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• Fact sheets /
• As of 2019, an estimated 9 million people get sick from typhoid and 110 000 people die from it every year.
• Symptoms include prolonged fever, fatigue, headache, nausea, abdominal pain, and constipation or diarrhoea. Some patients may have a rash. Severe cases may lead to serious complications or even death.
• Typhoid fever can be treated with antibiotics although increasing resistance to different types of antibiotics is making treatment more complicated.
• The typhoid conjugate vaccine is recommended for use in children from 6 months of age and in adults up to 45 years or 65 years (depending on the vaccine).

Two typhoid conjugate vaccines have been prequalified by WHO since December 2017 and are being introduced into childhood immunization programmes in typhoid endemic countries.

Typhoid fever is a life-threatening infection caused by the bacterium  Salmonella  Typhi. It is usually spread through contaminated food or water. Once  Salmonella  Typhi bacteria are ingested, they multiply and spread into the bloodstream.

Urbanization and climate change have the potential to increase the global burden of typhoid. In addition, increasing resistance to antibiotic treatment is making it easier for typhoid to spread in communities that lack access to safe drinking water or adequate sanitation.

Salmonella  Typhi lives only in humans. Persons with typhoid fever carry the bacteria in their bloodstream and intestinal tract. Symptoms include prolonged high fever, fatigue, headache, nausea, abdominal pain, and constipation or diarrhoea. Some patients may have a rash. Severe cases may lead to serious complications or even death. Typhoid fever can be confirmed through blood testing.

Epidemiology, risk factors and disease burden

Improved living conditions and the introduction of antibiotics resulted in a drastic reduction of typhoid fever morbidity and mortality in industrialized countries. However, the disease continues to be a public health problem in many developing areas of the WHO African, Eastern Mediterranean, South-East Asia and Western Pacific Regions.

As of 2019 estimates, there are 9 million cases of typhoid fever annually, resulting in about 110 000 deaths per year.

Typhoid risk is higher in populations that lack access to safe water and adequate sanitation, and children are at highest risk.

Typhoid fever can be treated with antibiotics.  Antimicrobial resistance is common with likelihood of more complicated and expensive treatment options required in the most affected regions.

Even when the symptoms go away, people may still be carrying typhoid bacteria, meaning they can spread it to others, through shedding of bacteria in their faeces.

It is important for people being treated for typhoid fever to do the following:

• Take prescribed antibiotics for as long as the doctor has prescribed.
• Wash their hands with soap and water after using the bathroom and avoid preparing or serving food for other people. This will lower the chance of passing the infection on to someone else.
• Have their doctor test to ensure that no  Salmonella  Typhi bacteria remain in their body.

Typhoid fever is common in places with poor sanitation and a lack of safe drinking water. Access to safe water and adequate sanitation, hygiene among food handlers and typhoid vaccination are all effective in preventing typhoid fever.

Typhoid conjugate vaccine, consisting of the purified Vi antigen linked to a carrier protein, is given as a single injectable dose in children from 6 months of age and in adults up to 45 years or 65 years (depending on the vaccine).

Two additional vaccines have been used for many years in older children and adults at risk of typhoid, including travellers. These vaccines do not provide long-lasting immunity (requiring repeat or booster doses) and are not approved for children younger than 2 years old:

• an injectable vaccine based on the purified antigen for people aged 2 years and above; and
• a live attenuated oral vaccine in capsule formulation for people aged over 6 years.

All travellers to endemic areas are at potential risk of typhoid fever, although the risk is generally low in tourist and business centres where standards of accommodation, sanitation and food hygiene are high. Typhoid fever vaccination should be offered to travellers to destinations where the risk of typhoid fever is high.

The following recommendations will help ensure safety while travelling:

• Ensure food is properly cooked and still hot when served.
• Avoid raw milk and products made from raw milk. Drink only pasteurized or boiled milk.
• Avoid ice unless it is made from safe water.
• When the safety of drinking water is questionable, boil it, or if this is not possible, disinfect it with a reliable, slow-release disinfectant agent (usually available at pharmacies).
• Wash hands thoroughly and frequently using soap, in particular after contact with pets or farm animals, or after having been to the toilet.
• Wash fruits and vegetables carefully, particularly if they are eaten raw. If possible, vegetables and fruits should be peeled.

WHO response

In October 2017, the Strategic Advisory Group of Experts on Immunization (SAGE), which advises WHO on vaccine use, issued a recommendation for the typhoid conjugate vaccine to be added to routine childhood immunization programmes in typhoid endemic countries. SAGE also called for the introduction of typhoid conjugate vaccine to be prioritized for countries with the highest burden of typhoid disease or high levels of antibiotic resistance to  Salmonella  Typhi.

Starting in 2019, Gavi, the Vaccine Alliance has provided funding to support typhoid conjugate vaccine use in eligible countries.

As at March 2023, WHO has prequalified two conjugate vaccines for the prevention of typhoid. Typhoid conjugate vaccine has longer-lasting immunity than the older typhoid vaccines and can be given as a single dose to children from the age of 6 months.

In addition to decreasing the disease burden in endemic countries and saving lives, widespread use of the typhoid conjugate vaccine in affected countries is expected to reduce the need for antibiotics for typhoid treatment and slow the increase in antibiotic resistance in  Salmonella  Typhi.

• WHO typhoid vaccine position paper
• Immunization schedule
• Guide on safe food for travellers
• WHO's work on typhoid

Typhoid Fever

• Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
• Sections Typhoid Fever
• Pathophysiology
• Epidemiology
• Physical Examination
• Complications
• Approach Considerations
• Laboratory Studies
• Imaging Studies
• Histologic Findings
• Medical Care
• Surgical Care
• Consultations
• Antibiotics
• Corticosteroids
• Glycylcyclines
• Carbapenems
• Further Outpatient Care
• Further Inpatient Care
• Deterrence/Prevention
• Patient Education
• Questions & Answers

Typhoid fever, or enteric fever, is a potentially fatal multisystemic infection produced primarily by Salmonella enterica serotype typhi and to a lesser extent Salmonella enterica serotypes and paratyphi A, B, and C. Salmonella are motile enterobacteriaceae that can produce a variety of gastrointestinal infections. The most serious of these is typhoid that is primarily produced by Salmonella enterica serotype typhi and, to a lesser extent, S enterica serotypes paratyphi A, B, and C. It presents in a wide variety of ways ranging from an overwhelming septic illness to minor cases of diarrhea with low-grade fever. The classic presentation is one of fever, malaise, diffuse abdominal pain, and constipation . Untreated typhoid fever may progress to delirium , obtundation, intestinal hemorrhage, bowel perforation, and death within 1 month of onset. Survivors may be left with long-term or permanent neuropsychiatric complications.    The term typhoid derived from the ancient Greek word for cloud, was chosen to emphasize the severity and long lasting neuropsychiatric effects among the untreated. Yearly, 21 million people acquire typhoid fever throughout the world. It is fatal in approximately 161,000. Over the years, it has developed increasing resistance to antibiotics. During 2016, extensively drug-resistant typhoid (XDR) were documented in Pakistan. Only three classes of antimicrobial agents, azithromycin, carbapenems, and tigecycline, remain affective among these strains. [ 1 ]  

Typhoid thrives    in conditions of poor sanitation, crowding, and social chaos. [ 1 ]  Although antibiotics have markedly reduced the frequency of typhoid fever in the developed world, it remains endemic in developing countries. The incidence of infections with S paratyphi may be surpassing those due to S typhi . This may be due to the immunologic naïveté of a given population as well as the incomplete coverage provided by current Typhoid vaccines against these pathogens. Non -Typhoidal strains usually produce mild, self-limiting gastroenteritis. [ 2 ]

Pathogenic Salmonella species are engulfed by the phagocytic cells of the gut, which then present them to the macrophages of the lamina propria. By means of their toll-like receptor (TLR)–5 and TLR-4/MD2/CD-14 complexes, the macrophages recognize pathogen-associated molecular patterns (PAMPs) such as flagella and lipopolysaccharides. Macrophages and intestinal epithelial cells then mobilize T cells and neutrophils with interleukin 8 (IL-8). Hopefully, the resulting inflammation will be adequate to suppress the infection. [ 3 , 4 ]

  S typhi and paratyphi enter the host's system primarily through the distal ileum. They have specialized fimbriae that adhere to the epithelium over clusters of lymphoid tissue in the ileum (Peyer patches), the main relay point for macrophages traveling from the gut into the lymphatic system. The bacteria then induce their host macrophages to attract more macrophages. [ 3 ]

S typhi has a Vi capsular antigen that masks PAMPs, avoiding neutrophil-based inflammation, whereas the most common paratyphi serovar, paratyphi A , does not. This may explain the greater infectivity of Typhi as compared with paratyphi isolates. [ 5 ]

In addition,serotypes typhi and paratyphi are able to Quorum Sense. This is a type of intracellular communication by which the organisms coordinate swarming and biofilm production. [ 6 ]

Typhoidal salmonella co-opt the macrophages' cellular machinery for their own reproduction [ 7 ] as they are carried through the mesenteric lymph nodes to the thoracic duct and the lymphatics and then through to the reticuloendothelial tissues of the liver, spleen, bone marrow, and lymph nodes. Once there, they pause and continue to multiply. When a critical density is reached, the bacteria bring about macrophage apoptosis.This allows salmonella to enter the bloodstream [ 4 ]

The bacteria then infect the gallbladder via either bacteremia or direct extension of infected bile. The result is that the organism re-enters the gastrointestinal tract in the bile and reinfects Peyer patches. Bacteria that do not reinfect the host are shed in the stool and so become available to infect others. [ 2 , 4 ]  

Chronic carriers are responsible for much of the transmission of the organism. While asymptomatic, they may continue to shed bacteria in their stool for decades. The organisms sequester themselves either as a biofilm on gallstones or gallbladder epithelium or, perhaps, intracellularly, within the epithelium itself. [ 8 ] The bacteria excreted by a single carrier may have multiple genotypes, making it difficult to trace an outbreak to its origin. [ 9 ]

Risk factors

Typhoidal salmonella have no nonhuman vectors. An inoculum as small as 100,000 organisms of typhi causes infection in more than 50% of healthy volunteers. [ 10 ]   Paratyphi requires a much higher inoculum to infect, and it is less endemic in rural areas. Hence, the patterns of transmission are slightly different.

