Typhoid: Not Just a Disease of Contaminated Water, but Also a Challenge of Accurate Diagnosis and Antibiotic Resistance

Adrian Mercer

Typhoid is commonly understood in Nepal as an illness associated with prolonged fever. In practice, when someone develops fever, weakness or headache, there is often a tendency to quickly assume that the person has typhoid. Medically, however, diagnosing typhoid is not that simple.

Its symptoms overlap with many other infections, and the use of antibiotics based on inaccurate tests or assumptions can complicate not only the treatment of an individual patient but also the broader problem of antimicrobial resistance.

Typhoid is a systemic infection caused by the bacterium Salmonella Typhi. The bacterium lives only in humans and is transmitted mainly through food or water contaminated with fecal matter from an infected person. For this reason, the risk is higher in communities where access to safe drinking water, sanitation and food hygiene is inadequate.

According to World Health Organization estimates for 2019, typhoid causes around 9 million illnesses and approximately 110,000 deaths globally each year. Nepal has also long remained among countries with a significant burden of typhoid. Global Burden of Disease estimates for 2019 suggested at least 82,449 typhoid cases and 919 deaths in Nepal.

Why Can the Symptoms Be Misleading?

Typhoid may begin gradually. Prolonged fever, headache, severe fatigue, weakness, loss of appetite, nausea, abdominal pain, constipation or diarrhea are among the possible symptoms. Some patients may also develop faint reddish spots on the skin.

However, similar symptoms can occur in dengue, viral fever, malaria, other bacterial infections and a range of other illnesses. Therefore, fever and headache alone are not enough to conclude that a patient has typhoid.

If left untreated or allowed to progress, severe typhoid can lead to intestinal bleeding, intestinal perforation, neurological complications and other serious health problems. Such complications are more likely when the disease remains untreated for a prolonged period.

Why Is Accurate Testing Important?

One of the most important issues in typhoid management is proper diagnosis.

According to the U.S. Centers for Disease Control and Prevention, blood culture remains the mainstay of laboratory diagnosis for typhoid. In some cases, a single culture may fail to detect the bacteria, so additional samples may be required depending on the patient’s condition and clinical assessment.

Special caution is necessary with the Widal test, which has long been widely used in Nepal and other parts of South Asia. The test can produce false-positive results because antibodies may reflect previous exposure, cross-reactions or background immunity.

For this reason, diagnosing typhoid and prescribing antibiotics solely on the basis of a Widal result is not considered reliable clinical practice.

Similarly, rapid tests based on IgM or IgG antibodies cannot replace a complete clinical evaluation. The type of test, the timing of the illness, the patient’s symptoms and the physician’s assessment must all be considered together.

Why Is Self-Medication with Antibiotics Risky?

Because typhoid is caused by bacteria, antibiotics are effective when appropriately prescribed. However, the choice of antibiotic should be made by a physician based on local resistance patterns, the severity of illness and, whenever possible, culture and antimicrobial susceptibility results.

Salmonella Typhi has developed resistance to multiple antibiotics in several parts of the world. This means that medicines that worked reliably in the past may no longer be effective in some patients.

Starting antibiotics without medical advice as soon as fever appears, stopping treatment once the fever improves, or taking medication prescribed for someone else can all contribute to the problem.

Such practices may result in incomplete treatment and may also encourage the emergence of bacteria that are increasingly difficult to treat.

Typhoid Vaccination: An Important Step for Nepal

Nepal introduced the typhoid conjugate vaccine into its national immunization programme in 2022.

During the initial nationwide campaign, children between 15 months and 15 years of age were targeted. The vaccine was subsequently incorporated into the routine immunization schedule, with a dose provided at 15 months of age.

The vaccine is an important tool for reducing typhoid risk, particularly among children.

However, vaccination does not eliminate the need for safe drinking water, proper food hygiene and handwashing. No vaccine guarantees complete protection against infection.

Prevention Still Depends on Water and Sanitation

The most sustainable way to control typhoid remains access to safe drinking water and effective sanitation.

People should drink boiled or otherwise safely treated water, eat food that is thoroughly cooked and served hot, avoid ice made from unsafe water, and wash raw fruits and vegetables carefully with clean water.

Handwashing with soap after using the toilet and before preparing or eating food may appear simple, but it remains one of the most effective ways to prevent typhoid transmission.

Even during recovery, some infected individuals may continue to shed the bacteria in their stool, making personal hygiene particularly important.

When Should Medical Attention Be Sought?

Medical evaluation is important if fever persists, weakness becomes severe, abdominal pain increases, vomiting continues, blood appears in the stool, mental status changes, or the patient is unable to drink adequate fluids.

Typhoid should neither be treated as simply another name for prolonged fever nor should every fever automatically be labelled as typhoid.

Three elements are central to effective control: *accurate diagnosis, responsible use of antibiotics, and safe water and sanitation.*

Nepal has already taken an important step through vaccination. The next challenge is to strengthen reliable laboratory diagnosis, antimicrobial resistance surveillance, and access to safe water and sanitation.

If these measures are pursued together, the country will be in a much stronger position to reduce the long-term burden of typhoid.