Review Articles - 2

Typhoid Fever: The Challenges of Medical Management

Dr J A Otegbayo
Gastrointestinal/ Liver Unit, Department of Medicine,
University of Ibadan/ University College Hospital, Ibadan, Nigeria

Keywords: Typhoid, medical management, challenges

1. Poor environmental sanitation
INTRODUCTION 2. Potable water
Salmonella enterica serotype typhi is the aetiological 3. Health education
agent of typhoid fever, a multisystemic disease with 4. Confounding disease
protean manifestations and initial lesions in the 5. Personal and communal hygiene
bowel. Typhoid fever still remains a major public 6. Laboratory facilities
health problem in developing countries even in the 7. Drug resistance
twenty first century[1,2]. This was also the case in 8. Fake and counterfeit drugs
America and Europe three centuries ago, until mea-
sures for sanitary disposal and supply of potable Poor Sanitation
water were put in place. Unacceptable morbidity Adequate sanitation is the safe management of hu-
and mortality are still recorded in developing coun- man excreta and includes both “hardware” (sanita-
tries in spite of availability of several drugs over the tion technologies, such as toilets and hygienic latrines)
years for the treatment of typhoid fever. There is and “software” (hygiene promotion, such as hand
enough evidence to show that the prevalence of ty- washing with soap). The World Health Organiza-
phoid fever in any community is an index of com- tion stated in the year 2000, that 40% (2.4billion) of
munal hygiene and effectiveness of sanitary disposal. the world’s population lacked access to basic sani-
In Nigeria, as in other developing countries tation [4].
of the world, studies have estimated over 33 million One of the major public health concerns in
cases and 500,000 deaths due to typhoid fever per cities in developing economies are slums with over-
year [3]. Several factors are responsible for the fail- crowding at its worst. Poor urban planning without
ure of public health measures to tame the tide of the regard for waste disposal and drainage facilities. All
continuing rise in the incidence, prevalence, mor- these tend to encourage transmission of infectious
bidity and mortality of typhoid fever. The objective diseases. An international workshop in1986 identi-
of this review is to highlight the challenges in medical fied ingestion of foods or water contaminated by
management of typhoid fever and to proffer solu- acutely infected persons or chronic typhoid carriers
tions. as the most common form of transmission of the dis-
The major challenges to the management of ease[5]. As a result of poor sanitation, typhoid fe-
typhoid fever are diverse and formidable; especially ver is very common in communities where contami-
so in economically disadvantaged continents such nated water and food is common.
as Central and South America, Middle-East, South-
East Asia and Africa. These challenges are similar Potable Water
and interactive in all countries listed. This review will Availability and potability of drinkable water is still a
focus on the under listed factors: luxury in most developing nations of the world. The
WHO estimated that 1.2 billion of the world’s popu-
lation lack access to potable water [5]. At the peak
of the dry season, especially in developing coun-
All Correspondence to Dr J. A. Otegbayo
tries, water is often sourced from various doubtful
Gastrointestinal/ Liver Unit, Department of Medicine, places most of which are contaminated by human
University of Ibadan/ University College Hospital, waste. This no doubt accounts for the rise in the
Ibadan, Nigeria. incidence of typhoid fever, which has been docu-
E-mail: otegbayoa@comuiedu.ng

Annals of Ibadan Postgraduate Medicine. Vol.3 No1 June, 2005 60

 Typhoid Fever: The Challenges of Medical Management
mented in such communities during this period of members of the community use it for various do-
the year [2,6]. mestic purposes including drinking, cooking, etc.

