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Chapter 22 - Typhoid and Paratyphoid Fevers
Dwight M. Kuhns, M. D., and Capt. Donald L. Learnard, MSC
HISTORICAL NOTE 1
The problem of typhoid and paratyphoid fevers is well recorded in the annals of military history. Until 1818, however, there were no records of disease and epidemiology in the United States Army. With the appointment of Dr. Joseph Lovell as the first Surgeon General of the United States Army and recognition of the Medical Department as a staff department of the Regular Army by Act of Congress, 2 the first system of reports was initiated.
With the onset of the Spanish-American War in 1898 and the campaigns in Cuba, the Philippine Islands, and Puerto Rico, typhoid fever became widespread throughout the Army. As a result of the alarming pace at which the death rate increased month by month, the Army set up a Typhoid Fever Board to study the epidemiology of typhoid fever in United States military camps, and Maj. Walter Reed, MC, Maj. Victor C. Vaughan, MC, and Maj. Edward O. Shakespeare, MC, were appointed as members. The board brought to light much of the present knowledge of the disease and its epidemiology.5
1 Acknowledgment is hereby made to Martin Roth, M. A., for his faithful assistance in the research for historical material for this section and in the final preparation of the manuscript.
2 Military Medical Manual. 5th ed. Harrisburg: The Military Service Publishing Co., 1942.
3 Medical and Surgical History of the War of the Rebellion.Medical History.Washington: Government Printing Office, 1888, vol. I, pt. III.
4 Bulloch, W.: History of Bacteriology.In A System of Bacteriology.[Great Britain] Medical Research Council. London: His Majesty's Stationery Office, 1930, vol. I, pp. 15-103.
5 Reed, Walter; Vaughan, Victor C.; and Shakespeare, Edward O.: Report on the Origin and Spread of Typhoid Fever in United States Military Camps During the Spanish War of 1898. Washington: Government Printing Office, 1904, vol. I.
6 Gay, Frederick P.: Agents of Disease and Host Resistance. Springfield: Charles C Thomas, 1935, p. 1557.
7 Siler, J. F., Dunham, G. C., and Longfellow, D.: Typhoid Fever. Baltimore: The Johns Hopkins Press, 1941.
8 See footnote 2, p. 463.
rate for the World War I period was 37 per 100,000 strength. Typhoid
fever contributed only
0.04 percent of the total admissions to hospitals for all diseases and,
of all deaths from disease
during World War I, only 0.39 percent were attributed to typhoid fever.
There were 1,529
admissions to hospital for typhoid fever among approximately 4,000,000
troops to give an
annual rate of 0.37 per 1,000 strength throughout the Army. As had been
anticipated, a higher
incidence rate was experienced in Europe than in the United States. The
overseas was, in all probability, due to breakdown of induced immunity
in certain individuals by
numerous and repeated exposures to massive doses of the causative
organism in specific sections
where food, milk, and water were contaminated, sewage. disposal
inadequate, and a general low
civilian health standard prevailed. Paratyphoid fevers were likewise
not a major problem during
the World War I period. Admission rates for the entire United States
Army for this period were
0.05 per 1,000 strength annually, considerably lower than the admission
rate for typhoid fever.
Six deaths from paratyphoid fever were reported in 1918 and five in
The contrast between the typhoid-paratyphoid problem
in World War I as compared with that of
the Spanish-American War can be attributed to the continuous
application of control measures.
In those days, it was thought that: "The control of typhoid fever is
based first, on preventing the
transmission of massive or continuous infection by water, food and
contact, that is, by water
purification, food control and waste disposal, and second, on
immunization by prophylactic
9 Dunham, George C.: Military Preventive Medicine. 3d ed. Harrisburg: Military Service Publishing Co., 1940, p. 163.
10 Seckinger, D. L.: Epidemiological
Studies Upon Typhoid Fever in Georgia. Problems Associated With Its
Control. South. M. J. 26: 933-941. november 1933.
