Reuters and WHO report that approximately 2500 people have been infected with typhoid in Deir al-Zor, an area of Syria held by rebel forces. With no fuel or electricity to run pumps, people are forced to drink from the Euphrates River.

Typhoid is caused by Salmonella typhi, a bacterium that can hide in the human bloodstream or intestinal tract. Salmonella typhi are shed through feces, or stool. So, transmission can occur when someone ingests contaminated water, or when someone comes into contact with food or water handled by a typhoid carrier. In Syria’s case, the breakdown of sanitation infrastructure has allowed Salmonella typhi bacteria to spread to drinking water sources.

The disease causes high fever, headache, diarrhea and enlarged liver or spleen. Sometimes a rash may develop. Symptoms may be mild or may not ever appear. However, infected people without symptoms can still be carriers of the bacterium and spread it to others. Such was the case for the infamous “Typhoid Mary,” previously referenced on The Disease Daily.

Mary Mallon, an Irish immigrant, worked in New York City as a cook in the early 1900s. One family for whom she worked, the Warrens, rented a house on Oyster Bay for the summer. When a member of the Warren family was struck with typhoid, the Thompsons, who owned the vacation house, felt they needed to discover the source of the infection if they wanted to continue renting their house. The Thompsons hired George Soper, a civil engineer “known for his ability to track down the source of disease.” As told by PBS in “The Most Dangerous Woman in America,” Soper could not find anything wrong with the house, the Thompsons or the Warrens. Then he learned they had a cook, Mary Mallon. Soper tracked Mary’s history and learned that six of the eight families she worked with had been afflicted by typhoid. At that time, infectious disease was not well understood. Mary knew she had never experienced illness from typhoid and believed, therefore, she could not infect others. What ensued were, reportedly, several hostile confrontations between Soper and Mallon, quarantines, court cases, and discussions of curbing civil liberties for public health. Mary Mallon remained in quarantine on North Brother Island until her death in 1938. According to PBS, she had given 47 people typhoid fever.

The fact that typhoid can be transmitted by asymptomatic patients also makes it difficult for people to understand and manage their risk of exposure. For many other diseases, symptoms serve as a warning sign of infection, and people may be better able to reduce their contact with infected people.

The complexity of typhoid transmission combined with the overall political instability in Syrica have sparked the current outbreak. Elisabeth Hoff, the WHO representative in Syria, explained that these types of outbreaks are common in situations of political upheaval where sanitation infrastructure is overwhelmed. Hoff called on the Syrian rebel forces to take charge in dealing with this outbreak.

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