Tropical Medicine and International Health

volume 8 no 6 pp 575–578 june 2003

Short communication: Prevalence of typhoid fever in febrile

patients with symptoms clinically compatible with typhoid fever
in Cameroon
Emmanuel Fru Nsutebu1, Peter Martins2 and Dieudonne Adiogo2

1 TB Research and Development Programme, Nuffield Institute for Health, University of Leeds, UK
2 Department of Microbiology and Infectious Diseases, Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Cameroon

Summary Typhoid fever is difficult to differentiate from other causes of infection such as malaria because their
signs and symptoms often overlap. There has been an unprecedented increase in the number of typhoid
fever cases diagnosed in Cameroon. Febrile patients are often treated for malaria and typhoid fever
simultaneously. This cross-sectional study was carried out to determine the prevalence of typhoid fever in
200 consecutive patients with fever and symptoms clinically compatible with typhoid fever to verify
recent estimates of a high prevalence of typhoid fever in Cameroon. Patients were enrolled in three
of the 10 provinces of Cameroon. Blood culture, thick and thin blood smears and Widal tests using acute
sera were performed in all cases; stool culture for 120 patients. Typhoid fever was confirmed in only
2.5% as evidenced either by culture (four cases) or high salmonella antibody titres (one case); malaria
was diagnosed in 94 (47%) patients. Typhoid fever is not as endemic in Cameroon as recently feared.

keywords typhoid fever, prevalence, differential diagnosis, malaria, Cameroon

There is no doubt as to the endemicity of typhoid fever in

Introduction
Fever is the most common cause for consultation in the
tropics and subtropics where most fevers are of infectious
origin. Typhoid fever usually presents as fever and head-
ache without localizing signs and without diarrhoea in the
early stages. But malaria and many other viral and parasitic
infections have the same clinical presentation (Chees-
brough 1985). In many African countries such as Camer-
oon, the Widal test is the most widely used test in typhoid
fever diagnosis because it is relatively cheaper, easy to
perform and requires minimal training and equipment.
However, it is undoubtedly non-specific (Wicks et al.
1974; Somerville 1981).
Annual reports from the Ministry of Public Health in
Cameroon showed that 1800 and 5300 patients were
affected in 1987 and 1989, respectively (Ghangha 1991),
showing a rise in the number of cases diagnosed. Recent
reports suggest that the diagnosis of typhoid fever is
becoming more and more frequent in health facilities in
Cameroon [Ministry of Health (MOH) 1996], resulting in a
public scare. Patients are commonly treated for typhoid
fever based on a single positive Widal test. It is also
common practice amongst doctors to prescribe antimalarial
treatment and antibiotics simultaneously because typhoid
fever is endemic and difficult to exclude on clinical grounds.
Cameroon, but precise estimates of the prevalence of
typhoid fever among febrile patients are unavailable. In
view of the high costs of drugs used for the treatment of
typhoid fever and their numerous side-effects, we aimed to
determine its prevalence amongst febrile patients with
clinically compatible symptoms.
Patients and methods
Over a period of 7 months (March 1997–September 1997)
patients were recruited prospectively from the Yaoundé
Central Hospital (YCH), Polyclinic Bonanjo-Douala and
C.D.C Central Clinic-Tiko, in three provinces of Cameroon.
Recruited for the study were febrile patients with symptoms
clinically compatible with typhoid fever and therefore with
typhoid fever as a provisional diagnosis. Patients with fever
and gastrointestinal symptoms such as anorexia, nausea,
vomiting, diarrhoea and abdominal pain were recruited,
especially if accompanied by other symptoms such as
headache, joint pains, fatigue, malaise or cough. Patients
with obvious evidence on initial examination of pneumonia,
pyelonephritis, abscesses, meningitis, tuberculosis or hepa-
titis, and children under 4 years were not included in the
study. Questionnaires were used to record the patients’
medical history and physical examination. Informed consent

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Tropical Medicine and International Health volume 8 no 6 pp 575–578 june 2003