11 (1) Grinnell, F. B.: A Study of the Comparative Value of Rough and Smooth Strains of B. typhosus in the Preparation of Typhoid Vaccines. J. Immunol. 19: 457-464, November 1930. (2) Perry, H. M., Findlay, H. T., and Bensted, H. J.: Antityphoid Inoculation. The Role of Bacterium typhosum, Strain Rawlings. J. Roy. Army M. Corps 60: 241-254, April 1933. (3) Perry, H. M., Findlay. H. T., and Bensted, H. J.: Antityphoid Inoculation; Observations on the Immunizing Properties and on the Manufacture of Typhoid Vaccine.J. Roy. Army M. Corps 62: 161-177, March 1934. (4) Perry, H. M., Findlay, H. T., and Bensted, H. J.: Antityphoid Inoculation; Observations Relative to the Immunological Value of Different Cultures of "Bacterium typhosum." J. Roy. Army M. Corps 63: 1-12, July 1934.
12 See footnote 7, p. 464.
revealed that the camp's water supply was contaminated with coliform
bacteria, indicating a,
fecal contamination. It was discovered that blasting operations
conducted in preparation of the
camp had opened fissures in the rock strata, allowing seepage directly
from the latrines to the
This outbreak serves to add to the evidence that
immunization is not entirely protective when
large numbers of the causative organisms of typhoid fever are ingested,
but such immunization
does lower the mortality of the disease and check the seriousness and
duration of the illness.
can be seen that the annual rate for typhoid and paratyphoid combined was reduced to a remarkably low level by 1920 and maintained there until 1931 when there was a slight increase.
WORLD WAR II EXPERIENCE WITH TYPHOID AND PARATYPHOID FEVERS
By 1940, standard regulations had become well established from actual experience gained in previous military operations in war and peace. These rules were described in Army regulations.13 Generally, they provided for the responsibility of commanders in regard to housing; water supplies; waste and garbage disposal; food and drink preparation; cleansing of dishes, messkits, and utensils; and examination of permanent foodhandlers. The Medical Department was charged with investigation of sanitary conditions, checking of water supplies, recommending types of water purification, and making periodic surveys of the potability of water.
13Army Regulations No. 40-205, 31 Dec. 1942, and No. 40-210, 15 Sept. 1942.
14 Nichols, Henry J.: Carriers in Infectious Diseases.Baltimore: Williams and Wilkins Co., 1922.
manders were notified whenever carriers were to be transferred to their commands.Reports were made to The Surgeon General of any individual who retained his carrier state for more than 6 months. Through close cooperation with certain State boards of health, known typhoid and paratyphoid carriers were detected and reported to The Surgeon General by State health authorities. No provisions were made, however, to exclude or discharge carriers from the Army, although this problem had been discussed at length by members of the Army and the National Research Council.15 Known carriers were placed on duty not involving handling of food or other materials that might be contaminated.
15 Memorandum for file, Capt. P. E.Sartwell, 21 Aug. 1944, subject: Conference with Professional Service on Typhoid Carriers.
1 September 1940, the paratyphoid fractions were reinstated, and the prescribed course included three 1 cc. subcutaneous injections of triple typhoid vaccine given approximately 3 years after the initial immunization. Only two complete series were required for any individual except, where deemed advisable by the medical officer concerned, in such cases as (1) outbreaks of the disease; (2) when personnel were assigned to a theater of operations; and (3) upon boarding an Army transport or airplane for travel beyond the limits of the United States, unless vaccination had been completed within 12 months prior to departure. Individuals over 45 years of age were not required to complete revaccination unless they were leaving the United States.
Special measures.-Special measures were executed during
epidemics of any intestinal disease.
Extra efforts were made to detect and hospitalize early cases and to
detect and restrict carriers.
Suspected common sources of infection (such as milk, water, and food)
as indicated by
epidemiologic study were excluded from use by the command until the
proved cause or causes of
the epidemic had been discovered or until adequate corrective measures
had been applied to the
suspected source or sources. Special attention was given to the
examination of foodhandlers,
sanitation of kitchens, mess, garbage-disposal methods, latrines, and
the control of flies. Close
cooperation with civilian health authorities in determining sources of
infection was established
Other required sanitation measures included compliance with local regulations regarding sewage disposal, collecting and processing of liquid wastes from kitchens and bathrooms, avoidance of water and stream pollution, analysis of sewage, and control of flies.
