Trends for typhoid and paratyphoid Morbidity in the West

Gonja District of Ghana: A Descriptive Analysis from DHIMS 2

data, 2017–2021
Eduah-Afriyie David [UHAS20212008]. [Health Information]
Fred N. Binka School of Public Health, University of Health and Allied Sciences, Hohoe

Background: Typhoid and paratyphoid fever remain a global public health burden, yet annual estimates of
prevalence vary. Estimates have ranged between 9.9 and 24.2 million cases annually. Similar differences in
estimates are seen within countries but point to a serious health challenge. In Ghana, for instance, typhoid fever
has been ranked among the top twenty causes of outpatient morbidity and constituted 1.2%, 1.7%, and 1.3% of
hospital admissions in 2017, 2016, and 2015 respectively.
Objective: The objective of the study was to determine the trend of typhoid and paratyphoid in the West Gonja
Municipality.
Methods: Data on all reported cases of typhoid fever in the West Gonja municipality as entered into the District
Health Information Management System 2 (DHIMS 2) database between 2017 and 2021 were extracted. Excel
was used to clean and analyze data.
Findings: The results showed that a total of 8781 individuals suffered from typhoid fever during the five years.
Of these numbers, 3343 (38%) were males, and 5438 (62%) were females. The females and the 20–34 age group
were the most affected. The trend analysis showed growing cases of typhoid over the period of study. Prevalence
for the various years was found as follows: 2017 – 1239 per 100,000, 2018 – 1765 per 100,000, 2019 – 2057 per
100,000, 2020 – 2750 per 100,000, and in 2021 – 6028 per 100,000.
Conclusions: Typhoid fever remains and continues to be a major public health challenge in the municipality. This
calls for health authorities and service providers to educate the public about the disease if the challenge is to be
addressed.

1. Introduction
Typhoid and paratyphoid fever remain important
public health problems globally and major causes of
morbidity in the developing world. Typhoid and
paratyphoid fevers are acute and often life-
threatening febrile illnesses caused by systemic
infection with the bacterium Salmonella enterica
serotype typhi and paratyphi, respectively. Classical
symptoms include the gradual onset of sustained
fever, chills, hepatosplenomegaly, and abdominal
pain. In some cases, patients experience rash, nausea,
anorexia, diarrhea or constipation, headache, relative
bradycardia, and reduced level of consciousness.
While both diseases share clinical features,
paratyphoid fever tends to have a more benign course
of illness. Without effective treatment, typhoid fever
has a case-fatality rate of 10–30%. This number is
reduced to 1–4% in those receiving appropriate
therapy.
The burden of typhoid and paratyphoid deaths is
greatest in low-income countries where access to
water and sanitation-related services is poor. Without
effective treatment, typhoid fever has a case-fatality
rate of 10–30%. In Sub-Saharan Africa (SSA), typhoid
and paratyphoid fever morbidity outcomes are
correlated with poverty and other sociodemographic
factors.
In Ghana, the burden of typhoid fever and its
associated complications have been reported in
various prior studies. This, notwithstanding, the latest
reported cases of typhoid fever in Ghana still showed
a worrying trend and a major public health concern.
For instance, typhoid fever has been ranked among
the top twenty causes of outpatient morbidity and
constituted 1.2%, 1.7%, and 1.3% of hospital
admissions in 2017, 2016, and 2015 respectively.

