nursing case study on typhoid fever

Typhoid Fever

Typhoid fever , which remains a global health problem, is common in developing countries where there is overpopulation and poor sanitary condition. Typically if detected early, it can be successfully managed with antibiotics but if untreated, this illness can be fatal.

In this study guide , you’ll learn all about typhoid fever including its transmission, symptoms, management, and nursing interventions .

Table of Contents

What is typhoid fever, pathophysiology, statistics and incidences, clinical manifestations, assessment and diagnostic findings, pharmacological management, nursing assessment, nursing diagnosis, nursing care planning and goals, nursing interventions, documentation guidelines.

The name Salmonella typhi is derived from the ancient Greek typhos, an ethereal smoke or cloud that was believed to cause disease and madness.

• Typhoid fever , also known as enteric fever , is a potentially fatal multisystemic illness caused primarily by Salmonella enterica serotype typhi and, to a lesser extent, Salmonella enterica serotypes paratyphi A, B, and C.
• Typhoid fever has a wide variety of presentations that range from an overwhelming multisystemic illness to relatively minor cases of diarrhea with low-grade fever.
• It may have responsible for the Great Plague of Athens at the end of the Peloponnesian War.
• Untreated typhoid fever may progress to delirium , obtundation, intestinal hemorrhage , bowel perforation, and death within 1 month of onset.

All pathogenic Salmonella species, when present in the gut are engulfed by phagocytic cells, which then pass them through the mucosa and present them to the macrophages in the lamina propria.

• Salmonella typhi and paratyphi enter the host’s system primarily through the distal ileum.
• They have specialized fimbriae that adhere to the epithelium over clusters of lymphoid tissue in the ileum (Peyer patches), the main relay point for macrophages traveling from the gut into the lymphatic system.
• Typhoidal salmonella co-opt the macrophages’ cellular machinery for their own reproduction as they are carried through the mesenteric lymph nodes to the thoracic duct and the lymphatics and then through to the reticuloendothelial tissues of the liver , spleen , bone marrow, and lymph nodes .
• Once there, they pause and continue to multiply until some critical density is reached; afterward, the bacteria induce macrophage apoptosis, breaking out into the bloodstream to invade the rest of the body.
• The bacteria then infect the gallbladder via either bacteremia or direct extension of infected bile ; the result is that the organism re-enters the gastrointestinal tract in the bile and reinfects Peyer patches.
• Bacteria that do not reinfect the host are typically shed in the stool and are then available to infect other hosts.

Typhoid fever is commonly acquired through an ingestion of food or water contaminated by the urine or feces of infected carriers. While a typhoidal salmonella have no nonhuman vectors.

• Contaminated food. Paratyphi is more commonly transmitted in food from street vendors; it is believed that some such foods provide a friendly environment for the microbe.
• Migration. Paratyphi is more common among newcomers to urban areas, probably because  they tend to be immunologically naive to it; also, travellers get little or no protection against paratyphi fro the current typhoid vaccines, all of which target typhi.
• Decreased stomach pH. Typhoidal salmonella are able to survive a stomach pH as low as 1.5; antacids, histamine-2 receptor antagonists (H2 blockers), proton pump inhibitors, gastrectomy, and achlorhydria decrease stomach acidity and faciltate S typhi infection .
• Poor hygiene . As the middle class in south Asia grows, some hospitals there are seeing a large number of typhoid fever cases among relatively well-off university students who live in group households with poor hygiene .

Since 1900, improved sanitation and successful antibiotic treatment have steadily decreased the incidence of typhoid fever in the United States.

• Typhoid fever occurs worldwide, primarily in developing nations whose sanitary conditions are poor.
• Typhoid fever is endemic in Asia, Africa, Latin America, the Caribbean, and Oceania, but 80% of cases come from Bangladesh, China , India, Indonesia, Laos, Nepal, Pakistan, or Vietnam.
• Typhoid fever infects roughly 21.6 million people and kills an estimated 200, 000 people every year.
• Treated, it has few long-term sequelae and a 0.2% risk of mortality.
• Untreated typhoid fever is a life-threatening illness of several weeks’ duration with long-term morbidity often involving the central nervous system .
• Fifty-four percent of typhoid fever cases in the United States reported between 1999 and 2006 involved males.
• Most documented typhoid fever cases involve school-aged children and young adults.

Clinical syndromes associated with Salmonella typhi and paratyphi are indistinguishable. The following are the signs and symptoms of typhoid fever: 

• Fever. The fever pattern is stepwise, characterized by a rising temperature over the course of each day that drops by the subsequent morning; the peaks and troughs rise progressively over time.
• Gastrointestinal symptoms. Over the course of the first week of illness, the notorious gastrointestinal manifestations of the disease develop; these include diffuse abdominal pain and tenderness and, in some cases, fierce colicky right upper quadrant pain .
• Rose spots. The patient develop rose spots, which are salmon-colored, blanching, truncal, maculopapules usually 1-4 cm wide and fewer than 5 in number; these generally resolve within 2-5 days.
• Abdominal distention. The abdomen becomes distended, and soft splenomegaly is common; on the third week, abdominal distention is severe.
• Pea soup diarrhea . Some patients experience foul, green-yellow, liquid diarrhea .

The diagnosis of typhoid fever is primarily clinical.

• Culture. The criterion standard of typhoid fever has long been culture isolation of the organism; cultures are widely considered 100% specific.
• Polymerase chain reaction. PCR has been used for the diagnosis of typhoid fever with varying success.
• Radiography. Radiography of the kidneys, ureters , and bladder is useful if bowel perforation is suspected.
• CT scanning and MRI. These studies may be warranted to investigate for abscesses in the liver or bones , among other sites.
• Bone marrow aspiration . The most sensitive method of isolating S typhi is BMA culture.
• Histologic findings. The hallmark histologic finding in typohid fever is infiltration of tissues by macrophages that contain bacteria, erythrocytes , and degenerated lymphocytes .

Medical Management

Treatment for typhoid fever should not be delayed for confirmatory tests since prompt treatment drastically reduces the risk of complications and fatalities.

• Medical care. If a patient presents with unexplained symptoms described above within 60 days of returning from an typhoid fever endemic area or following consumption of food prepared by an individual who is known to carry typhoid, broad-spectrum empiric antibiotics should be started immediately.
• Surgical care. Surgery is usually indicated in cases of intestinal perforation; if antibiotic treatment fails to eradicate the hepatobiliary carriage, the gallbladder should be resected.
• Diet. Fluids and electrolytes should be monitored and replaced diligently; oral nutrition with a soft digestible diet is preferable in the absence of abdominal distention or ileus.
• Activity. No specific limitation on activity are indicated for patients with typhoid fever; as with most systemic diseases, rest is helpful, but mobility should be maintained if tolerable.

Definitive treatment of typhoid fever is based on susceptibility.

• Antibiotics. Until susceptibilities are determined, antibiotics should be empiric, for which there are various recommendations.
• Corticosteroids. Dexamethasone may decrease the likelihood of mortality in severe typhoid fever cases complicated by delirium , obtundation, stupor, coma, or shock if bacterial meningitis has been definitely ruled out by cerebrospinal fluid studies.

Nursing Management

Nursing management of a patient with typhoid fever include the following:

Assessment of a patient with typhoid fever include:

• History. Assess the patient’s history of travel, if any; a severe, nonspecific febrile illness in a patient who has been exposed to typhoidal salmonella should always raise the diagnostic possibility of typhoid fever.
• Physical exam. The clinical presentation of typhoid fever varies from a mild illness with low grade fever, headache, fatigue , malaise, loss of appetite, cough , constipation and skin rash or rose spots to in some cases, a fatal complications such as intestinal perforations, gastrointestinal hemorrhages, encephalitis and cranial neuritis

Based on the assessment data, the major nursing diagnosis for typhoid fever are:

• Risk for fluid volume deficit related to less intake, nausea , vomiting , and diarrhea. 
• Imbalanced nutrition : less than body requirements related to less intake due to nausea, vomiting , anorexia or diarrhea related to excessive output.
• Acute pain related to inflammation of the small intestine .
• Activity intolerance related to mandatory bed rest .
• Hyperthermia related to increase in metabolic rate.

The major nursing care planning goals for typhoid fever:

• To maintain a normal fluid volume.
• To improve intake of nutritional requirements.
• To reduce or diminish pain .
• To resume ADLs.
• To maintain a normal body temperature.

The following are the nursing interventions for a patient with typhoid fever:

• Provide assistance for ADLs. Provide assistance to meet their daily needs; involve the family in the fulfillment of ADL; and explain the purpose of bed rest to prevent complications and speed up the healing process.
• Encourage increase in fluid intake. Monitor the status of hydration as needed; monitor the fluid intake daily; encourage an increase in fluid intake; and collaborate with other medical team for IV fluid administration.
• Improve nutritional intake. Monitor the amount of caloric intake; monitor weight loss ; provide a comfortable environment during meals; and encourage an increase in protein and vitamin C intake to meet nutritional needs.
• Reduce or diminish pain . Assess the level of pain, location, duration, intensity, and characteristics; provide warm compresses on areas with pain; and administer analgesics as prescribed.
• Improve body temperature. Monitor patient temperature degree and patterns; observe for chills and profuse diaphoresis; provide tepid sponge baths and avoid the use of ice water and alcohol; and administer antipyretics as prescribed.

Nursing goals for typhoid fever are met as evidenced by:

• Patient was able to maintain a normal fluid volume.
• Patient was able to improve intake of nutritional requirements.
• Patient was able to reduce or diminish pain.
• Patient was able to resume ADLs.
• Patient was able to maintain a normal body temperature.

