The accuracy of widal test for typhoid fever diagnosis in Ethiopia: Systematic review and meta-analysis

Introduction: Widal agglutination test is a serologic investigation that is used to diagnose typhoidfever. This is an easy, fairly inexpensive, and readily available test it'ith questionable reliability. The test performance differs from setting to setting depending on the technique used and otherfactors. The accuracy ofthis test in Ethiopia is poorly understood. So, the aim of this scientific work was to analyze the accuracy of Widal agglutination in diagnosing typhoidfever in Ethiopia. Methods: We performed a systematic review and meta-analysis. Two electronic databases (PubMed/Medline and Google scholar) were searched using preset search strategv to find relevant studies. The methodological quality of the studies included was evaluated "'ith a QUADAS-2. We extracted important variables from the eligible articles. Statistical analysis was conducted using STATA version 14. The protocol of our systematic review and metaanalysis is registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the record number CRD42020194252. Results: The electronic quests yielded 42 papers of which 8 "'ere eligible for analysis. The quality of these studies was rated to be moderate based on the QUADAS-2. The pooled sensitivity, specificity, and negative, andpositive predicthe values ofthe Widal test were 80.8%, 53.0%, 98.5%, and 2.1% respecth'ely. Conclusion: The "'idal agglutination test has average specificity, ven good negative predicth'e value, and ven poor positive predictive value for the diagnosis of typhoidfever. Depending on Widal to diagnose typhoid fever may lead to over-diagnosis of typhoid fever and related complications including inappropriate use of antibiotics. There is an urgent needfor quick and dependable tests for diagnosing typhoidfever, particularly in settings like Ethiopia M'here doing timely culture is notfeasible.

Typhoid ileal perforation in children: does clinical diagnosis alone justify laparotomy?

Introduction: Typhoid ileal perforation is one of the most common surgical complications of typhoid fever, with high morbidity and mortality in resource poor tropical areas in Africa and other developing countries. Objective: The aim of this study was to evaluate clinical diagnosis of typhoid ileal perforation as justification for laparotomy. Method: A retrospective study from January 2008 to December 2011 in the Paediatric Surgery Division of the University of Abuja Teaching Hospital. Results: The age group most commonly affected was aged 6-9 years (43.5%); there were 20 (43.5%) males and 26 (56.5%) females. The commonest clinical features were fever, vomiting, abdominal pain, tenderness and distension (52.3%). Thirty one (67.4%) of the patients did not have any diagnostic radiological investigations. Fifteen (32.6%) patients had superficial wound infection, ten (21.7%) died, eleven (23.9%) had no complications. Conclusion: We advocate that under circumstances where urgent diagnostic radiological and laboratory investigations are not available promptly, clinical diagnosis of typhoid ileal perforation, especially signs of peritonitis should justify an emergency laparotomy

Difficultés diagnostiques de la fièvre typhoïde en milieu urbano-rural congolais. Etude menée à Kalemie, province du Tanganyika (République Démocratique du Congo)

Introduction : La fièvre typhoïde est un problème de santé publique qui affecte surtout la population des pays en voie de développement suite aux déficits des mesures d'hygiène. L'objectif de cette étude consistait à déterminer ses modalités diagnostiques.Patients, matériel et méthodes : C'est une étude rétrospective, descriptive et analytique de 2013 à 2014 à l'hôpital général de référence de Kalemie (RD Congo). Elle concernait les cas diagnostiqués et traités de fièvre typhoïde en médecine interne et pédiatrie.Résultats : La fréquence des patients chez qui le diagnostic de la fièvre typhoïde a été évoqué représente 3,3% avec 3,0% en pédiatrie et 4,1% en médecine interne. Les enfants étaient les plus affectés, surtout de sexe féminin. La clinique restait dominée par la fièvre, asthénie physique, anorexie, céphalée et troubles digestifs. Le test de Widal-Félix sur plaque a été demandé dans 82,9% avec 70,1% de positivité alors que 17,1% des patients étaient diagnostiqués sur base des arguments cliniques. Il a été noté une forte association diagnostique (traitée) paludisme-fièvre typhoïde (73,8%).Conclusion : Dans notre série, le diagnostic de la fièvre typhoïde pose de sérieux problèmes liés notamment aux explorations de biologie médicale. Cette dernière devrait contribuer à appuyer la clinique. Les efforts devraient être fournis pour améliorer le diagnostic et prise en charge adéquate des patients, épargnant ainsi au malade des antibiothérapies inutiles