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In the Savannah Region of Ghana, it is very obvious of the Constitutional Instrument (CI) 105, which was
that water supply influenced typhoid and paratyphoid signed into force by the President.
morbidity outcomes. In the West Gonja District of the
It lies on longitude 10 51 and 20 581 West and Latitude
Savannah region of Ghana where this study was
80 321 and 100 21 North. It shares boundaries in the
conducted, district-level data show that typhoid and
south with Central Gonja District, Bole and Sawla-
paratyphoid fever is among the top five morbidity
Tuna-Kalba Districts in the West, and North Gonja
conditions at the facility level from out-patient
District to the North. It has a total land area of 4,715.9
records. In 2021, District Health Information
km2.
Management System II (DHIMS 2) reported that the
number of typhoid and paratyphoid cases in the West
Gonja District was 3825, a more than 100% rise from
1745 cases reported in 2020, with higher typhoid and
paratyphoid morbidity among females compared to
males. However, no published study has examined
trends for typhoid and paratyphoid morbidity in the
West Gonja District in the Savannah Region of Ghana
over five years; hence there is no evidence of typhoid
and paratyphoid reported cases in the district to
enhance decision-making on typhoid and paratyphoid
outcomes.
The anticipation is that this study would provide
Fig. 1: Map of West Gonja Municipal.
empirical baseline information to the West Gonja
Municipal Health Directorate regarding the
2.1.2. Disease Profile. About 41,180 persons,
prevalence rate of typhoid and paratyphoid fevers in
comprising 50.2 percent of males and 49.8 percent of
the district. This could then lead to the
females lived in the West Gonja District, according to
implementation of efficient public health policies and
the 2010 Population and Housing. The district disease
programs aimed at combating the problem.
profile data show that 10.7% of all household deaths
Knowledge of the prevalence can also be used by
in the district were due to accident/violence/homicide
other areas in Ghana and possibly other sub-Saharan
while 9.7% of deaths are due to other causes like
African countries in designing policies and programs
malaria, hypertension, pneumonia, gastroenteritis,
aimed at improving and promoting public health and
etc. The total fertility rate in the district is estimated
well-being.
at 3.3%. for reproductive age women from 15 to 49
years.
2. Materials and Methods
2.1.3. Health Systems. The West Gonja District
2.1. Study Area/Setting
Hospital is the highest-level healthcare facility in the
2.1.1. Geography. The study was conducted in West district. This is supported by Health Centres at
Gonja Municipal. It is one of the seven administrative Langbonto, Laribanga, Achubunyo, Mole, and Busunu.
districts in the Savannah region of Ghana. It was The Tamale Teaching Hospital serves as a referral
established on the 23rd of December 1988 by PNDC center for medical conditions that these facilities are
Law 207. The district was declared a Municipal unable to contain. Other people also assist to provide
Assembly under a declaration of Municipality health services to the population, namely, Trained
instrument (L.I. 2398). On 12th February 2019, Traditional Birth Attendants (TBAs), Village health
Damongo was declared the capital of the newly workers, and Guinea-worm volunteers.
created Savannah Region with the coming into force There is a Health Assistance Training School in the
District to augment the human resource needs of the

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sector.
2.2. Study Design/Population. The study is a
retrospective assessment of reported typhoid and
paratyphoid cases from facility-level data and the
study population included patient records of reported
typhoid and paratyphoid cases in the study area from
2017 to 2021.
2.3. Data Source/Area. District-level surveillance data
from the West Gonja District (Figure 8) was extracted
from the District Health Information Management
System (DHIMS 2) for the years 2017-2021. DHIMS is
a routine facility-level database that provides monthly
reporting of the burden of disease morbidity across
districts in Ghana under the Ghana Health Service
system of data reporting. In retrieving data from the
DHIMS for analysis, age and sex variables were
retrieved for analysis.
For the retrieval of the data, a checklist was used
to collect data from the DHIMS 2 database. Age
groups and sex-reported cases of typhoid and
paratyphoid were extracted. The checklist was
designed to collect the required data from the West
Gonja District DHIMS 2 database.
The data was collected by
(1) gathering of documents on diarrhea cases from
2017 to 2021 in the district
(2) variables on age group and sex reported cases
of typhoid and paratyphoid and year of records
being recorded using the checklist
(3) The data on these variables were then exported
to excel for data cleaning, verification, and
analysis.
2.3. Included and Excluded Data Cases. The study
included all outpatient typhoid and paratyphoid cases
in the district which were entered into the DHIMS 2
database. It excluded inpatient typhoid and
paratyphoid cases.
2.4. Data Processing and Cleaning. All OPD typhoid
and paratyphoid cases in the specified period under
study were extracted. A checklist was used to collect
3
data from the DHIMS 2 database. Patient age and sex
were the two sociodemographic variables assessed
and analyzed in the study. The checklist was designed
to collect the required data from the West Gonja
District DHIMS 2 database.
2.5. Data Analysis. DHIMS 2 data extracted on a
checklist was entered into Excel for data cleaning,
verification, and analysis. Standard age and sex
groupings for reporting DHIMS 2 data were used to
extract data. Autocorrelation in Excel was used to plot
the actual observed cases of typhoid and paratyphoid
by year to assess trends.
Age groups and sex were the two variables
considered in the study. From the DHIMS 2 database,
age has been coded into 12 classes which include
under 28 days, 1-11 months, 1-4, 5-9, 10-14, 15 -17,
18-19, 20-34, 35-49, 50- 59, 60-69, and 70 and above
years for the same sex differences which in this
research was recorded into under 5, 5-14, 15-19, 20-
34, 35-59, and 60 and above years for the same sex
differences. This category was to highlight vulnerable
age groups under 5, younger children, teenagers,
working age, and the retirement age in Ghana whom
typhoid and paratyphoid diseases can also affect.
A descriptive statistical analysis of the data
conducted by a person, age time. No inferential
statistics were performed. The population at risk for
the period under study, 2017, 2018, 2019, 2020, and
2021, comprising 50304, 50504, 51716, 52623, and
53673, respectively, was used to calculate the
Prevalence rate for each year under study. The
population at risk was estimated by the Ghana
Statistical Service in the district which the West Gonja
District Health Directorate uses for their estimations
of disease burden.
The estimated Incidence Rate (IR) was calculated
using the formulae;
Number of existing cases
Number of persons in the population at X10,000
risk
3. Results
The results of the data extracted from DHIMS 2 and
analyzed are presented below.
Table 1: Demographic characteristics of typhoid and paratyphoid cases in West Gonja District from 2017-2021.
Year of TYPHOID incidence
2017 2018 2019 2020 2021 Total
Demographic
variables N= 786 N= 1120 N= 1305 N= 1745 N=3825 N=8781
N (%) N (%) N (%) N (%) N (%) N (%)
Sex
Male 324(41) 395(35) 515(39) 680(39) 1429 (37) 3343(38)
Female 462(59) 725(65) 790(61) 1065(61) 2396(63) 5438(62)