The following are modes of transmission of typhoidal salmonella:

Oral transmission via food or beverages handled by an often asymptomatic individual—a carrier—who chronically sheds the bacteria through stool or, less commonly, urine

Hand-to-mouth transmission after using a contaminated toilet and neglecting hand hygiene

Oral transmission via sewage-contaminated water or shellfish (especially in the developing world). [ 11 , 12 , 13 ]

Paratyphi is more commonly transmitted in food from street vendors. It is believed that some such foods provide a friendly environment for the microbe.

Paratyphi is more common among newcomers to urban areas, probably because they tend to be immunologically naïve to it. Also, travellers get little or no protection against paratyphi from the current typhoid vaccines, all of which target typhi . [ 14 , 15 ]

Typhoidal salmonella are able to survive a stomach pH as low as 1.5. Antacids, histamine-2 receptor antagonists (H2 blockers), proton pump inhibitors, gastrectomy, and achlorhydria decrease stomach acidity and facilitate S typhi infection. [ 4 ]

HIV/AIDS is clearly associated with an increased risk of nontyphoidal Salmonella infection; however, the data and opinions in the literature as to whether this is true for S typhi or paratyphi infection are conflicting. If an association exists, it is probably minor. [ 16 , 17 , 18 , 19 ]

Other risk factors for typhoid fever include various genetic polymorphisms. These risk factors often also predispose to other intracellular pathogens. For instance, PARK2 and PACGR code for a protein aggregate that is essential for breaking down the bacterial signaling molecules that dampen the macrophage response. Polymorphisms in their shared regulatory region are found disproportionately in persons infected with Mycobacterium leprae and S typhi . [ 12 ]

On the other hand, protective host mutations also exist. The fimbriae of S typhi bind in vitro to cystic fibrosis transmembrane conductance receptor (CFTR), which is expressed on the gut membrane. Two to 5% of white persons are heterozygous for the CFTR mutation F508del, which is associated with a decreased susceptibility to typhoid fever, as well as to cholera and tuberculosis . The homozygous F508del mutation in CFTR is associated with cystic fibrosis. Thus, typhoid fever may contribute to evolutionary pressure that maintains a steady occurrence of cystic fibrosis, just as malaria maintains sickle cell disease in Africa. [ 20 , 21 ]

As the middle class in south Asia grows, some hospitals there are seeing a large number of typhoid fever cases among relatively well-off university students who live in group households with poor hygiene. [ 22 ] American clinicians should keep this in mind, as students from these areas often come to the United States for further education. [ 23 ]

United States

Since 1900, improved sanitation and successful antibiotic treatment have steadily decreased the incidence of typhoid fever in the United States. In 1920, 35,994 cases of typhoid fever were reported. In 2006, there were 314.

Between 1999 and 2006, 79% of typhoid fever cases occurred in patients who had been outside of the country within the preceding 30 days. Two thirds of these individuals had just journeyed from the Indian subcontinent. The 3 known outbreaks of typhoid fever within the United States were traced to imported food or to a food handler from an endemic region. Remarkably, only 17% of cases acquired domestically were traced to a carrier. [ 24 ]

International

Typhoid fever occurs worldwide, primarily in developing nations whose sanitary conditions are poor. Typhoid fever is endemic in Asia, Africa, Latin America, the Caribbean, and Oceania, but 80% of cases come from Bangladesh, China, India, Indonesia, Laos, Nepal, Pakistan, or Vietnam. [ 25 ] Within those countries, typhoid fever is most common in underdeveloped areas. Typhoid fever infects roughly 21.6 million people (incidence of 3.6 per 1,000 population) and kills an estimated 200,000 people every year. [ 26 ]

In the United States, most cases of typhoid fever arise in international travelers. The average yearly incidence of typhoid fever per million travelers from 1999-2006 by county or region of departure was as follows [ 24 ] :

Western Hemisphere outside Canada/United States - 1.3

Africa - 7.6

Asia - 10.5

India - 89 (122 in 2006)

Total (for all countries except Canada/United States) - 2.2

Mortality/Morbidity

With prompt and appropriate antibiotic therapy, typhoid fever is typically a short-term febrile illness requiring a median of 6 days of hospitalization. Treated, it has few long-term sequelae and a 0.2% risk of mortality. [ 24 ] Untreated typhoid fever is a life-threatening illness of several weeks' duration with long-term morbidity often involving the central nervous system. The case fatality rate in the United States in the pre-antibiotic era was 9%-13%. [ 27 ]

Typhoid fever has no racial predilection.

Fifty-four percent of typhoid fever cases in the United States reported between 1999 and 2006 involved males. [ 24 ]

Most documented typhoid fever cases involve school-aged children and young adults. However, the true incidence among very young children and infants is thought to be higher. The presentations in these age groups may be atypical, ranging from a mild febrile illness to severe convulsions, and the S typhi infection may go unrecognized. This may account for conflicting reports in the literature that this group has either a very high or a very low rate of morbidity and mortality. [ 22 , 28 ]

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Hanel RA, Araujo JC, Antoniuk A, et al. Multiple brain abscesses caused by Salmonella typhi: case report. Surg Neurol . 2000 Jan. 53(1):86-90. [QxMD MEDLINE Link] .

Koul PA, Wani JI, Wahid A, et al. Pulmonary manifestations of multidrug-resistant typhoid fever. Chest . 1993 Jul. 104(1):324-5. [QxMD MEDLINE Link] .

Khan M, Coovadia Y, Sturm AW. Typhoid fever complicated by acute renal failure and hepatitis: case reports and review. Am J Gastroenterol . 1998 Jun. 93(6):1001-3. [QxMD MEDLINE Link] .

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Baker NM, Mills AE, Rachman I, et al. Haemolytic-uraemic syndrome in typhoid fever. Br Med J . 1974 Apr 13. 2(5910):84-7. [QxMD MEDLINE Link] .

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Breakey WR, Kala AK. Typhoid catatonia responsive to ECT. Br Med J . 1977 Aug 6. 2(6083):357-9. [QxMD MEDLINE Link] .

Buckle GC, Walker CL, Black RE. Typhoid fever and paratyphoid fever: Systematic review to estimate global morbidity and mortality for 2010. J Glob Health . 2012 Jun. 2 (1):010401. [QxMD MEDLINE Link] .

• Life cycle of Salmonella typhi.
• Table 1. Incidence and Timing of Various Manifestations of Untreated Typhoid Fever [ 2 , 33 , 34 , 35 , 36 , 37 ]
• Table 2. Sensitivities of Cultures [ 2 , 39 , 40 , 41 ]

Contributor Information and Disclosures

John L Brusch, MD, FACP Corresponding Faculty Member, Harvard Medical School John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians , Infectious Diseases Society of America Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard B Brown, MD, FACP Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha , American College of Chest Physicians , American College of Physicians , American Medical Association , American Society for Microbiology , Infectious Diseases Society of America , Massachusetts Medical Society Disclosure: Nothing to disclose.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha , American College of Physicians , American Medical Association , Association of Professors of Medicine , Infectious Diseases Society of America , Oklahoma State Medical Association , Southern Society for Clinical Investigation Disclosure: Nothing to disclose.

Roberto Corales, DO, AAHIVS Senior Director, HIV Medicine and Clinical Research, Trillium Health Roberto Corales, DO, AAHIVS is a member of the following medical societies: American Medical Association , International AIDS Society , American Osteopathic Association Disclosure: Nothing to disclose.

Steven K Schmitt, MD Staff Physician, Department of Infectious Disease, Cleveland Clinic Steven K Schmitt, MD is a member of the following medical societies: Infectious Diseases Society of America Disclosure: Nothing to disclose.

Thomas Garvey, MD, JD † Primary Care Physician, Burlington Medical Associates; Co-Chair, Medical Advisory Committee For the Elimination of Tuberculosis Thomas Garvey, MD, JD is a member of the following medical societies: American College of Legal Medicine , American College of Physicians , American Society of Law, Medicine & Ethics Disclosure: Nothing to disclose.

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Typhoid fever

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This PrimeView highlights the epidemiology, pathophysiology, diagnosis and management of typhoid fever as well as discuss prevention strategies and future research directions.

