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Diagnostic Value of Widal Test in the Diagnosis of Typhoid Fever: A Systematic Review

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Hylemariam Mihiretie Mengist at Debre Markos University
Hylemariam Mihiretie Mengist
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Introduction: Typhoid fever the common cause of morbidity and mortality especially in the developing countries where Widal test is routinely used as diagnostic tool to rule out the disease. The diagnostic ability of Widal test is debatable as the test method has a low sensitivity, specificity and positive predictive value (PPV). Therefore, reviewing articles across the world regarding the diagnostic value of Widal test is necessary. Methods: Systematic review of published articles regarding the diagnostic value of Widal test to rule out typhoid fever was carried out. Published articles were identified from PubMed, Google scholar, HINARI and other sources. The mean, median, percentile and standard deviation of sensitivity, specificity, NPV and PPV of the reviewed articles were computed by SPSS software version 24. Results: A total of 16 articles were included in the systematic review with the oldest publication in the year 1994 and the recent in 2015. The mean sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of Widal test was 73.5%, 75.7%, 60% and 75.2%, respectively. Conclusion: The systematic review results show that the reliability of Widal test is comparatively poor. Therefore, Widal test should not be used as a diagnostic tool to rule out typhoid fever unless supported by invasive clinical pictures and other confirmatory tests.
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Research Article Open Access
Mengist and Tilahun, J Med Microb Diagn 2017, 6:1
DOI: 10.4172/2161-0703.1000248
Research Article Open Access
Journal of
Medical Microbiology & Diagnosis
ISSN: 2161-0703
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Volume 6 • Issue 1 • 1000248
J Med Microb Diagn, an open access journal
ISSN: 2161-0703
*Corresponding authors: Mengist HM, Department of Medical Laboratory
Sciences, Wollega University, Nekemte, Ethiopia, Tel: 251576617981;
E-mail: hylemariam@gmail.com
Received September 08, 2016; Accepted February 01, 2017; Published February
06, 2017
Citation: Mengist HM, Tilahun K (2017) Diagnostic Value of Widal Test in the
Diagnosis of Typhoid Fever: A Systematic Review. J Med Microb Diagn 6: 248.
doi:10.4172/2161-0703.1000248
Copyright: © 2017 Mengist HM, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Abstract
Introduction: Typhoid fever the common cause of morbidity and mortality especially in the developing countries
where Widal test is routinely used as diagnostic tool to rule out the disease. The diagnostic ability of Widal test
is debatable as the test method has a low sensitivity, specicity and positive predictive value (PPV). Therefore,
reviewing articles across the world regarding the diagnostic value of Widal test is necessary.
Methods: Systematic review of published articles regarding the diagnostic value of Widal test to rule out typhoid
fever was carried out. Published articles were identied from PubMed, Google scholar, HINARI and other sources.
The mean, median, percentile and standard deviation of sensitivity, specicity, NPV and PPV of the reviewed articles
were computed by SPSS software version 24.
Results: A total of 16 articles were included in the systematic review with the oldest publication in the year 1994
and the recent in 2015. The mean sensitivity, specicity, positive predictive value (PPV) and negative predictive value
(NPV) of Widal test was 73.5%, 75.7%, 60% and 75.2%, respectively.
Conclusion: The systematic review results show that the reliability of Widal test is comparatively poor. Therefore,
Widal test should not be used as a diagnostic tool to rule out typhoid fever unless supported by invasive clinical
pictures and other conrmatory tests.
Diagnostic Value of Widal Test in the Diagnosis of Typhoid Fever: A
Systematic Review
Hylemariam Mihiretie Mengist1* and Kelemu Tilahun2
1Department of Medical Laboratory Sciences, Wollega University, Nekemte, Ethiopia
2Department of Public Health, Wollega University, Nekemte, Ethiopia
Keywords: Diagnostic value; Widal test; Typhoid fever
Introduction
Typhoid fever is a systemic disease caused by Salmonella typhi and
is the major cause of morbidity and mortality worldwide [1]. Reports
by the World Health Organization revealed that about 21 million cases
and >600,000 annual deaths from typhoid fever occur throughout
the world. Developing nations share the highest burden due to rapid
population growth, increased urbanization, and limited safe water and
health systems [2,3].
