Number one, The camp at Chickamauga was a perfect hell on earth. War itself would have been a paradise compared with the peace of this camp. I saw many awful sites there, men dying under the trees for the want of a glass of water. I found there men who had been sick with typhoid fever for days, and who had not received medical attendants. No one had even taken their temperature. It was awful for five hundred men in
hospitals there were only a dozen attendants. The water from the creek was simply mud, and yet the boys had to bathe in it and drink it. Everything about the camp was badly managed. As for the food, there is only one way to describe it.
It was rotten. Number two.
Someone is to blame for keeping an army of forty five thousand men at a camp where all the water was unfit for a dog to drink, where there was no drainage, no proper food or medicine, and where the conditions were so unhealthy that every man of forty five thousand and had intestinal troubles. Three fourths of the army slept in little dog tents, as we called them. They were five feet long and four feet high. There were no cots. The men slept on the ground, and it
rained nearly all the time for six weeks. Our division hospital was arranged to hold two hundred men, but we had over five hundred sick men in it. Each tent was arranged to hold six men, but we had ten and twelve crowded in. There were not cots enough, and sick men had to lie on litters on the wet ground, sometimes for a week. The sick came in fifty and seventy five at a time, and there were no cots, no medicines, no food for them except the irregular army
rations issued to well men. The men detailed for nurses were the poorest soldiers in the camp. They nursed the sick eight hours in the day and then worked three hours digging sinks and trenches and cleaning up the camps. Number three, in the camp of the third United States Volunteer Cavalry, we found the sinks fold to the top with fecal matter. Soiled paper was scattered around the sinks, and the woods behind the regimental camp was strewn with
fecal matter. The second Kentucky Volunteer Infantry was located in the woods. Fecal matter was deposited around trees, and flies swarmed over these deposits, not more than one hundred and fifty feet from the company mess tents. The odor in the woods just outside of the regimental lines was vile. Yeah, yeah, why why are they poop and InSync?
Like there was nowhere else to poop? Okay, dig a hole what I mean?
So, but all the holes got filled either with poop or with water, and then the rain water would make the pop rise to the surface and spread around.
That's atrocious. Yeah.
So that was from the report of the Commission appointed by the President to investigate the conduct of the War Department in the War with Spain, essentially the Spanish American Wars reports from that around nineteen hundred is one of these reports were all made, Yeah, a few different excerpts. I thought it was more fun to do a little smattering of harries essentially.
Yes, and you'll.
Hear why I picked the Spanish American War for the subject of today's episode later on.
But first, Hi, I'm Aaron Welsh.
And I'm Aaron Olman Updyke.
And this is this podcast will kill You.
And we're back with season four.
We are back, and I'm very excited.
I think we definitely needed.
That break, oh big time.
Yeah, so we appreciate you guys for being patient and sticking with us, Yes and yeah, letting us get a little bit of a time to take a breather and yeah.
Well and also get a bunch of fun new episodes lined up for.
Oh so many fun new episodes.
Yeah.
Yeah, speaking of fun new episodes, what is the topic of today's episode?
Maybe our break was too long?
Eric, No, No, I actually love that. I feel like most of the time lately, our first hands completely give it away, and now it's like Spence has been building for like.
Two whole minutes. Yeah.
Well, I guess if no one clicked on the title of the episode, maybe there's an auto played.
But today we're talking about typhoid fever.
Oh, typhoid fever.
This one has been a long time coming, Oh, very long time coming.
I am super excited to cover this one because typhoid fever was sort of the episode. I feel like that really changed our lives.
Yes, it changed our lives one thousand percent, even though we have not yet covered it. Yeah, because typhoid the story of typhoid Mary is the story that Georgia Hartstark told when she first gave us a shout out on My Favorite Murder, which is like what led to like our lives changing forever.
All the way back, in case you're interested in listening all the way back in episode one oh five titled per I looked it up and I listened to it again.
It's for research for this episode.
Yeah, yeah, this is definitely like a full circle moment.
We've been waiting for this episode since like twenty eighteen eighteen, yeah, eighteen.
Yeah, I'm just so excited for it.
Me too.
But before we get into the actual meat of the episode, we do have some pieces of business, starting.
With quarantin any time.
Quarantine any time, Aaron, What are we drinking this week?
Of course, we could be drinking nothing other than a bloody Mary, bloody typhoid Mary, bloody typhoid Mary. Not just any bloody Mary, not just any.
This one is titled differently, but yeah, other than the title, it is essentially a bloody Mary who doesn't love the bloody Mary. You can pick and choose whatever pickled vegetables you want to put in there. It's tomato juice, it's cu it's you know, worcessre sauce, it's hot sauce. It's whatever you want to put in there.
It's how you like a bloody Mary?
Yeah, an entire like hamburger on a on a stick. Yeah, anything you want to put in there. We will post the recipe to the bloody typhoid Mary as well as the non alcoholic plac Brita on our website this podcast will Kill You dot com, as well as on all of our social media channels.
What other business do we have to attend to, Aaron.
Well, let's see, let's go over the usual suspects. I mean, number one, we've got merch. We've got some super cute new things that.
Are very exciting things.
In fact, the amazing artist Holly Sullivan did some new designs for us, including and you can get prints of her designs right now, and stickers of your Cinea pestis eighties a jip dye of the influenza virus of Giardia.
However you like to say it.
And then there's also other really cool things like one of my favorites is the Quarantining Time T shirt. It is so soft and I also have to admit of to always wearing the hoodie around.
It's like the perfect weight.
And then I drink out of the pint glasses and the socks are just too cute.
I can't handle it.
We also heard you, guys when you asked for face masks, since those are now pretty much a staple of everyone's wardrobe, so we have two different face masks, including one that says wash your hands. You have filthy animals.
They both do.
Oh, they both do.
They are super cute. I really I love them all. So yeah, go check it out. You can get to it by the This podcast will Kill You dot com website, click.
On the merch tab. Yeah great, let's see. Okay, more business.
We can run through the rest of the usual suspects, which includes hey, check it out. We've got a bookshop affiliate account, so if you're interested in doing any additional reading on any of the topics that we cover, we link to the books there also through our website, and we also have a good Reads list, so check it out too. Other people can add suggestions there, so you get like a whole smattering of both fiction and nonfiction disease readings.
It's pretty cool, and if you would like alcohol free versions, of these episodes. Maybe you're a teacher, you want to use these for whatever reason, Maybe you just don't want to hear us talk about quarantinies. You can find those as well on our website, this podcast will Kill You dot Com.
And then we have a couple of new announcements.
So the first is that we are going to be picking up again our Anatomy of a Pandemic series, which covers the COVID nineteen pandemic. So we stopped releasing episodes in May, and now we are going to take some time to revisit some of these topics. You know, what have we learned so far about the virus. Everyone wants to know about the vaccine and where we stand with that, and so we are going to be putting those out as we work through these normal episodes. So don't worry,
the normal episodes won't be interrupted. Yeah, and we also still have the first the COVID nineteen first hand account submission form still active, So if you would like to share your story potentially as a first hand account in one of these episodes, please head to this podcast We'll Kill You dot com and click on the COVID nineteen first hand tab at the top of the page.
Is that all the things?
I think that's it. I'm exhausted.