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Typhoid fever

On this page, when to see a doctor, risk factors, complications.

Typhoid fever, also called enteric fever, is caused by salmonella bacteria. Typhoid fever is rare in places where few people carry the bacteria. It also is rare where water is treated to kill germs and where human waste disposal is managed. One example of where typhoid fever is rare is the United States. Places with the highest number of cases or with regular outbreaks are in Africa and South Asia. It is a serious health threat, especially for children, in places where it is more common.

Food and water with the bacteria in it cause typhoid fever. Close contact with a person who is carrying the salmonella bacteria also can cause typhoid fever. Symptoms include:

• High fever.
• Stomach pain.
• Constipation or diarrhea.

Most people who have typhoid fever feel better about a week after they start treatment to kill bacteria, called antibiotics. But without treatment, there is a small chance of death from typhoid fever complications. Vaccines against typhoid fever can provide some protection. But they can't protect against all cases of illness caused by other strains of salmonella. Vaccines can help lower risk of getting typhoid fever.

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Symptoms are likely to start slowly, often showing up 1 to 3 weeks after exposure to the bacteria.

Early illness

Early symptoms include:

• Fever that starts low and increases throughout the day, possibly reaching as high as 104 degrees Fahrenheit (40 degrees Celsius).
• Weakness and fatigue.
• Muscle aches.
• Diarrhea or constipation.

People also may have a cough, loss of appetite and sweating.

Later illness

A few weeks after symptoms start, the illness can cause problems in the intestines. People may have:

• Very swollen stomach.
• An infection caused by gut bacteria spreading throughout the body, called sepsis.

In very serious cases, people may:

• Become confused.
• Not be able to pay attention to anything around them.
• Not be able to react to the world around them.

These are life-threatening complications.

In some people, symptoms may return up to a few weeks after the fever has gone away.

See a health care provider right away if you think you might have typhoid fever.

If you get sick while traveling in a foreign country, know who to call for a list of providers. For some that might be the closest embassy or consulate.

If you have symptoms after you return home, consider seeing a provider who focuses on international travel medicine or infectious diseases. This might help get typhoid fever diagnosed and treated more quickly.

From Mayo Clinic to your inbox

A bacteria strain called Salmonella enterica serotype typhi causes typhoid fever. Other strains of salmonella bacteria cause a similar disease called paratyphoid fever.

People pick up the bacteria most often in places where outbreaks are common. The bacteria passes out of the body in the stool and urine of people who are carrying the bacteria. Without careful hand-washing after going to the bathroom, the bacteria can move from the hands to objects or other people.

The bacteria also can spread from a person who carries the bacteria. It can spread on food that isn't cooked, such as raw fruits without a peel. In places where water isn't treated to kill germs, you can pick up the bacteria from that source. This includes drinking water, using ice made from untreated water, or by drinking unpasteurized milk or juice.

Typhoid carriers

Even after antibiotic treatment, a small number of people who recover from typhoid fever still have the bacteria living in their bodies. These people are known as chronic carriers. They no longer have symptoms of the disease. But they still shed the bacteria in their stools and spread it.

Typhoid fever is a serious worldwide threat and affects millions of people each year. Places with the highest number of cases or with regular outbreaks are in Africa and South Asia. But cases are recorded worldwide, often due to travelers to and from these areas.

If you live in a country where typhoid fever is rare, you're at increased risk if you:

• Work in or travel to areas where typhoid fever is established, especially if you travel to visit family or friends. People visiting loved ones may have higher social pressure to drink or eat foods that present a higher risk.
• Work as a clinical microbiologist handling Salmonella enterica serotype typhi bacteria.
• Have close contact with someone who is infected or has recently been infected with typhoid fever.

Damage to the intestines

Typhoid fever complications can include damage and bleeding in the intestines. Typhoid fever also can cause cells in the walls of the small intestine or large bowel to die off. This allows the contents of the gut to leak into the body. That can cause severe stomach pain, vomiting and infection throughout the body called sepsis.

Damage to the intestines can develop in the later part of the illness. These life-threatening complications require immediate medical care.

Other possible complications include:

• Inflammation of the heart muscle, called myocarditis.
• Inflammation of the lining of the heart and valves, called endocarditis.
• Infection of major blood vessels, called mycotic aneurysm.
• Inflammation of the pancreas, called pancreatitis.
• Kidney or bladder infections.
• Infection and inflammation of the membranes and fluid surrounding the brain and spinal cord, called meningitis.
• Psychiatric problems, such as delirium, hallucinations and paranoid psychosis.

People can get a vaccination against typhoid fever. This is an option if you live where typhoid fever is common. It is also an option if you plan to travel to a place where the risk is high.

Where typhoid fever is common, access to treated water helps avoid contact with the Salmonella enterica serotype typhi bacteria. Management of human waste also helps people avoid the bacteria. And careful hand-washing for people who prepare and serve food is also important.

Two vaccines are available in the United States for people age 2 and older.

• One is given as a single shot at least one week before travel.
• One is given orally in four capsules, with one capsule to be taken every other day.

The effectiveness of these vaccines wears off over time. So repeat immunization is needed.

Because the vaccine won't provide complete protection, follow these guidelines when traveling to high-risk areas:

• Wash your hands. Frequent hand-washing in hot, soapy water is the best way to control infection. Wash before eating or preparing food and after using the toilet. Carry an alcohol-based hand sanitizer for times when soap and water aren't available.
• Avoid using untreated water. Contaminated drinking water is a problem in areas where typhoid fever is common. For that reason, drink only bottled water or canned or bottled carbonated beverages, wine and beer. Carbonated bottled water is safer than noncarbonated bottled water. Ask for drinks without ice. Use bottled water to brush your teeth, and try not to swallow water in the shower.
• Avoid raw fruits and vegetables. Because raw produce may have been washed in contaminated water, avoid fruits and vegetables that you can't peel, especially lettuce. To be safe, you may want to avoid raw foods.
• Choose hot foods. Avoid food that's stored or served at room temperature. Freshly made, steaming hot foods may be less risky than uncooked foods.
• Know where the health care providers are. Find out about medical care in the areas you'll visit. Carry a list of the names, addresses and phone numbers of health care providers.

Prevent infecting others

If you're recovering from typhoid fever, these measures can help keep others safe:

• Take your antibiotics. Follow your health care provider's instructions for taking your antibiotics and be sure to finish the entire prescription.
• Wash your hands often. This is the single most important thing you can do to keep from spreading the infection to others. Use hot, soapy water and scrub thoroughly for at least 30 seconds, especially before eating and after using the toilet.
• Avoid handling food. Avoid preparing food for others until your health care provider says you're no longer contagious. If you work with food, you may need to take a test to show you aren't shedding typhoid bacteria. If you work in health care, you also may need to show you aren't shedding the bacteria.

Jan 28, 2023

• Loscalzo J, et al., eds. Salmonellosis. In: Harrison's Principles of Internal Medicine. 21st ed. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed Dec. 8, 2022.
• Andrews JA, et al. Enteric (typhoid and paratyphoid) fever. https://www.uptodate.com/contents/search. Accessed Dec. 8, 2022.
• Brunette GW, et al., eds. CDC Yellow Book 2020: Health Information for International Travel. Oxford University Press; 2017. https://wwwnc.cdc.gov/travel/page/yellowbook-home-2020. Accessed Dec. 19, 2022.
• World Health Organization. Typhoid vaccines: WHO position paper, March 2018 — Recommendations. Vaccine. 2019; doi:10.1016/j.vaccine.2018.04.022.
• Espinoza LMC, et al. Occurrence of typhoid fever complications and their relation to duration of illness preceding hospitalization: A systematic literature review and meta-analysis. Clinical Infectious Diseases. 2019; doi:10.1093/cid/ciz477.
• CDC health advisory: Extensively drug-resistant Salmonella typhi infections among U.S. residents without international travel. Centers for Disease Control and Prevention. https://emergency.cdc.gov/han/2021/han00439.asp. Accessed Dec. 16, 2022.
• Typhoid fact sheet. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/typhoid. Accessed Dec. 19, 2022.
• Your health abroad. U.S. Department of State, Bureau of Consular Affairs. https://travel.state.gov/content/travel/en/international-travel/before-you-go/your-health-abroad.html. Accessed Dec. 19, 2022.
• Goldman L, et al., eds. Salmonella infections (including enteric fever). In: Goldman-Cecil Medicine. 26th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Dec. 16, 2022.
• Typhoid fever. Merck Manual Professional Version. https://www.merckmanuals.com/professional/infectious-diseases/gram-negative-bacilli/typhoid-fever#. Accessed Dec. 16, 2022.
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typhoid fever

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typhoid fever , acute infectious disease caused by the bacterium Salmonella enterica serovar Typhi. The bacterium usually enters the body through the mouth by the ingestion of contaminated food or water, penetrates the intestinal wall, and multiplies in lymphoid tissue ; it then enters the bloodstream and causes bacteremia .

Most major epidemics of typhoid fever have been caused by the pollution of public water supplies . Food and milk may be contaminated, however, by a human carrier of the disease who is employed in handling and processing them; by flies ; or by the use of polluted water for cleaning purposes. Shellfish , particularly oysters , grown in polluted water and fresh vegetables grown on soil fertilized or contaminated by untreated sewage are other possible causes.