Documentation in a patient with typhoid fever include:

• Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
• Cultural and religious beliefs, and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.

Sources and references for this study guide for typhoid fever:

• Black, J. M., & Hawks, J. H. (2005).  Medical- surgical nursing . Elsevier Saunders,. [ Link ]
• Kimberlin, D. W. (2018).  Red Book: 2018-2021 report of the committee on infectious diseases  (No. Ed. 31). American academy of pediatrics.
• Willis, L. (2019).  Professional guide to diseases . Lippincott Williams & Wilkins. [ Link ]

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Typhoid Fever Nursing Diagnosis and Nursing Care Plan

Last updated on December 31st, 2022 at 11:50 am

Typhoid Fever Nursing Care Plans Diagnosis and Interventions

Typhoid fever or enteric fever is a systemic illness that is potentially fatal due to a multisystemic infection. The bacteria are shed through an infected individual’s urine or feces passed on after drinking or eating contaminated food or drink then spread quickly into the bloodstream causing an infection.

Signs and Symptoms of Typhoid Fever

Typhoid fever can develop suddenly or very gradually causing the following symptoms lasting for weeks:

Causes of Typhoid Fever

Risk factors to typhoid fever, complications of typhoid fever.

Typhoid fever can be a very serious medical condition and should require adequate treatment to prevent complications such as:

Diagnosis of Typhoid Fever

Treatment for typhoid fever, prevention for typhoid fever.

These precautions can be done to reduce the risk and prevent acquiring typhoid fever.

Nursing Diagnosis for Typhoid Fever

Typhoid fever nursing care plan 1.

Desired Outcomes:

Typhoid Fever Nursing Care Plan 2

Typhoid Fever Nursing Care Plan 3

Desired Outcomes :

Typhoid Fever Nursing Care Plan 4

Typhoid Fever Nursing Care Plan 5

Nursing References

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020).  Medical-surgical nursing: Concepts for interprofessional collaborative care . St. Louis, MO: Elsevier.  Buy on Amazon

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A Look Back: Nursing Care of Typhoid Fever

The pivotal role of nurses at the children’s hospital of philadelphia between 1895 and 1910: how the past informs the present..

Walton, Mary K. MSN, RN; Connolly, Cynthia A. PhD, RN

Mary K. Walton is manager for nursing practice–informatics, translational nursing research, Hospital of the University of Pennsylvania, Philadelphia. Cynthia A. Connolly is an assistant professor, Yale University School of Nursing, and an assistant professor, History of Medicine and Science, Yale University, New Haven, CT. Contact author, Mary Walton: [email protected] .

Research on nurses’ work at Children’s Hospital of Philadelphia in the late 19th and early 20th centuries shows that nurses were crucial in the treatment of pediatric victims of the typhoid fever epidemics.

“It is the real test of a nurse whether she can nurse a sick infant.” —Florence Nightingale 1

It was not until 1895—the year the Children’s Hospital of Philadelphia opened its Ingersoll Training School for Nurses—that the hospital began accepting infants onto its wards. Before that year, they weren’t admitted because of the frequent severity of their illnesses and consequent rapid decline.

In changing hospital policy, did the board of directors assume that the presence of skilled nurses would reduce morbidity and mortality in this population? It’s reasonable to assume so.

Yet such strong reliance on nurses as professionals in those early days seems to surprise many (at least many outside of nursing). In fact, in our research on nurses at Children’s Hospital of Philadelphia in the late 19th and early 20th centuries, we uncovered strong evidence that, in fact, nurses both practiced independently and worked collaboratively with physicians. Using data from the annual reports of the hospital and other primary and secondary sources from the years between 1895 and 1910, we examined the nursing care of patients with typhoid fever (a disease we chose because of its prevalence at that time and the attention it received in the nursing and medical literature). We found that it was nurses who saved lives.

Then, as now, expert nursing care and collaboration with medical colleagues ensured optimal outcomes. A better understanding of the historic importance of the professional bedside nurse may improve our ability to attract and retain nurses—so important today. By achieving this, we may be able to improve the practice environment and, ultimately, patient care.

TYPHOID FEVER AND A NEW UNDERSTANDING OF DISEASE

In the 1870s and 1880s the work of Robert Koch, Louis Pasteur, Joseph Lister, and others forged the germ theory of disease causation. Previously, the causes of illnesses were considered moral and theological concerns. Those who were mentally ill were regarded often as possessed by demons. Those who were sick and couldn’t work were thought to be so afflicted because of poor hygiene or immorality. But germ theory took the discussion of the origins of disease into the laboratory, where causative agents for specific diseases were discovered. Between 1880 and 1890 the organisms responsible for typhoid fever, leprosy, malaria, tuberculosis, cholera, and diphtheria were identified, as well as those for a host of other conditions. 2 While these discoveries opened new diagnostic vistas and spurred advances such as surgical gloves and sterilization, they had yet to provide new therapies for infectious diseases.

Typhoid fever, an acute, life-threatening bacterial illness contracted by ingesting contaminated water or food, was one of the most serious health problems in 19th-century America. In the 1890s water and food were often impure but it would be two generations before antibiotic cures were discovered.

As a result of Philadelphia’s unfiltered water supply, the city experienced three typhoid fever epidemics between 1895 and 1910. 3 According to annual reports of the hospital’s board of managers from 1895 to 1910, more than 1,200 children diagnosed with typhoid fever were admitted to Children’s Hospital of Philadelphia during those 15 years. In one year alone, the disease killed more Philadelphians under the age of 16 than any other serious childhood threat of the time, including diphtheria, croup, and scarlet fever. Between 1902 and 1904 at Children’s Hospital of Philadelphia, 8% of patients with typhoid died. 4 This was not surprising; in 1897 renowned New York professor and pediatrician L. Emmett Holt had described medical care for typhoid fever in the United States as involving “very little active treatment,” meaning there were few drug remedies and no substantiated medical or surgical cures. 5

NURSING CARE OF TYPHOID FEVER

Children with typhoid fever experienced sustained high fever, nausea, vomiting, diarrhea, weakness, and steady weight loss. Many became severely emaciated and dehydrated; they often suffered delirium at night or were semistuporous for weeks at a time. Because nurses were always present, they were able to respond to the children’s urgent needs. In addition, an examination of the elements of care of pediatric typhoid fever shows that nurses’ observations and judgments probably influenced many of the physicians’ decisions.

Managing care.

Treatment centered on rest, rehydration, and the disinfection of bodily discharges. Care plans were managed by nurses who oversaw the sequence and timing of feeding, bathing, and skin care, which were organized with consideration of the child’s sleeping-and-waking pattern, as well as food and bathing preferences. Ameliorating symptoms of fever, diarrhea, and vomiting was necessary, as was limiting the children’s physical activity. Nurses provided all the care and comfort the sick children required, as parents were usually not present at the bedside.

A liquid diet was a treatment mainstay during and immediately following the febrile period. Encouraging oral intake to a weak and feverish child presented (then, as now) one of the most difficult nursing challenges—one even physicians acknowledged. For example, one physician observed that in a direly sick child, even the “most gentle handling” of a nurse drawing a child’s cheeks together so that the feeding would not run out of the mouth could result in traumatic bruising. 6

Norms for child growth and development had not yet been established. Yet rudimentary recognition of the need to track and display weight changes is evident in charts published in Diseases of Children for Nurses, written by Robert S. McCombs, a physician at the Children’s Hospital. 7 This book included not just a physician-designed infant-weight chart but also a nurse-designed chart that measured weight in ounces instead of pounds and required monitoring of weight changes in days rather than months. It’s important to note that a nurse conceived the idea of tracking weight in small increments over time, which also provided evidence that nurses and physicians worked together.

Nurses also needed to know when to reinitiate solid foods, which, if given too early, increased the risk of intestinal perforation at the site of the aggregated lymphoid nodules of the small intestine, lesions that sometimes appeared in patients with typhoid fever. Although rare (seen in only 1% of patients), intestinal perforation was typically fatal because no treatment existed. 8 But once children began to feel better, they began to clamor for food. And because the nurse made detailed observations of patients, it was invariably her job to tell the physician when a child was well enough to resume eating solid foods.

Promoting rest and maintaining absolute bed rest were crucial to recovery from typhoid fever. If a child was restless or combative during the febrile, semistuporous phase of the illness, the nurse monitored movement and instituted precautions to prevent injury caused by thrashing during a febrile seizure. Although children who were febrile, weak, or in pain didn’t need coercion to rest, nurses had to be creative in finding diversions for convalescing children that allowed for rest and recuperation.

Skin assessment and care were also important. Prolonged fever, bed rest, diarrhea, and inadequate nourishment put these patients at high risk for skin breakdown and pressure ulcers. Nurses paid scrupulous attention to washing and removing all traces of discharges, changing position frequently, maintaining smooth bed surfaces, carefully cleaning the tongue to prevent gangrenous stomatitis (typically fatal), and attending to the first signs of skin breakdown with dressings and an air cushion (an inflated ring cushion that protected skin from pressure injury) 9 —all considered crucial nursing interventions today.

Monitoring and recording temperature, providing antipyretic therapy, and assessing the response were critical nursing measures. Nurses were responsible for selecting and administering the least intrusive way to reduce fever, including graduated-temperature baths or sponging with cold water or alcohol. Nurses determined when the baths should be given, considering contraindications such as “extreme prostration” with great cardiac weakness. 10

Physician reliance on nursing expertise was made clear in a paper presented at the 1905 American Pediatric Society meeting. Written by a physician at Children’s Hospital and published in 1906 in the Archives of Pediatrics, it reported that in patients with typhoid fever, certain nurses brought about better responses to tub baths than others did. The author also mentions discussing patient status with several nurses over several shifts; these discussions confirmed the fact that improved patients’ responses were due to nursing management. 11

Observation.