All right, let's circle back around tomorrow to pick up the actual episode.
A perfect good idea, good idea.
Ah, but I guess yeah.
Can we finally start talking about typhoid?
Yes?
I think we are ready. We'll take a quick break first. Great. I think this is one of the most classic and also most specific diseases that we've done in a very long time.
You mean, like it's not super complicated where it has all these different norms and this and that.
No, No, it's plenty complicated.
Oh good, Okay, but it is a very classic TPWKY feel, which is kind of fun and why we chose to do it for our fourth season premiere exactly.
It's a very classic feel. But then it's also well, I'll get into it and you'll see what I mean by specific. Okay, okay, okay. So, typhoid fever, which is also called enteric fever depending on where you live, is the disease that is caused by a gram negative rod shaped bacteria whose full name is Are you ready for this? I know you know this already, but I.
Know it's a big one. It's a mouthful.
Salmonilla enterica subspecies Enterica serah var typhe. And that's what I mean by specific.
I don't quite understand why why Okay, this is a sarah var. Great, really great question. I'm so glad that you asked it, Darren.
You know I was going to yes.
So first of all, we're just gonna call it by its shorthand name, Salmonella typhee. Okay, that's how you can refer to it. Now, there are something like twenty five hundred different serovars of salmonilla, salmonilla and terica even and at least fifty of them are pathogenic, although not all of those are pathogenic to humans. So you asked, how, like what makes the serovar? You can kind of think of it like, you know how we name influenza strains
by their H and their N yep. Okay, So serovars are differentiated by from each other by those specific antigens on their surface. So in the case of Salmonella, it's their lipopolysaccharide, which is an O antigen, and their flagella flagellar antigen, which is an H antigen. So that's how we identify them. You'd like to know the serovar name of salmonilla serovar type, it's O nine to twelve v IHD dash. That's an easy thing to remember, right, Yeah, Okay, So I'm going to start off with a side note.
There's another serovar, a couple of other seravars actually that are called para typhee. So there's paratype A, B, and C. This serahvar causes a very similar but generally more mild illness, and so the term enteric fever usually encompasses both the diseases caused by salmonilla typhee and salmonilla paratyphee. So we're going to try and stay as specific as possible in this episode and really just focus in on salmonilla typhe or typhoid fever.
Cool, gotcha Cool.
So Salmonella typhe is what is referred to as a host restricted pathogen, so it primarily infects just humans and then also like chimpanzees. All right, so how is it transmitted? I know, you know, and everyone that listened to the first hand probably has a guess.
I mean, if you're playing bingo with the number of times that fecal is going to be said in this episode.
With a lot. Yeah, fecal oral so poop in mouth wherever poop can end up then ends up in your mouth, you can get infected. Okay. One thing that's important, and I think this is actually really interesting considering that this is a fecal oral transmitted parasite, is that Salemonella is actually really acid labile, so it does not tolerate the
environment of your stomach very well at all. So that means that the infectious dose is really really high compared to a lot of other bacteria and viruses that we've talked about on this podcast.
Interesting, like r how high.
At least ten thousand bacteria to cause an infection and even at that number, the attack rate, so the percentage of people who would actually get like sick is low, like ten to twenty percent at that infectious dose.
Okay, how much bacteria is an infected person or a carrier?
Shetting?
Such a good question. I don't even know if I know the answer to that. Let me scroll through my notes in an average poop in an average poop, that's a good Aaron, what a good question that I don't have the answer to in all of my notes.
Just FYI, guys, we just spent a little bit of time both looking for the answer. I mean, like not that long, but you.
Know, more than a few minutes.
We spent more than a few minutes, and we couldn't find anything, and so we just think it's safe to assume that it's.
It's probably a lot.
It's not going to be like there's been a lot of typhoid fever epidemics and it's.
Got to be a lot because it takes a lot to get you sick, and you poop a lot when you have typhoid fever, so uh, you know, and it's a it's a Salmonella bacteria which reproduced very quickly, so a lot a lot.
Hey, if somebody can find the actual number, that would be that would be super cool.
Love would love that actual number. But what I did want to say about this is that what's really interesting saying is that the smaller the infectious dose, the longer the incubation period, So the longer between when you first get exposed to when you start to show symptoms, which is logical, but it's nice when we can see that
in data. Cool. Okay, Yeah, So the incubation period, that time from infection to symptoms usually is between five and fifteen days, but it can be quite a bit longer, like even a month or more.
Gotcha.
Okay, so let's talk about the symptoms of typhoid fever, shall we.
Let's okay.
The classic description goes something like this. It starts with a fever fever, but not just any fever, because we have to get specific. This is a fever that gets progressively worse. It's called a step ladder or a step wise fever. So once it begins, it remains high and then progressively rises over the course of or so weeks before it peaks, and then stays pretty high like a plateau phase.
Huh okay, okay, like how high?
Good question? Not bonkers high, Like, we're not talking one oh six, But a fever is classified as one hundred point four fahrenheit or thirty eight celsius. So it'll start there just like a low grade fever, and then progressively just get higher. I don't know what the maximum peak is, probably depends on the person, but we're not talking like one oh six one oh seven. It's just a slowly progressive fever. And what's important is that it stays high.
A lot of other diseases you might have a fever for part of the day and then part of the day your temperature will go back down. With typhoid, once your fever rises, you stay with an elevated temperature. Okay, okay, okay. And the other classic symptom that's very interesting is that and oh my gosh, Aron, please don't ask me why this happens. Okay, just I'm forewarning you. But classic typhoid has what's called a relative brad acardia, So that means
that your heart rate is slow. And normally, when you have a fever, a normal physiologic response would be your body going, hey, I'm feeling stressed out because my temperature's high, so my heart rate is going to increase because of that high temperature. But with typhoid, it doesn't do that. Your heart rate stays low.
I am bursting with questions, how dare you censor me? Okay, I won't ask why, I will ask are there other diseases or other times that fever occurs when the same thing happens.
There are some others. Absolutely, this isn't the only thing that causes this, but that's one of those classic findings. Okay, okay, Wow, I know Okay, all right, Now that's the initial phase. Okay, So it's like this two weeks of increasing fever. In the second week, people might start to get a faint rash on their trunk. There are these little salmon colored spots for sure. That's not why it's called salmonilla though. Okay. And then in the third week of illness, you often
get abdominal pain. You can get either diarrhea or constipation, which is interesting. We'll talk more about that later, bleeding from the intestinal tract. Often you can get secondary bacterymia. So if this bacteria enters your bloodstream and starts to replicate in your bloodstream, that's what bacterymia is. And sepsis, almost everyone will get hepatitis and a painful hippatosplinomegaly, which is a fun word we often say on this podcast.
So swelling of your liver and spleen. And now this I want to put a pin in so that you remember it because we're going to talk more about it. But salmonilla typhee is also a cause of acute coly cystitis aka gallbladder infection. Okay, that's important. Just remember it now. This is not a bacteria that tends to infect your
nervous system, so neurologic manifestations are pretty uncommon. It's not impossible, but when you have them, they look more like febrile seizures and young children, which happens with a whole bunch of different diseases. And then it is possible to have other more serious complications like myocarditis, but this is really rare, so that would be if it infects your heart. But most of the time this is a gastrointestinal tract disease.
