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. 2023 Jun 2;10(Suppl 1):S67-S73.
doi: 10.1093/ofid/ofad138. eCollection 2023 May.

Characterization of Typhoid Intestinal Perforation in Africa: Results From the Severe Typhoid Fever Surveillance in Africa Program

Megan Birkhold  1 , Shrimati Datta  1 , Gi Deok Pak  2 , Justin Im  2 , Olakayode O Ogundoyin  3 , Dare I Olulana  3 , Taiwo A Lawal  3 , Oludolapo O Afuwape  4 , Aderemi Kehinde  5 , Marie-France Phoba  6 , Gaëlle Nkoji  6 , Abraham Aseffa  7 , Mekonnen Teferi  7 , Biruk Yeshitela  7 , Oluwafemi Popoola  8 , Michael Owusu  9 , Lady Rosny Wandji Nana  10 , Enoch G Cakpo  10 , Moussa Ouedraogo  11 , Edgar Ouangre  12 , Isso Ouedraogo  13 , Anne-Sophie Heroes  14   15 , Jan Jacobs  14   15 , Ondari D Mogeni  2 , Andrea Haselbeck  2 , Leah Sukri  1 , Kathleen M Neuzil  1 , Octavie Lunguya Metila  6   16 , Ellis Owusu-Dabo  9 , Yaw Adu-Sarkodie  9 , Abdramane Soura Bassiahi  10 , Raphaël Rakotozandrindrainy  17 , Iruka N Okeke  18 , Raphaël M Zellweger  2 , Florian Marks  2   19   20   21
Affiliations

Characterization of Typhoid Intestinal Perforation in Africa: Results From the Severe Typhoid Fever Surveillance in Africa Program

Megan Birkhold et al. Open Forum Infect Dis. .

Erratum in

Abstract

Background: Typhoid intestinal perforation (TIP) remains the most serious complication of typhoid fever. In many countries, the diagnosis of TIP relies on intraoperative identification, as blood culture and pathology capacity remain limited. As a result, many cases of TIP may not be reported as typhoid. This study demonstrates the burden of TIP in sites in Burkina Faso, Democratic Republic of Congo (DRC), Ethiopia, Ghana, Madagascar, and Nigeria.

Methods: Patients with clinical suspicion of nontraumatic intestinal perforation were enrolled and demographic details, clinical findings, surgical records, blood cultures, tissue biopsies, and peritoneal fluid were collected. Participants were then classified as having confirmed TIP, probable TIP, possible TIP, or clinical intestinal perforation based on surgical descriptions and cultures.

Results: A total of 608 participants were investigated for nontraumatic intestinal perforation; 214 (35%) participants had surgically-confirmed TIP and 33 participants (5%) had culture-confirmed typhoid. The overall proportion of blood or surgical site Salmonella enterica subspecies enterica serovar Typhi positivity in surgically verified TIP cases was 10.3%. TIP was high in children aged 5-14 years in DRC, Ghana, and Nigeria. We provide evidence for correlation between monthly case counts of S. Typhi and the occurrence of intestinal perforation.

Conclusions: Low S. Typhi culture positivity rates, as well as a lack of blood and tissue culture capability in many regions where typhoid remains endemic, significantly underestimate the true burden of typhoid fever. The occurrence of TIP may indicate underlying typhoid burden, particularly in countries with limited culture capability.

Keywords: Africa; Salmonella Typhi; intestinal perforation; severe typhoid; typhoid fever.

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Conflict of interest statement

Potential conflicts of interest. All authors: No reported conflicts.

Figures

Figure 1.
Figure 1.
Study schematic and summary classification of typhoid intestinal perforations (inset). *Intestinal perforation confirmed during surgery or surgical evidence of a perforation or description including typhoid perforation, ileal perforation, and/or antimesenteric. Abbreviations: IP, intestinal perforation; SETA, Severe Typhoid in Africa Program; TIP, typhoid intestinal perforation.
Figure 2.
Figure 2.
Number of cases by age and sex. A–F, For each country, top panel shows the number of cases and bottom panel shows the percentage of cases among the Severe Typhoid in Africa Program (SETA)–recruited population for each age group.
Figure 3.
Figure 3.
A, Monthly counts of typhoid culture–confirmed and all intestinal perforations (IPs) (confirmed typhoid intestinal perforation [TIP], probable TIP, possible TIP, clinical IP) from all 6 countries from February 2016 to May 2020. The monthly counts of Salmonella Typhi are predictive of monthly IPs. ***P < .001. B, Monthly S. Typhi and IPs by country. Arrows indicate the beginning and the end of the surveillance period and the asterisks indicate countries where monthly case counts of S. Typhi are predictive of monthly IPs. **P < .01, ***P < .001. Abbreviation: DRC, Democratic Republic of Congo.
See this image and copyright information in PMC

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