Accurate diagnosis of typhoid fever at an early stage is important
not only for etiological diagnosis, but also to identify individuals that
may serve as potential carriers, who may be responsible for acute
typhoid fever outbreaks. Additionally, the diagnosis of typhoid fever on
clinical grounds is dicult, as the presenting symptoms are diverse and
similar to those observed with other febrile illnesses. Serodiagnosis of
typhoid fever has been attempted since the late nineteenth century by
Widal and Secard. e test is based on demonstrating the presence of
agglutinins (antibodies) in the serum of an infected patient, against the
H (agellar) and O (somatic) antigens of Salmonella enterica serotype
typhi (S. typhi) [4-8].
Widal test relies on the demonstration of a rising titer of antibodies
in paired samples 10 to 14 days apart. In typhoid fever, however, such a
rise is not always demonstrable, even in blood culture-conrmed cases.
In addition, interpreting the test has been such a problem that dierent
cut-os have been reported from dierent places which makes diculty
in patient management. Furthermore, the test has a low sensitivity,
specicity and positive predictive value (PPV) [9-12] which may create
over diagnosis of typhoid fever, patient dissatisfaction, inappropriate
economic loss and drug resistance in particular.
In the developed nations, Widal test is no longer used as a diagnostic
tool due to the low prevalence of typhoid, access to safe drinking water,
better laboratory facilities to isolate the bacteria, and the low sensitivity
and specicity of the Widal test [13]. is is not the fact in developing
countries including Ethiopia where Widal test is routinely used to
diagnose typhoid fever; although, the diagnostic value of the test has
been debated. Hence, reviewing articles across the world regarding the
diagnostic value of Widal test is necessary.
Methods
Study design and data source
Systematic review of the published literature of observational studies
was conducted. Original studies providing data on the diagnostic value
of Widal test were identied through a computerized search using
databases of Medline/PubMed, Google Scholar, HINARI (Health Inter
Network Access to Research Initiative) and manual search with detailed
search-strategy and cross-checking of reference lists. e search terms
used to search the database were diagnostic value, sensitivity, specicity,
positive predictive value (PPV) and negative predictive value (NPV)
and test eciency of Widal test. e data abstraction was performed
from September, 2015-July, 2016.
Study selection
A systematic review was made on observational studies which were
Citation: Mengist HM, Tilahun K (2017) Diagnostic Value of Widal Test in the Diagnosis of Typhoid Fever: A Systematic Review. J Med Microb Diagn
6: 248. doi:10.4172/2161-0703.1000248
Page 2 of 4
Volume 6 • Issue 1 • 1000248
J Med Microb Diagn, an open access journal
ISSN: 2161-0703
reported on the diagnostic value of Widal test in diagnosing typhoid
fever. Eligibility criteria for articles to be included in the review were
articles presenting data on the sensitivity, specicity, PPV and NPV of
Widal test compared to other tests independent of study design and
without restriction of publication date. Reports of original studies and
review articles written in English language were considered. Studies
available only in abstract form, unpublished theses, dissertations and
articles with sample size of less than 60 were also excluded (Figure 1).
Methodological quality assessment
Using culture method as a gold standard, sample size and use of
right statistical measurement to assess the diagnostic performance of
Widal test were noted as quality of indicators. All assessments were
entered into pre-formatted standardized data extraction forms. Studies
were assessed for quality and studies fullling 75% of quality assessment
parameters were included for analysis. High quality studies were:
studies that reported outcomes on at least 50 samples, cross-sectional
studies and surveillances whose response rate were greater than 80%
and used culture as a gold standard.
Data abstraction
e data abstraction was conducted independently by two of the
investigators (HMM, KT). e selected studies were reviewed by using
pretested and standardized abstraction form to extract data about title;
authors, year of publication, country, study design, study site, study base
(population-based or hospital-based), sample size, data collection procedure
and response rates. When there was a discrepancy in data abstraction, it
was resolved through consensus among the team of investigators.
Statistical analysis
Epi-info version 3.5.1 and SPSS version 24 soware’s were used for
data entry and analysis, respectively. e mean, standard deviation,
range and median sensitivity, specicity, NPV and PPV of the articles
were drawn. e dierence was measured using P value ≤ as a
signicance level.
Results and Discussion
Summary of articles included in the analysis
A total of 16 articles were included in the systematic review with
the oldest publication in the year 1994 and the recent in 2015. e
reviewed articles included 50 sample size with the smallest and 1735
samples with the largest. Ten cross sectional and 6 case control studies
were reviewed (Table 1).