So if you don't die from overwhelming sepsis and shock or from your intestines becoming perforated and just like exploding your gut juices everywhere, my god, then over a period of weeks to months, your symptoms gradually begin to resolve.
If you do not die, okay, over a period of weeks to months.
Weeks two months. This is a long lasting infection. So the big question in my mind is what makes Salmonella typhe so different from all the other serivars of salmonella and enterica. Right, A lot of other species of salmonilla, even salmonilla in terica, can infect us and maybe we get like the poops from it. But Salmonella typhee causes
this really disseminated infection. It's mostly GI symptoms, but the first symptoms that you see are this fever, which tells us that it's affecting a lot more than just our GI tract. Yeah, so why Yeah, I ask myself the questions that I can answer. So the difference really is because Salmonella typhe is this host restricted pathogen. It can very quickly invade through our gastrointestinal walls, so it is not limited. It's not causing an infection that's only in
our GI tract. Exactly how this happens, we still don't fully know, but we do know that it's at least in part due to the bacteria down regulating our immune response. So here's where it gets interesting. Okay, in our GI tract, we have these things called pyre's patches. I feel like we've talked about them a little bit on this podcast before, but they're basically like lymph nodes in the walls of our small intestine. So it's where like our white blood
cells hangout. It's like the immune center of our GI tract. Our GI tract has its own little immune system.
Oh, it's like a big deal.
It's a very big deal. Yeah, it's very cool. So salmonella actually invades through these pyre patches. So this is the area of our small intestine where it makes its way into our body. And what's very cool is it actually uses the same channels to enter through our cells that are missing in people with cystic fibrosis, those CFTR channels, right, cystic fibrosis trans membrane receptor I think so those also, you might remember our channels that are important in another bacterial disease, cholera.
Yeah, yeah, I was gonna say, isn't that when we talked about pyres patches?
It could have been I don't actually remember. That was a long time ago.
That was a long time ago.
But so these pyres patches, which is where our white blood cells hang out in our intestine, are where salmonilla first invades. So that's where it basically makes its way through the wall of our intestine, through that epithelial cell layer, and into our bloodstream. And it gets better. Salmonilla typhee is also facultatively intracellular. What that means is it can live inside of our cells and guess which cells it
likes to replicate inside of white blood cells. A white blood cell erin are macrifacious, so that is how it's able to very quickly establish an infection outside of our intestine. It invades and replicates within our own white blood cells and then travels literally wherever white blood cells go, and
because of that, it tends to cause infection. So basically, it'll you get infected by eating this bacteria essentially, and then it travels through your gut into your small intestine, invades through the wall of your small intestine, makes its way into your white blood cells, travels with these white blood cells to a few specific places where white blood cells hang out the liver, the spleen, the lymph nodes, and the gall bladder, Okay, and then from all of
these tissues, the bacteria is continually proliferating, it re enters the bloodstream, and that's when you start to actually see disease. So that's why you have this time lag right.
Right, It's got to make all those journeys and bulk up its.
Numbers exactly exactly. And then eventually, because it's infecting the liver and the gall bladder, from there, the bacteria actually re enters the intestine and that's when you start to see those abdominal symptoms. And so that's why those abdominal symptoms like diarrhea, abdominal pain is even later in the course of even though you got infected from your GI tract to begin with. Gotcha, Okay, And that's when the most serious complications and the most life threatening complication can occur,
which is intestinal perforation. And the reason that that happens, and this is so bizarre, it's thought and we again still don't one hundred percent understand this, but the bacteria, once they reinfect again your intestine, cause tissue death of those piers patches. So where they initially invaded, they come back in and they kill off enough cells in the wall of your intestine that they make it so that
that wall is weak and then eventually can perforate. And that has a mortality rate of like forty to eighty percent.
Like that's fascinating because you would think that there would be like a trigger, like clearly they're doing something different.
Mm hmm. They're totally doing something different, and it's quite rare. This only happens in like less than five percent of cases. Okay, Okay, listen, we haven't even gotten to the most fascinating part of Salmonilla typhee.
I am very excited.
Let's go okay, that is that so many people can become infected and maintain a chronic carrier state without ever showing symptoms of the disease. Oh yeah, okay, oh yeah. About twenty five percent of people who are chronic carriers never have any symptoms of disease. Yep, we all know this. This is the story of typhoid Mary. Aaron's gonna tell
it to us in a lot more detail. But the real question that I need to answer is how on earth could Mary and others have been spreading this infection for so long without ever even knowing they were infected.
It's I don't I don't know. I want to know. Tell me all right.
So a proportion of people who get infected with semonel typhee won't ever show symptoms. That's fine. About three to five percent of people overall who get infected with Salmonella type go on to become chronic carriers. So where is this bacteria hanging out, whether or not you've ever shown any symptoms? And the answer is the gall bladder erin
Oh okay, So in some people. And again this is also still something that we don't one hundred percent understand, but we have a much better understanding now than in Mary's time, for example.
I mean, yeah, so in.
We know that Salmonella type can invade the gallbladder, it can cause choliicystitis, which is like an acute infection, but in some people it can essentially start to form a biofilm. Oh so it doesn't just invade the cells of the gallbladder wall, but actually forms a its own biofilm. And this happens especially in people with gallstones, which, as it turned out, happen to be a medium on which Semonella typhee can persist and grow and form a biofilm.
Is what is a gallstone made of?
Often cholesterol. There's a few other things that it can be, but most of the time it's cholesterol. Okay, interesting, Yeah, so that's that's kind of the main thinking. That it's
gallstone related, biofilm related, something like that. And we know that it definitely causes chronic inflammation because infection, chronic infection with Salmonella typhee is pretty strongly associated with gallbladder carcinoma, so cancer, and we know that cancer and inflammation often go hand in hand, but it's a little bit more complicated because at least in some cases, cholis systectomy, which is the surgery that we do to remove the bladder,
doesn't always resolve the carrier state. Right, And also, not everyone that has gallstones becomes a typhoid carrier. A lot of people have gallstones. Not every person with gallstones that gets infected with Salmonella typhee is necessarily going to become a Salmonella typhee carrier. So we still don't fully understand the process, but we at least know more. Is it treatable, Eric, Oh, great questions. So it is treatable, and the good news is that treatment is extremely effective.
That's great, it is.
Yes, it's with antibiotics. Without any treatment. Typhoid has a mortality rate of between ten to thirty percent, so pretty deadly disease.
Very deadly, Like uh wow.
Right, with treatment, mortality rates estimates are like one percent, so still not perfect, and I would say one percent is still pretty high, but that's what the kind of global estimates are. And we'll talk a lot in the episection, but the short answer is, like we have a very poor understanding of the global incidence of typhoid fever.
Yeah, okay, I kind of figured that.
Yeah, very poor understanding. The good news is that in addition to treatment, there are vaccines. There are two different vaccines that are widely available. One is a polysaccharide, so it's like a sugar that's found on the outside of the bacteria that can be used starting in children at age two. And children are important because a lot of typhoid fever happens in children. It's really a disease of
childhood in a lot of places. That one has to have boosters every two years because it doesn't have a very long lasting immunity. And then there's a live attenuated vaccine, so it's a live bacteria that they've grown in a lab to be less virulent so it doesn't cause severe illness, but it still gives you protection. That one you can't give it to kids under six, so it's only for older kids and adults, and it needs boosters every five years. But we'll talk in the current events about a very
exciting new vaccine. Oh that's super new, that's very exciting.