The prevention of typhoid fever depends mainly on proper sewage treatment , filtration and chlorination of water, and exclusion of carriers from employment in food industries and restaurants. In the early part of the 20th century, prophylactic vaccination using killed typhoid organisms was introduced, mainly in military forces and institutions, and contributed to a lowering of the incidence of the disease.

After an average 10–14-day incubation period, the early symptoms of typhoid appear: headache , malaise , generalized aching, fever , and restlessness that may interfere with sleep . There may be loss of appetite , nosebleeds, cough , and diarrhea or constipation . Persistent fever develops and gradually rises, usually in a stepwise fashion, reaching a peak of 39 or 40 °C (103 or 104 °F) after 7–10 days; left untreated, the fever continues with only slight morning remissions for another 10–14 days, sometimes longer.

During about the second week of fever, typhoid bacilli are present in great numbers in the bloodstream. At that point, some patients develop a rash of small rose-coloured spots on the trunk, which lasts four or five days and then fades away. The lymph follicles ( Peyer patches ) along the intestinal wall in which the typhoid bacilli have multiplied become inflamed and necrotic and may slough off, leaving ulcers in the walls of the intestine. The dead fragments of intestinal tissue may erode blood vessels , causing hemorrhage , or they may perforate the intestinal wall, allowing the intestine’s contents to enter the peritoneal cavity ( peritonitis ). Other complications can include acute inflammation of the gallbladder , heart failure , pneumonia , osteomyelitis , encephalitis , and meningitis . With a continued high fever, the symptoms usually increase in intensity, and mental confusion and delirium may appear.

By the end of the third week, the patient is emaciated, abdominal symptoms are marked, and mental disturbance is prominent. In favourable cases, about the beginning of the fourth week, the fever begins to decline, the symptoms begin to abate, and the temperature gradually returns to normal. If untreated, typhoid fever proves fatal in about 10 to 30 percent of all cases; with treatment, as few as 1 percent of patients die from the disease. Patients with diseases such as cancer or sickle cell anemia are particularly prone to develop serious and prolonged infection with S. Typhi.

Diagnosis of typhoid fever is made by blood culture , stool culture, and serological testing. Infection is treated with antibiotics , primarily fluoroquinolones (e.g., ciprofloxacin), ceftriaxone, or azithromycin (or some combination thereof). Those agents help rid the body of S. Typhi, consequently lowering the patient’s fever and enabling progressive improvement thereafter.

The treatment of typhoid fever has been complicated by the emergence of antibiotic-resistant strains of S. Typhi. Historically, the antibiotic of choice against the disease was chloramphenicol . In the 1970s, because of widespread chloramphenicol resistance, ampicillin and trimethoprim-sulfamethoxazole became the treatments of choice. Those drugs, however, were eventually rendered ineffective by multidrug-resistant S. Typhi. Strains of the bacterium that are resistant to contemporary antibiotics, including fluoroquinolones, have been increasingly reported in Asia and Africa.

Typhoid bacteria can persist for an indefinite period of time in the bile passages of patients. If they practice poor hygiene or if they are food handlers, those carriers can pass the infection to healthy persons. Patients who are recovering from typhoid fever are transient carriers of the disease, excreting the causative bacteria in the stool or urine for up to three months. Patients who continue to excrete the bacteria for a year or more after infection are considered to be long-term carriers; those individuals harbour the microorganisms and typically shed them for years.

One of the most famous instances of carrier-borne disease in medical history was the case of “ Typhoid Mary ” (byname of Mary Mallon). Fifty-one original cases of typhoid and three deaths were directly attributed to her during the early 20th century.

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• 2 Punjab Medical College/University of Health Sciences
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• PMID: 32491445
• Bookshelf ID: NBK557513

Typhoid fever and paratyphoid fever are clinically indistinguishable febrile multisystemic illnesses caused by Salmonella enterica serotypes Typhi (S Typhi) and Paratyphi (S Paratyphi) A, B, and C. Collectively known as enteric fever, more than 9 million people are sickened, and 110,000 die from the disease every year around the globe.[WHO. Typhoid Fact Sheet. 2023] Enteric fever is the leading cause of community-acquired bloodstream infections in South and Southeast Asia. A reportable disease in the United States and many other developed nations, enteric fever is second only to malaria as a cause of severe and sometimes life-threatening infection in travelers. [2]

Following an incubation period of 6 to 30 days, enteric fever presents insidiously with the gradual onset of fever with fatigue, anorexia, headache, malaise, and abdominal symptoms. If treatment is delayed or inadequate, meningitis, sepsis, or intestinal perforation can occur. With a history of S Typhi and S Paratyphi strains rapidly developing antimicrobial resistance with the widespread use of successive antibiotics, the recent emergence of extensively drug-resistant strains has greatly complicated treatment and raised alarms.

S Typhi and S Paratyphi are said to spread by the "4 Fs" (flies, fingers, feces, and fomites). They afflict people living or traveling in low- and middle-income countries around the globe that lack clean water, adequate sanitation, and hygiene, known collectively as WASH. Improved WASH infrastructure is the foundation for decreasing the incidence of enteric fever and other diseases spread via the fecal-oral route.

Historically, enteric fever has received less investment and attention than the "big 3" (human immunodeficiency virus/acquired immunodeficiency syndrome, tuberculosis, and malaria). However, with the specter of untreatable variants on the horizon, enteric fever control efforts have been renewed. Recently developed typhoid conjugate vaccines, improved surveillance and understanding of antimicrobial resistance patterns, and WASH initiatives have decreased the disease burden.

This activity covers the epidemiology, pathophysiology, treatment, management, complications, patient education, prevention measures, and the role of the interprofessional team in improving patient care and decreasing the burden of this disease. While several barriers to controlling this disease exist, recent advancements provide hope that the impact of enteric fevers can be limited or eliminated in the future.

Copyright © 2024, StatPearls Publishing LLC.

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Conflict of interest statement

Disclosure: Jenish Bhandari declares no relevant financial relationships with ineligible companies.

Disclosure: Pawan Thada declares no relevant financial relationships with ineligible companies.

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Elizabeth DeVos declares no relevant financial relationships with ineligible companies.

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• Chattaway MA, Langridge GC, Wain J. Salmonella nomenclature in the genomic era: a time for change. Sci Rep. 2021 Apr 05;11(1):7494. - PMC - PubMed
• Meiring JE, Khanam F, Basnyat B, Charles RC, Crump JA, Debellut F, Holt KE, Kariuki S, Mugisha E, Neuzil KM, Parry CM, Pitzer VE, Pollard AJ, Qadri F, Gordon MA. Typhoid fever. Nat Rev Dis Primers. 2023 Dec 14;9(1):71. - PubMed
• Carey ME, Dyson ZA, Ingle DJ, Amir A, Aworh MK, Chattaway MA, Chew KL, Crump JA, Feasey NA, Howden BP, Keddy KH, Maes M, Parry CM, Van Puyvelde S, Webb HE, Afolayan AO, Alexander AP, Anandan S, Andrews JR, Ashton PM, Basnyat B, Bavdekar A, Bogoch II, Clemens JD, da Silva KE, De A, de Ligt J, Diaz Guevara PL, Dolecek C, Dutta S, Ehlers MM, Francois Watkins L, Garrett DO, Godbole G, Gordon MA, Greenhill AR, Griffin C, Gupta M, Hendriksen RS, Heyderman RS, Hooda Y, Hormazabal JC, Ikhimiukor OO, Iqbal J, Jacob JJ, Jenkins C, Jinka DR, John J, Kang G, Kanteh A, Kapil A, Karkey A, Kariuki S, Kingsley RA, Koshy RM, Lauer AC, Levine MM, Lingegowda RK, Luby SP, Mackenzie GA, Mashe T, Msefula C, Mutreja A, Nagaraj G, Nagaraj S, Nair S, Naseri TK, Nimarota-Brown S, Njamkepo E, Okeke IN, Perumal SPB, Pollard AJ, Pragasam AK, Qadri F, Qamar FN, Rahman SIA, Rambocus SD, Rasko DA, Ray P, Robins-Browne R, Rongsen-Chandola T, Rutanga JP, Saha SK, Saha S, Saigal K, Sajib MSI, Seidman JC, Shakya J, Shamanna V, Shastri J, Shrestha R, Sia S, Sikorski MJ, Singh A, Smith AM, Tagg KA, Tamrakar D, Tanmoy AM, Thomas M, Thomas MS, Thomsen R, Thomson NR, Tupua S, Vaidya K, Valcanis M, Veeraraghavan B, Weill FX, Wright J, Dougan G, Argimón S, Keane JA, Aanensen DM, Baker S, Holt KE, Global Typhoid Genomics Consortium Group Authorship Global diversity and antimicrobial resistance of typhoid fever pathogens: Insights from a meta-analysis of 13,000 Salmonella Typhi genomes. Elife. 2023 Sep 12;12 - PMC - PubMed
• Khan M, Shamim S. Understanding the Mechanism of Antimicrobial Resistance and Pathogenesis of Salmonella enterica Serovar Typhi. Microorganisms. 2022 Oct 11;10(10) - PMC - PubMed
• Moudgil KD, Narang BS. Pathogenesis of typhoid fever. Indian J Pediatr. 1985 Jul-Aug;52(417):371-8. - PubMed

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Typhoid Fever

What is typhoid fever.