Sensitivity, specicity, PPV and NPV
Sensitivity is the probability that a truly infected individual will test
positive whereas specicity is the probability that a truly uninfected
individual will test negative. Positive predictive value (PPV) is the
probability that those testing positive by the test are truly infected and
Negative predictive value (NPV) is the probability that those testing
negative by the test are truly uninfected.
e mean sensitivity Widal test is 73.5 ± 12.6 (95% CI: 60.9-86.1).
e probability of a true typhoid patient to be positive by Widal test
ranges from 60.9% to 86.1%. erefore 13.9% to 39.1% of true typhoid
patients will be falsely negative by Widal test. e lowest sensitivity
of Widal test was 45.2% and the highest is 98%. e mean ability of
Widal test to declare Salmonella uninfected febrile patients as negative
falls between 55.5% to 95.9%. is indicates that 4.1% to 44.5% of true
negatives test falsely positive by this method compared to blood/stool
culture methods. e lowest specicity of Widal test was 13.8% and the
highest was 98%. e mean PPV of the Widal test is 60% ± 29% (95%
CI: 31% to 89%) and the mean NPV of Widal test is 75.2% ± 24.8%
(95% CI: 50.4% to 100%) (Table 2).
Figure 1: Flow chart diagram describing selection of studies for a systematic review.
Citation: Mengist HM, Tilahun K (2017) Diagnostic Value of Widal Test in the Diagnosis of Typhoid Fever: A Systematic Review. J Med Microb Diagn
6: 248. doi:10.4172/2161-0703.1000248
Page 3 of 4
Volume 6 • Issue 1 • 1000248
J Med Microb Diagn, an open access journal
ISSN: 2161-0703
Authors Year Country Design Comparison
Method
Sen
(%)
Spec
(%)
NPV
(%)
PPV
(%)
Summary of Conclusion
Ref.
No.
Ramyi et al. 2013 Nigeria Cross
sectional Stool culture 71.4 66.7 50 83 Although Widal test is sensitive, it not
relevant to diagnose typhoid alone [13]
Wasihun et al. 2015 Ethiopia Cross
sectional Blood culture 75 95.9 99.6 22.2 Patients were wrongly diagnosed and
treated for typhoid fever by Widal [14]
Aziz and Haque 2012 India Cross
sectional Blood culture 71 62 31 91 Widal test is relevant as a diagnostic
tool for typhoid fever [15]
Gopala Krishnan
et al. 2002 Malaysia Cross
sectional Blood culture 98 76 98 69 Typhoid is less time consuming and
easier than Widal test [16]
Keddy et al. 2011 South Africa Cross
sectional Blood culture 95.2 13.8 70.2 57.1 Both slide and tube Widal tests
performed poorly [17]
Kulkarni and Rego 1994 Karnataka Case control Blood culture 83.3 81 94.2 56.8
Widal test is one of the best, easy,
cheap and simple method to diagnose
typhoid fever
[18]
Andualem
et al. 2014 Ethiopia Cross
sectional Blood culture 71.4 68.4 98.9 5.7 Widal test has a low sensitivity,
specicity and PPV but good NPV [3]
Ley et al. 2010 Tanzania Cross
sectional Blood culture 75 98 100 26 Widal test performed well in terms of
sensitivity, specicity, and NPV. [9]
Sherwal et al. 2004 India Case control Blood culture 74 83 ND ND Typhoid is more reliable than Widal test
for typhoid fever [19]
Parry et al. 1999 Vietnam Case control Blood culture 74 95 90 86 Widal test is helpful for presumptive
diagnosis [20]
Al-Yasiri NP Najaf city Case control Blood culture 74 95 90 86 Widal test can be valuable in the
absence of culture [21]
Alam et al. 2011 Dhaka Case control Blood culture 65 76.4 31.7 81.1 The Widal test can be of diagnostic
value in the absence of culture [22]
Bhutta and
Mansurali 1999 Pakistan Cross
sectional Blood culture 63 81 55 85 Widal test is not sensitive and not
specic [23]
House et al. 2001 Vietnam Case control Serology 60 90 70 84 Widal test is not reliable compared to
other tests [24]
Adhikari et al. 2015 Nepal Cross
sectional Blood culture 45.2 82.3 87.8 34.2 Widal test is not sensitive enough for an
endemic areas for typhoid fever [25]
Sanjeev et al. 2013 India Cross
sectional Blood culture 78.7 58.8 ND ND Widal test is not reliable when
compared to blood culture and typhoid [26]
ND: Not Determined; NP: Not Published
Table 1: Summary the observational studies assessing the value of Widal test in the diagnosis of typhoid fever included in the systematic review.
