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Save a life: How to discern who has typhoid

By The Citizen
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In Nigeria, it is a general belief that when you treat malaria and you do not get better, the next thing to do is treat typhoid. So you either have 'malaria /typhoid' or you have malaria and typhoid. It is difficult to convince those holding this belief otherwise. To them, you either accept it or you are not knowledgeable enough to know. As such, knowing the actual numbers of typhoid cases becomes a challenge. Is it the real typhoid or the presumed typhoid? Your guess is as good as mine.

Here we will discuss the two 'Types' of typhoid. Resistant malaria/self diagnosed 'Typhoid''. This type of typhoid is commonly self-diagnosed. The individual will treat self for malaria without getting better and with or without the benefit of medical tests, will conclude that it must be typhoid and antibiotics treatment will be commenced immediately. In other cases, diagnostic tests would have revealed persistent malaria parasite despite previous anti-malaria medications. The doctor would have subsequently suggested further treatment for malaria or simple rest. But the patient will be quick to dismiss the doctor as not competent and go ahead on the advice of ''friends'' to swallow antibiotics before getting ''better.'' Another group of people will insist from the beginning that since they were born, they have not been sick of malaria. Rather, typhoid has been their problem, and it can only be resolved with the flushing of their system with 'drip.' A smart doctor who has tried without success to convince the patient will likely go along; so long as the drip will psychologically heal the patient without any harm and it will be 'paid' for. It must be mentioned that a significant number of typhoid treated in Nigeria fall into this category of ''if it is not malaria, it must be typhoid.''

Real Typhoid:
Typhoid fever is caused by the Salmonella typhi bacteria or its paratyphi variant. It is a disease that is known to infect humans only and has been known in ancient time to wipe out a whole settlement of people. With the advent of antibiotics, death due to the disease which used to be almost 50% high is now much lower than 10%.But typhoid fever remains a major cause of morbidity and mortality in countries where hygiene and clean drinkable water is a challenge. Currently, India and other parts of Asia witness about ¾ of typhoid cases in the world, with Africa having a fair share of the rest. In total, about a quarter of a million people annually still die of the disease worldwide.

The real incidence of typhoid in Nigeria may be difficult to quantify with prevalent abuse of antibiotics and paucity of data, however, as highlighted above, it can be said with some degree of certainty that its occurrence has been greatly exaggerated by both the patients and medical personnel. With an incubation period of about 7-14days, typhoid fever is transmitted faeco- orally through the consumption of water and foods already contaminated by the salmonella bacteria. An important mode of transmission is through carriers who have had typhoid fever previously, may not be currently ill but have a large reservoir of the organism in their system which they shed continually in their stool. These set of individuals have the potential to infect several people with typhoid, especially if they are involved in food preparation.

Symptoms:
Typhoid infection manifests with different symptoms based on the stage at which the disease is caught. Over a four week period varied signs and symptoms are seen. In the first week of infection, symptoms such as fever, abdominal pain, constipation/ diarrhea, and headache are seen In the second week, if treatment has not been commenced, there is a progressive worsening of the above symptoms and there could be abdominal distention, development of rashes and slowing of the heart beats. The third week witnesses more debilitating happenings, with fever still persisting, intestinal bleeding /perforation, confusion, apathy and outright psychosis. By the fourth week, if the patient is not dead, he or she will start observing improvements in symptoms and then begin a recovery spanning a long period of time with significant complications.

In our setting, the common and most popular test for detecting typhoid is the Widal test. By no means the gold standard, widal test has been in use since Mr Widal formulated it at the end of last century. Though the best methods for detecting typhoid is culture of the blood ,stool or urine, the associated cost and other factors, have greatly limited their use in most developing countries.

Widal test, a rapid diagnostic test which tests for antibody against typhoid has become the most widely used instead for diagnosing typhoid. But its accuracy has been queried and its tendency to diagnose typhoid false positively has been well documented, especially if the test is not appropriately interpreted. For Widal test to be significant: It must be carried out from the second week of infection, at which time the O and H antibodies are usually at their peak. But this is usually difficult in practice as delay in treatment may be fatal More than a single test must be carried out to demonstrate a rising titre. Again this is not practicable It must be done prior to application of antibiotics, a difficult situation in environments where antibiotics is commenced even before presentation at the hospital The values must be higher than the average titre in the population. Because this varies from for different region of the world, a value of 1/80 may be high in a particular country but low in another.

The previous typhoid history of an individual must be known, as the agglutinins are known to persist after an old infection, and may give a picture of an ongoing infection. Overall, the doctor is the best person to diagnose Typhoid fever, relying not only on the widal results but also on the clinical picture and previous medical history of the patient.

Treatments:
This is another area where many Nigerians are consultant physicians. Any adult will easily tell you that ciprotab is the drug to grab off the shelf if you have typhoid. While this may not be incorrect, as quinolones, the group to which ciprofloxacin belongs are effective in typhoid treatment; indiscriminate use of antibiotics may easily lead to resistance. Prevention: Nothing beats good hand washing and general hygienic practices when it comes to preventing typhoid fever. In addition, food handlers test should be carried out to detect carriers of the infection. Such carriers until cleared of all traces of the organisms are not qualified to prepare meals for others.

Vaccination
: Though not routine in Nigeria, typhoid vaccination is recommended for anyone who wants to be doubly sure of their protection against typhoid and can afford it. Two types of vaccines -oral and injectable -are available. The injectable can be given from the age of two years and above, while the oral can only be taken from the age of six years. The protection from the vaccines lasts an average of 3years, after which a booster dose may be required if the individual is still considered at risk.

Conclusion:
In conclusion, most people in Nigeria who have 'typhoid' are actually suffering from malaria or other febrile illnesses and not typhoid fever. But as long as patients insist they have typhoid and are willing to pay for the treatment, diagnosis of typhoid will continually be made and 'treatment' proffered. So, next time you have 'typhoid' just ask yourself, do I really really have typhoid? - Culled from The Nation.