Localised transmission hotspots of a typhoid fever outbreak in the Democratic Republic of Congo

Introduction: in a semi-urban setting in the Democratic Republic of Congo, this study aims to understand the dynamic of a typhoid fever (TF) outbreak and to assess: a) the existence of hot spots for TF transmission and b) the difference between typhoid cases identified within those hot spots and the general population in relation to socio-demographic characteristics, sanitation practice, and sources of drinking water.Methods: this was a retrospective analysis of TF outbreaks in 2011 in Kikwit, DRC using microbiological analysis of water sources and a structured interview questionnaire.Results: there were a total of 1430 reported TF cases. The outbreak's epidemic curve shows earliest and highest peak attack rates (AR) in three military camps located in Kikwit (Ebeya 3.2%; Ngubu 3.0%; and Nsinga 2.2%) compared to an average peak AR of 0.6% in other affected areas. A total 320 cases from the military camps and the high burden health areas were interviewed. Typhoid cases in the military camps shared a latrine with more than one family (P<0.02). All tap water sources in both the military camps and general population were found to be highly contaminated with faecal coliforms.Conclusion: the role of military camps in Kikwit as early hotspots of TF transmission was likely associated with lower sanitary and hygiene conditions. The proximity of camps to the general population might have been responsible for disseminating TF to the general population. Mapping of cases during an outbreak could be crucial to identify hot spots for transmission and institute corrective measures

Antibio-résistance des souches de Salmonella ssp isolées des hémocultures à Bukavu en RD Congo

Introduction: la fièvre typhoïde est un problème majeur de santé publique dans les pays en voie de développement jusqu'à ce jour à cause de la vétusté des infrastructures sanitaires et des circuits de distribution de l'eau presque inexistant. En RDC en général et à Bukavu en particulier, l'hémoculture est inaccessible à la majorité des patients. L'objectif de cette étude était d'évaluer la sensibilité de Salmonella spp aux antibiotiques couramment utilisés dans la prise en charge de la Fièvre Typhoïde à Bukavu.Méthodes: une étude transversale étalée sur 6 mois était organisée. Tout malade suspect de la Fièvre Typhoïde était sélectionné dans l'étude. L'hémoculture était faite systématiquement chez tout malade sélectionné. L'identification de la souche bactérienne et l'antibiogramme étaient réalisés par de méthodes conventionnelles. Les antibiotiques suivants étaient testés: Amikacine, Amoxicilline, Augmentin, Ceftazidime, Ceftriaxone, Cefuroxime, Chloramphénicol, Ciprofloxacine, Cotrimoxazole, Doxycycline, Gentamicine, Négram, Norfloxacine.Résultats: 460 malades ont été sélectionnés dans l'étude. 144 (31,30%) hémocultures positives ont été observées. Salmonella spp était le germe le plus isolé (41,66%). Les souches de Salmonella spp isolées à Bukavu sont sensibles à la ciprofloxacine (91,7%), au ceftazidime (81,7%), ceftriaxone (80%), norfloxacine (80%), amikacine (76,6%) et au cefuroxime (73,3%). Elles restent résistantes aux autres molécules d'antibiotiques. Conclusion: ces résultats montrent une sensibilité diminuée à la plus part d'antibiotique. Un test d'antibiogramme est requis en cas de fièvre typhoïde pour une meilleure prise en charge

