Typhus historically has had a knack for taking a terrible situation and making it worse. It can take what couldn't get worse and make it worse. 

Typhus is now very rare. For this, we can thank bathing, fewer lice, and less war and crowding.

Epidemic Typhus

Historically, it was a disease that accompanied chaos and suffering, often acting as a terrible finale.

It's a disease that used to be called war fever or jail fever.

It spread in these places, affecting soldiers, prisoners, judges, lawyers, and war-torn communities. 

It is the disease that took Anne Frank and many others in the Holocaust.

It took the "Year without summer" (1816) and made it fatal far from where the volcano Mt Tambora had erupted (in the summer of 1815 in now Indonesia). The volcano erased summer, plunging the world a few degrees colder around the globe. The world was too cold for summer or harvests. Far, far away, when harvests failed half a world away in Ireland, Typhus took 65,000 lives.

The disease didn't just terrify the poor with failed harvests. It also changed military history. It took more of Napoleon's army than the Russian army as the French retreated from Moscow in 1812.

Typhus also took many of the lives lost in the Irish Famine in the 1840s. The disease then spread abroad as the Famine led to emigration across the sea and the ocean.

Moreover, delousing on the Western Front of World War I helped stop Typhus, but the Eastern Front where millions were infected. The Russian Civil War (1917-22) likely saw a few million die from Typhus.

More recently?

Outbreaks, if they occur are associated with displaced persons camps. In the years following the Civil War in Burundi in 1993, over 50,000 cases were diagnosed, as people were crowded in refugee camps.

Outbreaks in jails were particularly a problem. Other outbreaks have occurred in Ethiopia and Rwanda.

The US has been largely free of Epidemic Typhus for 100 years. There have been 39 cases from 1976 to 2010 with no travel or obvious risk factors. It appears some of these cases are associated with flying squirrels. In March 2002, typhus fever was diagnosed in 2 patients from West Virginia and Georgia who had contact with flying squirrels.

What is Typhus?

First things first, Typhus is not Typhoid. The two diseases are very different and are caused by different bacteria which require different treatments.

Epidemic Typhus (pronoucned tie-fess) is caused by a bacteria spread by the human body louse. A bacteria with the long name - Rickettsia prowazekii - is to blame. This bacteria causes Epidemic Typhus which is the cause of explosive epidemics.

There is another bacteria which cause endemic (or murine) typhus - Rickettsia typhi.

Additionally, there is Scrub Typhus caused by a slightly different, non-Rickettsial bacteria.

What disease does Epidemic Typhus cause?

The disease is notable for a fever and rash. It starts often suddenly: headache, high fever, chills, cough, and severe muscle aches.  About 5-6 days layer, a rash develops, (macular) spots on the upper chest that then spreads to the rest of the body, except for the face, palms, and soles. As many as 2 in 5 will die from the infection if antibiotics are not available. With antibiotics most live.

How does Epidemic Typhus spread?

The crazy thing about Typhus is that it comes back in times of stress. People can carry the bacteria in their lymph nodes and it then reactivates, spreading in times of famine or war.

It does not need direct contact. Body lice, which can flourish in crowded conditions like jails, soldier barracks, or refugee camps, bounce from person to person, unseen, carrying the disease. It can spread when a louse bites, someone scratches the itch and the infected louse droppings then infect the bite.

Typhus is why washing is a great thing. It's also why lice are a terrible thing. With bathing and delousing, the outbreaks can be prevented.

Epidemics are almost always spread by people (and lice), even though in rare cases animals like the fly squirrels can carry the bacteria.

How is it treated?

Mortality used to be high, 40%, without antibiotics - and even higher in some cases. It can be treated with doxycycline.

What is Rickettsia?

Typhus  is caused by a Rickettsia bacteria - a Gram negative obligate intracellular bacteria, which means the bacteria cannot live outside of cells.

There are a number of other diseases caused by Rickettsia.

What is Murine Typhus?

Endemic typhus - also called Murine Typhus - is spread by fleas on rats (and apparently opossums).

It causes headache, fever, joint pain, nausea/vomitting, followed by a rash 6 days later in about half. It can lead to neurologic problems - like confusing, falling, or seizures.

It can be best treated with Doxycycline.

It is found worldwide, including in southern CaliforniaTexas and Hawaii. It is found in the spring and summer in Texas, and summer and fall in California. There has been a resurgence in Galveston, Texas, decades after the bacteria was controlled by stopping rat proliferation. Other animals, like opossums, may to be blame this time.

The disease is often under diagnosed. There is no rash in 1/2 of cases. When the rash is visible, it can look like measles, rubella, or Rocky Mountain Spotted Fever.

A similar infection can be carried, rarely, by fleas on cats.

What is Scrub Typhus?

Scrub Typhus used to be considered the result of a bacteria named Rickettsia tsutsugamushi, but the bacteria is now called Orientia tsutsugamushi. It is spread by mites. It is found in Asia between Japan, Northrern Australia, and the Middle East. It is generally associated with Pacific areas, but it is increasingly found in India.

The disease causes acute fever, chills, swollen lymph nodes and rash. It can go on to lung and liver problems, kidney damage, and severe problems breathing (ARDS). It can cause meningitis.

Before antibiotics, mortality was high, up to 60%.Treatment is usually successful with an antibiotic like a tetracycline, such as doxycycline, or chloramphenicol. Other antibiotics used have been azithromycin and ciprofloxacin, but without the same known track record.

Scrub Typhus has one really unusual characteristic. An acute infection is thought to sometimes lower HIV levels.

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