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Kim C, Goucher GR, Tadesse BT, Lee W, Abbas K, Kim JH. Associations of water, sanitation, and hygiene with typhoid fever in case-control studies: a systematic review and meta-analysis. BMC Infect Dis 2023; 23:562. [PMID: 37644449 PMCID: PMC10464135 DOI: 10.1186/s12879-023-08452-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/11/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Water, sanitation, and hygiene (WASH) play a pivotal role in controlling typhoid fever, as it is primarily transmitted through oral-fecal pathways. Given our constrained resources, staying current with the most recent research is crucial. This ensures we remain informed about practical insights regarding effective typhoid fever control strategies across various WASH components. We conducted a systematic review and meta-analysis of case-control studies to estimate the associations of water, sanitation, and hygiene exposures with typhoid fever. METHODS We updated the previous review conducted by Brockett et al. We included new findings published between June 2018 and October 2022 in Web of Science, Embase, and PubMed. We used the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool for risk of bias (ROB) assessment. We classified WASH exposures according to the classification provided by the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation, and Hygiene (JMP) update in 2015. We conducted the meta-analyses by only including studies that did not have a critical ROB in both Bayesian and frequentist random-effects models. RESULTS We identified 8 new studies and analyzed 27 studies in total. Our analyses showed that while the general insights on the protective (or harmful) impact of improved (or unimproved) WASH remain the same, the pooled estimates of OR differed. Pooled estimates of limited hygiene (OR = 2.26, 95% CrI: 1.38 to 3.64), untreated water (OR = 1.96, 95% CrI: 1.28 to 3.27) and surface water (OR = 2.14, 95% CrI: 1.03 to 4.06) showed 3% increase, 18% decrease, and 16% increase, respectively, from the existing estimates. On the other hand, improved WASH reduced the odds of typhoid fever with pooled estimates for improved water source (OR = 0.54, 95% CrI: 0.31 to 1.08), basic hygiene (OR = 0.6, 95% CrI: 0.38 to 0.97) and treated water (OR = 0.54, 95% CrI: 0.36 to 0.8) showing 26% decrease, 15% increase, and 8% decrease, respectively, from the existing estimates. CONCLUSIONS The updated pooled estimates of ORs for the association of WASH with typhoid fever showed clear changes from the existing estimates. Our study affirms that relatively low-cost WASH strategies such as basic hygiene or water treatment can be an effective tool to provide protection against typhoid fever in addition to other resource-intensive ways to improve WASH. TRIAL REGISTRATION PROSPERO 2021 CRD42021271881.
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Affiliation(s)
- Chaelin Kim
- International Vaccine Institute, Seoul, South Korea
| | | | | | - Woojoo Lee
- Graduate School of Public Health, Seoul National University, Seoul, South Korea
| | - Kaja Abbas
- London School of Hygiene & Tropical Medicine, London, UK
| | - Jong-Hoon Kim
- International Vaccine Institute, Seoul, South Korea.
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Hechaichi A, Bouguerra H, Letaief H, Safer M, Missaoui L, Cherif A, Farah S, Jabrane H, Atawa T, Yahia H, Hamdouni H, Zitoun K, Chahed K, Laamouri R, Daaboub J, Rabhi M, Salah AB, Chahed MK, Bouafif Ben Alaya N. Outbreak Investigation of Typhoid Fever in the District of Gabes, South of Tunisia. EPIDEMIOLOGIA 2023; 4:223-234. [PMID: 37489494 PMCID: PMC10366729 DOI: 10.3390/epidemiologia4030023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/28/2023] [Accepted: 05/08/2023] [Indexed: 07/26/2023] Open
Abstract
Typhoid fever is a significant public health concern in many parts of the world, particularly in developing countries with poor sanitation and hygiene conditions. In July 2016, an outbreak of typhoid fever occurred in Ghannouche, located in the south of Tunisia. This paper reports the results of a field investigation undertaken to identify possible transmission pathways and risk factors in order to propose control and preventive measures. A retrospective cohort study including a passive and active case finding, as well as an environmental and bacteriological investigation was conducted from July to September 2016. A case was defined as a person residing or having stayed in Ghannouche and having presented from the beginning of June clinical signs suggestive of typhoid fever, with, for a confirmed case, laboratory isolation of S.Tyhi, and for a probable case, an epidemiological link with a confirmed case. Attack rates were determined, and risk ratios were estimated with respect to exposures. Unadjusted and adjusted odds ratios were estimated using binary logistic regression. Among the 628 subjects investigated, 102 cases of typhoid fever were identified (74 confirmed and 28 probable) with an overall attack rate of 16.24%. Over 56% of cases were male and those under 10 years old were most affected (38.2%% of cases) with a median age of 12 years (interquartile range 5 to 25 years). The main clinical signs were fever (95%) and diarrhea (57%). Young