Typhoid fever is a serious infection caused by a type of bacteria. It is more common in Africa, Latin America, and Asia (especially in Southeast Asia), but less so in the U.S. Most cases in this country are in people who got the disease while traveling outside of the U.S.

You can get the disease by eating food or drinking water that is contaminated with the bacteria.

What causes typhoid fever?

Typhoid fever is caused by the bacteria Salmonella Typhi. The bacteria are passed on by eating food or drinking water that has been contaminated by someone with the disease or who is a carrier of the infection. The bacteria are found in the infected person’s stool. They may get onto the person's hands or other parts of the body if there are poor hygiene practices. You can also get the disease if water used for drinking or washing food is contaminated with sewage containing the bacteria.

People who recover from typhoid fever can sometimes still have the bacteria in their stool and can pass them on to other people. They are called "carriers."

What are the symptoms of typhoid fever?

Once the bacteria are in your body, they increase in number and spread into your blood. You may not have symptoms for 6 to 30 days after the first exposure. Symptoms may include:

Fever from 102°F to 104°F (39°C to 40°C)

Belly (abdominal) pains

Loss of appetite

Sometimes a rash of flat, pink or rose-colored spots

Constipation, vomiting, or diarrhea

The symptoms may look like other health problems. Always see your healthcare provider for a diagnosis.

How is typhoid fever diagnosed?

Your healthcare provider will use blood tests or a stool sample to diagnose typhoid fever. These tests can find the typhoid bacteria. But these tests are less accurate if you have just come down with the disease. Because of this, your provider will also look at your symptoms and travel history.

How is typhoid fever treated?

See your healthcare provider right away if you think you have any of the symptoms of typhoid fever. Most otherwise healthy adults get better on their own. But some people who are not treated may have a fever for weeks or months. And sometimes the germ can spread to other parts of the body and cause serious complications.

Antibiotics are often needed to treat typhoid fever.

Treatment will depend on your symptoms, age, and general health. It will also depend on how severe the condition is.

It is important to remember that the danger of typhoid fever does not end when symptoms go away. You could still be carrying the bacteria. The illness could also return. Or you could pass the disease to other people. You should:

Take any antibiotics exactly as your healthcare provider tells you to

Always wash your hands after using the bathroom

Have a series of stool cultures. This is to make sure that the bacteria are no longer in your body

What are possible complications of typhoid fever?

Complications of typhoid fever include intestinal bleeding, persistent fever and weakness, and spread of the germ to various parts of the body. The complications can sometimes be life-threatening.

Once your symptoms are gone, you may still have the typhoid bacteria in your body. Follow up with your healthcare provider to make sure the bacteria are completely gone and that you are not still a carrier. You will also need to practice good hygiene. Wash your hands before and after you use the bathroom. You should also not make food for anyone else until the bacteria are gone.

What can I do to prevent typhoid fever?

Typhoid fever is very common in developing countries. Travelers to Africa, Latin America, and Asian countries—except Japan—are at highest risk.

Two types of typhoid vaccines are available. One is a pill and one is a shot. A vaccine will be advised if you are traveling to high-risk locations or engaging in higher-risk activities while there. The best time to get the shot is 2 weeks before traveling. A booster shot is advised every 2 years for people who are at high risk.

Typhoid vaccines are not 100% effective. Use the tips below and always practice safe eating and drinking habits when traveling.

You can also prevent typhoid fever when traveling by:

Only using water that has been boiled or chemically disinfected for drinking or making beverages, such as tea or coffee, and for brushing teeth

Washing your face and hands. You can also use an alcohol-based gel to clean your hands.

Washing and peeling fruits and vegetables

Washing eating utensils, pots, and pans

Washing the surfaces of tins, cans, and bottles that contain food or beverages before opening them

Also don't eat food from street vendors. Any raw food could be contaminated. Stay away from:

Fruits and vegetables, particularly those that cannot be peeled 

Salad greens 

Unpasteurized milk and milk products

Any fish caught in tropical reefs rather than the open ocean

Other tips for prevention:

Don't eat food or drink beverages from unknown sources.

Don't put ice in drinks.

Stay away from overcrowded areas

Make sure food is correctly cooked and still hot when served

When should I call my healthcare provider?

Call your healthcare provider right away if your symptoms return or get worse, or you have new ones.

Key points about typhoid fever

Typhoid fever is a serious infection caused by bacteria.

In the U.S., most cases are in people who get the disease while traveling in other countries.

Symptoms include a high fever, weakness, belly pains, headache, and loss of appetite. Sometimes, a rash of flat, rose-colored spots may appear.

Antibiotics are often used to treat the disease.

To prevent typhoid fever, drink only boiled or chemically disinfected water. Also do not eat raw food that could be contaminated.

Talk to your healthcare provider about getting the typhoid vaccine if you will be traveling to a high-risk area.

Tips to help you get the most from a visit to your healthcare provider:

Know the reason for your visit and what you want to happen.

Before your visit, write down questions you want answered.

Bring someone with you to help you ask questions and remember what your provider tells you.

At the visit, write down the name of a new diagnosis and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.

Know why a new medicine or treatment is prescribed and how it will help you. Also know what the side effects are.

Ask if your condition can be treated in other ways.

Know why a test or procedure is recommended and what the results could mean.

Know what to expect if you do not take the medicine or have the test or procedure.

If you have a follow-up appointment, write down the date, time, and purpose for that visit.

Know how you can contact your provider if you have questions.

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About Typhoid Fever and Paratyphoid Fever

• Typhoid fever and paratyphoid fever are life-threatening illnesses.
• Each of the illnesses is caused by a kind of Salmonella bacteria (germs).
• Most people in the United States with these illnesses were infected during international travel.
• You can find out if you need a typhoid fever vaccine at www.cdc.gov/travel.

Typhoid fever and paratyphoid fever have similar symptoms , including fever. The illnesses are life-threatening and people with symptoms should get medical help immediately.

Germs responsible

The illnesses are caused by Salmonella bacteria.

• Typhoid fever is caused by Salmonella serotype Typhi.
• Paratyphoid fever is caused by Salmonella serotype Paratyphi.

Illness estimates

Every year, millions of people around the world get sick from these diseases.

Typhoid fever

• 9.2 million illnesses are estimated to occur worldwide each year
• 5,700 illnesses and 620 hospitalizations are estimated to occur in the United States each year. Most people are infected while traveling internationally.

Paratyphoid fever

• 3.8 million illnesses are estimated to occur worldwide each year
• CDC does not have estimates of illnesses and hospitalizations in the United States

Where illness is common

These illnesses are most common in parts of the world where water and food can be unsafe, and sanitation can be poor, including parts of:

• Asia (especially Pakistan, India, and Bangladesh)
• Latin America

Most people in the United States with typhoid fever or paratyphoid fever were infected while traveling to these places.

Risk factors

The chances of getting typhoid fever or paratyphoid fever in the United States are very low.

The chances increase for people in the United States who:

• Travel to countries in Africa, Asia, or Latin America where the diseases are common
• Visit rural areas of those countries
• Visit family and friends in those countries
• Are not vaccinated against typhoid fever

Almost all people in the United States with these diseases report that they have traveled internationally. Most report that they traveled to countries in South Asia, including Pakistan, India, or Bangladesh.

How it spreads

The bacteria spread to and among people in several ways.

The bacteria that cause these illnesses are shed (gotten rid of) in poop. People who shed the bacteria include:

• People who have symptoms of typhoid fever or paratyphoid fever
• People who are no longer sick but still have the bacteria in their body

You can get typhoid fever or paratyphoid fever after swallowing the bacteria. The bacteria can get in your mouth in several ways, including:

• Through food, drinks, and water that have been contaminated by sewage
• Through food that has been rinsed in contaminated water and then eaten
• Through food that has been touched by a person who did not wash their hands after using the bathroom or changing a diaper

You can take steps to keep safe from these diseases

Typhoid fever.

Typhoid fever and paratyphoid fever are life-threatening illnesses. Learn about how they spread, risk factors, and how you can prevent infections.

For Everyone

Health care providers, public health.

Overview - Typhoid fever

Typhoid fever is a bacterial infection that can spread throughout the body, affecting many organs. Without prompt treatment, it can cause serious complications and can be fatal.

It's caused by a bacterium called Salmonella typhi, which is related to the bacteria that cause salmonella food poisoning .

Typhoid fever is highly contagious. An infected person can pass the bacteria out of their body in their poo or, less commonly, in their pee.

If someone else eats food or drinks water that's been contaminated with a small amount of infected poo or pee, they can become infected with the bacteria and develop typhoid fever.

Read more about the causes of typhoid fever .

Who's affected?

Typhoid fever is most common in parts of the world that have poor sanitation and limited access to clean water.

Worldwide, children are thought to be most at risk of developing typhoid fever. This may be because their immune system (the body's natural defence against infection and illness) is still developing.

But children with typhoid fever tend to have milder symptoms than adults.

Typhoid fever is uncommon in the UK, with around 300 infections confirmed each year.

