Typhoid in Children: The Real Illness, the Widal Test and Prevention

Typhoid, and "Typhoid" as a Label

Typhoid fever is an infection caused by a bacterium, Salmonella Typhi. A milder but similar illness, paratyphoid, is caused by Salmonella Paratyphi. Both are spread when food or water is contaminated with tiny amounts of stool from a person who carries the bacteria. The bacteria pass from the gut into the blood, and spread through the body.

Typhoid is real in Nigeria, and it can be serious. The word "typhoid" is also used far more loosely. Children with a fever, a tummy ache or a few days of feeling unwell are often told they have "typhoid" — or "malaria and typhoid" — on the basis of a Widal test. Studies in Nigeria and across Africa have found that many children given this label, often most, do not have typhoid when a proper test is done. The real cause, often a virus, malaria, a urine infection or pneumonia, can be missed.

Telling the two apart gets your child the right test, the right treatment, and no medicines they do not need.

What True Typhoid Looks Like

Symptoms usually begin one to three weeks after swallowing the bacteria. Typhoid tends to start slowly and build up:

• A fever that climbs day by day over the first week, often reaching 39 to 40 °C, and does not settle by itself.
• Headache, weakness and tiredness that get worse rather than better.
• Tummy pain and loss of appetite.
• Constipation in older children, or diarrhoea, which is more common in younger children.
• A dry cough, a coated tongue, or feeling "far away" and dull in the second week.
• Sometimes a faint rash of small pink spots on the chest or tummy, though this is often not seen on dark skin.

Without treatment, the illness often lasts three to four weeks. The more serious complications usually come in the second or third week, which is why a fever lasting more than a few days always needs to be properly investigated.

Typhoid is unlikely if the fever lasted only a day or two, if the child is running around and eating normally between fevers, or if there are clear signs of another cause, such as a runny nose and cough.

When to Come In

The most serious complication of typhoid is a hole in the bowel (intestinal perforation). It is more common in West Africa than in many other parts of the world, and it needs surgery quickly. If your child has any one of the "come in now" signs, come to Limi Children's Hospital now, day or night. If you cannot get here quickly, go to the nearest emergency department. Have someone else drive if you can, so you can watch your child, and call 0813 408 5400 on the way so the team can prepare.

Use our fever checker for general advice about fever at your child's age, and our dehydration checker if your child has diarrhoea or is vomiting.

Why the Widal Test Misleads

The Widal test does not look for the typhoid bacterium. It measures antibodies — the body's defences — against proteins that Salmonella shares with other bacteria. In a country where typhoid and other infections are common, many healthy people have these antibodies. The World Health Organization does not recommend relying on the Widal test to diagnose typhoid. The problems:

• It is often positive in people without typhoid: after a past infection, after other Salmonella or bacterial infections, after a typhoid vaccine, and in malaria.
• It is often negative early in real typhoid, because antibodies take time to rise.
• A single result means little. Laboratories use different "cut-off" levels, and the familiar "O and H" numbers on the report cannot tell a doctor on their own whether the child is infected now.

The Tests That Do Help

• Blood culture. Blood is placed in a bottle and the laboratory grows any bacteria. It is the standard test, is most likely to be positive in the first week of illness, and also shows which antibiotics will work. It takes a few days, and it is much less likely to find the bacteria once antibiotics have been started.
• Stool culture can help later in the illness and to check for carriers.
• Other tests — a full blood count, a malaria test, a urine test, and a chest X-ray if there is a cough — help find or rule out other causes of the fever.

Rapid typhoid tests sold in some laboratories also miss cases and give false positives. When the result matters, ask for a blood culture.

Treatment and Antibiotic Resistance

Typhoid is treated with antibiotics. The choice depends on how ill your child is, the blood culture result, and which antibiotics work against typhoid in the area.