Acute cholecystitis from typhic origin in children

Background: To evaluate the particularities of typhoid cholecystitis in children. Materials and Methods: This was a 5-year prospective study of typhoid cholecystitis in children under 15 years old at Djougou and Sylvanus Olympio teaching hospital. The diagnosis of typhoid cholecystitis was based on clinical and investigation findings; confirmed by operative findings at cholecystectomy. Results: Six children with typhoid acalculous cholecystitis were treated over a five-year period (4 males and 2 females). Their ages ranged from five to 13 years (median 8.8 years). The mean duration of symptoms was six to 21 days. The clinical signs were fever; abdominal pain; which predominated at the right upper abdominal quadrant; and type II Hackett splenomegaly. The diagnosis was confirmed by a positive Widal's test and Salmonella typhi isolation from the culture in all patients; four patients had ultrasound evidence of acalculous cholecystitis. Open cholecystectomy was successful in the six cases. The operative findings were gangrene (3); perforation (2) and empyema (1). All the patients made an uneventful recovery; and have remained symptom free one and three months on follow-up. Conclusion: Typhoid acalculous cholecystitis is a frequent complication in children. Late presentation and diagnosis is associated with complications. Cholecystectomy in association with antibiotic is the treatment of choice

Sensitivity and specificity of typhoid fever rapid antibody tests for laboratory diagnosis at two sub-Saharan African sites

Objective:To evaluate three commercial typhoid rapid antibody tests for Salmonella Typhi antibodies in patients suspected of having typhoid fever in Mpumalanga; South Africa; and Moshi; United Republic of Tanzania. Methods The diagnostic accuracy of Cromotest (semiquantitative slide agglutination and single tube Widal test); TUBEX and Typhidot was assessed against that of blood culture. Performance was modelled for scenarios with pretest probabilities of 5and 50. Findings In total 92 patients enrolled: 53 (57.6) from South Africa and 39 (42.4) from the United Republic of Tanzania. Salmonella Typhi was isolated from the blood of 28 (30.4) patients. The semiquantitative slide agglutination and single-tube Widal tests had positive predictive values (PPVs) of 25.0(95confidence interval; CI: 0.6-80.6) and 20.0(95CI: 2.5-55.6); respectively. The newer typhoid rapid antibody tests had comparable PPVs: TUBEX; 54.1(95CI: 36.9-70.5); Typhidot IgM; 56.7(95CI: 37.4-74.5); and Typhidot IgG; 54.3(95CI: 36.6-71.2). For a pretest probability of 5; PPVs were: TUBEX; 11.0(95CI: 6.6-17.9); Typhidot IgM; 9.1(95CI: 5.8-14.0); and Typhidot IgG; 11.0(6.3-18.4). For a pretest probability of 50; PPVs were: TUBEX; 70.2(95CI: 57.3-80.5); Typhidot IgM; 65.6(95CI: 54.0-75.6); and Typhidot IgG; 70.0(95CI: 56.0-81.1). Conclusion Semiquantitative slide agglutination and single-tube Widal tests performed poorly. TUBEX and Typhidot may be suitable when pretest probability is high and blood cultures are unavailable; but their performance does not justify deployment in routine care settings in sub-Saharan Africa

Typhoid ileal perforation in children in Benin city

Background: Typhoid ileal perforation is a common complication of typhoid fever; a multi-systemic infection; which is endemic in many developing countries. Objective: This study reviews and compares the incidence; morbidity and mortality at the University of Benin Teaching Hospital with other referral centres located in areas with similar socioeconomic and population status. Materials and Methods: The incidence; morbidity and mortality of typhoid ileal perforation in children treated among Edo People at the University of Benin Teaching Hospital; Nigeria; in the period from 1993 to 2007 were retrospectively studied and compared with centres in localities of similar socioeconomic and population status. Results: Twelve children; all of middle class parents who resided in suburban community with poor water supply and substandard sewage disposal; accounted for 70.6patients with typhoid ileal perforation managed over 15 years while 29.4occurred in adults. The children comprised seven males and five females (M/F ratio 1.4:1); aged between five and 13 (average 9) years. This number seen over 15 years in this centre was extremely low when compared with other referral centres; as many as 191 patients were seen over 10 months in one of the centres. The few patients seen were traced to cultural beliefs in Benin City; which influenced proper sewage disposal by the about four million Edo people; especially those living in rural areas. Consequently; no child from the rural area with clean natural water supply or urban areas with pipe born water supply where sewages are disposed of properly had typhoid perforation. Unacceptably high morbidity (100) and mortality (75) due to late referrals were recorded in comparison with other centres. Conclusion: Proper sewage disposal may have influenced the low incidence in this centre but early referral is advocated so as to reduce the high associated morbidity and mortality