age (adjusted OR = 0.95 and 95% CI = 0.93-0.97), low level of education (adjusted OR = 4.76 and 95% CI = 1.34-16.81), and the habitat type Arab or rudimentary house (adjusted OR = 4.93 and 95% CI = 2.61-8.27) were the socio-demographic factors independently associated with typhoid fever. Typhoid fever was found to be associated with drinking softened water (adjusted OR = 2.64 and 95% CI = 1.16-4.82), eating raw fruit and vegetables from family gardens (adjusted OR = 6.13 and 95% CI = 3.66-11.06), and using uncontrolled waste disposal (adjusted OR = 3.52 and 95% CI = 2.03-6.94). A total of 110 drinking water samples were analyzed; out of the 38 samples of softened water, 12 were non-compliant and 5 were positive for Salmonella. The screening activity identified two asymptomatic carriers, one of whom was a softened water seller. We concluded that drinking softened water from informal or unauthorized sale units, consuming fruit and vegetables from family gardens, uncontrolled dumping of household waste, and poor socio-economic conditions increase the risk of typhoid fever in this region. Many recommendations were implemented to stop this outbreak and to prevent further episodes.
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Affiliation(s)
- Aicha Hechaichi
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
| | - Hind Bouguerra
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
| | - Hajer Letaief
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
| | - Mouna Safer
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
| | - Lamia Missaoui
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Amal Cherif
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Saffar Farah
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Houcine Jabrane
- Direction Régionale de Santé Gabès, Place du Gouvernorat, Gabès 6000, Tunisia
| | - Taoufik Atawa
- Direction des Soins de Santé de Base, Ministry of Health, 31 Khartoum Street, Tunis 1002, Tunisia
| | - Hamdi Yahia
- Direction Régionale de Santé Gabès, Place du Gouvernorat, Gabès 6000, Tunisia
| | - Hayet Hamdouni
- Direction des Soins de Santé de Base, Ministry of Health, 31 Khartoum Street, Tunis 1002, Tunisia
| | - Khadija Zitoun
- Direction Régionale de Santé Tunis, 9 Rue Ibn El Haythem, Tunis 1002, Tunisia
| | - Karim Chahed
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Ramzi Laamouri
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
| | - Jaber Daaboub
- Direction de L'hygiène du Milieu et de la Protection de L'environnement, Ministry of Health, Bab Saadoun, Tunis 1006, Tunisia
| | - Mohamed Rabhi
- Direction de L'hygiène du Milieu et de la Protection de L'environnement, Ministry of Health, Bab Saadoun, Tunis 1006, Tunisia
| | - Afif Ben Salah
- Graduate Studies and Research, Arabian Gulf University, Road 2904 Building 293, Manama 329, Bahrain
| | - Mohamed Kouni Chahed
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
| | - Nissaf Bouafif Ben Alaya
- National Observatory of Emerging Diseases, Ministry of Health, Diplomat Building, 5-7 Khartoum Street, Le Belvédère, Tunis 1002, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, Tunis 1007, Tunisia
- Preventive Medicine Department, Faculté de Médecine de Tunis, Université de Tunis El Manar, LR01ES04 Epidémiologie et Prévention des Maladies Cardiovasculaires en Tunisie, Tunis 1007, Tunisia
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Giri S, Mohan VR, Srinivasan M, Kumar N, Kumar V, Dhanapal P, Venkatesan J, Gunasekaran A, Abraham D, John J, Kang G. Case-Control Study of Household and Environmental Transmission of Typhoid Fever in India. J Infect Dis 2021; 224:S584-S592. [PMID: 35238355 PMCID: PMC8892545 DOI: 10.1093/infdis/jiab378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background Typhoid fever causes substantial morbidity and mortality in low- and middle-income countries. We conducted a case-control study in Vellore, southern India, to understand risk factors for transmission of typhoid. Methods From April 2018 to October 2019, households of blood culture-confirmed typhoid cases that occurred within a fever surveillance cohort aged 6 months–15 years, and controls matched for age, sex, geographic location, and socioeconomic status, were recruited. Information on risk factors was obtained using standard questionnaires. Household and environmental samples were collected for detection of Salmonella Typhi using real-time polymerase chain reaction. Multivariable analysis was used to evaluate associations between risk factors and typhoid. Results One hundred pairs of cases and controls were recruited. On multivariable regression analysis, mothers eating food from street vendors during the previous week (odds ratio [OR] = 2.04; 95% confidence interval [CI], 1.03–4.12; P = .04) was independently associated with typhoid, whereas treatment of household drinking water (OR = 0.45; 95% CI, 0.25–0.80; P = .007) was protective. There was no significant difference in S Typhi detection between the environmental samples from case and control households. Conclusions Street-vended food is a risk factor for typhoid in densely populated urban communities of Vellore. Improved sanitation facilities and awareness about point-of-use water treatment are likely to contribute to typhoid control.