Age grouping
<5 83(10.5) 102(9.1) 123(9.4) 161(9.2) 468(12.2) 937(11)
5-14 80(10.2) 179(16.0) 194(14.9) 177(10.1) 440(11.5) 1070(12)
15 -19 89(11.3) 112(10.0) 115(8.8) 136(7.8) 269(7.0) 721(8)
20-34 274(34.9) 315(28.1) 395(30.3) 535(30.7) 1153(30.1) 2672(30)
35-59 216(27.5) 308(27.5) 353(27.0) 525 (30.1) 1047(27.4) 2449(28)
60+ 44(5.6) 104(9.3) 125(9.6) 211(12.1) 448(11.7) 932(11)

3.1 Characteristics of typhoid and paratyphoid cases Prevalence rate (16 per thousand persons) was
extracted from DHIMS2 recorded in 2017. The pattern of Prevalence rate in
Table 1 shows the demographic characteristics of the district within the period under study is observed
typhoid and paratyphoid cases in West Gonja District to be inclining from 2017 to 2021.
from 2017 to 2021. There was a total period incidence
of 8781 typhoid and paratyphoid cases with females
having the highest incidence of 5438 (62%) reported Table 2: Typhoid and paratyphoid fever annual
cases. Persons between the ages of 20-59 years Incidence rate in West Gonja District from 2017 to
experienced the highest (more than half of the cases
2021.
reported) incidence within the age groupings with
5121 (58%) reported cases with persons with 20-34 Year Incidence Pop. Risk IR
being the most (30% of the total incidence). 2017 786 50304 15.63
2018 1120 50504 22.18
3.2. Incidence and Trends for Reported typhoid and
paratyphoid Cases in West Gonja District. 2019 1305 51716 25.23
Table 2 presents findings on the annual incidence rate 2020 1745 52623 33.16
of typhoid and paratyphoid in the West Gonja District 2021 3825 53673 71.26
from 2017 to 2021. Between 2017 and 2021, a total of
8,781 cases of typhoid and paratyphoid were Total 8781
reported, with an estimated incidence rate of Source: data extracted from the District DHIMS 2 and West
approximately 209 per thousand persons by the Gonja District Health Directorate. Note: Pop. Risk=
Global Burden of Disease in 2019. The annual population at risk, IR= Incidence rate per 1000.
incidence rates range from approximately 15 to 71
cases per thousand persons within the period under
study. The highest prevalence rate (71 per thousand
persons) was recorded in 2021 and the lowest

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Table 3: Incidence rate of diarrhea cases by sex in the West Gonja District from 2012-2016.
Both sexes Male Female
Year
Incidence PR IR Incidence PR IR Incidence PR IR
2017 786 50304 15.63 324 25604 12.65 462 24700 18.7
2018 1120 50504 22.18 395 25706 15.37 725 24798 29.24
2019 1305 51716 25.23 515 26323 19.56 790 25393 31.11
2020 1745 52623 33.16 680 26785 25.39 1065 25838 41.22
2021 3825 53673 71.26 1429 27319 52.3 2396 26354 90.92
Total 8781 258820 33.93 3343 131737 25.38 5438 127083 42.79