Relapse was common, and complications such as intestinal hemorrhage or perforation were more likely to occur later in the course of illness. If intestinal hemorrhage occurred, the child was returned to full bed rest, and the nurse applied ice to the abdomen, elevated the foot of the bed, and administered morphine hypodermically. ( Diseases of Children for Nurses indicated that nurses implement this protocol before informing physicians.) Of course, measures to calm a child frightened by bloody rectal discharge were also essential, and it was noted that, in conjunction with medication, “delirium is controlled by a soothing voice and touch.” 12

Preventing the spread of disease.

“The subject of prophylaxis and the care of the contagious cases is the field in which the nurse is in supreme command,” McCombs wrote. “She does more for the prevention of disease and the health of the human race than any other factor in medicine.” 13

Indeed, in order to prevent the spread of typhoid fever, nursing care incorporated the principles of the new germ theory. Nurses were responsible for monitoring and educating patients, staff, and visitors on the measures required to prevent the spread of disease. In addition, environmental disinfection—removing waste from the patient care area, disinfecting bodily fluids before disposal, and cleaning everything from linens to doorknobs—was critical to infection control. Stool and vomitus, in which the contagion was known to reside, were disinfected and discarded.

Evidence of the nurses’ success in the typhoid-fever ward is found in the comments of one physician, who noted that there was little cross-contamination in the wards and that diarrhea is “rarely troublesome.” 14 This indicates that the physician had some distance from the work required on the ward. It’s our assumption that this distance was made possible by seamless nursing care.

HOW THE PAST INFORMS THE PRESENT

It’s a common mistake to underestimate the “value of good nursing,” wrote Holt in 1897. 15 Indeed, nurses’ roles in children’s health care are almost always invisible in the popular historical narratives, which often focus on institutional changes, physician practice, and new technologies. Our study highlights how such narrow vision can skew understanding of the past.

As we have shown, nurses had a primary role in the care of patients with typhoid fever, and they enjoyed valuable collaboration with physicians. In this way, the nurses at the Children’s Hospital of Philadelphia helped to develop a template upon which later principles of pediatric nursing could be created.

Today’s critical nursing shortage has resulted in national recognition of the need to attract and retain nurses to achieve good outcomes. As clinicians, educators, and researchers continue to seek understanding of practices that promote high-quality care, a look at nursing history can help change perceptions of our current situation. While this study examined only one aspect of that history, it’s reasonable to assume that many more such instances existed. t

Affirmations of Nursing in an Early-20th-Century Textbook.

I n the preface of the 1907 textbook Diseases of Children for Nurses , author Robert McCombs, a physician at the Children’s Hospital of Philadelphia, acknowledged Jennie A. Manly, medical ward head nurse, for “practically all of the points” on nursing (page 8). In addition, McCombs included in the text a form used to monitor weight that was designed by “Rena C. Fox, head nurse, Children’s Department of Philadelphia Hospital” (page13). The Manly–McCombs collaboration and the promotion of a nurse-designed chart are evidence that physicians of the era relied on the expertise of nurses.

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A Patient and Family Centered Care Study on Typhoid Fever

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• Open access
• Published: 20 December 2009

Investigation of a community outbreak of typhoid fever associated with drinking water

• Amber Farooqui 1 ,
• Adnan Khan 1 &
• Shahana U Kazmi 1  

BMC Public Health volume  9 , Article number:  476 ( 2009 ) Cite this article

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54 Citations

Metrics details

This report is about the investigation of an outbreak of typhoid fever claimed three human lives and left more than 300 people suffered within one week. The aim of this report is to draw the attention of global health community towards the areas that are still far from basic human essentialities.

A total of 250 suspected cases of typhoid fever were interviewed, out of which 100 were selected for sample collection on the basis of criteria included temperature > 38°C since the onset of outbreak, abdominal discomfort, diarrhea, vomiting and weakness. Food and water samples were also collected and analyzed microbiologically.

Inhabitants of village lived in poor and unhygienic conditions with no proper water supply or sewage disposal facilities and other basic necessities of life. They consumed water from a nearby well which was the only available source of drinking water. Epidemiological evidences revealed the gross contamination of well with dead and decaying animal bodies, their fecal material and garbage. Microbiological analysis of household and well water samples revealed the presence of heavy bacterial load with an average total aerobic count 10 6 -10 9 CFU/ml. A number of Gram positive and Gram negative bacteria including Escherichia coli, Klebsiella, Bacillus species, Staphylococcus species, Enterobacter species, and Pseudomonas aeruginosa were isolated. Lab investigations confirmed the presence of multidrug resistant strain of Salmonella enterica serovar Typhi in 100% well water, 65% household water samples and 2% food items. 22% of clinical stool samples were tested positive with Salmonella enterica serover Typhi

Conclusions

This study indicated the possible involvement of well water in outbreaks. In order to avoid such outbreaks in future, we contacted the local health authorities and urged them to immediately make arrangements for safe drinking water supply.

Peer Review reports

Salmonella is most commonly involved bacteria in gastrointestinal tract infections. Its significant involvement in human mortality and morbidity is a major health concern. In 2006, The World Health Organization (WHO) estimated incidence of 16 to 33 million typhoid fever cases globally every year, with 500,000 to 600,000 deaths and case fatality rate of between 1.5 and 3.8% [ 1 ]. With more than 80% of global cases, South Asia is the most commonly reported region for the acquisition of typhoid fever since 1996 to 2005 [ 2 ]. The rate of incidence is 110 cases/100, 000 population [ 3 ]. There are several hospital based studies carried out in Pakistan that describe high incidence rate of typhoid fever in children [ 4 , 5 ]. However hospital based data does not reflect the actual disease status in normal community. Especially in remote areas where people live under low socioeconomic conditions and without basic necessities of life such as water, food, electricity and transport, incidence rate is much higher and often associated with small disease outbreaks.

Consumption of unsafe drinking water and inadequate sanitary conditions also contribute in increased rate of typhoid fever. In remote places, people usually rely on private and unsafe drinking water reservoirs for example ground wells are frequently found in these localities and act as only reservoir of drinking water without proper quality check [ 6 ]. According to an estimate in 2003, water borne infections claim 250,000 deaths each year in Pakistan among which typhoid fever is the leading cause [ 7 ].

In addition with high frequency and easy transmission, typhoid fever outbreaks also accompany with the threat of multidrug resistance. Multidrug-resistant (MDR) strains of Salmonella; resistant to chloramphenicol, ampicillin and trimethoprim are commonly observed since two decades and responsible for numerous outbreaks [ 8 ].

This study is based on the investigation of an outbreak of typhoid fever occurred in Nek Muhammad village, situated 25 kilometer far from metropolitan city of Karachi-Pakistan. Outbreak of typhoid fever claimed three human lives and left more than 300 people infected within one week.

Epidemiological Description of Area

Nek Muhammad village is a remote area situated 25 kilometer far from borders of metropolitan city of Karachi-Pakistan. The area is not well connected to the city due to less established means of communication. Approximately 500 poor people, mostly adults between age of 20-45 years and children under 12 years of age reside in this area with very limited facilities of water, food, electricity and health care. In October 2004, an outbreak of diarrhea and vomiting with high grade fever hit this area. Onset of symptoms was rapid and infected more than 300 people within 2 days. Local people contacted Edhi Foundation- an NGO that immediately set up a medical camp to provide treatment and sent severe cases to local hospitals of Karachi. Due to severity of symptoms like over dehydration three people lost their lives within 5 days. In order to investigate the cause of outbreak, a team of microbiologists and medical professionals from Immunology and Infectious Diseases Research Lab, Microbiology, KU visited the vicinity. We discovered a well in the locality which was polluted with dead and decaying bodies of birds and amphibians, their fecal material and garbage. The well was only source of drinking water. The villagers also informed us about their attempts to clean the well 2 days before the onset of symptoms. We interviewed the patients and collected various environmental and clinical samples with the help of Edhi Foundation. The investigation was approved by the Ethical Review Board of the University of Karachi, Pakistan.

Sample collection and Inclusion Criteria

We gathered information regarding their general health problems, onset of symptoms, daily activities, education status, age and eating habits through hypothesis generating interviews. A total of 250 people were interviewed. Due to small population size, we selected 100 patients for stool sample collection who belonged to different age groups and families and met the criteria of suspected typhoid fever. Inclusion criteria included temperature > 38°C since the onset of outbreak, abdominal discomfort, diarrhea, vomiting and weakness. Attack rate was also calculated on the basis of age. Due to unwillingness of healthy subjects to participate in investigation process, we were not able to conduct case control study. Stool samples were collected in clean plastic containers. A pea sized material from each sample was also transferred to Cary-Blair transport medium. Samples were immediately transported to lab and processed within 2 hrs of collection.

A total of 10 water samples were collected from contaminated well using five different water collection buckets. Ninety well water samples, stored for different household purposes including cooking were also collected from different houses.

Laboratory Investigation of Environmental Samples

Quality assessment of water samples was performed by standard method [ 9 ]. Briefly, samples were processed to determine total aerobic bacterial count by standard Pour Plate technique. Presence of coliforms and Fecal E. coli was determined by Most Probable Number (MPN) and membrane filtration methods. In case of food items, 25 grams of each sample was weighed and transferred to sterile flask containing 100 ml of phosphate buffer saline (PBS). Samples were homogenized under aseptic conditions. Three 10-fold serial dilutions were prepared from homogenates to inoculate different culture media.