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Affiliation(s)
- Sidhartha Giri
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | | | | | - Nirmal Kumar
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Vinoth Kumar
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Pavithra Dhanapal
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | | | - Annai Gunasekaran
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Dilip Abraham
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Jacob John
- Department of Community Health, Christian Medical College, Vellore, India
| | - Gagandeep Kang
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
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Brockett S, Wolfe MK, Hamot A, Appiah GD, Mintz ED, Lantagne D. Associations among Water, Sanitation, and Hygiene, and Food Exposures and Typhoid Fever in Case-Control Studies: A Systematic Review and Meta-Analysis. Am J Trop Med Hyg 2020; 103:1020-1031. [PMID: 32700668 DOI: 10.4269/ajtmh.19-0479] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Typhoid fever transmission occurs through ingestion of food or water contaminated with Salmonella Typhi, and case-control studies are often conducted to identify outbreak sources and transmission vehicles. However, there is no current summary of the associations among water, sanitation, and hygiene (WASH); and food exposures and typhoid from case-control studies. We conducted a systematic review and meta-analysis of case-control studies to evaluate the associations among typhoid fever and predicted WASH or food exposure risk factors (13), and protective factors (7). Overall, 19 manuscripts describing 22 case-control studies were included. Two studies were characterized as having low risk of bias, one as medium risk, and 19 as high risk. In total, nine of 13 predicted risk factors were associated with increased odds of typhoid (odds ratio [OR] = 1.4-2.4, I 2 = 30.5-74.8%.), whereas five of seven predicted protective factors were associated with lower odds of typhoid (OR = 0.52-0.73, I 2 = 38.7-84.3%). In five types of sensitivity analyses, two (8%) of 26 summary associations changed significance from the original analysis. Results highlight the following: the importance of household hygiene transmission pathways, the need for further research around appropriate food interventions and the risk of consuming specific foods and beverages outside the home, and the absence of any observed association between sanitation exposures and typhoid fever. We recommend that typhoid interventions focus on interrupting household transmission routes and that future studies provide more detailed information about WASH and food exposures to inform better targeted interventions.
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Affiliation(s)
- Sarah Brockett
- Tufts University School of Medicine, Boston, Massachusetts
| | - Marlene K Wolfe
- Department of Civil and Environmental Engineering, Stanford University, Stanford, California.,Department of Civil and Environmental Engineering, Tufts University, Medford, Massachusetts
| | - Asa Hamot
- Department of Civil and Environmental Engineering, Tufts University, Medford, Massachusetts
| | - Grace D Appiah
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric D Mintz
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Daniele Lantagne
- Department of Civil and Environmental Engineering, Tufts University, Medford, Massachusetts
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5
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Masinaei M, Eshrati B, Yaseri M. Spatial and spatiotemporal patterns of typhoid fever and investigation of their relationship with potential risk factors in Iran, 2012–2017. Int J Hyg Environ Health 2020; 224:113432. [DOI: 10.1016/j.ijheh.2019.113432] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/21/2019] [Accepted: 12/09/2019] [Indexed: 11/15/2022]
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Radhakrishnan A, Als D, Mintz ED, Crump JA, Stanaway J, Breiman RF, Bhutta ZA. Introductory Article on Global Burden and Epidemiology of Typhoid Fever. Am J Trop Med Hyg 2018; 99:4-9. [PMID: 30047370 PMCID: PMC6128367 DOI: 10.4269/ajtmh.18-0032] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This article is the introduction to a 12-paper supplement on global trends in typhoid fever. The Tackling Typhoid (T2) project was initiated in 2015 to synthesize the existing body of literature on typhoidal salmonellae and study national and regional typhoid fever trends. In addition to a global systematic review, eight case studies were undertaken to examine typhoid and paratyphoid fever trends in endemic countries alongside changes in relevant contextual factors. Incidence variations exist both within and between regions with large subnational differences as well, suggesting that public health changes impacting typhoid and paratyphoid fevers in one setting may not have similar impacts in another. This supplement also brings to light the lack of national typhoid fever surveillance systems, inconsistencies in diagnostics, and the lack of typhoid fever associated morbidity and mortality data in many countries, making it difficult to accurately quantify and track burden of disease. To better understand typhoid fever there is a need for more high-quality data from resource-poor settings. The implementation of typhoid surveillance systems alongside the transition to blood-culture confirmation of cases, where possible, would aid in the improvement of data quality in low-income settings. The following supplement includes the results of our global systematic review, eight-country case study articles, a qualitative article informed by semistructured interviews, and a conclusion article on potential ways forward for typhoid control.
