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Epidemiology, microbiology, clinical manifestations, and diagnosis of enteric (typhoid and paratyphoid) fever

Edward T Ryan, MD, DTMH
Jason Andrews, MD
Section Editor
Stephen B Calderwood, MD
Deputy Editor
Allyson Bloom, MD


Enteric fever is characterized by severe systemic illness with fever and abdominal pain [1]. The organism classically responsible for the enteric fever syndrome is Salmonella enterica serotype Typhi (formerly S. typhi). Other Salmonella serotypes, particularly S. enterica serotypes Paratyphi A, B, or C, can cause a similar syndrome; however, it is usually not clinically useful or possible to reliably predict the causative organism based on clinical findings [2]. The term "enteric fever" is a collective term that refers to both typhoid and paratyphoid fever, and "typhoid" and "enteric fever" are often used interchangeably.

The epidemiology, microbiology, clinical manifestations, and diagnosis of enteric fever will be reviewed here. The pathogenesis, treatment and prevention of enteric fever are discussed separately. (See "Pathogenesis of enteric (typhoid and paratyphoid) fever" and "Treatment and prevention of enteric (typhoid and paratyphoid) fever" and "Immunizations for travel".)


Enteric fever is more common in children and young adults than in older patients [3]. Worldwide, enteric fever is most prevalent in impoverished areas that are overcrowded with poor access to sanitation. Incidence estimates suggest that south-central Asia, Southeast Asia, and southern Africa are regions with high incidence of S. Typhi infection (more than 100 cases per 100,000 person years) [4-6]. Other regions of Asia and Africa, Latin America, the Caribbean, and Oceania have a medium incidence of 10 to 100 cases per 100,000 person years. These estimates, though, are limited by lack of consistent reporting from all areas of the world and are based on extrapolation of data across regions and age groups. More recent population-based studies from Latin America, in particular, are lacking, and surveillance suggests that rates have declined substantially over the past 30 years. Furthermore, subsequent data from Africa have revealed substantial heterogeneity between countries, with some Southern and Northern African countries having very low rates (<5 cases per 100,000 person years) while several countries in Eastern and West Africa have rates >100 per 100,000 [7]. S. Paratyphi A remains uncommon in Africa [7], but accounts for a substantial proportion of enteric fever cases in areas of South Asia [8].

Because humans are the only reservoir for S. Typhi, a history of travel to settings in which sanitation is poor or contact with a known typhoid case or carrier is useful for identifying people at risk of infection outside of endemic areas, although a specific source or contact is identified in a minority of cases. Transmission from an index case to a contact is rarely documented in resource-rich settings [9].

Approximately 200 to 300 cases of S. Typhi are reported in the United States each year [10]. About 80 percent of these cases occur among travelers to countries where enteric fever is endemic, particularly countries in South-Central Asia, but domestic acquisition still occurs [11]. In a study of 428 cases of enteric fever reported among travelers from resource-rich countries through the multinational GeoSentinel Surveillance Network between 2006 and 2011, 67 percent of cases were acquired in south-central Asia (34, 13, 7, and 6 percent of total from India, Nepal, Pakistan, and Bangladesh, respectively) (figure 1) [12]. Individuals visiting relatives in endemic countries accounted for 28 percent of the typhoid cases.

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Literature review current through: Nov 2017. | This topic last updated: Nov 27, 2017.
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