Typhoid Perforation: Determinants of Outcome in Children in Ile-Ife; Nigeria

Background: Ileal perforation can be a fatal complication of typhoid fever in children as its clinical presentation is often atypical. The risk of death from intestinal perforation in typhoid fever is more than four times when compared with patients without perforation. A high index of suspicion therefore; and early intervention are mandatory to reduce morbidities and deaths due to this disease in children. Aim: To highlight the factors that adversely influence treatment outcome following typhoid ileal perforation in a paediatric population and how they could be modified to reduce morbidity and mortality. Methods: This was a retrospective study whereby medical records of children aged 1 to 15 years with typhoid fever admitted to OAUTHC; Ile-Ife; over a 10-year period; 1994-2004. Results: A total of 38 patients; 20 males and 18 females in the ratio 1.1:1; were managed for typhoid perforation during the 10-year study period. Twenty-nine patients (76.3) survived while 9 (23.7) died. Of the many factors evaluated; only the duration of time before operation was found to significantly influence treatment outcome adversely (P=0.009); while large single or large multiple perforations (P=0.256); severe peritoneal contamination (P=0.291) and extensive surgery (P=0.089) did not. Conclusion: Typhoid ileal perforation has a poor treatment outcome in children in Ile-Ife; Nigeria. The duration of time before operation was the single most important factor that adversely affected treatment outcome. Therefore; swift preoperative resuscitation and early surgical intervention will enhance overall outcome irrespective of the number of perforations; severity of faecal contamination and extent of surgery

Outcome of primary closure of abdominal wounds following typhoid perforation in children in Ile-Ife, Nigeria

Background: Abdominal wounds following surgery for typhoid perforation are classified as dirty; with an infection rate of over 40. To date; the optimal method for closure of these wounds remains controversial. Delayed primary closure which was conventionally recommended as standard practice; is now considered to be of no value in preventing surgical site infection (SSI). This study evaluates the outcome of primary closure of this class of wounds in children in Ile-Ife; Nigeria; and advocates a multidisciplinary wound management protocol. Patients and Methods: This is a retrospective study of children aged 1-15 years who had had surgery for typhoid perforation in a teaching hospital in south western Nigeria; over a period of ten years. Results: Thirty-two patients; 18 males and 14 females; in the ratio of 1.3:1 were managed for typhoid perforation during the ten year period. All 32 patients had primary closure of their abdominal wounds. There was primary wound healing in six (18.8) patients; while 19 (59.4) patients had surgical site infections. Wound dehiscence; intraabdominal abscess; and faecal fistulas were the other complications documented in the study. Conclusion: Abdominal wounds of typhoid perforation; though classified as being dirty; can be closed primarily with good healing outcomes. A multidisciplinary approach to wound management will reduce the incidence of wound sepsis and its associated morbidity and costs

Bowel resection in Nigerian children

Background : Although bowel resections are commonly done for congenital malformations in children in developed countries; they usually follow neglected and preventable acquired diseases of the intestine in developing countries. Objectives : To determine the indications and outcome of bowel resections in children of a developing country in a university teaching hospital. Materials and Methods: Data of the patients operated (from birth to 15 years) was retrospectively collected over eight years (January 1999 to December 2006). The biodata of children included the following: Indications for operation; type of operations; duration of admission; and outcome of treatment including complications. Patients with Hirschsprung's disease were excluded from the study because bowel resection forms part of their definitive surgical management. Results : There were 70 patients (38 boys and 32 girls). The age ranged between four hours to 15 years (median; five months). There were 16 (22.9) neonates; 26 (37.1) infants; and 28 (40) grown children. The indications were congenital anomalies in the 16 neonates. Also; 23 (88.5) infants had intussusception; 2 (7.7) had midgut vovulusm and 1 (3.8) had congenital small intestine band. Among the grown children; typhoid ileal perforation (TIP) was seen in 14 (50.0); intussusception in 5 (17.9); and other causes in nine patients. Overall; intussusception was the most common indication for bowel resection; followed by TIP. A total of 24 patients developed 33 complications. Complications included wound infection in 47.8and anastomotic leak in 42.8. The duration of admission ranged between 4-35 days (median; 15 days). The overall mortality was 17.1-; which was highest among neonates (56.3); followed by the infants (26.9-). Conclusion : Bowel resections are mainly done for intussusception and complications of TIP at our centre. Late presentation; preexisting malnutrition; and nonavailability of parenteral nutrition contributed to unacceptable morbidity and mortality