Source: Data extracted from the District DHIMS 2 and West Gonja District Health Directorate. NOTE: PR=Population at Risk, IR= Incidence
rate per 1000

3.3. Age and Sex Differentials and the Incidence of
Reported typhoid and paratyphoid Cases in West
Gonja District.
Age and sex categories were used to estimate the
incidence of typhoid and paratyphoid for the various
age groupings. Typhoid and paratyphoid cases among
persons between 20-34 years were the highest
compared to other age groupings as seen in table 4.
Typhoid and paratyphoid among people of age 20-
34years in the period under study accounted for 30%
of the total number of typhoid and paratyphoid cases
(8781) within the period under study, age group 35-
59years accounted for the second highest with a
90.9 per thousand persons, respectively, for males
and females whereas the least occurred in 2017 for
both sexes, with an incidence rate of 12.6 and 18.7 per
thousand persons for males and females respectively.
Table 5 also shows the prevalence of typhoid
between both sexes and it is shown from the table
that typhoid prevails more among females throughout
the study period. Both sexes recorded their highest
prevalence in 2021.
Table 4: Trend of typhoid and paratyphoid morbidities
by age groups.
1400
1200

percentage incidence of 28% whiles 15-19 age group 1000

800
accounted for the least among the six age groupings
600
with an incidence percentage of 8%.
400
Working age accounted for 58% of the incidence
200
for the period of study. Moreover, the age group 60
0
years and above (retirement age) accounted for 11% 2017 2018 2019 2020 2021
incidence of reported cases. There is a statistically <5 5-14 15-19 20-34 35-59 60+
significant difference in typhoid and paratyphoid
cases in the West Gonja Municipal among the age Table 5: Trend of typhoid and paratyphoid morbidities
groupings. by sex.
3000
Table 3 shows the population incidence rate of 2500
63%
typhoid and paratyphoid cases for both sexes and the 2000
37%
sex differential among residents in the West Gonja 1500 61%
District. The highest incidence rate for both sexes of in 1000 65% 61% 39%
59% 39%
41% 35%
the district occurred in 2021 with an incidence rate of 500
71.26 per thousand persons. In terms of sex 0
2017 2018 2019 2020 2021
difference, the highest incidence rate occurred in the MALES 324 395 515 680 1429
same year 2021 with an incidence rate of 52.3 and FEMALES 462 725 790 1065 2396