Measurement Sensitivity Specicity NPV PPV
Mean 73.5 75.7 75.2 60
Median 74 81 87 69
SD 12.6 20.2 24.8 29
Minimum 45.2 13.8 31 5.7
Maximum 98 98 100 91
25 66.5 67 52.5 30
Percentile 50 74 81 87.8 69
50 78 88.3 98.7 84.5
SD: Standard Deviation; PPV: Positive Predictive Value; NPV: Negative Predictive
Value
Table 2: Analysis of Widal test performance reported by articles included in
the review.
Conclusion
e systematic review results show that the reliability of Widal
test is comparatively poor. e mean sensitivity, specicity, NPV and
PPV of Widal test remains below 80%. e eciency of Widal test
in diagnosing typhoid fever without other conrmatory tests is not
of diagnostic value. erefore, Widal test should not be used as a
diagnostic tool to rule out typhoid fever unless supported by invasive
clinical pictures and other conrmatory tests.
Competing Interests
Authors declare that they have no conict of interest associated with the
publication of this manuscript.
Authors' Contribution
Conceived and designed the experiments: HMM. Performed the experiments:
HMM. Analyzed the data: HMM. Contributed reagents/materials/analysis tools:
HMM, KT. Wrote the paper: HMM. Assisted with design, analysis, and interpretation
of data: KT. Critical review of the manuscript: HMM, KT. Read and approved the
nal manuscript: HMM, KT. Critical appraisal of the manuscript: HMM, KT.
Acknowledgement
We want to acknowledge Wollega University for providing internet service
and administrative support. We are glad to thank authors of articles reviewed in
advance.
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Diagnosis of Typhoid Fever: A Systematic Review. J Med Microb Diagn 6: 248.
doi:10.4172/2161-0703.1000248
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... and categorized WASH exposures from case-control studies according to JMP WASH classification, but was applied in a broader level without using specific service ladders. Both studies included findings based on Widalconfirmed typhoid fever cases in addition to cases confirmed through blood culture, which may introduce bias because of the low specificity of the Widal test [13]. ...
... Clinical symptoms of typhoid fever are not specific enough to differentiate from other enteric diseases [51]. Also, previous literature indicated that Widal test had low sensitivity and specificity (< 80%) and did not recommend using Widal test alone when diagnosing typhoid fever [13]. Fourthly, the previous study included more than one estimate from each sample whereas we only included only one estimate from each sample to avoid violating the assumption of Fig. 6 Association between hygiene and typhoid fever. ...
Associations of water, sanitation, and hygiene with typhoid fever in case–control studies: a systematic review and meta-analysis
Article
Full-text available
  • Aug 2023
  • BMC INFECT DIS
Background Water, sanitation, and hygiene (WASH) play a pivotal role in controlling typhoid fever, as it is primarily transmitted through oral-fecal pathways. Given our constrained resources, staying current with the most recent research is crucial. This ensures we remain informed about practical insights regarding effective typhoid fever control strategies across various WASH components. We conducted a systematic review and meta-analysis of case-control studies to estimate the associations of water, sanitation, and hygiene exposures with typhoid fever. Methods We updated the previous review conducted by Brockett et al. We included new findings published between June 2018 and October 2022 in Web of Science, Embase, and PubMed. We used the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool for risk of bias (ROB) assessment. We classified WASH exposures according to the classification provided by the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation, and Hygiene (JMP) update in 2015. We conducted the meta-analyses by only including studies that did not have a critical ROB in both Bayesian and frequentist random-effects models. Results We identified 8 new studies and analyzed 27 studies in total. Our analyses showed that while the general insights on the protective (or harmful) impact of improved (or unimproved) WASH remain the same, the pooled estimates of OR differed. Pooled estimates of limited hygiene (OR = 2.26, 95% CrI: 1.38 to 3.64), untreated water (OR = 1.96, 95% CrI: 1.28 to 3.27) and surface water (OR = 2.14, 95% CrI: 1.03 to 4.06) showed 3% increase, 18% decrease, and 16% increase, respectively, from the existing estimates. On the other hand, improved WASH reduced the odds of typhoid fever with pooled estimates for improved water source (OR = 0.54, 95% CrI: 0.31 to 1.08), basic hygiene (OR = 0.6, 95% CrI: 0.38 to 0.97) and treated water (OR = 0.54, 95% CrI: 0.36 to 0.8) showing 26% decrease, 15% increase, and 8% decrease, respectively, from the existing estimates. Conclusions The updated pooled estimates of ORs for the association of WASH with typhoid fever showed clear changes from the existing estimates. Our study affirms that relatively low-cost WASH strategies such as basic hygiene or water treatment can be an effective tool to provide protection against typhoid fever in addition to other resource-intensive ways to improve WASH. Trial registration PROSPERO 2021 CRD42021271881.