Most of these people became infected while visiting relatives in Bangladesh, India or Pakistan. But you're also at risk if you visit Asia, Africa or South America.

Symptoms of typhoid fever

The main symptoms of typhoid fever are:

• a persistent high temperature that gradually increases each day
• general aches and pains
• extreme tiredness (fatigue)
• constipation

As the infection progresses, you may lose your appetite, feel sick, and have a tummy ache and diarrhoea . Some people may develop a rash.

If typhoid fever isn't treated, the symptoms will continue to get worse over the following weeks and the risk of developing potentially fatal complications will increase.

Read more about the symptoms of typhoid fever  and the complications of typhoid fever .

How typhoid fever is treated

Typhoid fever requires prompt treatment with antibiotics .

If typhoid fever is diagnosed early, the infection is likely to be mild and can usually be treated at home with a 7- to 14-day course of antibiotic tablets.

More severe typhoid fever usually requires admission to hospital so antibiotic injections can be given.

With prompt antibiotic treatment, most people will start to feel better within a few days and serious complications are very rare.

Deaths from typhoid fever are now virtually unheard of in the UK.

If typhoid fever isn't treated, it's estimated that up to 1 in 5 people with the condition will die.

Some of those who survive will have complications caused by the infection.

Read more about treating typhoid fever .

Typhoid fever vaccination

In the UK, 2 vaccines are available that can provide some protection against typhoid fever.

These involve either having a single injection or taking 3 capsules over alternate days.

Vaccination is recommended for anyone planning to travel to parts of the world where typhoid fever is widespread.

The areas with the highest rates of typhoid fever are:

• the Indian subcontinent
• south and southeast Asia
• South America

It’s important to get vaccinated against typhoid fever if you’re travelling to a high risk area because some strains of the typhoid bacteria are becoming resistant to antibiotics.

Vaccination is particularly important if you're planning to live or work closely with local people.

But as neither vaccine offers 100% protection, it's also important to follow some precautions when travelling. For example, you should only drink bottled or boiled water, and you should avoid foods that could potentially be contaminated.

Read more about the typhoid fever vaccination .

Travel advice

When travelling to a foreign country, it's a good idea to make a list of relevant contact details and telephone numbers in case of an emergency.

You can get travel information and advice for different countries on:

• Travel Health Pro: country information
• GOV.UK: foreign travel advice

Page last reviewed: 20 September 2021 Next review due: 20 September 2024

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Mary Mallon (1869-1938) and the history of typhoid fever

Filio marineli.

History of Medicine Department, Medical School, University of Athens, Athens, Greece

Gregory Tsoucalas

Marianna karamanou, george androutsos.

Mary Mallon was born in 1869 in Ireland and emigrated to the US in 1884. She had worked in a variety of domestic positions for wealthy families prior to settling into her career as a cook. As a healthy carrier of Salmonella typhi her nickname of “Typhoid Mary” had become synonymous with the spread of disease, as many were infected due to her denial of being ill. She was forced into quarantine on two separate occasions on North Brother Island for a total of 26 years and died alone without friends, having evidently found consolation in her religion to which she gave her faith and loyalty.

Isolating Salmonella

Long before the bacillus responsible for the disease was discovered in 1880, Karl Liebermeister had already assumed that the condition was due to a microorganism. He also tried, with his colleagues, to demonstrate that the spread of epidemic was related to drinking water contaminated by the excrement of patients with typhoid fever [ 1 ]. William Budd, a doctor in Bristol who was interested in cholera and in intestinal fevers, demonstrated in 1873, that typhoid fever could be transmitted by a specific toxin present in excrement and that the contamination of water by the feces of patients was responsible for that propagation. According to Budd, every case was related to another anterior case. A great number of doctors and scientists had tried to discover the nature of the microorganism responsible for the disease and had encountered great difficulty in isolating the bacillus. It was Karl Joseph Eberth, doctor and student of Rudolf Virchow, who in 1879 discovered the bacillus in the abdominal lymph nodes and the spleen. He had published his observations in 1880 and 1881. His discovery was then verified and confirmed by German and English bacteriologists, including Robert Koch [ 2 ]. The genus “ Salmonella ” was named after Daniel Elmer Salmon, an American veterinary pathologist, who was the administrator of the USDA research program, and thus the organism was named after him, despite the fact that a variety of scientists had contributed to the quest [ 3 ]. Salmonella thus became new scientific knowledge and therefore the contagion mechanisms, as well as the existence of healthy carriers were relatively in status nascendi [ 4 ].

The contagion

Mary Mallon was born in Ireland in 1869 and emigrated to the United States in 1883 or 1884. She was engaged in 1906 as a cook by Charles Henry Warren, a wealthy New York banker, who rented a residence to Oyster Bay on the north coast of Long Island for the summer. From 27 August to 3 September, 6 of the 11 people present in the house were suffering from typhoid fever. At this time, typhoid fever was still fatal in 10% of cases and mainly affected deprived people from large cities [ 5 , 6 ].

The sanitary engineer, committed by the Warren family, George Sober, published the results of his investigation on the 15th of June 1907, in JAMA . Having believed initially that freshwater clams could be involved in these infections, he had hastily conducted his interrogation of the sick people and also of Mary who had presented a moderate form of typhoid [ 7 ]. Mary continued to host the bacteria, contaminating everything around her, a real threat for the surrounding environment. Although Sober initially feared that the soft clams were the culprits, this proved to be incorrect as not all of those stricken had eaten them. Finally Sober had solved the mystery and became the first author to describe a “healthy carrier” of Salmonella typhi in the United States. From March 1907, Sober started stalking Mary Mallon in Manhattan and he revealed that she was transmitting disease and death by her activity. His attempts to obtain samples of Mary’s feces, urine and blood, earned him nothing but being chased by her. Sober reconstituted the puzzle by discovering that previously the cook had served in 8 families. Seven of them had experienced cases of typhoid. Twenty-two people presented signs of infection and some died [ 5 , 6 ].

That year, about 3,000 New Yorkers had been infected by Salmonella typhi , and probably Mary was the main reason for the outbreak. Immunization against Salmonella typhi was not developed until 1911, and antibiotic treatment was not available until 1948 [ 4 ]. Thus, a dangerous source like Mary had to be restrained. Mary was then frequently accused of being the source of contact for hundreds of the ill. Sober, after enlisting the support of Dr. Biggs of the N.Y. Department of Health, persuaded Dr. Josephine Baker, who along with the police, was sent to bring Mary Mallon in for testing. Baker and the police were met by an uncooperative Mary, who eluded them for five hours. At the end she was forced to give samples. Mary’s stool was positive for Salmonella typhi and thus she was transferred to North Brother Island to Riverside Hospital, where she was quarantined in a cottage [ 5 ].

In 1909, Mary unsuccessfully sued the health department. During her two-year period of confinement, she had 120/163 stool samples test positive. No one ever attempted to explain to Mary the significance of being a “carrier”, instead they had offered to remove her gallbladder, something she had denied. She was unsuccessfully treated with Hexamethylenamin, laxatives, Urotropin, and brewer’s yeast. In 1910, a new health commissioner vowed to free Mary and assist her with finding suitable employment as a domestic but not as a cook. Mary was released but never intended to abide by the agreement. She started working again in the cuisines of her unsuspecting employers, threatening public health once more [ 4 ].

As a cook of Sloane Maternity in Manhattan, she contaminated, in three months, at least 25 people, doctors, nurses and staff. Two of them died. She had managed to be hired as “Mary Brown” [ 8 ]. Since then she was stigmatized as “Typhoid Mary” ( Fig. 1 ) and she was the butt of jokes, cartoons, and eventually “Typhoid Mary” appeared in medical dictionaries, as a disease carrier. Mary was placed back on North Brother Island where she remained until her death. On Christmas morning, 1932, a man who came to deliver something to her found Mary on the floor of her bungalow, paralyzed. She had had a stroke of apoplexy and never walked again. Thereafter, for six years, she was taken care of in the “Riverside Hospital” ( Fig. 2 ). She died in November 1938. Her body was hurried away and buried in a grave bought for the purpose at St. Raymond’s Cemetery in Bronx. A post mortem revealed that she shed Salmonella typhi bacteria from her gallstones raising the issue of what would have happened if she had accepted the proposed operation. Some other researchers insisted that there was no autopsy and that this was another urban legend, whispered by the Health Center of Oyster Bay, in order to calm ethical reactions [ 5 ].

Mary Mallon as “Typhoid Mary” in the local newspaper of the era

Mary Mallon in the “Riverside Hospital”

Mary Mallon, the first known case of a healthy carrier in the United States, was proven responsible for the contamination of at least one hundred and twenty two people, including five dead [ 5 ].

Ethical issues

Much speculation remains regarding the treatment that Mary received at the hands of the Department of Health, City of New York. She was never fined, let alone confined. Instead of working with her, to make her realize she was a risk factor, the state quarantined her twice, making her a laboratory pet. Mary endured test after test and was only thinking of how she could cook again. She had become a victim of the health laws, of the press and above all of the cynical physicians, who had plenty of time to test but never had time to talk with the patient [ 9 , 10 ].

