In countries like Nigeria, people rarely treat malaria without adding medications for typhoid. Most times it’s joked about, other times it’s mandated.
Question is: Do we always need to treat for typhoid? What are the consequences?
What is typhoid fever?
Typhoid fever is a systemic infection that is caused by the bacterium Salmonella enterica serotype Typhi (S. Typhi), and to a milder extent, serotype Salmonella paratyphi.
It can be life-threatening if not diagnosed and treated on time.
How does it spread?
Typhoid usually spreads through the faecal-oral route, i.e, the bacteria are taken in when someone consumes contaminated food or water.
What are the sources?
- Drinking water contaminated by sewage
- Not washing your hands, especially after using the toilet
- Eating food prepared by a carrier of the bacteria
- Consuming raw or undercooked foods washed with contaminated water
- Living or travelling to areas with poor sanitation.
Due to the unsanitary conditions in some rural areas in Nigeria, typhoid is a persistent threat.
Symptoms of typhoid fever
Typhoid presents with nonspecific symptoms, and that’s one of the reasons it’s so widely misdiagnosed.
They include:
- Persistent high-grade fever (occurring in a step-wise fashion)
- Stomach pain or discomfort
- Loss of appetite
- General feeling of unwellness
- Fatigue
- Constipation or diarrhoea
- Dry cough
- Headache
- Rose colored spots on the body.
These symptoms can also be seen in other illnesses like malaria, hepatitis A, gastroenteritis and urinary tract infections.
How is it diagnosed?
The most accurate way to diagnose typhoid fever is through a blood culture test.
However, this is rarely done due to a lack of infrastructure, high cost and trained personnel.
Other methods include:
- Bone marrow aspirate: Accurate but invasive and expensive
- Stool or urine culture: Less sensitive
- Widal test: Unreliable
Why is typhoid overdiagnosed in Nigeria?
Typhoid is overdiagnosed in Nigeria because of over-reliance on the Widal test due to low cost and availability.
Why is this a problem?
In a study carried out comparing the Widal test to blood culture, it was seen that a lot of people were positive to the Widal test, even when blood culture was negative.
Concurrently, of those who tested negative, several people were seen to be positive using a blood culture test.
This shows that the Widal test has low sensitivity, specificity and cannot accurately diagnose those with typhoid fever.
Aside from that, there’s a high possibility of the Widal test being positive if the malaria parasite is present in the bloodstream.
In a study carried out, 100 out of 193 patients with malaria tested positive for the Widal test.
However, on further investigation using blood culture, only 5 of them had typhoid infection.
Other reasons typhoid is overdiagnosed include:
- Empirical diagnosis and treatment by doctors, especially in rural areas that lack access to good laboratories.
- Lack of specific symptoms, as so many other illnesses present, like typhoid.
What is the solution?
- Stop over-reliance on the Widal test
Access to accurate testing, like blood culture, should be improved and made affordable in hospitals and laboratories.
This would reduce reliance on inaccurate Widal tests.
- Physicians have a role to play
Health professionals should understand the inaccuracy of Widal tests and tread carefully by either performing them twice or recommending a better method of diagnosis.
- The masses
Not every fever is typhoid fever, and malaria is not always a co-infection with typhoid.
Stop self-medicating and present to a hospital for a better diagnosis.
- Prevention
Practice good personal hygiene, from washing your hands after using the loo to making sure your water and food are not contaminated.
Dangers of over-diagnosis
- Antibiotic resistance: Unnecessary use of antibiotics can lead to microbial resistance, which increases future treatment time and costs.
- Wasted resources: Waste of money on treatments that are not needed, and in the same vein, not treating the actual cause of illness.
- Anxiety, frustration and loss of trust in the healthcare system due to sustained illness.
In summary
Typhoid fever is real, but overdiagnosing it is also a serious problem.
- Physicians and patients alike should avoid jumping to conclusions without a proper diagnosis
- The Widal test is inaccurate in most cases and should not be relied upon
- Drink clean and treated water
- Eat well-cooked foods, avoid street foods and raw vegetables not washed in clean water
- Get vaccinated if living or travelling to an endemic area.
Malaria and typhoid are not collabo.
Stay informed and safe.
By Pharm. Oluoma @zizelle_
