THE INCIDENCE AND ANTIMICOBIAL SENSITIVITY OF TYPHOIDAL FEVER

AMONG PATIENTS ATTENDING COAST GENERAL TEACHING AND REFERRAL

HOSPITAL FROM JANUARY TO APRIL 2022.

BY

CHARO PEMBE SULUBU

INDEX NUMBER 1061200552

SUPERVISOR: MR GEORGE OSIMBO

A RESEARCH PROJECT SUBMITTED TO THE KENYA NATIONAL EXAMINATION

COUNCIL IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD
OF DIPLOMA IN MEDICAL LABORATORY TECHNOLOGY AT KENYA COAST
NATIONAL POLYTECHNIC

NOVEMBER, 2022

i
 DECLARATION
This is my original work that has never been presented to any institution following the award of
diploma or any other awards.

STUDENT NAME: CHARO PEMBE SULUBU

Sign:……………………………………………Date:……………………………………………

SUPERVISOR NAME: MR GEORGRE OSIMBO

I declare that, I supervised this work and it is original work of the above named student.

Sign:……………………………………………….Date:………………………………………

ii
 ACKNOWLEDGEMENT
I acknowledge the effort of my supervisor Mr. George Osimbo, and the head of department, Mr.
Haji Ade that have assisted me to improve my work and make it successful. Their support was of
great value to the success in this work.

iii
 DEDICATION
I dedicate this work to my living God who has kept me safe and health during the preparation
time of this work. I also dedicate it to my family which has stand with me from the start of this
work and give full support to me to ensure that my work is successful.

iv
TABLE OF CONTENTS
DECLARATION.............................................................................................................................ii

ACKNOWLEDGEMENT..............................................................................................................iii

DEDICATION................................................................................................................................iv

ABSTRACT..................................................................................................................................vii

CHAPTER ONE..............................................................................................................................1

1.0 INTRODUCTION.....................................................................................................................1

1.1 BACKGROUND OF THE STUDY..........................................................................................1

1.2 PROBLEM STATEMENT AND JUSTIFICATION................................................................2

1.3 OBJECTIVES............................................................................................................................2

1.3.1 General Objectives..................................................................................................................2

1.3.2 Specific objectives..................................................................................................................2

1.4 STUDY QUESTIONS...............................................................................................................2

1.5 SCOPE OF THE STUDY..........................................................................................................2

CHAPTER TWO.............................................................................................................................3

2.0 INTRODUCTION.....................................................................................................................3

2.1 LITERATURE REVIEW..........................................................................................................3

2.2 CLINICAL MANIFESTATION AND LABORATORY DIADNOSITIC FEAFUURES.......4

CHAPTER THREE.........................................................................................................................6

METHODOLOGY..........................................................................................................................6

3.1 STUDY SITE.............................................................................................................................6

3.2 STUDY DESIGN......................................................................................................................6

3.3 STUDY POPULATION............................................................................................................6

v
3.3.1 THE INCLUSION CRITERIA...............................................................................................6

3.3.2 THE EXCLUSION CRITERIA.............................................................................................6

3.4 SAMPLE SIZE DETERMINATION........................................................................................6

3.5 SAMPLING METHOD.............................................................................................................8

3.6 QUALITY CONTROL..............................................................................................................8

3.6.1 PRE-ANALYTICAL QUALITY CONTROL.......................................................................8

3.6.2 ANALYTICAL CONTROL...................................................................................................8

3.6.3 POST ANALYTICAL CONTROL........................................................................................8

3.7 DATA MANAGEMENT..........................................................................................................8

3.7.1 DATA COLLECTION...........................................................................................................8

3.7.2 DATA ANALYSIS................................................................................................................8

3.7.3 DATA PRESNTATION.........................................................................................................8

3.7.4 ETHICAL REVIEWS............................................................................................................8

3.8 DATA ANALYSIS AND PRESENTATION...........................................................................9

CHAPTER FOUR.........................................................................................................................10

4.0 RESULTS................................................................................................................................10

4.2 DISCUSION............................................................................................................................13

