Incidence of typhoid fever in Burkina Faso, Democratic Republic of the Congo, Ethiopia, Ghana, Madagascar, and Nigeria (the Severe Typhoid in Africa programme): a population-based study

Prevalence and Antimicrobial Resistance of Typhoid Fever in Ghana: A Systematic Review and Meta-Analysis

Background/Objectives: Typhoid fever caused by Salmonella enterica serovar Typhi remains an important public health problem in Ghana. Understanding the epidemiology and antimicrobial resistance patterns of S. Typhi is crucial to guide the treatment and control of typhoid fever. This systematic review and meta-analysis aimed to estimate the prevalence of typhoid fever in Ghana and describe the antibiotic susceptibility profiles. Methods: Literature searches were conducted using the PubMed repository and three databases: Scopus, Web of Science, and ScienceDirect. Observational studies reporting typhoid fever prevalence among Ghanaian participants diagnosed by culture or Widal test and published between 1 January 2004 and 16 August 2024 were eligible. Quality was assessed using standardized JBI critical appraisal checklists. Random-effects meta-analysis with a 95% confidence interval was performed to estimate pooled prevalence and conduct subgroup analyses. Results: A total of 22 studies involving 228,107 participants were included in the systematic review. The pooled prevalence of typhoid fever was 4.14% (95% CI: 2.78-5.75). Blood culture detected more cases (3.68%) than stool culture (1.16%). Multidrug resistance was documented in 20-66% of isolates, and ciprofloxacin had the lowest prevalence of resistance (0-17%). Conclusions: This review highlights the substantial typhoid fever burden and evolving antimicrobial resistance in Ghana. Continuous surveillance of the disease is warranted to optimize empiric treatment and control strategies, given the resistance to first-line drugs. Enhanced prevention through water, sanitation, and vaccination programs is imperative.

Evaluation of Moore and grab sampling method for Salmonella Typhi detection in environmental samples in Ghana

BACKGROUND

Typhoid fever causes substantial mortality and morbidity in low and middle-income countries (LMICs) as a result of inadequate water, hygiene, and sanitation facilities. The gold standard for typhoid diagnosis is blood culture, however this method is expensive and mostly unavailable in LMICs. Environmental surveillance (ES) could offer a low cost alternative to identify circulation of Salmonella enterica serovar Typhi (S.Typhi) and help inform public health interventions including vaccination.

METHODS

We implemented standardized protocols for ES at 40 validated sites in peri-urban communities in Ghana from July 2022 to August 2023. Grab samples (GS) and Moore swabs (MS) were collected monthly for the initial 6 months and subsequently monthly MS were maintained for the rest of the study period. Wastewater samples were tested for S. Typhi target genes (ttr, staG, tviB) and a biomarker of human faecal contamination (Bacteroides HF183) using multiplex quantitative PCR (qPCR). Clinical surveillance for typhoid fever was performed by blood culture of febrile cases presenting to the local hospital who lived in the study area.

RESULTS

For the first 6 months of wastewater ES, we observed a higher prevalence of S. Typhi in MS compared to GS [100/240 (42%; 95% Confidence Interval [CI]: 34-50% vs. 24/240 (10%; 95% CI: 6-16%)]; p-value < 0.001]. Overall, the detection of S. Typhi throughout the study period based on MS was 42.1% (202/480; 95% CI: 35-50%). The prevalence of S. Typhi in blood culture surveillance was 0.21% [12/5,576; 95% CI: 0.12-0.38%]. Precipitation (1.1 (95% CI: 1.02-1.10) and number of wet days (2.0 (95%CI: 1.40-2.88) were positively associated with an increased odds of S. Typhi detection in MS and GS.

