1. TYPHOID FEVER IN NIGERIA REAL OR UNREAL THE SOUTH EASTERN NIGERIA EXPERIENCE   DR. R. C. OKANI, DR. N. UDONWA AND DR. A. A. OPARA University of Calabar Teaching Hospital, Calabar.
Annual General and Scientific Meeting of West African College of Physicians (Nigeria Chapter), April 1994.

2. ABSTRACT
In recent times, there has been a state of public alarm and panic in S. E. Nigeria over a febrile illness, purported to be typhoid. Clinical and laboratory bases for the diagnosis of typhoid fever were reviewed. The specificity and reliability of the widal test as a serological diagnostic tool was revisited in 640 normal sera and 677 clinical specimens. Titres of 80 occurred in more than 5% of normal Sera in the area. Tires above 80 were therefore suggested as possible evidence of typhoid fever. Of the 677 clinical samples processed in the laboratory between 1992 and 1993, only 6.8% had titres above 80. Investigation revealed as gross abuse of the Widal test arising from over reporting and wrong interpretation. This has led to an abuse of antibiotics particularly chloramphenicol.
It is recommended that in the absence of paired sera for the demonstration of rising titres, a baseline titre should be established for each area. Also, a combination of clinical presentation and laboratory investigations should form the basis for diagnosis of typhoid fever and treatment with chloramphenicol.
It is concluded that there is no bacteriologically proven typhoid epidemic in this area.

3. INTRODUCTION
Typhoid fever is believe to be unique to man (1) and it is an enteric fever cause by Salmonella spp, a Gram-B=Negative, non-sporing bacilli.
 The disease is common in Tropical Africa (2) and in Nigeria (3,4,5,6) where up to a 30% of patient admitted may die from the infection (6). The high incidence is attributed to attendant poor personal hygiene and environmental sanitation. Comparatively, in the developed countries of Europe and North America of individual and public hygiene and the availability of effective drugs, the incidence is said to be low, while the severity in adult is more than in children. (6).
 The illness has an incubation period of 10 days with a wide variation of between 4 to 60 days (6, 7).
 Fever is one of the commonest modes of presentation (3). Patience who attend clinics with the complaint of fever are subjected to clinical assessment and tests to exclude Typhoid fever. Fernad Widal, a Paris physician (1862 – 1928) had developed the specific test for Typhoid. Widal reaction which is an agglutination reaction test remains the main serological diagnostic tool (8). The patients serum is tested for the presence of antibody which appears in the cause of enteric

4. INTRODUCTION (CONT’D)
Fever and other Salmonella infections. A demonstration of rising Salmonella antibody titres is significant in the diagnosis. Also in the absence of a paired sera, there is a need to have a baseline information on the level of the Slamonella antibody that is prevalent in the community in which the test is done; that is the “normal level for that population” (9). In addition to these technical conditions for diagnosis of typhoid fever by interpretation of widal test, the test itself has been reported to be non-specific, poorly standardized, and often confusing and difficult to interpret (9,10). It has outlived its usefulness, thus; only redundant procedure of appropriate body fluid should be used in diagnosis of Typhoid fever (11, 12, 13.
There is a public alarm about Typhoid fever (10) which can be viewed in the light of the high incidence in Nigeria but the magnitude of the problem has not been known (3).
An attempt to define the magnitude of the problem in South Eastern Nigeria is made in this Study.

5. PATIENTS AND METHODS:
All the patients in this study came form various parts of South Eastern Nigeria and were seen at the out-patient clinics and wards of University of Calabar Teaching Hospital in 1992 and 1993.
Each patient was assessed clinically. Serum samples were analysed by the Widal agglutination technique for the presence and level of Salmonella antibodies using the standardize heat killed Salmonella suspensions (wellcom Reagents, England).
Six Hundred and Forty-eight (648) samples were obtained from normal subjects for the baseline information (14); while 400 and 277 clinical samples were obtained in 1992 and 1993 respectively.

6. RESULTS
Table 1 shows the distribution of Salmonella typhi. And paratyhi. Agglutinins in 677 clinical samples.
Only 33 (8.3%) of the 400 clinical samples analysed in 1992 had titres up to or above 160; while 13 (4.7%) of the 277 samples collected in 1993 had tires of 160 and above.
Generally, of the 677 clinical samples, only 46 (6.8%) had tires of 160 and above.
Over fifty-four and one half percent and 56.3% had agglutinin tires of 80 and below in the two periods respectively.