Media used for the detection of coliforms and Fecal E. coli included MacConkey's broth, 5% sheep Blood agar, Nutrient agar, MacConkey's agar and Eosin Methylene Blue agar. Bile Echlin agar was used to check the presence of fecal Streptococci. In order to find out possible involvement of Salmonella, Shigella and Campylobacter , samples were inoculated on Salmonella Shigella (SS), Xylene lactose decarboxylase (XLD) and Campylobacter selective media.

Lab Investigation of Clinical Samples

Diarrheal stool samples were analyzed microscopically for the presence of ova and parasite(s). Bacteriological analysis was performed for the detection of Salmonella, Shigella , E. coli O157: H7, Yersinia, Vibrio cholerae using MacConkey's agar, SS agar, TCBS agar and Sorbitol MacConkey's agar (Oxoid). Briefly, half pea sized samples were inoculated on culture media plates and incubated aerobically at 37°C for 48 hours. Samples collected in transport swabs were used to inoculate Campylobacter selective medium supplemented with 5% Sheep Blood followed by incubation under microaerophilic environment at 42°C for 48 to 72 hours. Transport swabs were further immersed in Selenite F broth (Oxoid).

Bacterial isolates from environmental and clinical samples were processed for identification using standard biochemical reactions such as oxidase, triple sugar iron, indole, sulfide, motility, citrate and urea hydrolysis. API20E strips (bioMerieux, Inc.) were used for further confirmation. Antibiotics susceptibility pattern was determined by standard methods [ 10 ]. Serotyping was performed to identify Salmonella strains using Specific antisera (BD).

Epidemiologic Investigation

An outbreak of typhoid fever hit remote area of Nek village in October 2004 typically after 2 days of partial cleaning of reservoir well, the only source of drinking water in the village. Well cleaning was performed only by physical means. No chemical ingredient was used. The villagers did not share any common exposure or activity such as food and travel other than well water. Epidemiological analysis of food items indicated no statistical association with outbreak. Despite of cleaning attempt, the well was found to be polluted with dead and decaying bodies of birds, their fecal material and garbage which supported our suspicion regarding its involvement in disease outbreak. As shown in figure 1 , symptoms started after 2 days of well cleaning which can be assumed as incubation period of the infection. Almost 300 people showed symptoms within 3 days post incubation period. In order to control the infection, 500 mg of Ciprofloxacin was given per oral 12 hourly as antimicrobial regime. In case of children less than 12 years of age, 10 mg of drug/kg of body weight was given 12 hourly. Treatment was initiated with intravenous infusion in case of severely ill patients. Although, treatment measures were initiated after 2 days of disease onset, symptoms persisted for more than one week in most of individuals and claimed 3 human lives. Among the patients interviewed, 91% reported fever, 65% diarrhea, 98% weakness, and 42% vomiting and other symptoms as listed in table 1 . Analysis of attack rate indicated the involvement of different age groups ranged from 6 months to 60 years as shown in table 2 .

Percent of typhoid patients showing symptoms during the outbreak . (n = 300)

Lab Investigation of Environmental samples

Water samples tested positive for total coliforms and other fecal indicators. Total viable bacterial count ranged from 10 6 -10 9 CFU/ml of water which exceeded the standard limits of untreated potable water. Total viable count was predominantly constituted with coliform bacteria, however a number of other Gram positive and Gram negative organisms were also present in addition with normal environmental flora. Microbiological analysis revealed the presence of Salmonella enterica serovar Typhi in all well water samples while 65% of household stored water tested positive. The details are listed in table 3 . Food items were loaded with environmental bacteria but no coliform was detected. Only 2% samples tested positive for Salmonella Typhi. Figure 2 illustrates the presence of a variety of bacteria in water samples for example Escherichia coli . No O157:H7 serotype and other major gastrointestinal pathogens were observed. Other bacteria included Klebsiella isolated from 65% samples, Bacillus species (82%), Staphylococcus species (45%), Enterobacter species(64%), Pseudomonas aeruginosa (85%) and others.

Rate of water samples being contaminated with various bacterial species . Samples (n = 100). CoNS = Coagulase negative Staphylococci

Salmonella enterica serovar Typhi strains were found to be resistant to first line therapeutic drugs i.e. ampicillin, chloramphenicol, co-trimoxazole/trimethoprim, however no ciprofloxacin and nalidixic acid resistance was observed. Other coliform bacteria were susceptible against a wide range of commonly used antibiotics including gentamicin, ciprofloxacin, imepenem, piperacillin/tazobactam, cefuroxime, and ceftriaxone. Ampicillin resistance was prevalent among 75% isolates.

Due to initiation of antibiotic treatment prior to sample collection, we decided to collect stool samples instead of blood culture to increase the chances of pathogen recovery. Moreover, majority of patients were not ready to participate in blood sample collection. Salmonella Typhi was isolated as sole pathogen from clinical samples. A total of 22 samples were found positive with MDR strains of Salmonella Typhi. However, the number of positive samples is under representing the actual number due to antibiotic treatment. Attack rate in different age groups was also calculated on the basis of bacteriological analysis as listed in Table 4 . The data represents the recovery of organisms from every age group which is in agreement with symptoms observed. No other significant pathogen including Shigella , E. coli O157: H7, Yersinia, Vibrio cholerae and Campylobacter was isolated from stool samples. No evidence of protozoal and parasitic involvement was observed by microscopy.

Drinking safe and healthy water is the right of every human being. Unsafe drinking water and inadequate sanitary conditions increase the risk of various public health hazards such as typhoid fever. On the basis of literature reviews and surveys, WHO estimates the involvement of diarrheal diseases in 39% of total water, sanitation and hygiene related disease burden worldwide. In Pakistan, 13.6% of total deaths are due to water sanitation and hygiene [ 11 ]. Disease magnitude is higher and unquantifiable in some remote areas where people usually rely on private water reservoirs like ground wells without any quality assessment. Most of the wells are not up to the mark of safe drinking water [ 12 , 13 ] what we observed in Nek Muhammad village.

In this study, laboratory findings, clinical symptoms and epidemiological evidences link the presence of Salmonella enterica serovar Typhi in contaminated well water with illness. We were not able to perform DNA fingerprinting of Salmonella Typhi which was required to confirm bacteriological findings. Moreover, no genotypic characterization of E. coli and detection of viral pathogens were performed due to limited funds which can be considered as main limitations of our study.

The disease is not new for the region. There are several reports regarding the prevalence of Salmonella Typhi in different geographical locations of Pakistan [ 4 , 5 ], and [ 14 ] for example in 1998, Luby et al reported the prevalence of typhoid in Karachi, resulted from high-dose exposures from multiple sources [ 15 ]. On the contrary the affected area in our study has never been reported for typhoid burden before. Involvement of MDR Salmonella Typhi strain is another health aspect to consider. Since two decades, MDR S. Typhi strains have been responsible for numerous outbreaks in several South Asian countries including Pakistan, India, and Bangladesh [ 8 ]. Rapid spread of MDR infection in small community like Nek Muhammad Village can provide a niche for the spread of antibiotic resistant strain among larger population.

Grossly contaminated and uncovered well, consumption of un-boiled water, poor sanitary and domestic hygiene conditions indicated the vulnerability of individuals. Moreover, inadequate well cleaning by local people disturbed the ecology of the natural source which increased the bio-load of well water and resulted in the addition of major diarrheal pathogens.

In order to prevent such outbreaks at global level, recently WHO introduced several household water interventions (HWST) including solar disinfection, bleach addition, boiling and use of low cost ceramic filters. The program not only benefits poor communities at individual level but will also lead to a benefit of up to US$60 for every US$ 1 invested [ 16 ]. Despite of large scale global efforts, situation cannot be easily controlled in rural areas like Nek Muhammad Village where majority of the inhabitants live in very poor economical conditions that doesn't allow them to boil or treat water. We, therefore advised them to at least filter the water through several layers of clean, fine cotton clothe before drinking till the time they get proper arrangement. Later, a local NGO transported safe drinking water tankers to the vicinity. We also contacted local health authorities to immediately set up teams to visit the suburb and educate people about proper method of well cleaning as well as make arrangements for supplying safe drinking water. The incidence was publicized in media but no foreign health watchdogs were informed formally.

Pakistan is the country of growing geographical importance in these days. Provision of good quality life is not only better for the country but also important for the world community. Although, provision of quality education and poverty alleviation programs are government priorities, it is important to keep continuous vigilance in remote areas where people still live under inhumane conditions and provide them basic necessities of life. Reach and experience of local NGOs to such areas can be very helpful to bring up strong and sustained health reforms.

Our study presented the link of contaminated well water with the outbreak of typhoid fever in a remote village which claimed three human lives and left more than 300 people suffered within one week. In order to avoid such incidences in future, we contacted the local health authorities and urged them to immediately make arrangements for safe drinking water supply.

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Acknowledgements

We would like to pay our sincere gratitude to Mr. Faisal Edhi and all team of Edhi Foundation-Pakistan who helped us to visit vicinity and managed to draw the attention of authorities and media with the intension of getting better living facilities for the villagers.

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AF: designed investigation parameters, conducted experiments, analyzed the data and wrote manuscript. AK: participated in study design, coordinated in interview process and carried out data analysis. SUK: provided material and bench space and supervised investigation process. All authors read and approved the final manuscript.