The preventive medicine officer in each of the major theaters of operations established policies and procedures for prevention of intestinal infections, and port authorities-both sea and air-made every effort to apprehend and place under medical supervision each individual suspected of harboring a contagious disease. This was perhaps more effective in the European theater than in
areas because medical facilities were fairly well established before
large numbers of troops
had arrived. Special epidemiologic reports were devised for typhoid
which were forwarded to The
Surgeon General when completed. In many cases these were not
conveniently accomplished, the
patient and the medical officer both being far removed from the source
Special methods for
control of typhoid, paratyphoid, and other intestinal diseases included
of stools for the causative organism in all cases of diarrhea. This was
feasible, even in theaters of
operations, because laboratory service was available in most instances
at hospitals, Army
laboratories, and when necessary in regular public health laboratories.
A period of 4 days between
the time of specimen collection and the time of culturing was permitted
for transit. Dish culturing
was instituted throughout the various service commands of the Army for
the purpose of periodically
evaluating the thoroughness achieved in mess sanitation. Laboratories
and laboratory technicians
were evaluated by proficiency studies whereby known specimens were
forwarded by the various
service command laboratories thereby promoting skill in the laboratory
detection of pathogenic
In the initial phase of mobilization, the incidence of typhoid fever was no higher in the Army in the United States than in the 2 previous years of 1938 and 1939. There were 3 reported cases of typhoid fever in home troops in 1940 and 12 cases in 1941.The annual rates per 1,000 average strength for typhoid fever in the United States (among enlisted men only) were 0.02 for 1938, 0.02 for 1939, and 0.01 for 1940. In 1941, the rate was 0.01 indicating that control measures were effective during a period of inducting large numbers of troops from every section of the country.16
16 Holt, R. L.: Current Status of Immunization Procedures. Typhoid Fever. Am. J. Pub. Health 38: 481-484, April 1948.
of water discipline, food from unauthorized sources, or human carriers. In the China-Burma-India theater, local conditions were unhealthy, there was little or no enforcement of sanitary laws, and deplorable facilities existed for the disposal of garbage and human excreta.
fever than in controlling typhoid fever, although its program was, on the whole, efficient and admirable.
17 Gordon, J. E.: A History of Preventive Medicine in the European Theater of Operations, U. S. Army, 1941-45. [Official record.]
other locality to report more than 5 cases was Latin America with 7. It
is readily discernible
from this account that soldiers stationed in areas of good local
sanitation, such as the United
Kingdom, were no more likely to contract the disease than troops in the
United States, the case rate
per 1,000 men being approximately the same. In the Middle East and the
clinical and subclinical paratyphoid and other enteric fevers were
rampant in the native population.
Necessarily, Americans were exposed to local conditions and,
unknowingly or carelessly, consumed
highly contaminated foods and water. Considering at the same time the
measures practiced in the Latin American theater, where the case rate
for paratyphoid fever was 0.07
per 1,000 troops per annum, it is apparent that adequate military
control can be exercised to prevent
enteric fevers even in communities where natives are suffering from the
Experience during 1943.-In the year
1943, United States troops were widely distributed all over
the world. Large numbers of soldiers were engaged in active combat
operations in North Africa,
Sicily, Italy, and throughout the. Pacific Ocean area on isolated
islands. They were stationed in
northern regions such as Alaska, the Aleutian Islands, Iceland,
Greenland, and Newfoundland, as
well as in built-up areas in the United Kingdom, the Persian Gulf,
Burma, China, Australia, New
Zealand, India, and Hawaii. Air installations were in remote and
farflung places such as the Azores,
the Caribbean Islands, South America, and the Pacific. There were
reported 175 cases of typhoid
fever throughout the Army, 150 of which were from overseas, for a total
Army case rate of 0.03 per
1,000 troops. In the Mediterranean theater, there were 83 cases, partly
associated with an outbreak
in a prisoner-of-war camp in North Africa during October, November, and
December, the case rate
being 0.18 per 1,000 troops. The Middle East theater reported 12 cases
and a rate of 0.23 per 1,000
Eighteen cases were known in the Southwest Pacific, records not being available to state the exact locations. Twenty-five cases were reported from the China-Burma-India theater for a case rate of 0.63 per 1,000 average strength, the highest incidence throughout the Army during the year.