CONCLUSION

Generally the proportion of S.Typhi detections in wastewater samples was less than blood culture-based detections. Limited detection of confirmed typhoid fever cases at the local hospital may reflect healthcare seeking behaviours, access as well as early treatment with over-the-counter antibiotics. Further work is required to confirm these qPCR detections with amplicon sequencing methods. Strategies also needs to be developed for integration of ES into public health decision making for the prevention of typhoid fever.

A review of the environmental spread of Salmonella enterica serovars through water in Africa

Salmonella is an enteric pathogenic bacterium in mammals that thrives in sewage, soil, and aquatic environments because of its wide ecological adaptability. The spread of Salmonella infection is associated with a lack of clean water, poor hygiene, and poor sanitation in developing countries. However, the input of Salmonella-contaminated surface water and groundwater in the environmental dissemination of antimicrobial-resistant Salmonella is obscure outside developed countries. This study aimed to assess literature that described Salmonella from groundwater, surface water, and treated water in Africa and profiled the bacteria for antimicrobial resistance (AMR). We seek to highlight the pitfalls in S. enterica identification schemes and determine the entry routes of S. enterica into surface water and groundwater to comprehend the spread patterns of S. enterica through the water ecosystem. Salmonella was frequently recovered not only from groundwater but also from unprotected springs and river water in Africa. However, the insufficiency of standard methods limited the speciation of the bacteria and only a few studies determined the isolates' AMR patterns. Integrating the Salmonella surveillance in environmental and treated water into the global Salmonella surveillance can assist in controlling typhoid fever spread and generally reduce the burden of waterborne infections in Africa.

Carbapenems: The Final Line of Defense in Typhoid Fever Treatment at Hayatabad Medical Complex, Peshawar

INTRODUCTION

Typhoid fever, caused by Salmonella enterica serovar Typhi, remains a significant public health issue, particularly in low-income countries with inadequate sanitation. The rise of extensively drug-resistant (XDR) strains of Salmonella Typhi has led to a growing reliance on carbapenems as the final line of defense. This study aims to evaluate the effectiveness of carbapenems in treating multidrug-resistant (MDR) and XDR typhoid at Hayatabad Medical Complex, Peshawar.

OBJECTIVE

This study aims to assess the efficacy of carbapenems in treating MDR and XDR typhoid fever and identify alternative therapeutic strategies.

METHODOLOGY

A retrospective cohort study was conducted at Hayatabad Medical Complex from January to June 2024. A total of 501 patients with confirmed typhoid fever were included. Data on demographics, drug sensitivity, and resistance patterns were extracted from the hospital's Health Management Information System (HMIS) and analyzed using IBM SPSS Statistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York). Statistical significance was set at p < 0.05.

RESULTS

Among 501 patients, 299 (59.7%) were male, with a mean age of 23.84 ± 0.24 years. MDR was observed in 106 (36%) patients, while XDR and carbapenem resistance were present in only three (0.6%) cases. Imipenem demonstrated a high sensitivity of 466 (93%), while meropenem had 380 (75.8%) sensitivity with no resistance. Non-carbapenem antibiotics, such as polymyxin 468 (93.4%) sensitivity and colistin 446 (89%) sensitivity, exhibited higher efficacy than carbapenems. Alarmingly, cephalosporins such as cefepime exhibited 454 (91%) resistance. Resistance to carbapenems was rare, affecting only three (0.6%) patients.

CONCLUSION

Carbapenems remain highly effective against MDR and XDR typhoid, but non-carbapenem options such as polymyxin and colistin offer viable alternatives in reducing carbapenem dependence. Enhanced antimicrobial stewardship is critical to preserving these last-resort treatments.

The global burden of enteric fever, 2017-2021: a systematic analysis from the global burden of disease study 2021

Background

Enteric fever is a major public health challenge in developing countries. We conducted a systematic analysis from the Global Burden of Diseases 2021 Study to provide updated estimates of enteric fever's burden.