That's fun.
We can't talk about it yet.
So aarin, where did this bacteria come from what's it doing to us?
I am very excited because this is going to be a good one, but we have to take a short break first, definitely. So I talked a little bit at the very beginning of the episode about why we are
so excited to do this topic typhoid. And so not only is this like the full circle moment of like, oh, you know, we're finally doing the thing that like totally changed our lives forever thanks to Georgia and Karen on My Favorite Murder, but also typhoid fever is like first season TPWKY Totally, It's like a big deal.
It's a classic disease. It's like one of the you know, big names.
In I'm expecting like Ebers, Papyrus, Ancient rom et cetera, et cetera, poopinin holes, all of it.
I mean, we we've already got the poopinin holes. So it started off good, let's just see what else we've got here. But you know, in addition to that, I as I read more about the history of typhoid, and particularly Mary Mallin, who was who gave rise to the term typhoid Mary, I realized just how relevant her story is to what's going on today and the enormous conflict between public health and civil liberties that can emerge sometimes.
And finally, just how important science education and science literacy is to reducing that conflict.
Yeah, okay, so let's dive in.
Let's do it.
You can probably guess that typhoid fever has been around for millennia yep. Evolutionarily speaking, some researchers believe that it originated in Indonesia, like thousands and thousands of years ago, but it would have spread pretty easily and rapidly around
the world as travel became more widespread. And one interesting thing to note is that there doesn't seem to be a whole lot of genetic variation among strains geographically, with the exception of antibiotic resistance strains, which is thought to point towards the importance of carriers in perpetuating the disease.
Ah, if that makes sense.
So, like there's not a whole lot of like selection pressure by which hosts survive or whatever, because carriers are.
There, right, there's always carriers to just sort of keep the disease slowly moving through population ye and around the world.
Really interesting that I never.
Thought about being able to. Yeah, yeah, that's pretty cool.
It's cool. And I know that you were hoping for like the Ebers Papyrus and you know, ancient Roman stuff. Yeah, and so like, I can't explicitly say, no, it wasn't written about, but you know, it's a very like as a gi illness. It's like fairly you know, it's one of many people had a lot of running poops and like died from diarrhea all the time.
They weren't writing about a step wise fever and relative bratocardia in the ever'spyros.
Don't be shieve that they were.
I don't believe so. So anyway, so it wasn't explicitly described by a lot of ancient Greek or Roman physicians, but I mean undoubtedly it was around right for centuries. Its name typhoid was used to describe more a set of symptoms rather than a separate disease. Typhoid actually means it just means typhus.
Like and interesting.
Yeah, And I just want to give a little bonus factoid even though we're gonna cover typhus at some point in the future, because that's another big that's another big like Season one era kind of twky. I'm just gonna tell you the etymology of typhus now, because to say, oh, it's typhus like and then move.
On at least really Yeah.
Basically, typhus comes from the Greek typhos, meaning stupor caused by fever. It's also related to smoke or mist or fog, referring to the brain fog that's associated with typhus and occasionally with typhoid. Okay, So, because of its similarity to other gi illnesses, it's hard to pinpoint specific typhoid epidemics or estimate its impact separate from other illnesses caused by
poor sanitation or clean water infrastructure. But that doesn't mean people won't try to ascribe typhoid as causes of epidemics in history.
It's my favorite thing.
For instance, Alexander the Great may have died of typhoid at the age of thirty two. What Yeah, he was only thirty two.
He's only thirty two.
I know, Oh, I know.
It also could have been I will note poisoning, malaria, brucellosis.
Et cetera.
And typhoid has also been blamed for the plague of Athens, which happened in four hundred and thirty BCE during the Peloponnesian War between.
Athens and Sparta.
Okay, this epidemic, the plague of Athens, killed approximately one third to two third of the population of Athens, including the leader Pericles, and about one fourth of the army, basically sealing the fate of Athens.
But it was it actually typhoid?
Probably not, so there was, and the reason that people think it was is because there was an article reporting Salmonella enterica genetic material in ancient DNA samples of likely victims.
But those findings have been highly criticized. Okay, smallpox, typhus, and measles are also decent contenders, with of course, the possibility that it was a totally different pathogen that's no longer circulating, right, Yeah, But what is definitely true again is that typhoid was an infamous killer during wartime or times of unrest, primarily because of poor hygiene and a lack of clean water made transmission easy, as you heard in the first hand snippets, and add on to that
a lack of knowledge about germ theory and how the disease is transmitted, and you have a recipe for disaster.
In the Jamestown Colony.
Oh, typhoid was responsible for wiping out an estimated sixty five hundred of seventy five hundred.
Colonists in the early sixteen hundreds. Oh, yeah, a lot.
I mean, you know, they weren't They also weren't in the best like they weren't in the best health otherwise, the right.
That's the thing I mean, yeah.
I mean it was sort of like it was a what did they call it in some of these descriptions, It was like a seasoning, Like you had to get there and it was like you had to go through this hazing of a disease, like the seasoning of a disease. I don't know how else to say it. But you either survived or you didn't, right, Yeah, I mean that was like all of childhood for so many thousands of years.
Yep.
Yeah. Population growth in the major cities during the Industrial Age way outpaced the infrastructure or knowledge or technology to manage the waste that was being produced, and this is reflected in the annual incidents of typhoid in Europe during this period, which was about one in two hundred people.
Wow, it's really high.
That's really high.
Yeah.
Albert Prince Consort of Queen Victoria, died in eighteen sixty one of probably typhoid, and President William Henry Harrison, who was the ninth and shortest serving US president, died from what was likely typhoid, just thirty one days after taking office.
He was also a.
Terrible person, he was. He was the twelfth The US president. Zachary Tyler may also have died from typhoid, and three of Louis Pasture's five children died.
From typhoid fever apparently. Oh yeah, so this was an.
Enormously feared disease, and it was one that did not respect divisions of class or wealth. Starting in the eighteenth century, physicians began to observe or describe that typhoid and typhus were two different diseases. Several physicians noted the difference in fever intensity or duration, or siclicity, etc. Or noted the lesions in the pyre's patches of the small intestine. Confusion lingered, though, especially in the diagnosis of non fatal cases of typhoid.
In eighteen thirty seven, two Philadelphia physicians, William Gerhard and Casper Pennock published their observations that typhoid and typhus were distinct diseases. An epidemic of typhus in eighteen thirty six allowed them to note not only how the diseases behave differently, so like typhus was more likely to cause an epidemic and much less likely to appear in sporadic cases, as well as how their pathophysiology differed. But there was still a major piece of the puzzle missing. How was typhoid
fever transmitted. Yeah, at this time, which was the first half of the nineteenth century, germ theory had not yet been developed, although the concept of contagion was well established.
I feel like that's what makes it so classic TPWKY like getting to talk about nobody knew germ theory and then we learned about germ theory, you know, that's like very classic.
It is it is I feel like also, I'm like, I hope people aren't sick of hearing about like the era of germ theory and like it just it is now such a mind blowing like the revolution of awareness of the world around us.