E. F. Nsutebu et al. Typhoid in Cameroon

was obtained from all study subjects. Institutional appro- ded as negative. The presence of any peripheral
val was obtained from the Ethics Board, Faculty of parasitaemia (at least one per 100 thick fields) was
Medicine and Biomedical Sciences, University of Yaoun- considered to be significant as all the patients presented
de 1. Blood samples were collected from all patients for with fever.
blood culture and acute sera obtained for the Widal test.
Results
Widal test
We recruited 200 patients, of whom 69 (34.5%) were from
The conventional tube agglutination Widal test was per- Yaoundé (Central Province), 45 (22.5%) from Douala
formed using the Widal Pasteur kit manufactured by (Littoral Province) and 86 (43%) from Tiko (SW Province).
Diagnostics Pasteur, (Marnes-la-Coquette, France) con- Patients’ ages ranged from 4 to 62 years [mean
taining O and H antigens of Salmonella typhi and 23.1 ± 17.8 years (SD)]. Eighty-seven (43.5%) of the
Salmonella paratyphi A, B and C antigens. A negative patients were male while 113 (56.5%) were female. The
saline control was introduced in each batch of tests. The duration of fever before consultation ranged from 1 to
sera were first tested at a dilution of 1/100 and further 30 days [mean 4.8 ± 4.5 days (SD)]. The most common
at serial dilutions of 1/200, 1/400, 1/800 and 1/1600 in signs and symptoms presented are shown in Table 1. Fever
0.9% normal saline when a 1/100 dilution gave a posit- was the most common symptom, followed by fatigue,
ive result. The sera were centrifuged at 3000 r.p.m. for headache and anorexia.
5 min and the results read immediately after. A total of 94 (47%) of patients had malaria while
5 (2.5%) had typhoid fever. Eighty-eight (93.6%) of the
malaria cases were due to falciparum malaria. All the
Blood and stool cultures
typhoid fever cases were due to S. paratyphi A and four
Five millilitres of blood collected aseptically from the (2%) of the typhoid fever case were diagnosed by culture
patients was inoculated into 50 ml of Tryptic soy broth while one (0.5%) was diagnosed by the Widal test.
using standard techniques (Cheesbrough 1985). All There were no other bacterial isolates besides Salmonella
inoculates were incubated at 37 C for 2–15 days. Sub- from blood cultures. Thirty-three (35.1%) of those with
cultures were performed after 48 h and on the 7th day and malaria were less than 15 years old. There were no
the cultures read daily until the 15th day. Absence of any patients with both malaria and typhoid fever. There was
lactose-negative organisms after 15 days of incubation no difference in signs and symptoms between patients
was labelled as negative. with malaria, typhoid fever and patients with an
When possible, stool was collected from patients and unknown diagnosis. Only eight (4%) patients
inoculated on both Selenite F Broth and MacConkey. All were sure they had taken antibiotics prior to
inoculates were incubated at 37 C for 48 h. Subculture consultation.
was performed after 18 h and the cultures were read daily
for 48 h. Absence of any lactose-negative organisms after Table 1 Common clinical signs and symptoms presented by
48 h of incubation was labelled as negative. patients
The suspected colonies were identified biochemically
using the Api 20-E Enterobacteria identification galeries Clinical signs and Percentage of patients
symptoms (number)
from bioMérieux (Marcy-l’Etoile, France) and confirmed
serologically by slide agglutination test using polyvalent Fever (>37.5 C) 100 (200)
antisera from Diagnostic Pasteur. All positive isolates were Fatigue 38.5 (77)
also sent to the Yaounde Reference Laboratory for Headache 32.5 (65)
identification. Anorexia 32.5 (65)
Joint pains 27 (54)
Abdominal pain 23.5 (47)
Detection of malaria parasites Vomiting 23 (46)
Cough 19 (38)
Blood was obtained by finger prick for thin and thick Diarrhoea 14.5 (29)
blood smears and stained with Field’s stain. Asexual Pallor 13.5 (27)
parasites were counted against 200 white blood cells on Splenomegaly 12.5 (25)
the thick smear and species confirmed on the fixed thin Tachycardia 8.5 (17)
Hepatomegaly 4.5 (9)
smear. Thick smears were examined on a minimum of
Abdominal tenderness 4 (8)
100 high-powered microscopic fields before being recor-