Mary’s case is a perfect example of how the Health Care system provokes social attitudes towards disease carriers, often associated with prejudice. This case highlighted the problematic nature of the subject and the need for an enhanced medical and legal-social treatment model aimed at improving the status of disease carriers and limiting their impact on society [ 9 , 10 ]. Probably the answer to the rhetorical question “was Mary Mallon a symbol of the threat to individual liberty or a necessary sacrifice to public health?” is a single word, “balance”. After all what Mary ever wanted was to be a good plain cook [ 11 ].

Concluding remarks

The history of Mary Mallon, declared “unclean” like a leper, may give us some moral lessons on how to protect the ill and how we can be protected from illness. Mary had refused the one operation which might have cured her. In later years she lost much of her bitterness and lived a fairly contented if necessarily restricted life. She evidently found consolation in her religion and she was then at perfect peace in the bosom of the church to which she gave the last years her faith and loyalty. By the time she died New York health officials had identified more than 400 other healthy carriers of Salmonella typhi , but no one else was forcibly confined or victimized as an “unwanted ill”. Mary Mallon is always a reference when mentioning the compliance of the laws concerning public health issues. The state’s pursuance and Mary’s stubbornness gave her an awkward place in the history of Medicine.

Medical School, University of Athens, Athens, Greece

Conflict of Interest: None

'Dengue Cases Among Children Too': Hospital OPDs full in Delhi-NCR Amid Spike in Viral Fever, Chikungunya, Typhoid & Jaundice

Reported By : Himani Chandna

Last Updated: August 30, 2024, 10:00 IST

New Delhi, India

Doctors have started seeing an increase in cases starting from July, which coincides with the beginning of the monsoon season but it has accelerated in August. (Image: Shutterstock)

Doctors pointed out that symptoms of dengue, and chikungunya sometimes overlap such as the appearance of rashes. In some cases, symptoms of Zika also confuses with chikungunya with pain in joints and fever.

Skin allergies, stomach infections, viral illnesses, and various types of fevers have led to long lines at hospitals, with patients crowding the OPDs of hospitals in Delhi-NCR with the unusually heavy rains. Both adults and children are now filling hospital outpatient departments.

This surge in waterborne and vector-borne illnesses has led to increased hospitalisations, with significant spikes in typhoid, jaundice, hepatitis A and E as well as acute gastroenteritis. However, patients have been typically showing improvement within two to three days of starting treatment.

Doctors have started seeing an increase in cases starting from July, which coincides with the beginning of the monsoon season but it has accelerated in August. They expect that this trend may continue until September.

According to Dr Pankaj Verma, senior consultant of internal medicine at Gurugram-based Narayana Hospital, “We have been witnessing a spike in cases of gastroenteritis, skin infections, and viral fevers in our OPD. On average, we treat nearly 50-70 patients weekly suffering from these conditions.”

The majority of these patients suffer from viral infections followed by gastroenteritis which includes vomiting and diarrhea. Skin infections, like fungal infections and dermatitis, are also common due to increased humidity.

“We are seeing several cases of dengue and typhoid this season,” Verma said while explaining the top symptoms of viral fevers doing the rounds which included high fever, chills, body aches, and fatigue.

For children, according to Dr Maninder Dhaliwal, an expert in paediatric pulmonology, viral upper respiratory infection and viral diarrhoea are common. “Typhoid is the same as in every monsoon and in fact, cases of hepatitis A and hepatitis E are also not uncommon.”

Hepatitis A and E are typically caused by consumption of contaminated food or water and it causes swelling in the liver.

Dhaliwal, senior consultant at Faridabad-based Amrita Hospital, noted that “dengue cases have just started coming in among children.”

Increased cases of swine flu

“Every year in August and September we have a 10 to 20 per cent increased footfalls in the OPD and IPD admissions due to increased incidence of fever, related to viral infections, dengue and other virals,” Dr Sumit Ray, medical director at Holy Family Hospital while adding that this season, H1N1 or swine flu is slightly more pronounced.

A similar observation was made by Dr Yatin Mehta, chairman, critical care, at Gurugram-based super speciality hospital Medanta who is presently treating five patients in his hospital’s intensive care unit (ICU).

Overlapping symptoms of dengue, chikungunya & Zika

Infact, Dr Jatin Ahuja, senior consultant, Infectious Disease, Indraprastha Apollo Hospitals, New Delhi told News18 that he keeps on diagnosing ‘coronavirus family strain’ in the PCR tests recommended to patients.

“There are several viruses doing the rounds including flu virus, respiratory virus, influenza B and influenza B. Zika, malaria and chikungunya is also infecting people,” Dr Ahuja said.

He said that symptoms of dengue, and chikungunya are sometimes overlapping such as the appearance of rashes. In some cases, symptoms of Zika also confuse with chikungunya with pain in joints and fever. However, in case of typhoid, fever starts mildly and hovers around 99 degrees for one or two days.

He suggested that people should start testing early. “The idea is to test as early as possible. Once you cross three days of fever, the diagnosis becomes difficult as tests stop picking the infection,” he said while his OPD was full of patients waiting for their turn.

• viral fever

Typhoid Fever and Filtered Water

By Steven J. Peitzman

Philadelphia in the late nineteenth century stood shamefully high among large American cities in rates of death from typhoid fever (also known as enteric fever). Caused by a type of Salmonella bacterium, the disease had become common in Philadelphia and other cities with crowded populations, inadequate disposal of human waste, and lack of water treatment. Local outbreaks and the knowledge that they might be prevented by improving the water supply spurred physicians, activists, and organizations to press Philadelphia’s city government to improve water quality with a filtering system. After a decade of delay and fumbling, a massive apparatus installed between 1900 and 1910 largely ended deaths from typhoid fever.

By the last decades of the nineteenth century, the Philadelphia region no longer suffered from massive epidemics of yellow fever , cholera , or smallpox—though the horrific influenza pandemic of 1918 lay in the future. Typhoid fever, meanwhile, had become both endemic (common) and given to outbreaks or local epidemics. Philadelphia endured outbreaks in 1876 (probably relating to the crowds coming to the city for the Centennial Exhibition ), 1888-1889, 1899, and 1906–but the disease was always present. During the 1890s, more than 5,400 deaths from typhoid fever occurred. More died from tuberculosis, but the means existed to prevent typhoid. The symptoms of typhoid include high fever, headaches, a subtle rash, vomiting, and sometimes diarrhea; complications such as bowel perforation or hemorrhage can cause death. The microbe spreads through the “fecal-oral” route, meaning contaminated milk, asymptomatic carriers, and most importantly, impure water. Before antibiotics, treatment consisted of a “mild” diet (milk, eggs, beef broth), bed rest, and cold baths, the last much loathed by patients. Surgery could occasionally save patients who had bowel perforations.

In a time of industrial growth and population increase, typhoid was a regional problem, but no regional framework existed to deal with it. In the nineteenth century, as in the twenty-first, Philadelphia drew its water from the Schuylkill and the Delaware Rivers, into which both the city and upstream districts discharged all manner of industrial and human waste. The creation of Fairmount Park in the nineteenth century lessened the city’s contribution to the Schuylkill’s considerable defilement. But Manayunk within the city and upstream industrial towns such as Norristown , Pottstown , and Reading created pollution “as diversified as the occupation of the people: sewerage, chemical, wool-washing, dye stuff, butcher and brewery refuse–there is almost nothing lacking,” according to the 1883 Annual Report of the Philadelphia Bureau of Water . In addition to the ills and pollution caused by industrial waste, matter added by latrines and flush toilets could disseminate typhoid. A similar situation, though perhaps less dire, befouled the Delaware.

Larger Reservoirs

As one response to this menace, in the 1880s the Bureau of Water built an “interceptor sewer,” a sort of bypass channel that drained waste from Roxborough , Manayunk, and Falls of Schuylkill (East Falls), diverting it from the river. The city also created larger reservoirs to allow water more time to settle, so that gravity could lead to sedimentation of particulate contamination. The rate of deaths from typhoid declined into the early 1890s, but still amounted to a persistent loss of life of young and old Philadelphians, which was generally recognized as preventable. More seemed to be needed. In 1889, influential Germantown physician and author Henry Hartshorne (1823-97) argued for filtration of the water supply in a pamphlet titled Our Water Supply: What it is and What it Should Be, published on behalf of a committee of citizens. Hartshorne cited recent experience in Europe, where cleansing of municipal water through “slow” filters of layers of sand and crushed coal had become an accepted technique. The method had recently been introduced into the United States and became more widely known through an important book published in 1895, The Filtration of Public Water-Supplies, by engineer Allen Hazen (1869-1930).

Into the 1890s, a variety of lay and medical groups in Philadelphia campaigned for clean water and particularly for a system of filters. These included the Women’s Health Protective Association (founded in 1893), the College of Physicians of Philadelphia , the Civic Club, and beginning in 1896 a broadly-based Citizens’ Organizations Filtration Committee. The City Councils (then bicameral) took up the issue, but political factionalism, unclear authority to borrow large funds, and an extreme diversity of opinion delayed approval of funding. For example, while some members of Council favored filtration, Thomas Meehan (1826-1901), the “dean of American horticulturists” and a locally prominent Germantown resident, dismissed its value and may have doubted the germ theory of infectious disease. In addition, the chief of the Bureau of Water, a capable engineer named John Cresson Trautwine (1850-1924), deplored the waste of water more than the waste in it, and so persistently urged the metering of water (then not in effect) more than the filtering of it. In addition, several proposals to bring pure water from either the Pine Barrens of New Jersey (suggested in 1891) or from unpolluted realms of the upper Schuylkill (1889, 1897) episodically competed for attention.

