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Characterization of Typhoid Intestinal Perforation in Africa: Results From the Severe Typhoid Fever Surveillance in
Megan Birkhold1, Shrimati Datta1, Gi Deok Pak2
1Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA.
Background:
Typhoid intestinal perforation (TIP) remains the most serious complication of typhoid fever. In many countries, the diagnosis of TIP relies on intraoperative identification, as blood culture and pathology capacity remain limited. As a result, many cases of TIP may not be reported as typhoid. This study demonstrates the burden of TIP in sites in Burkina Faso, Democratic Republic of Congo (DRC), Ethiopia, Ghana, Madagascar, and Nigeria.
Methods:
Patients with clinical suspicion of nontraumatic intestinal perforation were enrolled and demographic details, clinical findings, surgical records, blood cultures, tissue biopsies, and peritoneal fluid were collected. Participants were then classified as having confirmed TIP, probable TIP, possible TIP, or clinical intestinal perforation based on surgical descriptions and cultures.
Results:
A total of 608 participants were investigated for nontraumatic intestinal perforation; 214 (35%) participants had surgically-confirmed TIP and 33 participants (5%) had culture-confirmed typhoid. The overall proportion of blood or surgical site Salmonella enterica subspecies enterica serovar Typhi positivity in surgically verified TIP cases was 10.3%. TIP was high in children aged 5-14 years in DRC, Ghana, and Nigeria. We provide evidence for correlation between monthly case counts of S. Typhi and the occurrence of intestinal perforation.
Conclusions:
Low S. Typhi culture positivity rates, as well as a lack of blood and tissue culture capability in many regions where typhoid remains endemic, significantly underestimate the true burden of typhoid fever. The occurrence of TIP may indicate underlying typhoid burden, particularly in countries with limited culture capability.
Insights
Typhoid intestinal perforation (TIP) is a severe complication of typhoid fever. This study highlights TIP
Area of Science:
- Infectious Diseases
- Gastroenterology
- Public Health
Background:
- Typhoid intestinal perforation (TIP) is the most severe complication of typhoid fever.
- Diagnosis often relies on intraoperative findings due to limited diagnostic capacity in endemic regions.
- This can lead to underreporting of typhoid fever cases.
Purpose of the Study:
- To determine the burden of typhoid intestinal perforation (TIP) in several African countries.
- To investigate the correlation between Salmonella Typhi and TIP.
- To highlight the underestimation of typhoid fever burden due to diagnostic limitations.
Main Methods:
- Prospective enrollment of patients with suspected nontraumatic intestinal perforation.
- Collection of demographic, clinical, surgical, and microbiological data.
- Classification of TIP cases based on surgical and culture results.
Main Results:
- Out of 608 participants, 214 (35%) had surgically-confirmed TIP and 33 (5%) had culture-confirmed typhoid.
- Salmonella Typhi positivity in surgically confirmed TIP cases was 10.3%.
- TIP was notably high in children aged 5-14 in DRC, Ghana, and Nigeria, with a correlation found between S. Typhi case counts and TIP occurrence.
Conclusions:
- Low Salmonella Typhi culture positivity rates and limited diagnostic capabilities significantly underestimate the true burden of typhoid fever.
- Typhoid intestinal perforation (TIP) serves as an indicator of the underlying typhoid burden, especially in resource-limited settings.
- Further research and improved diagnostics are needed to accurately assess typhoid fever prevalence.
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