Global Typhoid Fever Incidence: A Systematic Review and Meta-analysis

Abstract

Background: Contemporary incidence estimates of typhoid fever are needed to guide policy decisions and control measures and to improve future epidemiological studies.

Methods: We systematically reviewed 3 databases (Ovid Medline, PubMed, and Scopus) without restriction on age, country, language, or time for studies reporting the incidence of blood culture-confirmed typhoid fever. Outbreak, travel-associated, and passive government surveillance reports were excluded. We performed a meta-analysis using a random-effects model to calculate estimates of pooled incidence, stratifying by studies that reported the incidence of typhoid fever and those that estimated incidence by using multipliers.

Results: Thirty-three studies were included in the analysis. There were 26 study sites from 16 countries reporting typhoid cases from population-based incidence studies, and 17 sites in 9 countries used multipliers to account for underascertainment in sentinel surveillance data. We identified Africa and Asia as regions with studies showing high typhoid incidence while noting considerable variation of typhoid incidence in time and place, including in consecutive years at the same location. Overall, more recent studies reported lower typhoid incidence compared to years prior to 2000. We identified variation in the criteria for collecting a blood culture, and among multiplier studies we identified a lack of a standardization for the types of multipliers being used to estimate incidence.

Conclusions: Typhoid fever incidence remains high at many sites. Additional and more accurate typhoid incidence studies are needed to support country decisions about typhoid conjugate vaccine adoption. Standardization of multiplier types applied in multiplier studies is recommended.

Keywords: Salmonella enterica serovar Typhi; incidence studies; meta-analysis; systematic review; typhoid fever.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of search strategy and selection of articles, systematic review and meta-analysis of global typhoid incidence, 1946–2018.

Figure 2.

Typhoid incidence estimates among population-based studies in Asia, 1954–2018. Gray shading indicates 100–500 per 100 000 per year. Abbreviation: CI, confidence interval.

Figure 3.

Typhoid incidence estimates among population-based studies in Africa, 1954–2018. Gray shading indicates 100–500 per 100 000 per year. Abbreviation: CI, confidence interval.

Figure 4.

Typhoid incidence estimates among multiplier studies in Africa, 1954–2018. Gray shading indicates 100–500 per 100 000 per year. Abbreviation: CI, confidence interval.