A particularly vicious outbreak in 1898-99 (which some alleged related to the movement of soldiers into the city at the time of the Spanish-American War) resulted in 948 deaths in 1899 and finally provoked progress. The City Councils approved the request of Mayor Samuel Ashbridge (1849?-1906) for a $12 million bond issue to build the system of sand filter beds. Construction began in 1901 and 1902 at the reservoirs and pump stations in Roxborough (“upper” and “lower”), West Philadelphia (Belmont), and Torresdale. The end of the decade saw the last filter beds completed, at the Queen Lane location. Numerous photographs made by the city show the enormity of these vast undertakings, probably then the largest municipal projects in Philadelphia’s history. The plan included laying massive pipes interconnecting the several water facilities. The entire effort ended up costing an estimated $26 million to $28 million.

Typhoid Declines

Typhoid fever rates eventually fell by more than 90 percent with the advent of filtered drinking water–which was also, at least sometimes, clear and free of odor, something new to Philadelphians. A serious outbreak occurred in 1906, but it was mainly limited to areas not yet receiving filtered water. In 1909 chlorination was added to further combat water-borne bacteria. In the 1910s and 1920s typhoid immunization came into wide use. Occasional small epidemics still occurred; one in 1911 resulted from a rupture of a large main supplying the Roxborough plant. Until immunization made most of the population resistant to the disease, some outbreaks could be traced to a picnic mishap or other tainted food. Into the 1920s and 1930s, the city’s public health officials rightly or wrongly deemed most cases to have been acquired outside the city, particularly at the New Jersey shore during the summer. Enough cases continued to occur, however, to induce the closing of the popular springs throughout Fairmount Park, though these likely did not spread typhoid to any great extent. By 1935, rarely did a Philadelphian die from typhoid fever.

Steven J. Peitzman   is Professor of Medicine at Drexel University College of Medicine. His historical work includes the book  A New and Untried Course: Woman’s Medical College and Medical College of Pennsylvania, 1850 – 1998 (Rutgers University Press, 2000) and articles about medicine and medical education in Philadelphia and Germantown. He also has published on the history of his clinical area, kidney disease. (Author information current at time of publication.)

Copyright 2016, Rutgers University

"A Decidedly Mixed Drink"

Philadelphia Water Historical Collection/Adam Levine

This editorial cartoon by Fred Morgan, published in the Philadelphia Inquirer on April 6, 1899, shows William Penn balking at the idea of drinking the "mixed drink" offered him. The “mixed drink” consisted of Schuylkill River water that had become polluted from the upstream sources. These upstream sources were industrial towns such as Manayunk, Norristown, Pottstown, and Reading that created pollution “as diversified as the occupation of the people: sewerage, chemical, wool-washing, dye stuff, butcher and brewery refuse–there is almost nothing lacking,” according to the 1883 Annual Report of the Philadelphia Bureau of Water. This is one of a series of cartoons drawn by Morgan, protesting the state of the city's drinking water and trying to encourage the passage of legislation authorizing the construction of a water filtration system. (Caption adapted from PhillyH2O.org)

Lower Roxborough Filter Plant, 1901

PhillyHistory.org

A particularly vicious outbreak of typhoid in 1898-99 resulted in 948 deaths in 1899 and provoked the city to move toward water filtration. The City Councils approved the request of Mayor Samuel Ashbridge for a $12 million bond issue to build a system of sand filter beds. Construction began in 1901 and 1902 at the reservoirs and pump stations in Roxborough (“upper” and “lower”), West Philadelphia (Belmont), and Torresdale. The lower Roxborough filter plant is shown here under construction in 1901.

Before and After Photos of Water Processed Through the Roxborough Filter Plant

This image from 1903 shows bottles containing water from the lower Roxborough filter plant. The left bottle is labeled as "applied water," which is the combination of all incoming water before it was distributed to the filters. The right bottle is labeled as "effluent filter water," meaning it had gone through the filtration process. The difference shows how urgent the need was for water filtration in that era.

Belmont Filter Plant, 1902

Construction began in 1901 and 1902 at the reservoirs and pump stations in Roxborough (“upper” and “lower”), West Philadelphia (Belmont), and Torresdale. The end of the decade saw the last filter beds completed, at the Queen Lane location. The West Philadelphia (Belmont) reservoir is shown here during its construction in 1902.

Typhoid fever rates eventually fell by more than 90 percent with the advent of filtered drinking water— which was also, at least sometimes, clear and free of odor, something new to Philadelphians.

In this February 25, 1909, editorial cartoon from the Philadelphia Press, William Penn, anticipating the filtration of the entire city water supply a few days later, happily raises a glass of filtered water to the departing devil, whose suitcase reeks with the germs of typhoid, diphtheria, and scarlet fever. (Caption adapted from PhillyH2O.org)

Fairmount Park Map

Historical Society of Pennsylvania

During the early 1800s, the City of Philadelphia began to purchase land along the Schuylkill River to protect the city's water supply, land that eventually became Fairmount Park. The first property the city purchased for this purpose was a forty-three-acre parcel previously owned by Henry Pratt, situated just north of the waterworks on the east bank of the river in this map. Fairmount Park was officially established in 1855 and expansion plans were begun soon after. This 1859 map shows the first proposed expansions of the park to the west of the river (the left portion of land on this map).

Map of Typhoid Fever Death Rates, 1890 Census

David Rumsey Historical Map Collection

This map, based on 1890 census data, shows the death rate attributed to typhoid fever in the Mid-Atlantic region, with the Philadelphia area showing thirty to forty deaths per thousand residents. Typhoid was common in the late nineteenth century, marked by periodic surges, and Philadelphia endured outbreaks in 1876, 1888-1889, and 1899.

Notably, the nearby rural areas of New Jersey and Delaware registered much lower death rates, below the the twenty-five per thousand level.

Eventually Philadelphia adopted a defense that had shown good results in Europe—cleaning up the water supply with filtration systems. After filtering plants were built in the early twentieth century, the rate of typhoid declined dramatically and the incidence of the disease eventually disappeared completely.

This map is excerpted from a typhoid map of the full United States that was published in 1898 by the Government Printing Office, based on the results of the eleventh census (1890).

Related Topics

• City of Medicine
• Greater Philadelphia
• Philadelphia and the Nation

Time Periods

• Nineteenth Century after 1854
• Twentieth Century to 1945
• Northwest Philadelphia
• College of Physicians of Philadelphia
• Fairmount Water Works
• Immigration (1870-1930)
• Infectious Diseases and Epidemics
• Influenza (“Spanish Flu” Pandemic, 1918-19)
• Pharmaceutical Industry
• Public Health
• Schuylkill River

Related Reading

Condran, Gretchen A., Henry Williams, and Rose A. Cheney. “The decline in mortality in Philadelphia from 1870 to 1930: The role of municipal services.” Pennsylvania Magazine of History and Biography  108, no. 2 (April 1984): 153-177.

Hartshorne, Henry. Our Water Supply, What it is and What it Should Be . Germantown, Philadelphia, 1889.

Hering, Rudolph, Joseph M. Wilson, and Samuel M. Gray. Report to the Hon. Samuel H. Ashbridge, Mayor of the City of Philadelphia, on the Extension and Improvement of the Water Supply of the City of Philadelphia . Philadelphia, 1899.

Levine, Adam. Drinking Water and Public Health in 19 th Century Philadelphia: An Exhibit Celebrating 100 Years of Water Filtration . (On-line version of exhibit created for the Philadelphia Water Department. www.phillyh2o.org/filtration.htm )

McCarthy, Michael P. Typhoid and the Politics of Public Health in Nineteenth-Century Philadelphia. Philadelphia: American Philosophical Society, 1987.

Related Collections

• Philadelphia Board of Health (Department of Health, Bureau of Health: name varies), Annual Reports (Record Group 76.3.) Philadelphia City Archives 548 Spring Garden Street, Philadelphia. (Some years are also available at Historical Medical Library, The College of Physicians of Philadelphia, 19 S. Twenty-Second Street. Philadelphia.)
• “Typhoid,” Philadelphia Bulletin Clippings Special Collections Research Center Charles Library, Temple University Libraries, 1900 N. Thirteenth Street, Philadelphia.

Backgrounders

Connecting Headlines with History

• Schuylkill floods through intake pumping station on Kelly Drive, no risk reported (WHYY, August 28, 2011)
• History offers explanations for deadly Germantown flood (NewsWorks, October 3, 2011)
• Philadelphia water department rebuts report on water testing (WHYY, January 27, 2016)
• PhilaPlace: The Fairmount Water Works — Disease and the City’s Water Supply (Historical Society of Pennsylvania)
• Watershed History: Roxborough Water Works (Philadelphia Water Department)
• https://water.phila.gov/blog/watershed-history-roxborough-pumping-station-demolition
• Shawmont Pumping Station Razed (Hidden City Philadelphia)

Connecting the Past with the Present, Building Community, Creating a Legacy