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... 14 This study revealed Widal's test NPV as 100% suggestive of a possibility of all participants with nonreactive Widal's test result as not having typhoid fever. 8,9 This finding was similar to most of the studies reviewed whose NPV was above 90% with exception of Mengist (2017) 11 This study revealed that the Widal's test had a sensitivity of 100%. This indicated that, the Widal's test had the ability to rule out the presence of typhoid fever and this surpasses that of Widal's test acceptable of 70%. ...
Typhoid diagnosis and associated prevailing drug resistance in Mbale city, Uganda
Article
  • Feb 2024
Background The study aimed at determining the predictive values of Widal’s test against culture and the antimicrobial sensitivity profile of Salmonella typhi ( S. typhi ) isolates from patients attending private health facilities in Mbale city, Uganda. This was to provide evidence-based information to policy implementers for guideline enforcement. Methods This was a quantitative cross-sectional study in which 172 participants were recruited. Blood and stool samples collected were cultured; and to each stool sample the following tests were done; Xylose Lysine Deoxycholate (XLD), Salmonella Shigella agar (SSA), and MacConkey. Isolates suggestive for S. typhi were examined with triple sugar iron (TSI) and SIM (Sulphur, indole, and motile) and antibiotic sensitivity test (Ciprofloxacin, Imipenem, Ceftriaxone, Chloramphenicol and Augmentin for sensitivity testing) conducted with Mueller Hinton respectively. Generated data was entered in the Epidemiological information (Epi Info) software (version 7) and analyzed using the contingency table to determine the sensitivity, specificity, positive predictive value and the negative predictive value. The analysis was then presented in form of graphs and tables. Results The positive predictive value (PPV) for Widal’s test was 6.8% while the negative predictive value (NPV) was 100%. Three isolates were sensitive to Ciprofloxacin (3, 100%) and Imipenem (3, 100%), intermediate to Ceftriaxone (2, 67%) and resistant to Chloramphenicol (2, 67%) and Augmentin (2, 67%). Conclusion In comparison with culture, Widal’s test is highly sensitive (100%) with a low specificity of 76% and PPV (6.8%) and NPV (100%). It should therefore be followed up with a more specific confirmatory test. S. typhi was highly sensitive to both Ciprofloxacin and Imipenem; and resistant Chloramphenicol and Augmentin.
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... confirming the validity of the PCR method (Chirambo et al. 2020). The lack of sensitivity and specificity of Widal test with the necessary to repeat the test make it unsuitable for rapid diagnosis of enteric fever (Mengist and Tilahun 2017). in study (Noha et al. 2023). ...
Evaluating the virulence factors of Salmonella typhi isolated from children suffering from severe diarrhea using molecular genetic techniques
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Full-text available
  • Jul 2023
Jaber AS. 2023. Evaluating the virulence factors of Salmonella typhi isolated from children suffering from severe diarrhea using molecular genetic techniques. Biodiversitas 24: 3543-3549. Salmonella enterica subsp. serotype Typhi is the bacteria that causes typhoid fever. Although its prevalence has significantly decreased in affluent nations, it continues to be a leading cause of illness and mortality in emerging nations. Because of changes in ecology, eating habits, and agricultural and food production techniques, Salmonella infections have increased in frequency in industrialized countries. This study aimed to use qualitative RT-PCR (based on the ttr gene) and conventional PCR to measure the frequency of Salmonella typhi in Iraqi children with chronic diarrhea (based on PagN and TolC genes). This study included 100 stool samples collected from children suffering from continuous diarrhea. Those samples were inoculated on CHROM-agar and incubated 37°C for 18-24 hours, then Salmonella was identified using a Vitek 2 compact system. DNA has been extracted, and qRT-PCR has been done to detect Salmonella sp. by the amplification of the ttr gene. Then PCR also done to amplify TolC and PagN genes. The amplified products then sequenced to reveal mutations within the amplified regions. The results of PagN gene showed 41 samples were positive, and 40 samples were positive for TolC. Results of qRT-PCR according to the ttr gene amplification showed 38 samples positive. The blood group O+ showed a higher number of positive samples (13), and males showed higher positive samples than females (23 and 15, respectively). Sequencing revealed various number of mutations within the amplified regions of both PagN and TolC in the samples which isolated from children with the longest period of illness.