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Affiliation(s)
| | - Daina Als
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | - Eric D Mintz
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Jefferey Stanaway
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington
| | | | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada.,Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Bhutta ZA, Gaffey MF, Crump JA, Steele D, Breiman RF, Mintz ED, Black RE, Luby SP, Levine MM. Typhoid Fever: Way Forward. Am J Trop Med Hyg 2018; 99:89-96. [PMID: 30047361 PMCID: PMC6128357 DOI: 10.4269/ajtmh.18-0111] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The Tackling Typhoid supplement shows that typhoid fever continues to be a problem globally despite socioeconomic gains in certain settings. Morbidity remains high in many endemic countries, notably in sub-Saharan Africa and South Asia. In addition, antimicrobial resistance is a growing issue that poses a challenge for clinical management. The findings from this supplement revealed that outside of high-income countries, there were few reliable population-based estimates of typhoid and paratyphoid fever derived from surveillance systems. This indicates the need for monitoring systems that can also characterize the effectiveness of interventions, particularly in low- and middle-income settings. The country case studies indicated that gains in economic conditions, education, and environmental health may be associated with reductions in typhoid fever burden. Over the study period, the effect is mainly notable in countries with higher baseline levels of economic development, female literacy, and investments in public sanitation. High burden countries must continue to invest in strategies at the local level to address environmental factors such as access to safe drinking water and improved public sanitation that are known to interrupt transmission or diminish the risk of acquiring typhoid. Developing more effective vaccines and incorporating appropriate immunization strategies that target populations with the greatest risk could potentially alleviate disease burden.
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Affiliation(s)
- Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Michelle F Gaffey
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Duncan Steele
- Enteric and Diarrheal Diseases, Bill & Melinda Gates Foundation, Seattle, Washington
| | - Robert F Breiman
- Emory Global Health Institute, Emory University, Atlanta, Georgia
| | - Eric D Mintz
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Robert E Black
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Stephen P Luby
- Centre for Innovation in Global Health, Woods Institute for the Environment, Stanford University, Stanford, California
| | - Myron M Levine
- Global Health, Vaccinology and Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland
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Estimating Typhoid Fever Risk Associated with Lack of Access to Safe Water: A Systematic Literature Review. JOURNAL OF ENVIRONMENTAL AND PUBLIC HEALTH 2018; 2018:9589208. [PMID: 30174699 PMCID: PMC6076975 DOI: 10.1155/2018/9589208] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 05/28/2018] [Indexed: 11/17/2022]
Abstract
Background Unsafe water is a well-known risk for typhoid fever, but a pooled estimate of the population-level risk of typhoid fever resulting from exposure to unsafe water has not been quantified. An accurate estimation of the risk from unsafe water will be useful in demarcating high-risk populations, modeling typhoid disease burden, and targeting prevention and control activities. Methods We conducted a systematic literature review and meta-analysis of observational studies that measured the risk of typhoid fever associated with drinking unimproved water as per WHO-UNICEF's definition or drinking microbiologically unsafe water. The mean value for the pooled odds ratio from case-control studies was calculated using a random effects model. In addition to unimproved water and unsafe water, we also listed categories of other risk factors from the selected studies. Results The search of published studies from January 1, 1990, to December 31, 2013 in PubMed, Embase, and World Health Organization databases provided 779 publications, of which 12 case-control studies presented the odds of having typhoid fever for those exposed to unimproved or unsafe versus improved drinking water sources. The odds of typhoid fever among those exposed to unimproved or unsafe water ranged from 1.06 to 9.26 with case weighted mean of 2.44 (95% CI: 1.65–3.59). Besides water-related risk, the studies also identified other risk factors related to socioeconomic aspects, type of food consumption, knowledge and awareness about typhoid fever, and hygiene practices. Conclusions In this meta-analysis, we have quantified the pooled risk of typhoid fever among people exposed to unimproved or unsafe water which is almost two and a half times more than people who were not exposed to unimproved or unsafe water. However, caution should be exercised in applying the findings from this study in modeling typhoid fever disease burden at country, regional, and global levels as improved water does not always equate to safe water.
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