Monday, 19 March 2012

MALARIA: Typhoid Fever and the Challenge of Nonmalaria Febrile Illness in Sub-Saharan Africa

John A. Crump
In this issue of Clinical Infectious Diseases, 2 papers shed important light on the problem of typhoid fever in Sub-Saharan Africa and stimulate reflection on the challenges raised by the syndrome of fever in low-resource settings. Neil et al [1] report the investigation of an increase in intestinal perforations from rural western Uganda. By improving the clinical microbiology services available in the outbreak area and by implementing active surveillance at healthcare facilities in the district, the research team was able to confirm Salmonella enterica serovar Typhi as the etiologic agent and estimate the typhoid fever annual incidence in the study area at 8092 cases per 100 000 persons. This very high typhoid fever incidence rate was associated not only with hundreds of hospitalizations and intestinal perforations but also with 47 deaths. Lutterloh and colleagues [2] investigated an outbreak of unexplained febrile illnesses with neurologic findings along the Malawi–Mozambique border. Again, making diagnostic services available in the rural and remote outbreak area allowed SalmonellaTyphi to be established as the cause. A careful clinical and epidemiologic investigation, including enhanced surveillance of suspected, probable, and confirmed cases of typhoid fever, characterized 40 patients with debilitating focal neurologic manifestations, including upper motor neuron signs, ataxia, and Parkinsonism, and 11 deaths.Fever is among the most common syndromes prompting persons to seek healthcare in Sub-Saharan Africa, and the numerous causes of febrile illness are often difficult to distinguish clinically. Although malaria may be ruled out by blood film examination or a malaria rapid diagnostic test, clinicians in resource-limited areas often have few diagnostic tools to determine the etiology and inform treatment decisions for those patients without malaria [3]. .....

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