Mieux prescrire les fluoroquinolones

Les fluoroquinolones; en particulier la ciprofloxacine; sont utilisees dans diverses infections; parfois de facon abusive. Cibler les indications appropriees permet aux patients de tirer le meilleur parti de ces antibiotiques

Non-traumatic Perforation of the Small Bowel

Background: Non-traumatic perforation of the small bowel is an uncommon serious complication associated with high morbidity and mortality. Diseases that cause small bowel perforation vary in different areas of the world. Objective: To highlight difficulties in the diagnosis and management of non-traumatic perforation of small bowel. Material and methods: The medical records of four patients who have presented with non-traumatic perforation of the small bowel and were treated at Al-Ain Hospital during the last 5 years were studied retrospectively. Results: The presenting symptoms of all patients were similar. Erect chest X-ray has shown free air under diaphragm in 3 patients. Leukocytosis was present in only one patient. HIV was confirmed in one patient. Patients were diagnosed to have typhoid; HIV; hook worms and tuberculosis. Only the HIV patient died while the others were discharged home in a good condition. Conclusion: Clinical findings of small bowel perforation are usually non specific and diagnosis is usually reached after surgery. The Histopathological examination of the small bowel ulcer were non conclusive in three patients. We have made our management plan according to the clinical findings. Non traumatic perforation in developing countries can be due to typhoid; HIV; tuberculosis and possibly hook worms

Pattern of Presentation and Management of Typhoid Intestinal Perforation in Sagamu; South-West Nigeria: a 15 year Study

Background: Mortality from typhoid intestinal perforation remains high in the West African sub-region. The aim of this retrospective analysis was to assess the presentation pattern; mode of therapy and outcome of cases diagnosed and treated as typhoid intestina perforation at Olabisi Onabanjo University Teaching Hospital; Sagamu; between January 1990 and December 2004. Methods: Complete records of 105 adult patients were studied. Results: The male to female ratio was 2:1. The mean age was 27years. Prior to arrival in our hospital; all the patients were on various combinations of antibiotics. Twenty-seven (26) patients had been hospitalized elsewhere during the current illness Chloramphenicol was the drug of first choice in the first ten years (phase 1). It was replaced with ciprofloxacin in the subsequent five years (phase 2). Blood culture was positive for salmonella organisms in 5(4) patients. Resistance to chloramphenicol was found in three (60) out of these five positive cultures. All patients had laparotomy after resuscitation. There were 112 perforations; mostly in the ileum and jejunum. Perforations were single in one hundred and one patients and multiple in four patients. Single perforations were treated by two-layered closure; multiple perforations by primary resection and anastomosis. Fifty-five (52.4) patients developed complications. Fourteen (13.3) patients died. There was a slight drop in mortality (8.8) in phase 2. Deaths were due to septicaemia in 8(57) patients. Conclusion: The pattern of presentation and outcome of management of typhoid intestinal perforation are similar to what is observed in other centres in our local environment. However the drop in mortality rate in the last 5 years of the study and the finding of strains of salmonella typhi resistant to chloramphenicol require further evaluation

Typhoid Fever in Sub-Saharan Africa: Challenges of Diagnosis and Management of Infections