4.3 CONCLUSSION.....................................................................................................................13

4.4 RECOMMENDATIONS.........................................................................................................14

4.5 REFERENCES........................................................................................................................15

vi
 ABSTRACT
Typhoid fever poses a significant health threat to many endemic countries. Salmonella enterica
serovar typhi (S. typhi), the etiologic agent can be transmitted through contaminated food and
water via the fecal-oral route. Annually, over 21 million cases and nearly 200,000 deaths are
reported worldwide (Crump and Mintz.... et all 2010).Despite major treatment and prevention
efforts, global typhoid cases remain very high (Lozano et al 2010, Murray et al 2010).The
disease is human restricted and the infected individual could persist as long term carriers which
is in turn serve as the reservoir for new infection and outbreak (GonzaleZ-Escobedo..et Al
2010)The epidemiological investigation of S. typhi is important for disease control such as
during a disease outbreak to trace the potential sources. Over the last few decades, many
molecular subtyping methods have been applied to genotype bacterial pathogens and among
these, Multilocus sequence typing ( MLST) is the most commonly used genotyping method to
determine the ancestral lineages of many bacteria including S. typhi (Achtman et al 2912, Lee
Kitcharoenphon et al 2012) Salmonella typhi is a serovar of subspecies enterica under species
Salmonella typhi of bacteria Salmonellae. (District laboratory practice in tropical countries-part
two by Monica Cheesbrough page 182)The bacteria is a Gram negative rods, actively motile and
capsulated. Salmonella typhi causes bacteraemia and septicaemia in young children in
developing countries. In Africa and elsewhere, Salmonella typhi bacteraemia is also common in
those who are co-infected with HIV. Others at high risk include those already in poor health,
those with malignancy, sickle cell disease, bartonellosis, and chronic schistosomisis. Salmonella
typhi is also reported as causing neonatal meningitis. (District laboratory practice in tropical
countries part 2 -Monica Cheesbrough pg 183)
Salmonella infection is restricted only to human and it is transmitted through ingestion of
contaminated food and water.

vii
 CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Salmonella typhi is a serovar of subspecies enterica under species Salmonella typhi of bacteria
Salmonellae. (District laboratory practice in tropical countries-part two by Monica Cheesbrough
page 182)

The bacteria is a Gram negative rods,actively motile and capsulated.

Salmonella typhi causes bacteraemia and septicaemia in young children in developing countries.
In Africa and elsewhere, Salmonella typhi bacteraemia is also common in those who are co-
infected with HIV. Others at high risk include those already in poor health, those with
malignancy, sickle cell disease, bartonellosis, and chronic schistosomisis. Salmonella typhi is
also reported as causing neonatal meningitis. (District laboratory practice in tropical countries
part 2 -Monica Cheesbrough pg 183)

Salmonella infection is restricted only to human and it is transmitted through ingestion of

contaminated food and water.

In developing countries, especially in sub-Saharan Africa, the True burden of enteric fever is
difficult to estimate due to the limited diagnostic resources and proper surveillance tools result in
poor characterization of the burden of enteric fever (Eng. SK, Pusparajah P, et al 2015).

The risk of infection is high in low and middle-income countries where typhoidal Salmonella is
endemic and that have poor sanitation and lack of access to safe food and water (Crump JA,
Karlsson MS, et al 2015)

Without treatment, the case fatality rate of typhoid fever is 10-30%, however an appropriate
therapy may decrease the case fatality to 1-4% (WHO 2014).

1
1.2 PROBLEM STATEMENT AND JUSTIFICATION
Africa was reported to have the highest prevalence of typhoid fever complication and mortality
when compared to other WHO regions. (Machelo CS et al….2017). A study carried out in
nairobi Kenya reveled a high prevalence of H58 genotype in Salmonella typhi case with76% of
the strains being MDR. (Kariuki S et al…2021). This call for more research to be carried out on
the prevalence and antimicrobial susceptibility of s typhi to be done in several parts of
Kenya .Mombasa is a city along the coast region of Kenya. The city is densely populated with
majority of its population relaying on foodstuffs from open air market which is a potential source
of s typhi infection and its spread.