576 ª 2003 Blackwell Publishing Ltd


Tropical Medicine and International Health
E. F. Nsutebu et al. Typhoid in Cameroon
Discussion
We excluded patients with obvious causes of fever such as
pneumonia and abscesses from this study and in so doing
may have excluded patients with obvious causes of
infection and concurrent typhoid. However it must be kept
in mind that in daily consultations, patients with obvious
causes of infection would not normally be investigated for
typhoid fever. Our inclusion criteria reflect what most
practitioners in Cameroon use to make a clinical diagnos
is of typhoid fever (Nsutebu 1996). Although the study
group included patients from three of 10 provinces of
Cameroon, the fact that all the patients were from urban
areas limits the extent to which the results can be
generalized. The fact that the Widal test, blood culture and
stool culture were performed simultaneously increased the
probability of detecting all cases of typhoid. We acknow-
ledge that multiple cultures would have increased culture
yields as patients who had received antibiotic treatment
were not excluded from the study. However we had limited
quantities of culture media and consequently could not
carry out multiple cultures. For similar reasons we could
not collect convalescent sera for Widal testing. Despite
these limitations, the results of this study provide infor-
mation from which useful conclusions can be drawn.
Keeping these limitations in mind, this study suggests
that malaria is the most common cause of fever in patients
with symptoms clinically compatible with typhoid fever in
Cameroon. Typhoid fever was confirmed in only 2.5% of
200 patients studied as evidenced either by culture (four
cases) or high Salmonella antibody titres (one case). The
findings greatly contradict the findings of Ammah et al.
(1999) who found that 26% of patients with fever and
signs compatible with typhoid fever actually had typhoid.
The inclusion criteria used by Ammah et al. (1999) were
identical to those of this study and standard culture
techniques were used in both studies. However, Ammah
et al. (1999) considered a titre of at least 1/160 for
O antibodies as positive while in this study we used an
O antibody titres of at least 1/200. In addition, Ammah
et al. (1999) make no mention of the specific method used
to identify suspected colonies. These factors may explain
the high numbers of typhoid fever cases diagnosed. The
biochemical and serological methods used to identify
suspected strains in this study are universally accepted
(Cheesbrough 1985). It was surprising to find that all the
typhoid fever cases identified were cases of S. paratyphi A
as S. typhi is known to be the most common germ
responsible for typhoid fever in West Africa. It is unlikely
to be due to laboratory error as all the isolates were
confirmed to be S. paratyphi in the Yaounde Reference
Laboratory. Our findings therefore put to question the
ª 2003 Blackwell Publishing Ltd
13653156, 2003, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1046/j.1365-3156.2003.01012.x by Yemen Hinari NPL, Wiley Online Library on [27/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
volume 8 no 6 pp 575–578 june 2003
belief that S. paratyphi is only common in the Far East and
Egypt (Le Minor & Véron 1990). On the other hand, our
finding may be coincidental as only a very small proportion
of patients was positive on cultures.
We used standard culture media and techniques and
therefore the low yield could not be attributed to technical
laboratory problems. The use of blood and stool culture
simultaneously was aimed at increasing the sensitivity of
this diagnostic test. The low yield of cultures may have
resulted from antibiotic therapy prior to consultation.
However, less that 5% of patients admitted to having
taken antibiotics prior to consultation. We acknowledge
that multiple cultures would have increased culture yields
but we had limited quantities of culture media and
consequently could not carry out multiple cultures. Fol-
lowing-up outpatients also presented enormous difficulties,
which is why we could not collect convalescent sera for
Widal testing that may have helped in the diagnosis of
some culture negative typhoid fever cases. Patients who
had received antibiotics prior to culture were not analysed
separately as only a small proportion of patients (<5%)
were sure that they had taken antibiotics prior to
consultation.
Malaria was found to be common in our study group
(47%). Our findings are similar to the findings of Ammah
et al. (1999) who found malaria in 57.5% of the 200
patients with signs and symptoms suggestive of both
malaria and typhoid fever. In 101 of 200 patients (50.5%)
the diagnosis was unknown because of the limited number
of tests we were able to do. These patients may represent
self-limiting or non-specific viral infections and other
bacterial or parasitic infections at an early stage (Onuigbo
1990).
The treatment of patients who do not have typhoid fever
results in unnecessary exposure to side-effects of antibiotics
such as chloramphenicol and also leads to unnecessary
expenditure by patients and families. Considering that
treatment of typhoid fever may cost between US$ 4 and
US$ 40 depending on the antibiotic used, this impoverishes
families, delays diagnosis and treatment of other acute
febrile illnesses and therefore puts lives at danger.
Currently, the most common diagnosis and treatment
strategy amongst clinicians in Cameroon is to carry out a
thick film and Widal test for all patients with fever and
who may have typhoid. As only a very small proportion of
patients suspected of having typhoid fever were actually
found to have it in this study, this does not a appear to be a
cost effective strategy. Precious financial resources of
impoverished families may be wasted on unnecessary
Widal tests, which cost up to US$ 10. The strategy of
routinely treating all of these patients for both malaria and
typhoid fever unverified by appropriate tests is likely to be
577