Methods

We presented estimates for incident cases and deaths, age-standardized incidence and mortality rates, years of life lost (YLLs), and case-fatality rates spanning the study period of 2017-2021, stratified by region, country, socio-demographic index (SDI), and age group. Random-effects Poisson regression for longitudinal data was used to estimate the association between SDI and case-fatality rates, adjusting for antimicrobial resistance patterns.

Findings

In 2021, there were 9.3 million global cases of enteric fever (95% uncertainty interval: 7.3-11.9) and 107.5 thousand deaths (56.1-180.8). The age-standardized incidence rate decreased from 152/100,000 person-years (118-195) in 2017 to 128/100,000 person-years (100-163) in 2021, and the mortality rate decreased from 1.87/100,000 person-years (0.95-3.18) to 1.50/100,000 person-years (0.78-2.54). There were wide geographical differences, with South Asia contributing the most cases and deaths. Age-standardized incidence exceeded the threshold for "high burden" of enteric fever (100/100,000 person-years) in 23 countries in 2021.Children under five accounted for 40% of deaths and 47% of YLLs, with incidence and mortality peaking during the second year. Case-fatality was highest in low SDI countries and showed a global trend toward reduction, except among children aged 1-4 years. After adjusting for the prevalence of multidrug resistance, fluoroquinolone non-susceptibility, and third-generation cephalosporin resistance, a higher SDI was associated with a lower case-fatality rate, with a 1.1% (0.7-1.7) reduction for each percentage point increase in SDI.

Interpretation

Despite notable improvements, several countries still showed a high burden of enteric fever, which remains a significant global health concern, especially among children under five. Although enhancing water and sanitation systems is crucial, the most significant reductions in the global disease burden are likely to be achieved through broader vaccine coverage. This includes the use of typhoid conjugate vaccines, which are effective in infants and young children and offer extended protection, along with improved data collection and surveillance to guide vaccine distribution efforts across high-incidence areas.

Funding

This work was partially supported by "Ricerca Corrente" funding from Italian Ministry of Health to IRCCSHumanitas Research Hospital.

Coulborn R, Ahuka-Mundeke S. Evaluation of centralised and decentralised models of care during the 2020 Ebola Virus Disease outbreak in Equateur Province, Democratic Republic of the Congo: A brief report

Background

Traditionally in the Democratic Republic of the Congo (DRC), centralised Ebola treatment centres (ETCs) have been set exclusively for Ebola virus disease (EVD) case management during outbreaks. During the 2020 EVD outbreak in DRC's Equateur Province, existing health centres were equipped as decentralised treatment centres (DTC) to improve access for patients with suspected EVD. Between ETCs and DTCs, we compared the time from symptom onset to admission and diagnosis among patients with suspected EVD.

Methods

This was a cohort study based on analysis of a line-list containing demographic and clinical information of patients with suspected EVD admitted to any EVD health facility during the outbreak.

Results

Of 2359 patients with suspected EVD, 363 (15%) were first admitted to a DTC. Of 1996 EVD-suspected patients initially admitted to an ETC, 72 (4%) were confirmed as EVD-positive. Of 363 EVD-suspected patients initially admitted to a DTC, 6 (2%) were confirmed and managed as EVD-positive in the DTC. Among all EVD-suspected patients, the median (interquartile range) duration between symptom onset and admission was 2 (1-4) days in a DTC compared to 4 (2-7) days in an ETC (p<0.001). Similarly, time from symptom onset to admission was significantly shorter among EVD-suspected patients ultimately diagnosed as EVD-negative.

Conclusions

Since <5% of the EVD-suspected patients admitted were eventually diagnosed with EVD, there is a need for better screening to optimise resource utilization and outbreak control. Only one in seven EVD-suspected patients were admitted to a DTC first, as the DTCs were piloted in a limited and phased manner. However, there is a case to be made for considering decentralized care especially in remote and hard-to-reach areas in places like the DRC to facilitate early access to care, contain viral shedding by patients with EVD and ensure no disrupted provision of non-EVD services.