1.3 OBJECTIVES

1.3.1 General Objectives

To determine the incidence and antimicrobial sensitivity of Salmonella typhi among patients
attending Coast Provincial General Hospital from January to December 2021 to April 2022.

1.3.2 Specific objectives

To determine the gender mostly infected with Salmonella typhi.

To find out the age groups most infected with Salmonella typhi.

To determine the most effective drugs for typhoid fever treatment.

1.4 STUDY QUESTIONS

Which gender has the highest Salmonella typhi infection?

Which age groups are most infected with Salmonella typhi?

Which dugs are the most appropriate for typhoidal fever treatment?

1.5 SCOPE OF THE STUDY

The study will only involve patients presented with typhoid fever in Coast General Teaching and
Referral Hospital from January to April 2022.

2
 CHAPTER TWO

2.0 INTRODUCTION

2.1 LITERATURE REVIEW

Typhoid fever poses a significant health threat to many endemic countries. Salmonella enterica
serovar typhi (S. typhi), the etiologic agent can be transmitted through contaminated food and
water via the fecal-oral route. Annually, over 21 million cases and nearly 200,000 deaths are
reported worldwide (Crump and Mintz.... et all 2010).

Despite major treatment and prevention efforts, global typhoid cases remain very high (Lozano
et al 2010, Murray et al 2010).

The disease is human restricted and the infected individual could persist as long term carriers
which is in turn serve as the reservoir for new infection and outbreak (GonzaleZ-Escobedo..et Al
2010)

The epidemiological investigation of S. typhi is important for disease control such as during a
disease outbreak to trace the potential sources. Over the last few decades, many molecular
subtyping methods have been applied to genotype bacterial pathogens and among these,
Multilocus sequence typing ( MLST) is the most commonly used genotyping method to
determine the ancestral lineages of many bacteria including S. typhi (Achtman et al 2912, Lee
Kitcharoenphon et al 2012)

This method allow discrete characterisation of isolates using the internal fragments of
housekeeping genes sequences (Achtman et al 2012).

However MLST is of limited use for monomorphic pathogens such as Salmonella typhi as their
populations accrue very limited variations thus hampering efforts in a population study. In the
recent years high throughput of whole genome sequencing (WGS) has become ultimate approach
to study bacteria population and phylogeny (Didelot et Al 2012).

Based on MLST, presumably, the global most widespread S. typhi is genetically characterised as
ST1 and ST2 in the earlier studies (Martinez-Gamboa et Al 2015).

3
In Africa, outbreaks of typhoid fever were reported in 15 countries since1950 and the majority
have occurred in the Southeastern part of the Africa continent. The frequency of reported
outbreak of Typhoid fever and the number of people affected appear to have increased over time.
The earliest reports were outbreaks during the Anglo-Boer war in South Africa between 1899
and 1902 (Cirillo V.J; Arthur Conan Doyle et al 2014) and the the most recent records was in
January 2018 where a sudden increase in typhoid observed in Harare, Zimbabwe ( ProMED-
mail, Typhoid fever Zimbabwe 3018).

The largest outbreak was in Kampala , Uganda between February and June 2015, where a total of
10,230 suspected cases were associated with a Typhoid confirmed breakout. Recent outbreak
have occured mostly in East Africa, Moyale,Kenya ( December 2014-January 2015)(Galgallo
DA,Toka ZG..et al 2018), Kampala Uganda (February-June 2015)(Kabwana SN, BulageL L..et
Al 2017), Kigoma Tanzania (May 2015)( Abade A, Eidex RB..et al 2018) and Kirehe Rwanda
(October 2015-January 2016)(Nahiman MT, Ngoc C7..et Al 2017).