Typhoid fever; caused by Salmonella enterica serovar Typhi (S. Typhi); is a disease transmitted by the faecal-oral route. It continues to be a public health problem in many developing countries in sub-Saharan Africa. School-age children; especially those from resource-poor settings with inadequate water and sanitation systems; are dispropor- tionately affected. It is estimated that a total of 400;000 cases occur annually in Africa; an incidence of 50 per 100;000 persons per year. Lack of effective diagnosis often leads to inappropriate treatment and management of these infections. Additionally; the emergence and spread of S. Typhi strains having multiple resistance to nearly all commonly available drugs in most developing countries has been a major challenge to health care systems; reducing the effective treatment options for the disease; increasing treatment costs and increasing the risk of complications and death. Although not much data from sub-Saharan Africa has been published; it seems clear that typhoid is common in Nigeria; Mali; Ethiopia and Kenya. Given the importance of information on disease incidence for targeting control measures; including improved sanitation and water supply; vaccination and assessing impact; priority should be given to strengthening surveillance systems for typhoid fever

Typhoid Fever in Ethiopia

This review focuses on the reports of salmonellosis by investigators in different parts of Ethiopia; in particular focusing on the levels of typhoid fever. Many of the reports are published in local journals that are not available online. There have been seven studies which diagnosed typhoid fever by laboratory culture and there is no coordinated epidemiological surveillance. All conducted research and reports from different health institutions in Ethiopia indicate that typhoid fever was still a common problem up to the most recent study in 2000 and that the extensive use of first-line drugs has led to the development of multiple drug resistance. In the sites covered by this review; the total number of published cases of typhoid fever dropped over time reflecting the decline in research capacity in the country. Data on the proportion of patients infected by different serovars of Salmonella suggest that the non-Typhi serovars of Salmonella are increasing. The published evidence suggests that typhoid fever is a current public health problem in Ethiopia although population based surveys; based on good microbiological diagnosis; are urgently needed. Only then can the true burden of enteric fever be estimated and the benefit of public health control measures; such as health education; safe water provision; improved food hygienic practices and eventually vaccination; be properly assessed

Clinical Features of Typhoid Fever Observed in the Uganda African Patient in Mulago Hospital

Typhoid fever being a disease commonly consufed with other common febrile illnesses; especially when the diagnosis is based on clinical features alone prompted the author to look into the frequency of its presenting features. Methods: One hundred case notes confirmed by a positive blood culture for Salmonella typhi at Mulago Hospital; were retrieved and analysed for clinical features. the majority of the cases diagnosed and treated as typhoid on other evidence were excluded from the study. Results: The commonest features were fever; body weakness; headache and loss of appetite and were present in 98of the cases. The other features comprised of dizziness in 96; coated tongue in 96; dehydration in 94; abdominal pain in 92; abnormal tenderness in 86; low blood pressure on admission in 80; rise in blood pressure after admission in 76; anaemia in 68; splenomegaly in 68; backache in 66; typhoid state in 64; joint pains in 62; chills in 62; partial deafness in 52; muscular pain in 52; constipation in 40; disorientation in 36; delirium in 34; painful toes in 28; pea soup stools in 26; crepitations in lungs in 18; presence of a splenic rub in 8; jaundice in 8; death in 6; thrombo-embolism in 2and convulsions in 2. Apparently; rose spots were not observed in this series. Conclusion: the common clinical features of typhoid in 100 Ugandan confirmed cases of typhoid fever in Mulago Hospital consist of fever; body weakness; headache; loss of appetite; dizziness; features of dehydration; abdominal pain and tenderness; low blood pressure; anemia and joint pains. Pea soup stools commonly stressed by books were seen in only a quarter of the cases and the classical rose spots were not seen and accordingly desearve no emphasis in the Ugandan context

Primary Health Care: Role and Functions

Primary Health Care (PHC) can be defined as the health care availed and accessed to individuals and their families in a particular community; through strategies/interventions that are acceptable to and affordable by the concerned target population. Such health care; as defined; must be broad-based and integrated in approach. It must recognise the interactions among the factors that influence health and give due consideration to these factors and points of interaction. Take; for example; water sources and environmental sanitation; these two factors are closely related and at the sametime affect health together. Diseases such as typhoid; trachoma and malaria are directly related to water supply and basic sanitation. Effective care against these diseases calls for involvement of hospital; health centre and dispensary staff in addition to the community. Teams addressing such diseases comprise of doctors; nurses; administrators; to mention but a few. This illustrates the broad-based nature and intergrated approaches in PHC. Experts in the subject have summarised the desired approaches of PHC into four pillars