Typhoid in the highlands of Papua New Guinea 1984-1990: a hospital-based perspective

A first-hand account is given of the epidemic of typhoid in the Goroka area as it evolved from 1984 to 1990. The monthly admissions for typhoid to Goroka Base Hospital showed a peak in 1988. The sex and age distribution showed a predominance of young adults. The overall case fatality rate of hospitalized patients was of the order of 10-15%; in a carefully documented group of 374 patients 27% were assessed as having severe typhoid and this subgroup had a case fatality rate of 44%. The clinical features were studied in 516 patients. The high mortality appeared to result from septic shock; ileal perforation was found in only 1.3% of patients. A skin lesion equivalent to but significantly different from the classic rose spot was found in 30% of patients. The typhoid facies was commonly encountered in patients with well-established typhoid. Cerebellar tremor and hearing loss were frequent diagnostic findings. Blood and bone marrow cultures were used to confirm the diagnosis; bone marrow culture proved practicable but gave little increased yield over blood culture. A clinical algorithm to help distinguish typhoid and malaria was developed, principally for use in health centres in the highlands. The mainstay of treatment was chloramphenicol and very few problems were encountered with its use in inpatients. Bacteriological resistance to chloramphenicol did not develop over the study period. Other drugs, such as fluorinated quinolones, may be more effective when all aspects are considered, despite higher cost, but this remains to be investigated. Hydrocortisone in patients with severe disease was evaluated and shown to be ineffective but whether high-dose dexamethasone would reduce the mortality from typhoid in patients in Papua New Guinea still remains an unanswered question.