So wise, it is just like you talked about in the Giardia episode when Van Lewin Hook looked through his microscope and saw the whole world in the water like it is. It is mind blowing and phenomenal to think about the time of that shift mindset. It is absolutely fascinating. Good.
Well, I'm glad you're not sick of it, because I'm not telling it either.
And we make the rules around here.
So so yeah, so people knew, maybe not about microbes, but they knew about contagion and that concept. And the English physician William bud And I highly recommend you check out his Wikipedia page just so you can see his incredible facial hair. He discovered the link between typhoid and fecal oral water contamination after tracing one outbreak of the disease in a village in eighteen forty seven and finding that the only link between the households was that they
shared a well. And then later, like years later, after learning about John Snow's work between cholera and the Broad Street pump, he became even more convinced that contaminated water was the source of typhoid outbreaks.
I was just about to ask what time was this in relation to John Snow and cholera.
I love it, And just like with cholera, there may have been some resistance and accepting that water, not bad air, could be the cause of so much illness and death. But if there was resistance in the face of typhoid fever and transmission, it was fairly short lived. As I mentioned, the massive global population growth had led to an equally massive waste problem. In London in July and August of eighteen fifty eight, for instance, I mean, you heard the
first hand of cholera. It's a pretty like memorable. The poop and trash in the River Thames baking in the summer sun led to such an overwhelming foul smell that it was called the Great Stink. There's an entire Wikipedia page about it. And I really I just want to read this. This is just an episode of growth stuff. So I wanted to read this excerpt from a contemporary
newspaper about the Great Stink. Yes, quote, For the first time in the history of Man, the sewage of nearly three million people had been brought to seethe and ferment under a burning sun in one vast open kloaka, lying in their midst I can't see, ah, I have to try that again. I can't say open Kloaca without a spark, without laughing.
Over kaka, oh dear.
In one in one vast open kloaka lying in their midst The result we all know, stench so foul, we may believe, had never before ascended to pollute the lower air. Never before, at least had a stink risen to the height of a historic event.
Do you see why I needed to read that?
Yes, I agree with it. It was the correct decision.
Yeah, so jack out the Wikipedia.
What a time.
Events like the Great Stink and the cholera epidemics finally forced public officials to recognize contaminated water was a public health issue, and this was only deepened with the development of germ theory. Side note, the Chicago River was reversed to try to control the outbreaks of typhoid and kara
whoa cool? Okay, So hopefully by now I have painted somewhat of a picture of the prominence or infamy of typhoid through the eighteen hundreds, so that you can understand why isolating the causative agent became a top priority for so many bacteriologists.
Yeah, definitely, And because.
Of its prevalence and popularity in research, it's a bit tough to establish priority on who first discovered the bacterium. One likely suspect was the Polish scientist oh Boy Tadoos Brawitz, who described rod shaped bacteria in the organs of people infected with typhoid, and he even isolated and cultured the bacteria, but he never followed through by trying to determine whether those cells were responsible for the disease itself.
Got it, He never did all of the Postulitz right.
Credit is usually given to German pathologist Carl Eberth for first isolation, and this is reflected in the fact that the first name given to the bacterium.
Was Eberthella Eberthella.
Okay.
The rest of the late.
Eighteen hundreds and early nineteen hundreds was a busy in productive time for typhoid researchers. The development of the Widel test allowed physicians to test for the typhoid bacterium. Basically, you take serum from a suspected patient and see how it reacts when exposed to a culture of the bacteria. If a precipitate forms, you've got typhoid, and then the vaccine was next. Just like with a discovery and description of the typhoid bacterium itself, There seems to be some
debate over who first created the typhoid vaccine. Many different people at least had a hand in it. Credit usually goes to Sir Almroth Wright, who was an English pathologist, and he began testing an early typhoid vaccine on army officers in the Indian Medical Service.
Not for effectiveness against typhoid though, but yeah.
But rather to see whether calcium chloride prevented hemorrhaging in those injected. What as like an additive or stabilizer.
So he made a whole new vaccine and was like, I'm not testing this vaccine. I just want to test the adjuvant.
I don't get it, but he usually gets credited for the first typhoid vaccine, even if many others paved the way for him. And he followed up his first tiny test with more extensive testing, this time to actually observe the efficacy of the vaccine in protecting against disease.
Oh what a concept.
What a concept.
But instead of exposing the participants to typhoid, which was, as we know, a method still occasionally practiced like you know, actual challenge or whatever, he tested the serum of those vaccinated to see whether typhoid bacteria.
Would agglutinate, so kind of smart. Yeah, I'm pretty smart.
And sure enough, the serum of those vaccinated did seem to agglutinate bacteria, but did that translate into actual protection in the body. The bacteria in the precipitates.
Were still viable after all.
So they did the unethical thing and exposed one of the participants to typhoid, and fortunately he did not get it. The development of a typhoid vaccine completely changed war.
Yeah.
I've talked before on the podcast about just how much death and illness during war comes from infection rather than combat, But I didn't realize just how much typhoid was often responsible for the most damage.
Yeah. I don't think I would have put that together necessarily.
Yeah, I mean, and it makes sense given like the conditions of living and so on, and like how do you prepare food in a clean way?
How do you poop in a clean way? Like how do you.
Clean yourself in a clean way?
Yeah?
Yeah.
During the American Civil War, for instance, eighty thousand of the two million soldiers in a Union army there were no good records for the Confederate army got typhoid. About five percent.
Yeah.
And in the Spanish American War, which is where the first hand accounts came from, approximately twenty one thousand troops were infected with typhoid and nearly sixteen hundred died.
Wow.
Yeah, it's a lot.
Most of the time, typhoid killed more soldiers than direct combat.
Yeah.
I feel like that's a theme that we often come back to, is it's not funly, it's awful.
World War One would be the first major conflict in which typhoid did not contribute enormously to the death toll because of the vaccine, Because of the vaccine, Because of the vaccine. In previous wars, the attack rate of typhoid was estimated to be one in five, but that dropped to one in two thousand by World War One due to the vaccine and improvements into panitation practices.
What that's bonkers, I know.
Yep, it's pretty clear.
The phenomenal Wow, huge, huge, Wowee.
All right, here we are in the early nineteen hundreds.
We're finally here.
We're finally here.
I just want to set the stage a bit for this next part of the story of typhoid.
Yes, so typhoid has.
Been a commonplace, but still very much fear disease for the past centuries, and while there have been some major developments in understanding its transmission and path of physiology, both sanitation infrastructure and medical treatments a life behind. So the threat remains. A doctor can diagnose a case, but they
can't treat it because antibiotics haven't been discovered yet. A typhoid vaccine did exist, but they were new and not trusted and generally reserved for the military, and cities began to grow at incredible rates.
All that poop with nowhere to go.
Uh.
Enter Mary Mallin.
Mary Mallan emigrated to the US from Ireland in eighteen eighty three at the age of fifteen and began working as a cook, and she seemed to be really good at it. She seemed to be in steady employment in the New York City area with short term contracts, working for wealthy families from season to season, and that was like a normal thing for a lot of cooks, just
like contract work. Mary's life continued in this rhythm for twenty and some years until the events that would turn her from Mary Mallin to the infamous typhoid Mary.