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Farooqui, A., Khan, A. & Kazmi, S.U. Investigation of a community outbreak of typhoid fever associated with drinking water. BMC Public Health 9 , 476 (2009). https://doi.org/10.1186/1471-2458-9-476

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• Stool Sample
• Typhoid Fever
• Safe Drinking Water
• Local Health Authority
• Vibrio Cholerae

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Associations of water, sanitation, and hygiene with typhoid fever in case–control studies: a systematic review and meta-analysis

• Chaelin Kim   ORCID: orcid.org/0000-0001-7720-3349 1 ,
• Gerard R. Goucher 1 ,
• Birkneh Tilahun Tadesse   ORCID: orcid.org/0000-0003-4005-8605 1 ,
• Woojoo Lee   ORCID: orcid.org/0000-0001-7447-7045 2 ,
• Kaja Abbas   ORCID: orcid.org/0000-0003-0563-1576 3 &
• Jong-Hoon Kim   ORCID: orcid.org/0000-0002-9717-4044 1  

BMC Infectious Diseases volume  23 , Article number:  562 ( 2023 ) Cite this article

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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.

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.

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.

Peer Review reports

Typhoid fever, an infection caused by Salmonella enterica serovar Typhi ( S . Typhi), is a global public health problem. An estimated 11 to 20 million typhoid fever cases including 128,000 to 161,000 deaths occur each year [ 1 , 2 , 3 , 4 ] with the majority in low- and middle-income countries (LMICs) [ 5 , 6 ]. Although several effective treatment and prevention strategies are available [ 7 ], improving water, sanitation, and hygiene (WASH) is considered key to preventing typhoid fever considering that S . Typhi is transmitted via fecally contaminated water or food [ 8 ].

Understanding the relative strengths of the association between different components of WASH and typhoid fever may lead to more cost-effective strategies for implementing various WASH components that can provide the strongest protection against typhoid fever [ 9 ]. Designing such a strategy requires a detailed understanding of the strength of the association between different components of WASH and typhoid fever.

Population levels of access to improved WASH are monitored by the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) in over 190 countries since 1990 [ 10 ]. The JMP WASH classification has three categories – drinking water, sanitation, and hygiene – and each category has service ladders indicating different levels of improvement. For instance, the drinking water category has five service ladders: safely managed, basic, limited, improved, unimproved, and surface water. JMP estimates on each of the different categories can be compared across each of the 190 countries that cover almost all of the LMICs.

Understanding the strength of the association between the levels of WASH and typhoid fever risk can create an opportunity to leverage the efforts of the JMP to better understand the risk of typhoid fever within and across countries. Although an association between typhoid fever and the levels of WASH practices is evident, the strength of this association tends to differ across studies. The systematic review and meta-analysis by Mogasale et al. [ 11 ] summarized the findings from case–control studies on the association between the levels of WASH and typhoid fever. This study focused only on the drinking water source and exposure categories of the included studies were not classified according to the JMP WASH categories. The systematic review and meta-analysis by Brockett et al. [ 12 ] included all three categories of WASH and categorized WASH exposures from case–control studies according to JMP WASH classification, but was applied in a broader level without using specific service ladders. Both studies included findings based on Widal-confirmed typhoid fever cases in addition to cases confirmed through blood culture, which may introduce bias because of the low specificity of the Widal test [ 13 ].

In this study, we aim to improve the estimates for the association between WASH exposures and typhoid fever by including new findings published since the previous review done by Brockett et al. [ 12 ], applying a rigorous risk of bias assessment, and clarifying the association between the JMP WASH categories and WASH exposures measured in case–control studies. Our study findings will be useful to infer actionable insights on the most effective ways to prevent the spread of typhoid fever and the ways to leverage the WHO/UNICEF JMP WASH data to explore the potential burden of typhoid fever.

Search strategy

We searched three databases – Web of Science, Embase, and PubMed – to find peer-reviewed articles in English. In each database, we searched using the following search terms: (“case control” OR “case–control”) AND “typhoid”. The search terms were consistent with the previous review done by Brokett et al. [ 12 ] except that we did not include “retrospective” to restrict our search to case–control studies. We restricted our search to articles published from June 2018 through Oct 2022 to identify articles that were published after the publication of Brockett et al. study [ 12 ], which included articles published between January 1990 and June 2018.

Inclusion and exclusion criteria

We developed inclusion and exclusion criteria based on the population, intervention, comparison, outcomes, and study design (PICOS) framework [ 14 ]. These predefined criteria were included in the protocol published in PROSPERO [ 15 ]. Eligible study populations encompassed populations of all ages, genders, and socioeconomic statuses living in low- and middle-income countries as defined by the World Bank [ 16 ]. Studies would be eligible for inclusion if they considered one of five WASH exposure categories, specifically: water source, water management, water treatment, sanitation, and hygiene. We excluded studies that were meant to evaluate vaccine efficacy in which the nature of interactions between WASH exposures and vaccination was not clear. Studies were considered eligible if they investigated association between typhoid fever and at least one WASH exposure using an odds ratio (OR).

WASH exposure categories

Studies varied in their WASH exposures, and we tried to systematically map the WASH exposures from included studies to the JMP WASH categories and service ladders (Table 1 ). The JMP provided service ladders for each of the three WASH categories: drinking water, sanitation, and hygiene. In addition to these three categories, we used two additional categories of water treatment and water management to delve into other important characteristics of water exposures. These two categories were also used in the previous review by Brockett et al . [ 12 ]. However, for hygiene, we aimed to utilize the JMP service ladder, which specifically focuses on handwashing practices by assessing the availability of handwashing facilities with soap and water at home. While we acknowledge the substantial role of food hygiene in typhoid infection, we did not include it in our study as we chose to follow the JMP's definition of hygiene [ 17 ].

We checked weather specific WASH exposures from included studies matched the JMP ladder definitions. If they matched one of these definitions, the exposure would be placed into the corresponding JMP ladder. For instance, basic in the JMP hygiene ladder was defined as “availability of a handwashing facility with soap and water at home”. Accordingly, we classified relevant exposures such as the use of soap for handwashing or soap available to wash hands under the basic hygiene category. We used the five WASH categories with 15 subcategories to synthesize the findings on the association between the WASH characteristics and typhoid fever.

Data extraction

We had three reviewers (CK, GG, JHK). Two reviewers assigned to each study determined the eligibility of articles in two separate phases. Any disagreements were resolved by discussion. Initially, titles and abstracts were screened to ensure that the studies used the case–control methodology, that the outcomes are typhoid cases, and that the context was in LMIC. Then, full manuscripts were read to ensure that articles met all of our PICOS criteria. Two reviewers (CK, GG) extracted data from the included studies, including author information, publication year, case/control definitions, WASH exposures, diagnostic methods, country, and effect size (odds ratio) for individual exposures. Google Sheets was used to manage the data.

Risk of bias assessment

We assessed the risk of bias of the included studies using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool [ 18 ] in seven domains: 1) confounding, 2) selection, 3) intervention classification, 4) intervention deviation, 5) missing data, 6) outcome measurement, and 7) selective reporting. Based on the assessment results in each domain, the studies were labeled as having a low, moderate, serious, or critical risk of bias. Two authors (CK, JHK) examined the risk of bias independently, and any discrepancies were resolved by discussion.

Statistical analysis

Data from studies that did not have critical risk of bias were used to generate the pooled estimates. Studies that did not use culture-confirmed cases were excluded in any data synthesis. The analyses were performed using the R statistical software (version 4.1.3). We developed a series of Bayesian random effects models using the brms package [ 19 ] to estimate the pooled ORs with 95% credible intervals (CrIs) for each exposure category with more than two studies. Random effects models were utilized as we assume that true effects may vary for each study depending on the contexts. Bayesian meta-analyses are particularly useful when the number of studies is small and enable us to use prior knowledge [ 20 ]. We assessed the possibility of publication bias through visual inspection of the funnel plots (Appendix B ). The repository for the data and software code of this study are publicly accessible at the GitHub repository [ 21 ].

Overview of included studies

The PRISMA flow diagram (Fig.  1 ) depicts the different phases of a systematic review. We identified 51, 44, and 50 articles from Web of Science, PubMed, and Embase, respectively. We obtained 101 unique articles after removing the duplicates. After reviewing the title and abstract, we excluded 89 non-eligible articles and reviewed the full-text copies of 12 studies. Following the full-text review, eight new studies were included in our review in addition to the 19 studies included in the previous review conducted by Brockett et al. [ 12 ], hence making a total of 27 studies included in our review. All extracted data from the included studies can be found in Appendix A . The newly identified studies are from the Democratic Republic of Congo, Fiji, India, Malawi, Pakistan and Uganda [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. Among the 27 included studies, 18 studies (67%) used blood culture to define cases. The included studies showed variability in terms of the WASH exposures studied and the variables controlled when estimating the association between these WASH exposures and the odds of typhoid fever (Table 2 ). After removing the studies with potentially critical risk of bias, we included 18 studies for meta-analyses.

PRISMA flow diagram. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram shows the number of articles at the different phases of identification, screening, and inclusion in the systematic review and meta-analysis

Except for six studies, which were categorized as having an overall moderate risk of bias, all other studies were classified as having an overall serious or critical risk of bias (Fig.  2 ). For the domain of confounding, 16 studies controlled for suspected confounding factors (i.e., age, sex, and socioeconomic characteristics) and were assessed as having a moderate risk of bias even though some level of confounding may still exist because of the inherent nature of the case–control study. For the domains of intervention classification, deviations from intended interventions, and the selection of the reported result, 23, 18, and 19 studies, respectively, were classified as having a moderate or low risk of bias. In addition, 13 studies were labeled as having a low risk of bias as they utilized a culture-confirmed typhoid fever diagnosis. However, 16 studies were rated as having a serious risk of bias as the case–control research design is prone to selection bias. Lastly, 13 studies did not provide adequate information to assess bias due to missing data. The figure on risk of bias assessment results broken down for each risk of bias criterion can be found in Appendix C .