of 0.02. The majority of these cases were overseas where the case rate
reached 0.03 per
1,000 strength. The highest number of cases was in the Mediterranean
theater where 46 were
reported, but the rate was exceeded in the China-Burma-India theater
with 0.23 for 38 cases. In the
Southwest Pacific, there were only four cases with a rate of 0.01.
outbreak of typhoid fever occurred during the year (1944) in Company G,
Infantry in Northern Italy. In November and December, 19 members were
admitted to hospital and
diagnosed as having typhoid fever. One man, who had become aware of
symptoms 30 days prior
to reporting sick, died in a toxic state 10 days after being admitted.
Although an extensive
investigation was carried out to determine the source of the infection,
no definite conclusions could
be reached. Possible reasons for the outbreak were given as (1)
indiscriminate drinking of water
from wells, shellholes, and other places without using halazone or
other purification methods (some
patients explaining that they had been issued halazone tablets only
once and after they were used,
no reissue was made); (2) consumption by some soldiers of civilian
food, including potatoes and
salami, though there were no samples of the food available for
examination; and (3) presence in the
unit of individuals with subclinical typhoid fever. The outbreak
followed a carrier pattern, 2
individuals from other units acquiring the disease after eating one or
two meals with Company G,
but the possibility of a carrier was not confirmed.18
Paratyphoid fever was twofold higher in incidence than the previous year with 340 cases, case incidence throughout the Army rising to 0.04 per 1,000 average strength. Overseas commands contributed 310 cases with a
18 Bruner, D. W.: Salmonella Infections of World War II. [Official record.]
0.07. The Southwest Pacific reported 140 cases with a rate of 0.14. The
Pacific Ocean area,
including the Central and South Pacific, reported 20 cases, but in view
of the large number of troops
involved the rate amounted to 0.05.
incidence of typhoid and paratyphoid fevers and diarrheal diseases.-Since
epidemiology of the diarrheal diseases is similar to that of typhoid
and paratyphoid fevers, it is of
interest to show comparative incidence of the diseases (table 82). It
is generally considered that
neither typhoid fever nor paratyphoid fever was a particularly serious
problem to the Armed Forces
in either World War I or World War II. For the two world conflicts,
these diseases were even less
of a problem in the second than they were in the first war. While this
may not be altogether apparent
upon cursory inspection of these statistics, it is readily acknowledged
when it is considered that
many more men were under arms in the Second World War than in the
First. It becomes clear on
examination of the rates, especially when dealing with preliminary
figures, that they are a more
reliable index of incidence than are the absolute numbers of cases
reported. The diarrhea-dysentery
problem in World War II was at least as serious as in World War I. This
lends support to the belief
that typhoid-paratyphoid vaccine played a tremendously important role
in the control of typhoid and
paratyphoid fevers. In the occurrence of diarrheal diseases and
dysentery, no such reduction took
place since no effective vaccine for these diseases has ever been
Incidence in Civilian Populations
The fact that United States troops were relatively free from typhoid fever should not be interpreted to indicate that there was litilt opporturjity for exposure. The disease, when it, did occur in military personnel, often did so against a background of it in civilian populations, the latter having been far less immune to typhoid fever than were the Armed Forces of the various nations engaged in combat. The disease was prevalent throughout war-ridden Europe, especially in France, Belgium, Holland, and Germany. Figures for typhoid in Russia are not available but were probably substantial. By way of illustration, the city of Saint-Etienne, France, lead 570 cases with 27 deaths in the autumn of 1944. At Greater Liege, in Belgium, there were 104 cases from 1 August to 18 November 1944. Thus, civilian populations were always a potential source of infection.