So she was like in her late thirties like, yes, mid to late thirties. Yes.
In nineteen oh six, an outbreak of typhoid occurred among the household of the wealthy New York City banker Charles Henry Warren, who was renting a summer home in Oyster Bay in New York. Two of his daughters, his wife, two maids, and the gardener all became sick. Isolated outbreaks like this did happen from time to time, but this was still a huge cause for concern, not.
Just because the disease could be fatal, but.
Because an outbreak of typhoid could tarnish a homeless reputation for years because it suggested that the waterlines weren't clean.
I'm scuffing my face at that.
I know that was a very good scoff face.
I wish that I had taken like a screenshot of it or something. So the owners of the house were desperate to trace where the outbreak originated.
I mean, okay, yeah, I.
Mean it makes sense, like you want to know, like, okay, if we can put a stop to this, let's put a stop to this.
Of course, and it is very deadly in that, but like the reputation thing, like.
Well, I mean, they were like, well, we need to make sure to rent our our h.
I R B and b our. I'm pretty sure I stole that joke from the good place.
It's a good one though.
Yeah.
Okay.
Anyway, so these owners hired George Soper, a sanitary engineer.
Okay, cool.
His job was basically a mix of health inspection and shoe leather epidemiology.
Awesome.
Yeah, And he went around the entire property on Oyster Bay looking to see whether the toilet waste ran into the water sources or if the local oysters from Oyster Bay were contaminated, and he found nothing. Okay, but the typhoid had to come from somewhere, and the source had to be unique to that household since no other cases were detected in the nearby town, soaper learned that the family had hired a new cook just before the outbreak started.
That cook's name was.
Mary Mary Mallan.
At first, it may have been hard to see how a cook could be the source of a typhoid outbreak, since the bacteria would be killed during the heating process, but then it was revealed that one of Mary's most popular dishes was ice cream and fresh peaches boom.
How sad? Like what a great that sounds like such a good dessert.
I mean, we probably should have made a quarantine that was like peach and ice cream themes.
We totally should.
But like bloody typhoid Mary, what else were we going to do that come up?
Also, the other thing is that where can you get peaches in November in this hemisphere? You cannot, So we couldn't have taken a photo.
It would be sad peaches for sure.
Very sad.
Yeah so yeah, yeah, well but as you can imagine ice cream in peaches, there's not a whole lot of heat in activation.
A no, that would happened.
And during the time that Soper was investigating this source of this outbreak, the existence of typhoid carriers had been hypothesized and observed, but it was not like a super widely known concept.
Interesting. Yeah.
Nevertheless, Soper became convinced that Mary was the one to blame. But there was one major problem because Mary had already moved on. She had gotten a new job and had left no forwarding address. Oh so, Soaper set to investigating her past employment to see whether she was linked to any other typhoid outbreaks. He became a bit obsessed because he essentially thought, Okay, if I can show that she is the cause of all of these cases, then that's my career made.
Boom done. Huh, Like it was his ticket to fame. So anyway, okay.
But what he found was that in seven of the eight families that Mary had worked for over the years, there had been a typhoid outbreak during or right after her employment.
Wow.
Yeah, seven of the eight, and so were finally caught up to her in nineteen o seven amidst another typhoid outbreak in the family that she was cooking for, and this one resulted in the first death definitively linked to Mary.
It was the daughter of that family.
Unfortunately, Mary didn't write or talk extensively about what happened from her perspective, so we have to rely on the words of contemporary sources, including George Soper. He wrote his account of events in which he and most subsequent retellings, secluding this one, he framed it like a detective story, with Mary as the villain at the center of it. Right in nineteen oh seven, when Soaper tracked down Mary's current place of employment and learned of the typhoid outbreak
currently occurring. He essentially stormed right in, pointed a finger at her, and loudly accused her of making everyone around her sick with her unclean habits and carelessness.
Like that's how. He just walked in out of nowhere off the street and was like, you're filthy and killing people with your pep hands.
Yeah, you're you're the cause, Like you're the reason people are dying.
Geez.
And then and then he was like, and you know what, I need a poop sample from you right now.
Good luck, buddy.
So Mary was like, excuse me. And he also after demanding this fecal sample, it's not like he was like, oh, this is how it might work. This is what a typhoid carrier is, right listen, we know that you didn't mean any harm, like we're just trying to was to the root of this.
There was no humanity, is what I feel like you're saying in his response, like there was no humanity whatsoever.
Absolutely not.
And Mary was like, excuse me, excuse me, And so she grabbed a carving fork, according to Soper, and charged him. So he ran away.
He ran he ran away.
Yeah, m oh my gracious, but sober didn't give up. Instead, he found out where she lived, and she was living as an unmarried woman with a disreputable boyfriend and a big dog, which Soper felt important to note big stinky dog, which like, is probably a really cute dog.
Yeah, I bet it was like shaggy and druly and nice.
Oh what sounds sweet?
And so he went to where she lived and tried to get a fecal sample from her, and then tried to befriend the boyfriend to try to be like, let's trick Mary into giving a fecal sent.
Like, what is this dude's damage? Man, I don't know, I don't know.
And every time Mary just shut down, crossed her arms and was like leaf just set and packing every single time.
It makes sense, right.
And eventually though, he got the New York City Health Department involved, including a doctor Sarah Josephine Baker, who was a huge figure in infant and maternal health, and so she was sent to reason to try to reason with Mary more calmly. Instead, Mary ran away and hid for hours, but eventually her hiding place was found out and she was dragged literally kicking and screaming, to the hospital where she would be forced to provide samples. Sure enough, she was teeming with a typhoid bacteria.
Do you have a number on that?
Erin, I'm sorry, Aaron, let me just google that real quick.
We don't one. No, but.
Okay, so but yeah, so she was the first carrier described no definitive carrier.
Yeah.
So, because she was considered a flight risk, she was held in the hospital and then moved to North Brother Island, where there was a hospital that started out as a smallpox isolation building but then turned into a any disease we choose isolation building, so like tuberculosis, leprosy, et cetera. And Soper tried to convince Mary to have her gallbladder removed, even though a a surgery in the early nineteen hundreds was like super.
Dangerous, yea, almost certainly death.
Like no antibiotics and b its. Removal, like you said, was no guarantee that she would then be typhoid free and so but she was like, no, I don't want that, and so then he was like, all right, well, then I'm going to write a book about you and I'll split the profits with you if you promised to stop cooking, And she was like no, She basically just refused to talk to him, and she remained an isolation and her fecal samples were regularly checked for the presence of the bacteria,
which were found more often than not, although there were some negative days. In nineteen oh nine, so that's two years and three months after she was first isolated, she filed a lawsuit for her release, saying that her imprisonment was unlawful and stripped her of her civil liberties. And it was at this time that the term typhoid Mary coined. In nineteen oh eight, at the annual meeting of the American Medical Association, like when they presented her carrier status,
this term reached the general public over all. The tone of the articles were very sympathetic to marry. Her imprisonment to the general public was seen as a violation of civil rights and prejudice against a poor immigrant woman. But this case took place at a time when courts tended to rule in favor of social protections rather than individual rights.
Interesting for instance, just a few years before, in the nineteen oh five decision Jacobson versus Massachusetts, the Supreme Court unanimously ruled that required smallpox vaccination did not violate individual rights.
