Clinical Application of the Widal Test

Thelma E. Tupasi,* Roxanne Lucas-Aquino,** Myrna T. Mendoza,*** Carmelita U.

Tuazon**** and Somsak Lolekha*****

(*Workshop Chairperson and Senior Scientist, Tropical Disease Foundation, Inc., Makati Medical Center;
**Consultant, Infectious Diseases, Department of Health and J.R. Reyes Memorial Medical Center, Manila;
***Assistant Professor, Department of Medicine, UP-PGH Medical Center, Manila; ****Professor of Medicine and
Director, Div. of Infectious Diseases, George Washington University, Washington DC, USA; *****Professor of
Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand)

[Phil J Microbiol Infect Dis 1991, 20(1):23-26]

PROBLEM

The Widal test is one of the most utilized diagnostic tests for typhoid fever in developing
countries. This test demonstrates the presence of somatic (O) and flagellar (H) agglutinins to
Salmonella typhi in the patient's serum using suspensions of O and H antigens. Antigens of S.
paratyphi A, S. paratyphi B, S. paratyphi C are included in most commercial kits. The
recommended method of performing the Widal test is by the tube agglutination technique where
serial two-fold dilutions of the subject's serum from 1:20 to 1:1280 are tested. 1 In later years, a
rapid slide test was developed which is now the most commonly used technique in local
laboratories because of its convenience.1
The over reliance on the Widal test in the diagnosis of typhoid fever has led to the
underutilization of blood culture. The unavailability of microbiologic facilities and the long
waiting time for culture results have been identified as reasons for the preference for the Widal
test. In a number of cases, physicians tended to give too much clinical significance to a "positive"
Widal test leading to an over-diagnosis of typhoid fever so that even in the absence of compatible
clinical signs and symptoms, antimicrobial therapy including chloramphenicol is given. Finally,
follow-up Widal tests have been inappropriately used as the basis for assessing the efficacy of
treatment. Some patients continue on prolonged courses of antimicrobial agents because of a
persistent "positive" Widal test. The PSMID will present its position in relation to these problems
based on local experience and a review of literature.

LITERATURE REVIEW

Prevalence of Salmonella O and H agglutinins in the general population

Typhoid fever and salmonellosis in general are endemic in the Philippines.

Epidemiologic studies in an endemic country have shown that at least seven subclinical cases
occur for each clinical case. 2 A "positive" Widal test may therefore be seen in apparently healthy
persons from an endemic area as a result of a previous subclinical infection. It has been reported
that 55% among 3,307 healthy Filipinos have detectable O and H agglutinins.3 Although the
geometric mean titers reported in this group of healthy subjects were low at 1:62 for O and 1:75
for H agglutinins, more recent studies done on a smaller population of apparently normal controls
showed 0 agglutinins of 1:80 in 65% by the slide agglutination technique 4 and 4% of 50 healthy
individuals, by the tube agglutination, method. 5 These observations have been confirmed by other
investigators from countries similar to ours.6-10
Furthermore, sporadic immunization with typhoid vaccine may lead to persistently
elevated H agglutinins and transient elevations of O agglutinins. These titers may rise as an
anamnestic response to a febrile non-typhoidal illness.11 A "positive" Widal test may therefore be
a nonspecific response which is not etiologically related to the febrile illness under investigation.
Sensitivity and Specificity of the Widal Test

There has been no consensus on the diagnostic titer for a single Widal test. Traditionally,
a "'positive" Widal test is based on a fourfold rise in O agglutinins in repeated tests or a titer of
1:80 or greater in a single test.12
The titer cut-off for O agglutinins used in local studies have varied from 1:205 to 1:8013
by tube dilution technique and 1:160 or higher by slide agglutination method with corresponding
reported sensitivity rates of 61%, 5 64% 13 and 72.5%.4 Using either O or H agglutinins and at
different cut-offs varied sensitivity and specificity rates have been reported from other developing
countries (Table 1).7-9,11,13-16 From the sensitivity and specificity data, it is clear that some culture-
proven cases of typhoid fever may be associated with a "negative" Widal test particularly if done
early in the course of illness so that the predic tive value of "negative" Widal test is limited.

Table 1. Sensitivity and specificity of Widal test done in developing countries endemic for typhoid fever.

Country Agglutinin Cut-Off Titer Sensitivity Specificity (%) Reference

(%)
I. Tube agglutination
Philippines O 1:20 61 88 Aquino5
Philippines O 1:80 64 100 Buck et al 13
Hong Kong O and H 1:50 84 99 Chow et al15
Jordan O and H 1:160 92 - Shehabi16
Peru O 1:160 58 - Levine7
H 1:160 82 -
Ceylon O and H 1:160 85.7 88 Senewiratne11
II. Slide agglutination
Philippines O 1:160 72.5 57.5 Roxas et al4
1:320 57.5 100
Jakarta O and H 1:20 53 98 Hoffmann et a114
Ethiopia O and H 1:160 82 - Abraham et al8
South Africa O and H 1:200 75 92.5 Somerville et al9

Conversely, a "positive" Widal test may be seen in non-typhoidal patients and healthy
controls from endemic areas. Local and foreign studies have reported varied specificities ranging
from 53% to 92% so that not only are we failing to identify culture positive cases but also we
may see a "positive" Widal test in a patient who may not actually have typhoid fever.

