Typhoid fever is a bacterial infection caused by the bacterium Salmonella typhi that spreads across human populations. In developing countries, typhoid fever is known as a public health challenge and mostly spreads through contaminated water, killing thousands a year. Here, we will explore the impacts of typhoid fever in developing countries.

Overview

Overview of typhoid fever

Typhoid fever, also known as enteric fever, is caused by Salmonella enterica serovar typhi (S. typhi) and is spread via the faecal-oral route, when faecal matter contaminates food, water, hands or high-contact surfaces at homes.^1,2 S. typhi invades the body through the small intestines. Following contact, it undergoes an incubation period between a range of 6-30 days, but more generally 10-14 days.³ The initial symptoms of typhoid fever are fatigue and a fever that starts light but gets worse over the day. Meanwhile, later symptoms of typhoid fever include:

• Severe lack of appetite
• Chills
• Stomach pain
• Rose spots on the chest or stomach area
• Nausea
• Intestinal perforation
• Neurological complications³ 

In children, diarrhoea, vomiting, and fever-related seizures are some of the more common symptoms of typhoid fever.³ Symptoms of the infection last between 7-21 days.¹

Epidemiology of typhoid fever

Typhoid fever is a global health issue with a worldwide estimation of up to 21 million cases and 110,000 deaths each year. It is most commonly seen in Sub-Saharan Africa but appears to a lesser extent in South Asia, Southeast Asia and South America, particularly in areas lacking proper sewerage systems.^1,3 In America and Europe, where typhoid fever isn’t common, people that do test positive for the bacteria are people who have recently travelled to endemic areas. Children, especially young children between the ages of 2-4, are the most at risk of contracting typhoid fever.¹

Health impact of typhoid fever

Complications

Typhoid fever has a range of symptoms, including fever, fatigue, rose spots and nausea. A delay in treatment can lead to more severe symptoms of typhoid fever, such as:

• Intestinal perforation
• Intestinal haemorrhage
• Liver inflammation, or hepatitis
• Anaemia
• Pneumonia
• Gallbladder inflammation, or cholecystitis⁴

Intestinal perforation is a particularly fatal symptom of typhoid fever. Even with medical attention, up to 1 in 5 patients pass away from intestinal perforation-related complications.⁴ In some areas, perforation is a common cause of surgery in both adult and child populations.⁵

Antibiotic resistance

Over the last 4 decades, there has been a steep increase in multidrug-resistant strains of S. typhi, making treatment more difficult. Previous first-line treatments, which were ampicillin, chloramphenicol and co-trimoxazole, fell out of use following widespread resistance in the 1980s.³ An increase in resistance to the fluoroquinolone class, such as ciprofloxacin, and 3rd generation cephalosporins, such as ceftriaxone and cefotaxime, means these classes of drugs are no longer effective in treating typhoid fever, while certain strains of S. typhi found in Pakistan are only sensitive to a single antibiotic class.⁶ Determining the antibiotic that a particular strain has sensitivity towards can be expensive and time-consuming, causing a delay in treatment that can prove fatal in severe cases of typhoid fever.

Public health issues

In more rural areas, a lack of understanding of typhoid fever can prevent patients from getting proper treatment until their symptoms have worsened. Early symptoms of typhoid fever, such as fatigue and fever, are nonspecific; they can’t be associated with one condition or illness. It’s common for people in early treatment stages to take paracetamol and continue working, especially if other people in their proximity have not recently shown symptoms of typhoid fever.⁷

A lack of rapid diagnostic tools also affects how quickly treatment can begin for typhoid fever.⁵ In rural areas, these diagnostic tools can be difficult to find, requiring patients to travel further in order to seek help for their symptoms.

Chronic carriers are people who have recovered from typhoid fever but still carry the S. typhi bacteria in their gallbladder.⁶ They can unknowingly spread the bacteria for up to a year after symptoms improve. However, this is more common if the full course of antibiotics was not completed.³

Socio-economic impacts

Household impact

For families in developing countries, treatment for typhoid fever is often followed by a period of economic difficulty. Direct costs can range from inexpensive to incredibly expensive, while indirect costs can be higher than the price of treatment itself. In some countries, even the low price of medicine can be deemed expensive due to the high cost of living in the local area.⁷ In a small percentage of patients, inpatient costs exceeded monthly family income.⁸

People in rural areas especially experience economic hardship if the patient suffers from a severe case of typhoid fever. Travelling to hospitals in more populated areas and hotel lodgings can be more expensive than the cost of medical treatment itself.^7,8 There is also an indirect cost due to a loss of income from missing days of work for patients of working age and the parents of unwell children.⁷

Complications of typhoid fever are another factor that increases the cost of treatment. In Niger, surgery to treat intestinal perforation can cost up to $551, while in India, it is up to $1735. The development of anaemia, another long-term complication of typhoid fever, can mean frequent hospital visits and long-term medication use, increasing the total cost of treatments. Other complications lead to patients requiring special diets and taking supplements following typhoid fever, further surging the financial costs of the condition.⁷ In areas with extensive drug resistance, laboratory costs can often be the highest expense. For example, in Pakistan, the average cost of treatment for S. typhi strains with extensive drug resistance was $223. 

Community impact

Typhoid fever reduces productivity, especially in areas where the main source of income is from manual labour, such as agriculture. In some studies, patients report typhoid fever leading to a loss of routine for household chores.⁷ Children who have to take time off school due to sickness or because their family can no longer afford their tuition fees will be behind their peers.⁸ In situations where a family is in debt from typhoid fever costs, food and other necessities will be reduced to make ends meet.

Often, families ask for help from their community. They borrow money from family or employers and ask family or close friends to take care of the unwell, though in areas where the cost of living is relatively high and people are unable to create savings, this takes time and money away from the community.⁷

Contributing factors to typhoid fever in developing countries

Infrastructure and sanitation

The main contributing factor to typhoid fever in developing countries is sewage contamination. Human waste entering the water or food supply is the most common way for S. typhi to spread amongst human populations. To further prove this point, typhoid fever has been found to decrease in areas after the development of sanitation systems.² Poor hand sanitation is another contributing factor.

Healthcare system limitations

Healthcare systems in developing countries can lack the funds and resources to manage typhoid fever. A lack of education on typhoid fever means people may not recognise the signs of it or how to properly prevent it.⁵ Limited vaccine access leaves people most at risk, vulnerable to the disease.

Climate

Climate change is predicted to be a major factor in the increase of typhoid fever cases. Flooding can contaminate food and the clean water supply, while droughts can reduce the drinking water supply.⁶

Strategies for mitigation

The impact of typhoid fever in developing countries can only be reduced with national and global cooperation. Surveillance and reporting of outbreaks of antibiotic resistance are necessary, but are only possible with investment in local healthcare systems.⁶ Educating the population is essential to help the people most vulnerable to typhoid fever learn the symptoms, treatment options and ways to prevent infections.

The WASH regimen, standing for water, sanitation and hygiene, can be used to reduce the spread of typhoid fever. WASH works by cleaning water through the use of a sewage system and promoting safe hand and food hygiene practices.

In developed countries, typhoid fever cases were reduced following the development of sewage sanitation systems, though this is expensive and, in many places, will take a long time to develop.² Vaccines are a cheaper, faster way of protecting the population. Newer forms of vaccines can be given to infants as young as 6 months, and are effective for many years.^3,6

Summary

Typhoid fever is a bacterial infection that has significant disadvantages on the health, society and economies of the affected populations. Reducing the incidence of typhoid fever is only possible through education, vaccination and investment into sanitation systems in developing countries.