Typhoid fever inflicts a significant public health burden in Kenya. The Global Burden of Disease
estimates that in 2016q, Kenya had 97,762 typhoid cases 62% among children aged less than 15
years, and 1,075 typhoid death, 66% among children aged less than 15 years.( Kenneth Simiyu
and Leslie Jamka)

About 200,000 people live in Kibera, a slum on the outskirts of Narobi Kenya, and the largest
informal settlement in East Africa, with an estimated one-pit latrine for every 200 people.
Residents use plastic bags for relief and then dispose of them anywhere. This practice known
as'flying toilets' is more common at night among women and children concerned about the area's
lack of security.

Without sanitation facilities to contain and dispose of human feces, those living nearby are at risk
for enteric diseases (those that cause diarrhea, nausea or vomiting) such as typhoid fever.( Global
Health Kenya; Typhoid fever targets Children from Kenya Urban Slums).

2.2 CLINICAL MANIFESTATION AND LABORATORY DIADNOSITIC FEAFUURES

Patients usually present with gradually onset of sustained fever, headache, nausea, loss of
appetite and constipation or sometimes diarrhea.
4
The symptoms are usually not specific and clinically non-distinguishable from other febrile
illness. However clinical severity varies and severe cases can lead to severe complication or
death (World Health Organisation 2017).

Complications caused by Salmonella typhi infection include intestinal bleeding or holes which is
the most serious complication of typhoid fever. This usually develop in the third week of illness.
In this condition the small intestine or large bowel develop holes. Contents from the intestine
leak into the stomach and can cause severe stomach pain, nausea, vomiting and bloodstream
infection (sepsis). This life threatening complication requires immediate medical Care.

Other less common complication include; Inflammation of the heart muscles (myocarditis),
Inflammation of the lining of the heart and valves (endocarditis). Infection of major blood
vessels (mycotic anaurysm), Pneumonia, Pancreatitis, Kidney or bladder infection, Meningitis,
Psychiatric problems such as delirium, hallucinations and paranoid psychosis.

The risk of infection has previously linked to factors such as exposure to contaminated water,
inadequate waste management, poor hygiene conditions as well as inhabitation of urban slums .
(Uzoka F-ME et al….2021).

5
 CHAPTER THREE

METHODOLOGY

3.1 STUDY SITE

The study will be undertaken at Coast Provincial General Hospital. It is a public level three
hospital found in Kenya Mombasa County Mvita sub-county.

3.2 STUDY DESIGN

An Experimental research was conducted from 16 January to 16 April on stool samples from
patients with suspected Salmonella typhi infection at Coast General Hospital in Mombasa
County. The I was receiving the samples in microbiology laboratory , giving them laboratory
numbers, conducted the pre -culture such as salmonella typhi antigen test using test kits and
culturing of the samples and also performing antimicrobial susceptibility test practically.

3.3 STUDY POPULATION

The study targets the data of patients of all age brackets with gastrointestinal and its related
complications who attended Coast Provincial General Hospital from January to April 2022.

3.3.1 THE INCLUSION CRITERIA

All patients who visited the hospital during the time of study and presented with clinical features
of Salmonella typhi were included in the study.

3.3.2 THE EXCLUSION CRITERIA

Patients who visited the hospital with cases not related with salmonella typhi were not included
in the study.

3.4 SAMPLE SIZE DETERMINATION

Sample size was calculated using the formular below (Fisher, et.al ,1998)

Where:

6
n = the desired sample size.

Z = the standard normal deviate usually set at 1.96, which is corresponds to the 95% confidence
interval.

P = the proportion of patients with Salmonella typhi infection ,which is 75%.

d= the degree of accuracy desired (absolute precision), which is 5.0%(0.05).

Since the population during the study period was 10,000 the sample adjusting formular was
applied. Sample size adjustment was done using the following formular.

Where:

nf =the desired sample size (when population is less than 10,000)

N = total population (800 patients with Salmonella typhi infection in 12 weeks periods as the
data collection took 12 weeks)

n =the desired sample size (when population is more than 10,000) =380.

=211.8 = 212

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3.5 SAMPLING METHOD
Systemic sampling technique (longitudinal study approach) was used.