Risk of bias assessment using the Cochrane ROBINS-I tool. The studies included in the systematic review were assessed for risk of bias due to 1) confounding, 2) selection, 3) intervention classification, 4) intervention deviation, 5) missing data, 6) outcome measurement, and 7) selective reporting

Meta-analyses

We performed meta-analyses for the seven categories for which there were more than two studies. Overall, the potential risk factors doubled the odds of typhoid (OR = 1.91, 95% CrI: 1.38 to 2.79), while the potential protective factors reduced the odds by half (OR = 0.51, 95% CrI: 0.38 to 0.65) (Appendix E ).

Water source

JMP definition of improved water source includes piped water, protected dug wells, tube wells, protected springs, rainwater, and packaged water. While the improved water source can be further divided using the service ladders (i.e., safely managed, basic, or limited), we used only one category of improved water source because the number of studies is small and descriptions about the exposure were not detailed enough for further classification. Three studies reported data on the improved water source [ 41 , 44 , 47 ]. The pooled estimate of the ORs of improved water source was 0.54 (95% CrI: 0.31 to 1.08) with the between-study heterogeneity (τ) of 0.29.

Drinking water from an unimproved water source (i.e., unprotected dug well or spring) or directly from surface water are risk factors for typhoid fever. Five values fitted into the surface water group. Surface water sources increased the odds of typhoid by 2.14 (95% Crl: 1.03 to 4.06) with the between-study heterogeneity (τ) of 0.35 (Fig.  3 ).

Association between water source and typhoid fever. The forest plot illustrates the association between water source and typhoid fever. Filled circles are posterior median values. Thick and thin black lines show 80% and 95% credible intervals, respectively

Water treatment

Household water treatment of any kind was included as a predicted protective factor due to prior evidence on decreasing typhoid fever burden [ 48 ]. Five studies reported information on water treatment and six exposures were classified as the water treatment group. The meta-analysis showed that any kind of household water treatment lowered the odds of typhoid by 0.54 (95% Crl = 0.36 to 0.8) with the between-study heterogeneity (τ) of 0.37. Using untreated water was a risk factor and increased the odds of typhoid fever by 1.96 (95% Crl = 1.28 to 3.27) with the between-study heterogeneity (τ) of 0.55 (Fig.  4 ).

Association between water treatment and typhoid fever. The forest plot illustrates the association between water treatment and typhoid fever. Filled circles are posterior median values. Thick and thin black lines show 80% and 95% credible intervals, respectively

Water management

Safely managed water refers to water being stored in a narrow-mouthed, closed lid to prevent contamination [ 49 ], and is considered a protective factor against water-borne diseases. In order to expand the concept of safe water management and get a broader pool of data, we considered narrow-mouthed and/or closed lids in our exposure categories. Two studies measured the association between safely managed water and typhoid fever [ 35 , 44 ]. Using metal coverage of water storage and keeping water containers covered were associated with around 80% lower odds of having typhoid fever (odds ratio [OR]: 0.22, 95% confidence interval [95% CI]: 0.1 to 0.6; OR: 0.2, 95% CI: 0.04 to 1.1) [ 3 , 4 ]. Unsafe water management, such as the use of contaminated water storage, is a risk factor, and using dirty containers to store drinking water was associated with double the odds of having typhoid fever (aOR: 1.99, 95% CI: 0.6 to 6.65) [ 32 ]. Meta-analysis was not performed in the water management category due to less than three studies.

JMP defines improved sanitation facilities as those that prevent human contact with excreta. The categories of improved sanitation facilities can be further divided into safely managed, basic, and limited categories. No exposure categories from studies could be classified into these ladder rungs. Prasad et al. [ 24 ] measured that people who were using unimproved pit latrine had nearly 50 times greater odds of having typhoid than the controls (aOR: 49.47, 95% CI: 9.42 to 259.92). On the other hand, the pooled estimate of the ORs of open defecation was 1.21 (95% Crl = 0.64 to 3.41) with the between-study heterogeneity (τ) of 0.56 (Fig.  5 ).

Association between sanitation and typhoid fever. The forest plot illustrates the association between sanitation and typhoid fever. Filled circles are posterior median values. Thick and thin black lines show 80% and 95% credible intervals, respectively

According to the JMP definitions, basic hygiene means that a handwashing facility with soap and water is available at home, and washing hands with soap is protective against diarrhea [ 48 ]. In meta-analysis, basic hygiene was associated with lower odds of typhoid (OR = 0.60, 95% Crl = 0.38 to 0.97) with the between-study heterogeneity (τ) of 0.24. Limited hygiene means that a handwashing facility is available at home without soap and/or water. Limited hygiene was associated higher odds of typhoid (OR = 2.26, 95% Crl = 1.38 to 3.64) with the between-study heterogeneity (τ) of 0.29 (Fig.  6 ).

Association between hygiene and typhoid fever. The forest plot illustrates the association between hygiene and typhoid fever. Filled circles are posterior median values. Thick and thin black lines show 80% and 95% credible intervals, respectively

We conducted a systematic review and meta-analysis of case–control studies to infer the association between water, sanitation, and hygiene (WASH) and culture-confirmed typhoid fever. Our analyses updated the previous estimates of Brockett et al. [ 12 ] by adding the data published between June 2018 and Oct 2022 in addition to those included in the previous review and conducting a more comprehensive risk of bias assessment using the ROBINS-I tool. Our pooled estimates for ORs clearly varied from existing estimates while our study confirmed that improved WASH such as treated water and basic hygiene provided substantial protection against typhoid fever and limited hygiene, using untreated water and surface water increased the odds of typhoid fever.

Our meta-analyses of the newly compiled data yielded varied quantitative inferences regarding the association between WASH and typhoid fever compared to prior meta-analyses [ 12 ] (Appendix F ), particularly in terms of pooled estimates and confidence (and credible) intervals. In terms of protective factors, improved water sources and treated water demonstrated a greater reduction in the odds of typhoid fever than previously reported, while the confidence (and credible) intervals of the new analyses encompassed the estimates from the prior analyses. On the other hand, surface water and limited hygiene were found to increase the odds of typhoid fever to a larger extent and untreated water had a smaller effect on increasing the odds of typhoid fever compared to the prior analyses [ 12 ]. This discrepancy could be attributed to variations in the included studies for conducting meta-analyses.

The details of the methods differed between our study and the previous study by Brockett et al. [ 12 ], which led to a different data set and consequently different pooled estimates for ORs. Firstly, for the risk of bias assessment, the previous study used the adapted version of the Quality Assessment Tool for Quantitative Studies [ 50 ]. On the other hand, we used the ROBINS-I tool and removed studies classified having “critical” risk of bias, which resulted in a smaller number of studies in the meta-analysis. Compared with other risk of bias assessment tools, the ROBINS-I is more systematic and comprehensive and was specifically designed to address weaknesses in other tools [ 18 ]. Secondly, We adopted the Bayesian framework as our primary analysis because it could better characterize the uncertainty of the estimates, particularly when the number of studies is small [ 20 ], and the difference between these two approaches are most noticeable in the width of confidence or credible intervals. (Appendix F ). Thirdly, the previous review [ 12 ] included studies in which typhoid fever was confirmed through the Widal test or clinical signs as well as blood culture whereas we included only studies in which typhoid fever was confirmed through blood culture. Clinical symptoms of typhoid fever are not specific enough to differentiate from other enteric diseases [ 51 ]. Also, previous literature indicated that Widal test had low sensitivity and specificity (< 80%) and did not recommend using Widal test alone when diagnosing typhoid fever [ 13 ]. Fourthly, the previous study included more than one estimate from each sample whereas we only included only one estimate from each sample to avoid violating the assumption of independent findings (i.e., unit-of-analysis error) [ 52 ]. For instance, the previous review included two estimates from Alba et al. [ 30 ], sometimes treating water before drinking (i.e., sometimes vs. always) and never treating water before drinking (i.e., never vs. always), as inputs for meta-analysis of the untreated water category. We only included one of the two estimates as the two estimates came from the same sample, and we chose the “never vs. always” exposure as we believed it better reflected the risk of untreated water. Similarly, the previous review included both crude and adjusted estimates of the same exposure from the same sample. On the other hand, we included only adjusted estimates in the meta-analysis. Also, when there are multiple exposure estimates from the same study that can be classified into the same JMP WASH category (e.g., use of soap and soap near the toilet can be classified into the hygiene category), the previous review included them in the meta-analysis together. We included only one from each study that fits the JMP definition better (i.e., soap near the toilet in this case) in the analyses. Fifthly, we utilized more detailed WASH subcategories. For instance, although the exposures, ‘washing hands before meals regularly or after using the toilet’, was included in the lack of hygiene category in the previous review, we did not include in our JMP hygiene categories as washing hands does not imply washing hands with soap, which better reflects the JMP hygiene category [ 43 ].

Our study has limitations. First, case–control studies included in our meta-analyses varied not only in terms of study place and time, but also in how potential biases were controlled. Therefore, the variances observed in the data set may overrepresent the actual variance of the association between the WASH and typhoid fever. However, the heterogeneities of the OR estimates did not appear to be very high (Appendix F ). Second, there were discrepancies across studies in how the WASH exposure data was collected even if they were included in the same JMP WASH category. Only few studies collected data through the direct observation (e.g., observation of soap availability) [ 32 , 41 , 43 ], while the majority of other studies relied on self-reporting, which is prone to recall bias. Third, various WASH indicators may be related to the habits of an individual and thus correlated with one another. This implies that some of the included studies that do not control for other WASH factors can not differentiate the impacts of different WASH components. Some studies controlled for other WASH factors [ 22 , 23 , 24 , 25 , 26 , 30 , 31 , 32 , 33 , 36 , 37 , 38 , 40 , 44 ], but we did not conduct separate analyses of these due to the small number of estimates available. While the estimates do not seem to vary much between the studies that account for other WASH factors and those that do not, future studies need to pay attention to the multicollinearity among the WASH variables. Fourth, while we used our best judgment to categorize the WASH exposures in case–control studies according to JMP categories, actual WASH exposures included in the same JMP WASH category still varied. Lastly, we only included findings from case–control studies as we were updating the previous review of case–control studies and also the majority of the data are available in the form of case–control studies. Findings from randomized controlled trials [ 53 , 54 ] and cohort studies [ 55 ] are consistent with our analyses. For example, in the clinical trial conducted in Kolkata, India, living in a better WASH environment led to 57% (95% CI: 15—78) reduction in typhoid risk [ 53 ].