Quote.
The liberty secured by the Constitution does not import an absolute right in each person to be at all times and in all circumstances wholly freed from restraint. Basically, the ruling was that if by exerting your own individual rights you are impinging on the rights or health of others, the no, you cannot do that.
Those are not rights. That's how it's always been.
Yeah, and so Mary lost this suit and continued to be held in a custody of the Board of Health of the City of New York, but not for very long. The following year, in nineteen ten, she was released on the condition that she promised not to work as a cook anymore and to report back to be tested. She agreed to the terms and then promptly disappeared and never went back for checkups. She was rediscovered in nineteen fifteen.
Soaper had resumed his work as a sanitary engineer and was in the process of investigating an outbreak of typhoid at Sloane Maternity Hospital when he learned that some of the staff referred to a typhoid Mary Cook, who seemed linked to the outbreak. He was like, this is are you serious, like, is this Who am I going to find? Am I actually going to find Typhoid?
Mary?
Am I going to find Mary Mallin? And it was, but Mary Mallin had been going by a different name. Turned out Mary had not upheld her end of the deal continued to seek out employment as a cook, which was likely the only profession that she had any skill or experience in. Since her nineteen oh nine case had put her name out there and gained her some notoriety, she couldn't use her real name to get employment, and when Mary was apprehended the second time, she did not
receive the same level of public sympathy. The New York City Health Department placed her in forceful isolation again on North Brother Island in the East River, where she would live out the rest of her days over twenty years,
never admitting or acknowledging her role as carrier. She did have a few friends on the island, and apparently a little fox terrier, and she worked a bit in the bacteriology lab, but she never felt she belonged on North Brother Island and felt that her freedom had been taken away unfairly. She died at the age of sixty nine on November eleventh, nineteen thirty eight, of pneumonia following a stroke.
In total, Mary was linked two fifty three cases and three deaths, although it's possible that the actual numbers were higher. The impact that Mary Mallin had on the world goes way beyond the people she infected.
Yep.
And I had a hard time putting all of my thoughts and feelings about Mary Mallin and typhoid Mary into one coherent thesis.
So I decided to.
Make a list of the different themes or lessons or whatever of the story. The first theme was probably also the earliest and the simplest, just medical mystery, epidemiological detective work.
Who done it right?
Yeah, boom, that's one story that people use. Number two the concept of a super spreader. The term typhoid Mary was in popular use even before this pandemic, and so, like you know, even before, we use it as someone who unknown or knowingly infected a bunch of people with something.
Without seeming like they were sick or anything like.
That, exactly.
Number three, discrimination and oppression. Mary belonged to a few groups that have been historically very much discriminated against. Here in the US, Mary was poor she was an immigrant, and she was an unmarried woman who did not fit
the contemporary standards of femininity. In Soaper's words, quote, those who knew her best in the long years of her custody said Mary walked more like a man than a woman, and that her mind had a distinctly masculine character like Okay, George, Okay, bity and Mary Mallin wasn't the only typhoid carrier in New York City, definitely not. In the years after she was imprisoned, at least fifty additional carriers had been identified, and one estimate from nineteen nineteen put New York City
as having over twenty five typhoid carriers. What Some who had been identified became repeat offenders like Mary, but no one None of them faced a similar lifetime imprisonment. What Most of them were given alternative jobs or means for providing for their family. But Mary wasn't considered a breadwinner because she had no family.
Because she was just a single woman in their eyes.
Mm hmm.
Maybe she was put on an island to serve as
an example. But although Mary's punishment may have been so extreme because of who she was or what she represented, the unavoidable fact that I keep coming back to is that her actions, particularly her deliberate choice to keep working as a cook, directly caused the illnesses and deaths in others, Which brings me to theme number four and the one I think has the most relevance for today, that of the tension between individual rights and public health, was Mary's
imprisonment too harsh or biased? I mean, yes, I think we can agree. Can all agree that yeah, it was? But should measures have been put into place that would have prevented her from making others sick?
Yes, without a doubt. Yes.
In any society, there is no such thing as absolute freedom. There is a limit. If by exerting your own individual rights you are impinging on the right or health of others, then that freedom is not something owed to you. This is part of the social contract, the agreement that we all make that by living in and benefiting from a society, we have to give up some of our individual freedoms. This can be a tough balance to strike, particularly in the realm of public health. There's a quote from one
of the books I read about typhoid Mary. Quote.
But first, and I just want to say, you said that really beautifully like, I absolutely loved it.
I feel very strong way about this.
It was I mean, I feel exactly one hundred percent exactly the same way. But the just the way that you worded that was perfect.
Thank you.
Okay, here's the quote. Yeah, on the one hand is the commitment to protect the public's health. On the other is the fear of arbitrary power and the loss of individual freedoms.
That's from Judith leave.
It, mandatory vaccinations, forced quarantines, public identification of so called patient zeros, and in the context of COVID nineteen mask mandates. These are all areas in which there has been ample discussion of individual freedoms being trampled upon, some of which may be justified, others definitely not. Like masks, let's not mistake inconvenience for oppression a whole snap, being imprisoned on an island for decades because you are an asymptomatic carrier
of typhoid. Yeah, okay, maybe there's a touch of oppression there, having to wear a mask to pop into the grocery store for fifteen minutes. That's not oppression, not your impression, end of story, not oppression.
It's not oppression.
So what can we learn from Mary Mallin's experience?
Oh good question.
As I was reading about the story of Mary Mallin, one thing that stuck out to me was how much pain and suffering, both for Mary and for the people that she infected, could have been prevented through simple communication. Yeah,
her doctor's the New York City Health Department. They could have taken the time to talk with her, not down to her, about the science behind typhoid fever transmission, and they could have explained in a non judgmental way, how she could transmit on inten intentionally the bacterium to those around her. And then maybe they could have given her more opportunities or training to find employment in.
A different area.
Maybe then she wouldn't have felt like she needed to lie to continue to cook. Yeah, We as a society have the knowledge and the platforms to communicate accurate scientific information, and when that information has the power to save people's lives and prevent misery and suffering, leaders have a responsibility to communicate that information without their own political agenda and accurately. YEP.
The disinformation and mistrust in science spread by Donald Trump and other members of the Republican Party during this pandemic and other world leaders I should know, Like, yep, you know Alonaro is not.
You know, Boris Johnson. It's fine. I was a nice to you. Now I'm fine.
This has already done incalculable damage.
How many deaths?
How much misery? How much suffering could have been prevented by communicating science rather than sowing hatred and fear. History is full of lessons like this. And you know, there's that saying that's like those who cannot learn from history are doomed to repeat it.
But like, I mean, yes, that's true, but.
I think what might be, you know, an addendum should be and those that do learn history are just doomed to watch others repeat it. We can always do better, but it feels like we rarely actually do well.
It also might be that people are taking the wrong lessons from history or learning the wrong parts of history.
That's definitely true.
We did a great job. We isolated Mary on an island and kept her there forever, Like, you.
Know, it's a much more nuanced story than that they are the nuance. I feel like that's important, Like, yes it was unfair, but yes she.
Also killed people.
So what can we do differently, Like, that's what we should be asking ourselves, and we have the opportunity now, so like yeah.
