How to prevent typhoid fever while eating out on your trip

Eating at a restaurant in Ubud, Bali

The name itself is a little confusing.  Typhoid fever sounds too much like typhus fever, a completely different disease.  Typhoid fever is caused by the bacteria Salmonella typhi, whereas typhus fever is caused by bacteria in the Rickettsia family. You can get typhoid fever from eating or drinking contaminated food or water.  You can get typhus fever by being bitten by an infected human body louse or tick.  Which disease wins in the popularity contest of diseases in U.S. travelers?  Typhoid fever wins by an overwhelming majority.

The CDC estimates that there are about 21 million cases of typhoid fever and 200,000 related deaths each year.  Each year, there are about 5,700 cases of typhoid fever in U.S travelers, most who got the disease while traveling in a developing country.  Which countries have the most cases of typhoid fever?  SOUTH ASIAN COUNTRIES, including INDIA AND PAKISTAN,  have a 6-30X higher risk than other countries.  However, other areas with a high risk of typhoid fever include Southeast Asia, East Asia, Africa, Central and South America, and the Caribbean. Essentially most places you would visit outside of North America, Western Europe, Australia, and New Zealand have a risk of typhoid fever.

So how bad is getting typhoid fever?  Typhoid fever usually causes high fevers, headache, malaise, decreased appetite, enlarged liver or spleen, or a rash consisting of pink “rose spots.”  Diarrhea is uncommon. The serious complications of typhoid fever include intestinal hemorrhage or perforation, which can lead to death.  In the pre-antibiotic era, the fatality rate was up to 20-30%.  Now, antibiotics are the treatment of choice for typhoid fever.  But even with the right antibiotic, it can still take 3-5 days for people with typhoid fever to start feeling better.  Children who get typhoid fever may need to be treated as an inpatient in the hospital.  The incubation period for typhoid fever is 6-30 days.  So even if you’re back home from your travels, remember to tell your doctor about your travel history if you get a high fever.

Families often ask me during a pre-travel visit, “How do I prevent typhoid fever?  First of all, practicing SAFE FOOD AND WATER PRECAUTIONS is very important.  See my previous post “Is this safe to eat?”  for more details on these very essential tips. The same precautions used to prevent traveler’s diarrhea will also prevent typhoid fever.  However, we also know that people who are known as “asymptomatic carriers” can pass typhoid fever on to another person.   For example, if a restaurant waitress, who has recently recovered from typhoid fever, does not wash her hands with soap and water after using the restroom, she can contaminate the food or drinks she serves to a customer.  From my experience, it is RARE to find soap in restaurant bathrooms in Asia.  Have you ever heard of the case of Typhoid Mary?  In 1900, Mary Mallon, aka Typhoid Mary, was a cook in NYC and the first person in the U.S. to be identified as an asymptomatic carrier.  She unknowingly infected 51 people, 3 of whom died.  She spent nearly 30 years in isolation before she died.

GETTING THE TYPHOID FEVER VACCINE before your trip will also prevent typhoid fever.  There are 2 safe typhoid fever vaccines available that offer 50-80% protection from the disease.  The injectable Typhim Vi vaccine  can be given to people age 2 and older.  The oral live attenuated typhoid vaccine, Vivotif, can be given to people age 6 and older, who can swallow pills (4 relatively large pills over the course of 7 days).  The oral vaccine needs to be refrigerated and completed at least 1 week before your trip.  The injectable vaccine is best given 2 weeks before your trip to give time for the immunization to work.   But even if your trip is in a few days, it is still better to get the vaccine late than not getting it at all. For the repeat travelers, the injectable Typhim vaccine will need to be given again in 2 years and the oral Vivotif vaccine will need to be given again in 5 years.  Side effects of typhoid vaccines are uncommon and mild.  For the typhoid shot, fever, headache, and local skin reactions are the usual side effects.  For the oral typhoid vaccine, fever, headache, and the rare stomach upset can occur.

Typhoid fever vaccine is the #1 vaccine I recommend most for travelers to developing countries.  Primarily because this disease is still so common in developing countries, where sanitation is poor and contaminated water is common.  I love to eat at local restaurants when I travel, but I cannot guarantee the safety of their food or the level of hygiene their staff practices.  And knowing how ill people with typhoid fever can get was the primary reason why I vaccinated myself and my daughter from this disease before our trip to East and Southeast Asia.

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