3.6 QUALITY CONTROL

3.6.1 PRE-ANALYTICAL QUALITY CONTROL

Proper patients’ identification was done by the use of a unique numeric system and labeled with
unique project number.

A biohazard precaution was taken to prevent risks of infections, for efficiency purposes SOPs
were observed correctly.

3.6.2 ANALYTICAL CONTROL

All procedures plan, SOPs and manufacturers’ instructions were followed correctly during
culturing of the stool samples. A control of each culture plate, antibiotic and reagents were
performed. Observations and interpretation of the results were done according to the SOPs.

3.6.3 POST ANALYTICAL CONTROL

Recording of results was done in a clear manner giving all relevant details. Results were verified,
signed and released without delay.

3.7 DATA MANAGEMENT

3.7.1 DATA COLLECTION

Data was collected and recorded in standard laboratory record book and research note
book.

3.7.2 DATA ANALYSIS

The data collected was analyzed using word and excel Microsoft’s.

3.7.3 DATA PRESNTATION

The data collected was presented in tables, graphs and pie charts.
8
3.7.4 ETHICAL REVIEWS
All the information which was obtained is confidential, as the permission to conduct this study
was obtained from Coast General Hospital. A consent in writing was obtained from each patient
and guardians when the patient was a child after details of the study were explained to each of
them.

3.8 DATA ANALYSIS AND PRESENTATION

The data will be analyzed using Microsoft excel and presented in chart, tables and graphs.

9
 CHAPTER FOUR

4.0 RESULTS

Fig 1: A pie chart showing analysis of Salmonella typhi infection by gender in terms of
percentage.

In this figure , a larger number of female patients tested positive for Salmonella typhi which
account for 56.13% than men which were account for 43.87% of the total positive cases.

10
Fig 2: a bar graph presentation of Salmonella typhi infection analysis by age.

This figure shows that children below ten years and the aged people are more susceptible to
Salmonella infection than individuals aged between 11-40 years.

11
Fig 3, overall antimicrobial activity of several drugs to Salmonella typhi. Ceftriaxone has the
highest antimicrobial activity to the bacteria, ciprofloxacin and azithromycin fellows. Resistance
is realized on cefotaxime and ampicillin.

12
4.2 DISCUSION
In figure 1,women have the highest number of positive cases which was 56% of the total number
of positive cases overall and men had 44% positive cases of the total tests that turned positive for
Salmonella typhi. The high number of positive cases in women could be as a results of their daily
choes that involves dealing with contaminated materials.

In figure 2, Children below the age of ten are more prone to typhoid fever than all age brackets.
A total number of 95 positive cases was obtained in the study samples collected from the age
group. This could due to the fact that at this age the children bare more playful and handle
material that are unhealthy as they are most likely to be contaminated with Salmonella typhi. At
this age there is reduced sanitation and it is difficult to maintain personal hygiene as the children
are playful and they make use of any available item which may be contaminated.

According to the results distributed in fig 3, the Salmonella typhi isolated showed sensitivity
with ceftriaxone, ciprofloxaciline and azithromycin with percentage sensitivity of 99.9%, 98%
and 97.5%. The bacteria shows resistance with ampicillin and cefotaxime with percentage
resistance of 65% and 80% respectively.

4.3 CONCLUSSION
Based on the results of this study, it was concluded that ;

The female gender is the most affected than male gender.

Children between the age of 0 to 10 years are more prone to typhoid fever than any other age
group.

Ceftriaxone is the most sensitive drug followed by ciproflaxacilin and azithromycin. Some
strains of Salmonella typhi are resistant to ampcilin and cefotaxime.

13
4.4 RECOMMENDATIONS
The following recommendations were made in respect to the results of this study.

Public and private health officers to work together in providing health education on how typhoid
fever is transmitted and the prevention and control measures.

People should also be educated on the need to maintain hygiene especially to the young
children.

Ceftriaxone, azithromycin an ciprofloxacin to be used in treatment of typhoid fever.

Health officers to make correct prescription of drugs based on laboratory tests and instruct the
infected individuals to adhere to the prescription made to ensure effective treatment.

14
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