Latin America: Declining due to improved sanitation but focal outbreaks persist
Travel-associated typhoid: ~500 cases/year in the US (70% from South Asia); ~300/year in UK. Attack rate in travelers to South Asia: 3–30 per 100,000 trips. India accounts for >60% of travel-associated typhoid globally. Antimicrobial resistance is the primary clinical challenge — XDR strains (resistant to chloramphenicol, ampicillin, co-trimoxazole, fluoroquinolones, AND ceftriaxone) now dominant in parts of Pakistan.
Who is most at risk
Traveling to endemic areas, consuming contaminated food or water, poor hygiene practices.
Potential complications
Untreated typhoid has 10–30% case fatality. Major complications:
Intestinal hemorrhage: Occurs in 1–4% during weeks 2–3
presents as melena or frank hematochezia
may cause hemorrhagic shock
Intestinal perforation: 1–3% of cases
typically ileal
requires emergency surgery
mortality 30–60% even with treatment
Hepatitis/hepatic abscess: Elevated transaminases in ~50%
frank hepatitis in 5%
Myocarditis: Rare but potentially fatal
presents as tachycardia, hypotension, ECG changes
Encephalopathy (typhoid psychosis): Delirium, confusion, obtundation
associated with high mortality
Osteomyelitis: More common in sickle cell disease patients
Chronic carriage: 1–5% excrete S. Typhi for >1 year (gallbladder colonization)
major public health concern — treatable with prolonged antibiotics ± cholecystectomy
Relapse: 5–20% of treated patients relapse 2–3 weeks after defervescence
Expected outcomes and recovery
Prognosis is good with appropriate antibiotic treatment. Untreated cases can be fatal.
This disease is vaccine-preventable. Effective protection is available through vaccination.
Talk to a travel health specialist about the recommended schedule before your trip.
Find a vaccination clinic →The content on this page is for informational and educational purposes only. It does not constitute medical advice, diagnosis, or treatment recommendations. If you have health concerns, consult a qualified healthcare professional. Medova is not a medical service provider.
Full terms of useGeographic distribution and active outbreaks
| Flag | Country | Risk level |
|---|---|---|
 | Pakistan | High risk |
 | Bangladesh | High risk |
 | Nepal | High risk |
 | Democratic Republic of the Congo | High risk |
 | Myanmar | High risk |
 | India | High risk |
 | Afghanistan | High risk |
 | Ethiopia | High risk |
 | Nigeria | High risk |
 | Cambodia | High risk |
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