A marked difference
call be seen in chart 48 between May and June and
even between consecutive
days. Not all of the infections were in newly captured prisoners. Many
of them occurred in prisoners
who had been field for all appreciable period of time. In the Advance
Zone, among 403,142 prisoners of war, there were 30 deaths from typhoid
in the 6-week period from
1 May to 15 June 1945.It is to be noted that it was not possible to
give the prisoners of war the best
medical care, and it is not unreasonable to hypothesize that typhoid
cases among prisoners of war
may not always have been correctly diagnosed.
19 See footnote 17, p. 473.
infection. The following report from a prisoner-of-war camp illustrates some of the symptoms of the disease as it occurred among prisoners of war:
there must have been some cases, but they were either undiagnosed or
is known that there was a high rate of diarrhea in the Philippines
following the fall of Bataan and
in the American prisoner-of-war camp in the Asiatic area. When the
Japanese conquered the
Philippine Islands, the Japanese Army Medical Department took over a
Philippine vaccine-production laboratory and produced a. vaccine that
contained typhoid, cholera, and dysentery
bacteria antigens. The typhoid and cholera com ponents may have been
effective. It is doubtful
whether the dysentery component was effective, although the death rate
in infants with dysentery
was reported to be lowered.
On Bataan, in the
reports of the patients hospitalized, there is no record or mention
made of true
cases of typhoid fever. In 1945, the senior author of this chapter
observed 3,000 sick Japanese
prisoners of war at the new Bilibid Prison in Manila.Although there
were many cases of bacillary
dysentery and also amebic dysentery, there were few if any cases of
typhoid fever among the
During and following World War I, the safeguarding of water and food supplies had approached and attained so high a standard that there developed a tendency to relegate its importance to secondary consideration. In World War II, in order to correct this tendency, Army engineers were given greater responsibility in such aspects as the location and appraisal of water supplies and the proper treatment of water, including chlorination, while the role of the Medical Department became more advisory in nature.
were among the first important workers.It has been said that the
reason for the supposedly
low incidence of paratyphoid in the continental United States during
the decade 1930-40 was
because effective techniques for the isolation of the organisms had not
as yet been developed. The
use of S.-S. (Shigella-Salmonella thiosulfate-citrate-bile)
agar, modified brilliant-green agar, sodium
selenite, and tetrathionate broths are examples of the progress made in
the development of
differential media for the growth of the various Salmonella species.
There was no marked
change in the routine serologic diagnostic methods, although a great
forward was made when the Kauffmann-White Schema was introduced with
simplification. The ultimate diagnosis of the infections from Salmonella
Salmonella typhosa) during World War II depended on the
classical standby method of culturing
the blood, urine, and stools of the patient.
Carrier control and detection.-As has been mentioned earlier, little was accomplished in the therapy of typhoid and paratyphoid carriers.However,
20 Hardy, A. V., Watt, J., and DeCapito, T. M.: Studies of the Acute Diarrheal Diseases.Pub. Health Rep. 57: 521-524, 10 April 1942.
was not relaxed, and great zeal was displayed in the finding and
apprehension of carriers.
The sulfonamide drugs were found to be ineffective, and more recently
the antibiotics have proved
ineffective in completely eliminating the organisms from carriers.
Mobile laboratories.-Mobile laboratories were tested and found
to be of considerable value in field
operations where fixed laboratory service was nonexistent or simply not
laboratory diagnosis of typhoid and paratyphoid fevers may prevent
large outbreaks when sporadic
21 The Medical Department of the United States Army. Preventive Medicine in World War II, Personal Health Measures and Immunization. Washington: U. S. Government Printing Office, 1955, vol. III, ch. VIII.
22 Batson, H. C.: Typhoid Fever Prophylaxis by Active Immunization. Pub. Health Rep. Supp. 212, August 1949.