Tropical Medicine and International Health
E. F. Nsutebu et al. Typhoid in Cameroon
very costly and also exposes patients to the unnecessary
side-effects of antibiotics. The most sensible and cost-
effective strategy appears to be to routinely carry out a
thick film for malaria and only perform a Widal test if the
thick films are found to be negative and if there is high
clinical suspicion for typhoid fever.
In conclusion, we found that typhoid fever is not as
endemic in Cameroon as recently reported. About 50% of
febrile patients with symptoms clinically compatible with
typhoid fever are falciparum malaria cases. Strong clinical
suspicion of typhoid fever still warrants therapeutic inter-
vention in order to avoid the severe complications associ-
ated with late onset of treatment. But when the diagnosis is
equivocal, patients should be investigated for malaria in
the first instance and the Widal test performed if thick films
for malaria are negative. If the Widal test is negative
(O antibody <1/200), patients should be re-assessed for
other causes of fever. In health facilities where thick films
and Widal tests cannot be performed, the clinician should
rely on clinical signs and the fact that the prevalence of
malaria is much higher than that of typhoid fever.
Improved diagnostic accuracy can be expected to benefit
patients by reducing the number of unnecessary Widal tests
requested and antibiotics prescribed for suspected cases of
typhoid fever.
Acknowledgements
This study was made possible through funds provided by
the Roche Foundation for Medical Research in Africa,
Authors
Dr Dieudonne Adiogo, Department of Microbiology and Infectious Diseases, Faculty of Medicine and Biomedical Sciences, University
of Yaounde 1, PO Box 8445, Cameroon.
Professor Peter Martins, Department of Microbiology and Infectious Diseases, Faculty of Medicine and Biomedical Sciences, University
of Yaounde 1, PO Box 8445, Cameroon.
Dr Emmanuel Fru Nsutebu, TB Research and Development Programme, Nuffield Institute for Health, University of Leeds, 71–72
Clarendon Road, Leeds LS2 9PL, UK. Tel.: +44 1132 334 861, E-mail: hssefn@leeds.ac.uk (Corresponding author).
578
13653156, 2003, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1046/j.1365-3156.2003.01012.x by Yemen Hinari NPL, Wiley Online Library on [27/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
volume 8 no 6 pp 575–578 june 2003
Cote d’Ivoire and the National Epidemiology Board,
Cameroon. Special thanks go to all the patients who agreed
to participate in this study.
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