• Children who are eating, drinking and not too unwell can usually take antibiotics by mouth at home, with a review to make sure they are improving.
• Children who are very unwell, vomiting, or have complications are treated in hospital with antibiotics into a vein, fluids, and close watching of the tummy.
• The fever takes several days to settle even on the right antibiotic. That is expected; it does not mean the medicine has failed.
• Finish the full course as prescribed, even when your child feels better, to lower the chance of relapse and of becoming a carrier.

Intestinal perforation is treated with an operation, antibiotics and intensive care. At Limi, our paediatric surgery team and paediatric intensive care unit treat children with these complications.

Why Random Antibiotics Make Things Worse

Salmonella Typhi has become resistant to many of the older, cheaper antibiotics that are still widely sold without a prescription. In some countries, strains resistant to almost every tablet antibiotic have appeared. When a child is given an antibiotic at a chemist "for typhoid":

• it may be one the bacteria are already resistant to, so the real infection carries on;
• the child may feel a little better for a while, hiding a serious illness until complications appear;
• the blood culture is then much less likely to find the bacteria;
• and every unneeded course helps resistance spread, for your child and for everyone.

Only give antibiotics that a doctor has prescribed after examining your child, in the dose prescribed, for the full course.

Caring for Your Child at Home

• Fluids first. Offer water, ORS, soups, pap and diluted fruit juice often. A child with a long fever loses a lot of water.
• Small, soft, frequent meals — rice, yam, pap with milk, eggs, moi moi, soups, ripe banana — as your child can manage. Children lose weight in typhoid and need to regain it.
• Paracetamol can ease the fever and aches, using the dose on the pack for your child's age, measured with the syringe or spoon that comes with it.
• Rest, and keep a note of temperatures, fluids and stools. Our symptom diary can help you track them.
• Wash hands with soap after using the toilet or handling nappies, and keep a child with typhoid away from preparing food for others.
• Watch the tummy. New severe pain, swelling, or vomiting green fluid means come in now.

Preventing Typhoid

Typhoid spreads through water and food, so the most important protection is in the kitchen and at the tap.

Safe Water

• Boil drinking water at a full rolling boil for at least one minute, let it cool covered, and store it in a clean container with a lid and a tap or clean cup for pouring.
• Or treat it with chlorine water-treatment products, following the instructions on the pack.
• Bottled and sachet water is safer when it is from a NAFDAC-registered producer with an intact seal. Water from unregistered producers may not be clean.
• Wells and boreholes near toilets or soakaways can be contaminated. Treat the water.
• Ice and drinks made with unsafe water carry the same risk.

Hands and Food

• Wash hands with soap and running water for about 20 seconds after the toilet, after changing nappies, and before preparing or eating food. Teach children to do it and check they do.
• Eat food hot and freshly cooked. Food left at room temperature for hours, then eaten cold, can grow bacteria.
• Wash fruit and vegetables in safe water, and peel fruit where you can. Salads and cut fruit from roadside sellers carry a higher risk.
• Street and school food: choose food that is cooked in front of you and served hot. Teach older children to do the same.
• Keep toilets clean and away from water sources, and keep flies off food.

The Typhoid Vaccine

The typhoid conjugate vaccine (TCV) is recommended by the World Health Organization in countries where typhoid is common. It can be given from six months of age as a single dose, and protects for several years. It is not yet part of Nigeria's routine schedule everywhere. Ask the care team about it at your child's vaccine visit, and see our vaccine schedule tool. The vaccine reduces the risk; it does not replace safe water and handwashing.

Carriers and Going Back to School

After typhoid, a small number of people carry the bacteria in their gut or gallbladder for months or years without feeling ill. They can pass it on through food they prepare. This is one reason typhoid can keep appearing in the same household or school.

• If someone in the home has confirmed typhoid, make handwashing and safe water a strict routine, and ask the doctor whether anyone else should be tested.
• Children can usually return to school once the fever has gone, they have finished treatment and feel well. Good toilet hygiene at school matters.
• Teenagers and adults who handle food for others — cooks, food sellers, school kitchen staff — may need stool tests to show they are clear before going back to that work. Ask the doctor.

Myths and What Is True

Questions Parents Ask