Repeat Widal Test

The recommended definitive interpretation of the Widal test is a fourfold rise in

agglutinins taken 7 to 10 days apart.9 Clinically, however, this is rarely demonstrated and two- to
three-fold rises are more commonly seen. 17 Although effective treatment early in the disease
appears to prevent further antibody rise 16 which would diminish the likelihood of demonstrating
the diagnostic fourfold rise, there is conflicting data on the effect of antimicrobial therapy on the
Widal test. is Indefinite persistence of elevated titers may follow an illness despite treatment.
Thus the Widal test cannot be used to gauge therapeutic response.

New Diagnostic Tests

Preliminary studies using monoclonal antibodies to detect flagellar antigens of S. typhi

suggest that it may be a useful diagnostic test.
POSITION

Culture isolation of Salmonella typhi from blood and bone marrow should be considered
the standard diagnostic test to confirm typhoid fever. A single Widal test in an endemic area is of
no diagnostic value. In addition, it should not be used as a screening test in asymptomatic
individuals. Neither should a "negative" Widal test rule out the diagnosis of typhoid fever in
patients with signs and symptoms of the disease since a "negative" Widal test may be seen early
in the course of illness. The Widal test should not also be used as the basis for deciding the
duration of antimicrobial therapy.

REFERENCES

1. Lenette EH, Balows A, Hausler WJ, Shadomy HJ. 1985. Manual of Clinical Microbiology. ASM: Washington, DC.
2. Murphy HR, et al. Characteristics of humoral and cellular immunity to Salmonella typhi in residents of typhoid endemic and
typhoid free regions. J Infect Dis 1987; 156:865-67.
3. Basaca-Sevilla V, Pastrana EP, Cross JH, Sevilla JE, Balagot R. The significance of the Widal test. Phil J Micro Infect Dis 1970;
8:96-108.
4. Roxas DJ, Mendoza M. Assessment of a single Widalt est in the diagnosis of enteric fever. J Phil Med Assoc1989; 65:211-14.
5. Lucas-Aquino R, Quimpo V, Saniel MC. The value of a single Widal test in the diagnosis of acute enteric fever (for publication).
6. Ara R, Afzal H, Chaudhry HA, et al. Prevalence of Widal antibodies ni apparently healthy human population. J Phil Med
Assoc1980; 30-269-71.
7. Levine MM, Grados O, Gilman RH, et al. Diagnostic value of the Widal test in areas endemic for typhoid fever. Am J Trop Med
Hyg 1978; 27:795-800.
8. Abraham G, Teklu B, Oedebu M, et al. Diagnostic value of the Widal test. Trop Geogr Med 1981; 33:329-33.
9. Somerville PC, Lewis M, Koomhof HJ, et al. The Widal test in the diagnosis of typhoid fever in the Transvaal. South Afr Med J
1981; 59:851-4.
10. Pang T, Puthucheavy SD. Significance and value of the Widal test in the diagnosis of typhoid fever in an endemic area. J Clin
Pathol 1983; 36:471-75.
11. Senewiratne B, Chix B, Senewiratne K. Reassessment of the Widal test in the diagnosis of typhoid fever. Gastroenterol 177;
73:233-36.
12. Schroeder SA. Interpretation of serologic tests for typhoid fever. JAMA 1968; 206:839-840.
13. Buck R, Escamilla J, Sanggalang RP, et al. Diagnostic value of a single, pre-treatment Widal test in suspected enteric fever cases
in the Philippines. Trans Roy Soc Trop Med Hyg 1987; 81:871-873.
14. Hoffmann SL, Flanigan TP, Klaueke D, et al. The Widal slide agglutination, a valuable rapid diagnostic test in typhoid fever
patients at the Infectious Disease Hospital of Jakarta. Am J Epid 1986; 869-875.
15. Chow CB, Wang PS, Cheung MW, et al. Diagnostic values of the Widal test in childhood typhoid fever. Pediatr Infect Dis J
1987; 6:914-917.
16. Shehabi, AA. The value of a single Widal test in the diagnosis of acute typhoid fever. Trop Geogr Med 1981; 33:329-333.
17. Satma VNB, Malaviya AN, Kumar R, et al. Development of immune response during typhoid fever in man. Clin Exp Immunol
1977; 28:35-39.
18. Robertson P, Wahab MFA. Influence of chloramphenicol and ampicillin on antibody response in typhoid-paratyphoid fever. Ann
Intern Med 1970; 219-221.