7. Aggutinin (Positive %)
Salmonella typhoid agglutinin titres of single clinical samples by Widal Test.
No Agglutinin
(Negative %)
Aggutinin (Positive %) 80
160
1992
148 (37)
155 (38.7)
64 (16)
33 (8.3)
N = 400
219 (54.8)
1993
108 (38.9)
57 (20.6)
99 (35.7)
13 (4.7)
N = 277
156 (56.3)
Total
N= 677
256 (37.8)
212 (31.3)
163 (24)
46 (6.8)
375 (55.4)

8. DISCUSSION:
The Salmonella agglutinin’s are commonly present in the sera of normal subjects in the study area (14).
The work which demonstrated the distribution of Salmonella agglutinin titres from normal subjects in South Eastern Nigeria showed that antibodies to the typhoid and paratyphoid Salmonella were commonly present in 482 (74.4%) out of 648 subjects.
Titres from were present in 180 (14.5%) of the subjects who had the presence of agglutinin titres in their sera.
Because only single clinical serum samples are often received these authors had established a baseline titre which serves as a guide in the absence of paired sera.
Further more their results showed that antibodies to the typhoid and paratyphoid salmonella were commonly present in a significant proportion of sera of the subjects.
Based on statistical analysis, they established that titres from 20 – 80 could be regarded as normal in this area.
Thus 80 has been taken as the baseline titre in this study.

9. Discussion (Cont’d)
From the clinical specimens analysed in the 1992 – 1993 period and based on the baseline titre of 80, 631 (93.2%) of the 677 had the baseline titre of 80. the present alarm over the alleged rise in typhoid cases can be attributed to the number of positive cases that are often reported without due consideration of the baseline titre.
In the present study 421 (62.2%) of 677 patients has positive results which may be wrongly interpreted to mean typhoid fever.
Due to greed for money, some clinicians and laboratory staff, present these positive results to the public as typhoid fever and even go on to treat.

10. REFERENCES:
1. OLUBUYIDE I,O., Typhoid Fever in the tropics, postgraduate Doctor Africa 19…, 14, 37, - 41.
2. HUCKSTEP RL: Typhoid Fever and other Salmonella infections F and S Livingstone Ltd, Edinburg and London 1962.
3. IDOKO J.A. ANJORIN FI, LAWANDE RV, Typhoid fever in Zaria Northern Nigeria, Nig. Med. Practitioner , ½ 21 – 23.
4. IKEME A.C AND ANAN CO, A clinical review of Typhoid fever in Ibadan. Nigeria Journal of Trop Med. & Hygiene 1966, 69, 15 – 21.
5. MULLIGAN T.O, Typhoid Fever in Illesha, Western Nigeria, West African Medical Journal 1971, 20, 358 – 368.
6. BOOSMA L.J, Clinical aspects of typhoid fever in two rural Nigerian Hospitals: A prospective study. Trop. Geogr. Med. 1987, 40: 07 – 102.
7. NYE F.J, BELL DR, Gastioentestional infections, Medicine, 5,

11. REFERENCES (Cont’d)
8. DUGUID J.P, MAMION BP, SWAIN RHA, Salmonella: 1 Typhoid and Paratyphoid Fevers in machine and McCartney Medical Microbiology 13 Ed. Vol. 1, ELBS and Churchill Living Stone 1978, 314 – 319.
9. THOMAS GGA. Gram-Negative Bacilli in Medical Microbiology. Bailere Tindall 3rd Ed – 275.
10. ONUIGBO M.A.C. Typhoid Fever Epidemic in Nigeria. The abuse of the Widal Test and the antibiotic Chloramphenicol Nigeria Medical Practitioner, 8, 2,
11. GEDDES A.M Typhoid Fever. Postgraduate Doctor (Africa Series): , 1981.
12. PANG T. and PUTHUCHERG S.D Significance and Value of the Widal Test in the Diagnosis of Typhoid Fever in and endemic area. J. CLIN. PATHOL. 38:
13. BR. MED. J. (News and Notes. Epidemiology) Typhoid Fever 1: 377, 1978.
14. AKPARA A.A: and NWAEKE A.E Baseline Values of Salmonella agglutinin’s in Parts of South Eastern Nigeria. Journal of Medical Laboratory Sciences 1,