But yeah, I've gone on way too long already.
So I'll just wrap up the history by saying that with improved sanitation and clean water infrastructure, combined with the development of chlorin fenacol in nineteen forty eight, typhoid like really dropped in the second half of the twentieth century
in most developed countries. However, however, it has continued to cause enormous outbreaks, which some of these outbreaks leading to over one hundred thousand deaths in many other parts of the world, and the emergence of drug resistance strains might pose an additional threat. But Erin, I'm gonna let you take it from here.
Oh great, love to pick it up on such a happy note.
Oh boy, I'm sorry, I'm sorry.
Let's take a quick break before we jump in. So I already said this, but I'll just repeat it. We do not have good data on the incidence of typhoid fever globally. There's really big ranges. One of the biggest papers that estimated typhoid disease burden was all the way back in two thousand and four, and that estimated over twenty one million cases annually. And that one also estimated an overall fatality rate of about one percent, which would
mean over two hundred thousand deaths annually globally. Oh my, so that was a two thousand and four estimate. Another paper from twenty twelve estimated thirteen and a half million cases annually. So if you look at the World Health Organization, they say somewhere between eleven to twenty one million people becoming sick with typhoid fever every year worldwide, and they estimate between one hundred and twenty eight and one hundred and sixty one thousand people dying every year.
Wow wan.
I yeah, if that's not depressing enough, Okay, here we go. Like I mentioned earlier, typhoid is largely a disease of children in places where it's endemic. So Pakistan is one place that I'm going to talk a lot about because there's some very good things happening in Pakistan right now. But sixty three percent of cases and eighty percent of deaths related to typhoid were among children under the age
of fifteen, for example. Oh my god. Yeah, So it's really, really awful in the US, just for sort of local coverage, the US estimates over five thousand, seven hundred cases of typhoid in the US every year, although we only actually diagnose about three hundred and fifty cases, which I think is really interesting.
Huh.
So that's like part of how we have such a huge discrepancy where we only diagnose this many and then we have to estimate that that's like less than ten percent of the total number of cases we think there actually are. Now, like you mentioned Aaron, antibiotic resistance is a massive problem for salmonilla typhee, as it is for most bacteria that we talk about. Boy, but another time, I'll talk about Pakistan, another depressing one before we get
to the good news. Since twenty sixteen, Pakistan has been in the midst of an extensively drug resistant typhoid epidemic since twenty sixteen. Between twenty sixteen and twenty nineteen, over ten thousand people had been infected with a strain that is resistant to all but one oral antibiotic.
Oh my gosh.
And it's not just there, I mean, typhoid is a global disease. It's in I think basically every country, right, like it's across the whole globe, and antibiotic resistance has been documented across the globe. So let's end with some slightly good news, shall we.
That sounds great.
In twenty seventeen, the World Health Organization prequalified a new vaccine. And this is an exciting one if you remember from our vaccines episode, which if you want to go back and listen, and you can do that, but I'm going to explain it anyways, so you don't have to. There's a bunch of different types of vaccines. And I mentioned that the vaccines that we already have for typhoid are a polysaccharide, which is just a sugar, or we have a live attenuated vaccine, but you can't give that to
small children. So a better type of vaccine would be a conjugate vaccine, which is when you take a polysaccharide which is a sugar, and you link it to a peptide or a protein, because the proteins are what actually allow for our body to make a stronger and more long lasting immune response. So in twenty seventeen, the World Health Organization prequalified a conjugate vaccine.
That's very exciting.
It's very exciting. Yes, it is, and so it's a very promising vaccine that was just a prequalification. Recent data from a phase three clinical trial that's going on in Nepal shows that it's very effective at inducing an immune response and it reduced Salmonella typhee infection across the study period. And this study was done in children aged nine months to sixteen years, So that means this is a vaccine
that will be able to be given to children. It's already being given to children and it's effective.
That's amazing.
Yes, Now, even though this is a vaccine that's still undergoing investigation, so we're still in like the last phase of trials. Typhoid is such a huge problem, and especially these antibiotic resistance strains. There's been enough studies of the safety of this vaccine that starting in twenty nineteen, this vaccine has been introduced into routine immunization in some countries, including Pakistan. This is like what's ongoing right now is that kids now are like starting are getting this vaccine.
So hopefully, yeah, in the next year, two years, three years, we should really see a drop in typhoid. That's awesome, isn't it. It's really like that's incredible to finally have a vaccine that's long lasting, that's effective, and that can be given to children so that we can really protect the most vulnerable groups. Like that's incredible, especially as it becomes more widely available. That's my good news thereon Oh good, I loved it. So that's I think the story of typhoid.
It's a long story, pretty.
Long, not our longest, not our longest. A good start to this season, though, I think it feels good.
It feels yeah, I am.
I'm looking forward to all of the diseases that we're going to be covering this season. We have a few fun ones lined up already, including spoilers, a crossover.
So the crossover is going to be good. I am very excited about it. So normally last season, when we did our COVID episodes, those were entirely separate. We talked a little bit about it today because you can't not, right, Yeah, not when you're talking about typhoid.
Marry you know, right.
But from this point forward, we will, as last season, have our COVID episodes be separate from our regular episodes, so there won't be a ton of COVID talk in our normal episodes. If you're like, don't want to listen to it or whatever?
Right, Yeah, so, but.
Yeah, it's this wasn't this was a very important episode I think to do in this climate.
Yeh oh boy? Well yeah, sources.
Okay, I've got a few books that can shout out. So one by Adler and Mara called Typhoid Fever, a History Judith Leavett who wrote Typhoid Fever Captive to the Public's Health. And also did you know that Anthony Bourdain wrote a book about typhoid Mary?
Stop Anthony Boardin like Anthony Bourdain?
Yeah what?
Yeah?
Did I read that one too, because she was a cook. Okay, there's an interesting one. And then I will shout out a few papers that were super helpful. So there was a couple of papers by VJ. Cirillo that were actually like really interesting, and then also by Priscilla Wold Typhoid Mary and the Science of Social Control. I have actually like a lot of different papers for this one, so just check it out on our website.
I don't want to spend the next five minutes reading them.
I had a few different papers on the kind of meganisms of typhoid and the clinical disease if you want to know more about the carrier state. That paper is by Gonzalez Escobato at All in Nature Reviews Microbiology, and then the papers and information about the new vaccine. All of that will be on our website this podcast will Kill You dot Com under the episodes tab where you can find the sources for this episode and every episode we've ever done. Sixty one.
This is number sixty one, sixty one Wow, of our normal season episodes. Yes, we've done more COVID but yeah, well. Thank you to Bloodmobile for providing the music for this episode and all of our episodes.
Big time shout out to Georgia Hartstark for introducing us with typhoid so many years ago.
Yes, thank you to also everyone at the exactly right network to make this podcast possible.
Definitely big time. Thank you, thank you, and thank you.
Thank you to you listeners for listening. It's honestly like, we're honored.
We can't believe people want to listen.
But a literal dream, a literal dream that we didn't even know that we had, and now we can't stop dreaming it, and it's the greatest.
It's basically what it feels like. Well, until next time, wash your hands, you.
Felt the animals, and literally just wear a mask.
Please wear a mask.