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4. Discussion
This study examined trends for reported typhoid and
paratyphoid morbidities at facility levels in the West
Gonja District of Savannah in Ghana using the DHIMS
2 database system. A total of 8781 cases of typhoid
and paratyphoid were reported in the district from
2017 to 2021 and a continuous increase of cases
within the period under study was observed. The
incidence of typhoid and paratyphoid from 2017 to
2021 was high among people between the ages of 20-
34 years. Females had the highest levels of typhoid
and paratyphoid incidence across all years. Overall,
typhoid and paratyphoid incidence in this study was
observed with an increasing trend.
Out of the total of five years of the study, typhoid
fever figures soared in all the years. This shows an
increasing rate of typhoid fever in the municipality as
the years go by, and from this, it could be predicted
that subsequent years could be higher if measures are
not put in place to deal with it. A similar increase in
Salmonella cases year by year was observed by
another study. Data from other typhoid fever studies
show a fluctuating trend during study periods but
usually point towards an increasing trend when
significance analysis is done. Malisa & Nyaki found
these same fluctuations and increasing incidence in
their work in Tanzania. Mweu & English’s estimate of
the global burden of enteric fever suggested a
moderate incidence of typhoid of 10–100 cases per
100,000 persons a year in most African countries. Neil
et al. give the annual typhoid fever incidence in Africa
as 13 to 845 cases per 100 000 population. Data from
this study also show an increasing trend in cases of
typhoid year after year. Without risk factor correction,
Mogasale et al. revealed that West Africa had a
typhoid fever incidence of 213 per 100,000. In that
study, Ghana was identified as a high-risk region
because she recorded more than 100 cases per
100,000 yearly, thereby confirming the results from
the study.
Period prevalence of typhoid fever from 2017 – 2021
In calculating the prevalence, the cue has been taken
from the work of Mogasale et al., which used a
population per 100,000 to calculate prevalence. This
is also done in studies by Buckle et al. and Crump and
6
many others. Data from the 2021 population and
housing census estimates the total population of the
West Gonja Municipality as 63,449, of which 32,270
representing 50.9% are males, and 31,179
representing 49.1% are females. Using this as the base
population during the study period and calculating the
prevalence by cases recorded in each of the study
years gives the following.
2017 – 1238.8 per 100,000
2018 – 1765.2 per 100,000
2019 – 2056.8 per 100,000
2020 – 2750.2 per 100,000
2021 – 6028.5 per 100,000
It should, however, be noted that these calculations
were done assuming that the population size remains
constant or reaches equilibrium when all other factors
are considered, with no adjustments made to cater to
the growth rate and fatality rate in the municipality.
Currently in Ghana, there exist donor support and
funding agencies that have been put in place to
support and improve water and sanitation and also
child health through health and nutrition, water and
sanitation, education, food security, etc. UNICEF
Ghana in collaboration with Ghana Education Service,
Red Cross/Red Crescent Climate Centre, Engagement
Lab at Emerson College, Right to Play, and Ghana Red
Cross in their innovative ideas have introduced a
program called Handwashing with Ananse which is an
educational game to teach children why, how, and
when to wash their hands with water and soap. It is a
three-chapter story and game experience centered
around a Ghanaian legends character who is known as
Ananse who stole all the knowledge about
handwashing and hid it in his pockets where children
have to play through three scenarios with a tricky move
to Ananse to win the handwashing knowledge back
from him. These interventions are working in reducing
diarrheal and typhoid and paratyphoid cases in Ghana
as our research identified an increasing trend of
typhoid and paratyphoid cases.
5. Strength and Limitations
This study presents some potential strengths and
limitations.
5.1. Strength. The use of the DHIMS 2 data le for our Abbreviations
study is relevant to bringing out how facility-level data
could be used for the implementation of strategies for AFRO: African Regional Office
the control of diarrhea based on context data.
AIDS: Acquired Immune Deficiency Syndrome
5.2. Limitation. A limitation, however, is a potential CDC: Centre for Disease Control
bias of under-reporting or over-reporting the number CFR: Case Fatality Rate
of typhoid and paratyphoid cases that may arise from
data collection and processing of this data since some DHIMS: District Health Information Management
facilities may lack well-trained data experts to ensure System
the validity and reliability of data collected as this EOF: Empirical Orthogonal Function
study uses only passive surveillance system dataset. GHS: Ghana Health Service
DHIMS 2 outpatient monthly morbidity report does
IDSR: Integrated Disease Surveillance and Response
not currently cover all individual and household
characteristics that can be used to draw associations IR: Incidence Rate
with typhoid and paratyphoid and other disease MoH: Ministry of Health
morbidity at the district level. Including more
individual-level and household background PR: Prevalence Rate
characteristics will help estimate factors that predict UNICEF: United Nations International Children’s
the occurrence of typhoid and paratyphoid based on Emergency Fund
sociodemographic factors. WHO: World Health Organization

6. Conclusion and Recommendations Data Availability

Typhoid fever remains very high and continues to be a
worrying public health challenge in the West Gonja
Municipality. Data from all the sub-districts in the
municipality as extracted from DHIMS2 point still to an
increasing trend, with females and the 20–34 age
group being the most at risk. Health authorities and
service providers have the responsibility to implement
an integrated plan toward reducing the incidence or
prevalence of typhoid and paratyphoid given the high
prevalence and this requires commitment from all
healthcare providers and stakeholders to work hand
in hand. Educating the public about the symptoms and
consequences of typhoid in the municipality, and
improving water, sanitation, and hygiene practices at
household levels are key to reducing the incidence
and trends of reported typhoid and paratyphoid cases
in the district. Further studies should be designed in
West Gonja District to assess district and household
behavior change practices needed to promote and
reduce the incidence of typhoid and paratyphoid-
related disease conditions in the district.
Studies and many reports have identified water
supply influences the incidence of water-borne
diseases like typhoid and paratyphoid among
populations nationwide; this research is of the view
that if water supply is improved, typhoid and
paratyphoid outcomes will be reduced drastically in
the study setting.
The data used to support the findings of this study are
available from the West Gonja Municipal Health
Information Officers upon request.
Conflicts of Interest
There were no conflicts of interest in this submission.
Acknowledgments
All thanks are to God for his strength, graces, and
wisdom in pursuing this agenda and I am also grateful
to the faculty of the School of Public Health, University
of Health and Allied Sciences, who equipped me with
knowledge on Scientific communication to write this
report. Also grateful to Mr. Gideon Kye-Duodu, my
Field Epidemiology lecturer who triggered this study.
Special acknowledgment goes to Miss Felicia Semaa
Bremang for her inspiration and support during the
research work.
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