Health Education Laboratory Facilities

Knowledge is limited about many infectious diseases It is very difficult to isolate Salmonella typhi from
in developing countries as many diseases are still urine and stool specimens in most developing coun-
attributed to spiritual attacks by the common folks. tries. This is often due to lack of culture media, ex-
Also, as a result of illiteracy, half-measures are of- pertise and sometimes previous exposure to inad-
ten taken by self- medicating, in order to avoid the equate doses of antibiotics.
unaffordable cost of modern healthcare in a situa- Another major problems relating to the labo-
tion where there is no health insurance cover. This ratory is the abuse of the Widal’s test. Some clini-
often leads to mismanagement with unsubstantiated cians will not treat or suspect the disease unless the
remedies and misplaced spiritual intervention. As a test is positive, while others treat with a positive re-
consequence of this, patients with typhoid fever of- sult even in low titres for an endemic zone of ty-
ten present late and so with complications. Olubuyide phoid fever or in the absence of clinical symptoms
in 1992 documented delay in seeking medical care, and signs. Ohanu et al showed that malaria could
misdiagnosis, and inappropriate therapy as the fac- interfere with serological diagnosis of typhoid fever
tors that may contribute to mortality from typhoid leading to overdiagnosis [12]. Typhoid fever in most
developing countries is thus a disease of over- and
fever among Nigerians [7]. Occasionally, inadequate
under diagnosis. It would be wise to carry out stud-
pre-medication before seeking medical care often
ies of baseline value of typhoid agglutinins for every
changes the expected clinical picture of the disease,
locality as has been done in some areas to know the
thus also leading to misdiagnosis.
diagnostic utility of the Widal’s test. Advances in di-
agnosis of typhoid fever with the use of enzyme-
Confounding Diseases linked immunosorbent assay [13] is still beyond the
Typhoid fever, as a multisystematic disease has been reach of most developing nations.
dubbed the great mimicker especially in the tropical
and subtropical environment, where several other Drug Resistance
confounding infections and infestations present with Resistance to chloramphenicol developed two years
febrile illness. Many of these febrile illnesses such as after its discovery in 1948; this phenomenon has since
malaria, viral hepatitis and liver abscess, often present become a major challenge to contend with in the
in a similar way as typhoid fever or even co-exist management of typhoid fever. Resistance has since
with typhoid fever. This often leads to delay or mis- been noticed with virtually all drugs including
diagnosis and subsequent increased incidence of trimethoprim and ampicillin [14]. Recent studies have
complications and mortality [8,9,10.11]. shown resistance and reduced susceptibility to
ceftriazone and the quinolones [15, 16], however,
Personal and Communal Hygiene quinolones are still regarded as the best and first-
Poor personal and communal hygiene is a common line drugs in the management of typhoid fever.
occurrence in less developed nations of the world
especially among the illiterate population. Lack of Fake and Counterfeit
public sanitation as a result of ineffective health poli- In 2001, the National Agency for Food and Drug
cies leads to reckless deposition of wastes and use Administration (NAFDAC) in Nigeria, reported
of bush paths and riverbanks as refuse dumps and 50% of the drug in circulation in Nigeria to be fake.
defecation points. During the early rainy season, fae- The problem of counterfeit and fake drugs no doubt
cal matter from some carriers of typhoid fever are has compounded the problem of management of
washed into rivers and brooks. Unsuspecting typhoid fever, with a great potential for increased
morbidity and mortality.

Annals of Ibadan Postgraduate Medicine. Vol.3 No1 June, 2005 61

 Typhoid Fever: The Challenges of Medical Management
Suggested Solutions to Challenges in
Mangement 6. Luby SP, Faizan MK, Fisher-Hoch SP,
It appears quite obvious that the solutions to medi- Syed A, Mintz ED, Bhutta ZA et al. Risk factors
cal management of typhoid fever will be along the for typhoid fever in an endemic setting, Karachi, Pa-
line of the identified problems noted above. Im- kistan. Epidemiol Infect. 1998; 120: 129-138.
provement in personal and communal hygiene, ef- 7. Olubuyide I.O. Factors that may contribute
fective waste disposal system and provision of po- to death from typhoid infection among Nigerians.
table water will no doubt go a long way in reducing West Afri J Med. 1992; 11:112-115.
the incidence of typhoid fever. Effective treatment 8. Ammah A, Nkuo-Akenji T, Ndip R and
of index cases, health education both for the popu- Deas JE. An update on concurrent malaria and ty-
lace and physicians are other important measures. phoid fever in Cameroon. Trans R Soc Trop Med
Determination of drug sensitivity patterns and ag- Hyg. 1999; 93: 127-129.
gressive policy will be quite helpful. The difficulty in
9. Khan M, Coovadia Y and Sturm AW. Ty-
diagnosis could also be overcome by making labo- phoid fever complicated by acute renal failure and
ratory facilities such as culture media available. Parry
hepatitis: case reports and review. Am J
et al recently suggested the use of conjugate Vi vac- Gastroenterol. 1998; 93: 1001-1003.
cine as part of the Expanded Programme of Immu- 10. Wilairatana P. Acute viral hepatitis A: a cause
nization[17]. The cost-effectiveness of this latter of jaundice in typhoid fever. Southeast Asian J Trop
measure may however be negative for resource – Med Public Health 1996; 27: 406-407.
poor countries, where preventive measures by way 11. Giorgio A, Tarantino L and De Stefano G.
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water would be more beneficial. Above all, re- nosis and management by percutaneous echo guided
sources should be made available, accessible and needle aspiration. Ital. J. Gastroenterol. 1996; 28:
affordable to the common man; National Health In- 31-33.
surance appears to be the answer to this as well as 12. Ohanu ME, Mbah AU, Okonkwo PO and
economic empowerment of the people in emerging Nwagbo FS. Interference by malaria in the diagno-
economies like Nigeria. sis of typhoid using Widal’s test alone. West Afr J
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