There is room for future research in this area. While we classified the effect measures (odds ratio estimates) for the WASH exposures on typhoid fever from each study using the updated WASH ladder metric, we had to resort to the old JMP metric of "improved/unimproved" when conducting meta-analyses because of the small number of studies to analyze. In particular, few or no existing studies examined the association between typhoid fever and WASH exposures that can be classified as unimproved water source, safely managed sanitation, basic sanitation, limited sanitation, or no hygiene facility. Future research should further investigate the association between WASH and typhoid fever in this area once more when OR estimates become available. Our findings, when combined with population-level JMP WASH trends, may be used to understand and forecast the population-level risk of typhoid fever, which can provide essential insights for decision-makers. Since the population levels of WASH have been monitored since 1990 in 191 countries, one can also analyse the longitudinal data to explore the country-level association and longitudinal trends between the levels of WASH and typhoid fever burden.

Our study findings will be useful to infer actionable insights on the most effective ways to control typhoid fever in LMICs. For instance, our findings reinforce the previous findings that, in addition to infrastructure improvements, behavioural changes such as washing hands with soap have a significant impact on the risk of contracting typhoid fever [ 9 ]. While major infrastructural improvements are crucial to reduce the burden of typhoid fever, they require resources that are difficult to commit to in LMICs. On the other hand, behaviour interventions may be feasible, affordable, and effective options to reduce disease risk in LMICs.

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Acknowledgements

We thank Justin Im (International Vaccine Institute) and John D. Clemens (International Vaccine Institute) for their review and feedback on this article.

This work was supported, in whole or in part, by Gavi, the Vaccine Alliance, Bowdoin College, and the Bill & Melinda Gates Foundation, via the Vaccine Impact Modelling Consortium (Grant Number OPP1157270 / INV-009125). The funders were not involved in the study design, data analysis, data interpretation, and writing of the manuscript. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy, or views of their affiliated organisations.

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J-HK and CK conceptualised and designed the study. GG, CK, J-HK reviewed studies and extracted data from the included studies. CK and J-HK examined the risk of bias and conducted the meta-analyses using statistical software. CK, J-HK, and GG wrote the first draft. All authors (CK, GG, BTT, WL, KA, J-HK) contributed to interpretation of analysis and reviewing the manuscript for important intellectual content and have approved the final version.

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Kim, C., Goucher, G.R., Tadesse, B.T. et al. Associations of water, sanitation, and hygiene with typhoid fever in case–control studies: a systematic review and meta-analysis. BMC Infect Dis 23 , 562 (2023). https://doi.org/10.1186/s12879-023-08452-0

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• Typhoid fever; Water, sanitation, and hygiene (WASH)
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Malaria and typhoid fever co-infection: a retrospective analysis of University Hospital records in Nigeria

• Tubosun A. Olowolafe 1 , 2 ,
• Oluwaseyi F. Agosile 1 ,
• Adekemi O. Akinpelu 1 ,
• Nicholas Aderinto 3 ,
• Ojima Z. Wada 4 , 5 &
• David B. Olawade 6 , 7  

Malaria Journal volume  23 , Article number:  220 ( 2024 ) Cite this article

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Studies have long documented the presence of malaria and typhoid fever in sub-Saharan Africa (SSA). However, studies on these diseases have primarily concentrated on rural settings, neglecting the potential impact on urban areas. This knowledge gap hinders effective surveillance and intervention strategies. To bridge this gap, this study investigated the prevalence of malaria and typhoid co-infections in an urban environment.

This study, conducted at Lead City University Hospital in Ibadan, Nigeria (West Africa’s largest metropolis), analysed medical records of over 3195 patients seen between April and June 2023. Descriptive statistics and chi-square tests were used to understand how these co-infections were distributed across different age and gender groups.

The prevalence of co-infection peaked in May (9.7%), followed by June (8.9%) and April (5.7%). Notably, children aged 6–12 years exhibited the highest co-infection rate (18.5%), while those under five had the lowest (6.3%). Gender analysis indicated a slight difference, with 8.8% of females and 7.1% of males co-infected. Malaria prevalence was highest at the beginning of the rainy season and significantly decreased over time. Conversely, typhoid fever displayed the opposite trend, increasing with the rainy season. Children under five years old were most susceptible to malaria, while typhoid fever predominantly affected adults over 25 years old, with prevalence decreasing significantly with age.

This study sheds light on the previously overlooked risk of malaria and typhoid co-infections in urban settings. These findings highlight the need for enhanced surveillance and targeted public health interventions, particularly for vulnerable groups like young children during peak transmission seasons.

In many developing nations, notably Nigeria, malaria and typhoid fever stand as two predominant infectious diseases that substantially affect public health [ 1 ]. Typhoid fever, attributed to the bacterium Salmonella typhi , predominantly proliferates through the consumption of tainted food and water. In contrast, malaria results from the Plasmodium parasites, transmitted via bites from infected female Anopheles mosquitoes. Their endemicity is particularly evident in tropical and subtropical regions due to overlapping geographic distributions [ 2 ].

Sub-Saharan Africa bears the brunt of malaria’s prevalence, accounting for an estimated 94% of global malaria cases and fatalities [ 2 ]. The ailment poses a grave threat to vulnerable demographics, especially pregnant women and children below five years. In 2019, this paediatric age bracket constituted 67% of global malaria-induced mortalities [ 2 ]. Despite persistent mitigation efforts encompassing vector control, prompt diagnostics, and efficacious treatments, malaria persists as a debilitating challenge, causing over 600,000 deaths annually and stymying socioeconomic progression in endemic regions [ 3 ].

Concurrently, typhoid fever, afflicting between 11 and 21 million individuals globally each year, results in 128,000–161,000 fatalities [ 4 ]. Its prevalence spans vast stretches of Asia, Africa, and Latin America, exacerbated by inadequate sanitation and restricted access to potable water. Although traditionally studied in isolation, evidence suggests that typhoid and malaria can manifest concurrently within a patient, intensifying symptom severity, protracting recovery, and elevating fatality risks [ 5 , 6 ]. This co-infection poses nuanced challenges for accurate diagnosis, treatment modalities, and comprehensive management [ 7 ]. Yet, the interplay and consequent ramifications of this concurrent infection remain under-researched, with most studies adopting a siloed approach, neglecting potential interactions or co-infection outcomes [ 8 ].

In communal settings, especially universities, the co-infection of typhoid and malaria stands out as a significant health concern. The close-knit nature of student dormitories and staff quarters can heighten the risk of exposure to these infectious diseases [ 9 ]. Such co-infections can drastically impact students’ academic progression and staff productivity. However, it's crucial to recognize that university environments typically comprise a society's more educated echelon. These academic communities, being more informed, often demonstrate better adherence to preventive measures, including rigorous hand hygiene, sanitation practices, and broader health consciousness [ 10 , 11 ]. Such enhanced awareness and practices might lead to a diminished prevalence of diseases like malaria and typhoid in these populations.

Moreover, urban settings, with their concentrated resources and targeted health interventions, historically exhibit lower disease prevalence [ 12 ]. Efforts in these areas often outpace those in rural regions, further widening the rural–urban disparities in Water, Sanitation, and Hygiene (WASH) practices, especially in the studied area [ 13 , 14 ]. Given these factors, this research delves into the prevalence of malaria, typhoid, and their co-infection in an urban university hospital catering predominantly to academics and their kin. This investigation seeks not only to augment the current understanding of co-infections but also to enrich data repositories on disease prevalence in a socioeconomically advantaged segment of the community. Insights drawn from this study can guide the formulation of targeted preventive strategies, inform policy adjustments, and hone healthcare delivery, ultimately benefiting those grappling with co-infections.

Study design and data source

This retrospective analytical study, utilized patient records from the Lead City University Hospital, Ibadan. The hospital provides a secondary level of care. It is a 30-bed facility with both in-patient and out-patient services. An average number of 70 patients is seen per day by qualified medical personnel. The laboratory section of the facility is headed by a qualified medical laboratory scientist. The laboratory only processes requests from within the hospital. In the facility, malaria and typhoid tests are conducted when requested by physicians. Data were systematically collected from records of patients who visited the hospital laboratory from April to June 2023. The study encompassed a total of 2895 patient records, representing all the patients in the laboratory register during this period. The laboratory records are kept in an Excel sheet. The data extraction process prioritized key variables such as demographic details, clinical symptoms, and diagnostic results.

Data collection

Relevant data were meticulously extracted from the hospital’s laboratory records using a structured Excel spreadsheet. The extracted variables included age, sex, and diagnostic test results for malaria and typhoid. Age was categorized into brackets (≤ 5, 6–12, 13–19, 20–25, > 25 years), and sex was recorded as male or female. Diagnostic methods comprised blood fluid microscopy examination and serology tests for malaria and typhoid, respectively. Coding in the hospital records identified patients with malaria (coded as 1), typhoid (coded as 2), and co-infection (coded as 3).

Data analysis

The acquired secondary data were analyzed using IBM SPSS (Statistical Package for the Social Sciences) version 23. The analysis included presenting data through percentages, bar charts, and frequency tables to assess the prevalence and patterns of malaria and typhoid co-infections. In addition, bivariate analysis was conducted via the Chi-square test for independence and was measured at a 95% confidence interval. Statistically significant associations between the diseases surveilled and independent variables like sociodemographic characteristics and infection month were measured following all the test assumptions. This thorough analysis aimed to provide clear insights into the occurrence and distribution of these infections within the studied population.

Ethical considerations

The study adhered to the Helsinki Declaration principles. Approval was granted by the Health Research Ethics Committee (HREC) of the University and permission was obtained from the Chief Medical Director of the Lead City University Hospital. Throughout the study, stringent measures were taken to ensure compliance with ethical standards and maintain the confidentiality of patient data.

A total of 2895 patient records were extracted from the laboratory records of those who attended the Lead City Hospital and required laboratory tests done between April and June 2023. There were 32 (1.1%) children under five, 27 (0.9%) patients in the age group 6–12 years, 843 (29.1%) patients in the age group 13–19 years, 757 (26.1%) patients in the age group 20–25 years and 1236 (42.7%) patients above 25 years. There were 1028 (35.5%) patients in April, 1191 (41.1%) in May and 676 (23.4%) in June. Out of these, there were a total of 1078 (37.2%) males and 1817 (62.8%) females (Table  1 ).

As revealed in Fig.  1 , the prevalence of malaria was 50.6%, 49.9% and 44.4% in April, May, and June, respectively. For typhoid, the prevalence was highest (7.5%) in June, followed by May (4%) and April (2.4%), while the prevalence of co-infection was highest in May (9.7), then in June (8.9%) and (5.7%).

Prevalence of malaria, typhoid and co-infection by months

The age group with the highest prevalence of malaria 25 (78.1%) was children under five, while the lowest prevalence of malaria was recorded in the age group 20–25 years with a prevalence of 339 (44.8%). The result showed a significant association (Table  2 ) between the age groups and the prevalence of malaria (p = 0.002). Females were recorded to have a higher prevalence of 899 (49.5%) compared to males who had a prevalence of 515 (47.8%).

Table 3 depicts the prevalence of typhoid fever among the patients. A total of 124 patients (4.3%) were positive for typhoid fever. Males had a prevalence of 4.3%, equal to that of females, which was also 4.3%. Although, the relationship between the sexes is not statistically significant (p = 0.974). The highest prevalence, 6.1%, of typhoid fever was observed in patients in the age group > 25, while 6–12 years recorded no typhoid fever infection. The observed difference between them is statistically significant (p = 0.001). The prevalence of typhoid fever was 25 (2.4%) in April, 48 (4.0%) in May and 51 (7.5%) in June. The difference in typhoid fever prevalence was significant (p < 0.001).

The age prevalence of co-infection with malaria and typhoid fever is shown in Table  4 . The age group of 6- 12 years had the highest co-infection of 5 (18.5%), and children under five had the lowest co-infection of 2 (6.3%). However, there was no significant difference in co-infection between the age groups (p = 0.124). Similarly, about 76 (7.1%) of the males and 159 (8.8%) of the females were co-infected with malaria and typhoid fever. However, there was no significant difference (p = 0.105) between the co-infected male and female patients. Table 4 shows that the prevalence of malaria and typhoid co-infection was 59 (5.7%) in April, 116 (9.7%) in May and 60 (8.9%) in June. The difference in prevalence of co-infection in the 3 months was statistically significant (p = 0.002)

This study utilized data from a private hospital in Ibadan, Nigeria. Given the high endemicity of both malaria and typhoid fever in Nigeria, similar to other tropical and subtropical regions [ 3 , 15 , 16 ], residents are at a significant risk of contracting both diseases simultaneously. The persistence of these diseases as serious public health issues in tropical regions can be attributed to factors such as malnutrition, poor sanitation, inadequate personal hygiene, insufficient healthcare services, and lack of education [ 17 , 18 , 19 , 20 ].

The findings reveal a high overall prevalence of malaria. This prevalence is higher than that reported in a clinic-based study from Kogi State, which focused on pregnant women attending antenatal clinics [ 8 ], but lower than the 60.5% recorded among university students in Akure [ 9 ]. The differences in prevalence rates may be influenced by the varying study populations: this study’s hospital-based records likely reflect higher prevalence due to individuals seeking medical care, whereas community-based studies may include asymptomatic or mildly symptomatic individuals, potentially resulting in different prevalence rates.

This study found that females had a higher malaria prevalence, consistent with findings from Sierra Leone, where females also showed a higher prevalence [ 21 ]. This could be due to hormonal differences or pregnancy. However, this contrasts with a study from Calabar, which reported a higher prevalence in males [ 22 ]. Children under five years had the highest malaria prevalence, followed by the 6–12 age group, aligning with findings from Calabar [ 22 ]. This is contrary to the study from FUTA, Akure, which showed the highest prevalence in the 21–25 age group [ 9 ]. The high prevalence in young children is likely due to their undeveloped immunity in high transmission areas [ 23 ]. Furthermore, malaria prevalence decreased from April (50.6%) to June (44.4%), possibly due to the rainy season’s initial impact on mosquito breeding and subsequent increased prophylaxis measures as the season progressed.

The prevalence of typhoid fever in this study was lower than in studies conducted in Sierra Leone and Calabar, which reported 80.5% and 46.8%, respectively [ 21 , 22 ]. These comparisons must be contextualized, as this study is based on hospital records, while the Sierra Leone and Calabar studies might include broader community samples. The highest prevalence of typhoid fever was found in patients older than 25 years, which is lower than the 54.5% prevalence in the 31–45 age group reported in Calabar [ 22 ]. While this study speculated that the high prevalence in this age group could be linked to contaminated drinking water and poor food hygiene, this study did not collect specific data on these variables, making this assertion speculative. Gender prevalence for typhoid fever was equal in this study, contrasting with findings from Ekwulumili, Anambra State, where females had a significantly higher prevalence [ 24 ]. This highlights the need for further research to understand the gender disparities in typhoid prevalence.

Typhoid fever showed an increasing trend from April (2.4%) to June (7.5%), which could be due to the rainy season's effects on water and sanitation conditions, increasing exposure to the pathogen. The overall rate of malaria and typhoid co-infection in this study was higher than that reported in Ekpoma, Edo State [ 5 ] but lower than rates found in Aba, Nigeria, and Adamawa, Cameroon, which reported co-infection rates of 40.82% and 30.3%, respectively [ 25 , 26 ]. The highest co-infection rate was observed in the 6–12 age group, consistent with findings from Cameroon [ 25 ]. This could be due to weaker immunity and poor hygiene practices among children, including a lack of understanding of risk factors or increased exposure [ 10 , 27 , 28 ]. Similarly, the age group 1–15 years had the highest co-infection rate in Calabar [ 22 ], although their prevalence was higher than in this study. Females had a higher co-infection rate than males, which aligns with studies from Aba and Adamawa [ 25 , 26 ]. This disparity could be due to socioeconomic factors that predispose females to higher risks. The high malaria prevalence observed in April, May, and June can be attributed to the rainy season, which fosters mosquito breeding due to stagnant water [ 29 ].

This study reveals a distinct pattern of malaria and typhoid fever prevalence within an urban university community in Ibadan, Nigeria, challenging the prevailing assumption that urban areas are less susceptible to these infections. Notably, the prevalence of typhoid fever is relatively low compared to regional averages, possibly due to improved access to clean water and sanitation facilities in the urban university setting. Despite this, the significant rates of malaria and co-infection with typhoid, particularly among children, highlight substantial public health challenges. The heightened vulnerability observed in children is likely linked to their developing immune systems and possibly to socio-economic factors that exacerbate exposure to disease vectors and unsanitary conditions.

The study's findings emphasize the necessity for targeted health interventions that specifically address the needs of vulnerable populations within urban settings. Given the seasonal surge in malaria cases coinciding with the rainy months, proactive strategies to control mosquito breeding, such as environmental management and enhanced community education, should be aggressively implemented. Furthermore, the increasing trend in typhoid fever during the same period underscores the critical need for ongoing improvements in food safety and water quality. Health education campaigns must particularly target at-risk groups, educating them on preventive measures and the critical importance of seeking timely medical attention.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

World Health Organization

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Tubosun A. Olowolafe, Oluwaseyi F. Agosile & Adekemi O. Akinpelu

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Nicholas Aderinto

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Global Eco-Oasis Sustainable Initiative (GESI), Ibadan, Oyo State, Nigeria

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TAO Conceptualized the study. TAO, OEA, AOA, NA, OZW, DBO analyzed the patient data. All authors were involved in writing the first and final draft. All authors read and approved the final manuscript.

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Olowolafe, T.A., Agosile, O.F., Akinpelu, A.O. et al. Malaria and typhoid fever co-infection: a retrospective analysis of University Hospital records in Nigeria. Malar J 23 , 220 (2024). https://doi.org/10.1186/s12936-024-05052-4

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EVALUASI DRUG RELATED PROBLEM (DRPs) PADA PASIEN DEMAM TIFOID DI INSTALASI RAWAT INAP RSU ISLAM KLATEN PERIODE NOVEMBER 2021-OKTOBER 2022

• Nabilla Marisya Affifah Putri Fakultas Farmasi, Universitas Muhammadiyah Surakarta Indonesia
• Tista Ayu Fortuna Fakultas Farmasi, Universitas Muhammadiyah Surakarta Indonesia
• Ni Nyoman Yudianti Mendra Fakultas Farmasi, Universitas Mahasaraswati Denpasar Indonesia

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