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... 15 The Widal test is no longer being used in developed countries due to its poor performance. 16 Hence, its use and interpretation should be done cautiously and in accordance with the clinical context, which is an arduous job. 6 Even in non-endemic countries, the diagnostic value of the Widal test is too low. ...
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... 12 The reliabilities of individual diagnostic tests are inadequate, requiring multiple diagnostic tools and clinical features to increase their diagnostic value. 16 Therefore, taken together, these factors may falsely increase the rate of idiopathic causes. The second common etiology was radiation-induced perforation. ...
Retrospective Cohort Study of Non-Traumatic Jejunum and Ileum Perforation: A Multi-center Study
Article
Full-text available
  • Mar 2023
Aim: Non-traumatic jejunum and ileum perforation (NTJIP) is a rare clinical entity. Contrary to infective causes occurring in Eastern countries, immune-mediated pathologies are predominant in the West. The studies on NTJIP in Southeast Asia are lacking. This study is designed to describe the involved patients incidences, etiological patterns, and outcomes. This study analyzed the predictors of mortality in these patients. Method: This retrospective cohort study involved patients with NTJIP who underwent surgery over 4 years from 2016 to 2019. Data were sourced from operative databases of five tertiary public hospitals in Sarawak, Malaysia. Small bowel perforation data were screened, and patients with adhesive obstruction from previous surgeries, trauma, and duodenal perforation were excluded. Patients' socio-demographic characteristics, surgical characteristics, and outcomes were stated in the prepared pro forma. Results: From 2016 to 2019, a total of 42 patients with NTJIP were included in this study. The mean [standard deviation (SD)] age of incidence was 55.7 (19.3) years old. Twenty-nine presented within 3 days of symptoms. Their etiologies were attributed mainly to non-specific causes (29%), followed by radiation-associated perforation (17%). The mean (SD) hospital stay was 10 (3) days, with the post-operative complication rate of ileus at 21%, surgical site infection at 23%, and anastomotic leak at 23%. The mortality rate was 36%, and the Mannheim peritonitis index was a reliable predictor of mortality. Conclusion: This study observed that radiation and vascular etiologies were the most common identifiable causes of NTJIP in the current series. Further research would prove beneficial to analyze inconclusive cases, as the dilemma surrounding etiologies for NTJIP remains.
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... However, microbiological culture is time-consuming and resource intensive, and therefore has been difficult to sustain in low-and-middleincome countries (LMICs) where typhoid fever is endemic 11 . Consequently, the Widal test, based on seroconversion to surface (O) and flagellin (H) antigens, is still commonly used to diagnose typhoid, despite its low sensitivity and specificity 12,13 . Currently there are no point-of-care diagnostics that are sufficiently accurate to replace blood culture 14 . ...
Environmental surveillance for Salmonella Typhi as a tool to estimate the incidence of typhoid fever in low-income populations.
Article
  • Jan 2023
Background: The World Health Organisation recommends prioritised use of recently prequalified typhoid conjugate vaccines in countries with the highest incidence of typhoid fever. However, representative typhoid surveillance data are lacking in many low-income countries because of the costs and challenges of diagnostic clinical microbiology. Environmental surveillance (ES) of Salmonella Typhi in sewage and wastewater using molecular methods may offer a low-cost alternative, but its performance in comparison with clinical surveillance has not been assessed. Methods: We developed a harmonised protocol for typhoid ES and its implementation in communities in India and Malawi where it will be compared with findings from hospital-based surveillance for typhoid fever. The protocol includes methods for ES site selection based on geospatial analysis, grab and trap sample collection at sewage and wastewater sites, and laboratory methods for sample processing, concentration and quantitative polymerase chain reaction (PCR) to detect Salmonella Typhi. The optimal locations for ES sites based on digital elevation models and mapping of sewage and river networks are described for each community and their suitability confirmed through field investigation. We will compare the prevalence and abundance of Salmonella Typhi in ES samples collected each month over a 12-month period to the incidence of blood culture confirmed typhoid cases recorded at referral hospitals serving the study areas. Conclusions: If environmental detection of Salmonella Typhi correlates with the incidence of typhoid fever estimated through clinical surveillance, typhoid ES may be a powerful and low-cost tool to estimate the local burden of typhoid fever and support the introduction of typhoid conjugate vaccines. Typhoid ES could also allow the impact of vaccination to be assessed and rapidly identify circulation of drug resistant strains.
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... Typhoid fever is endemic in STP, as it is common in SSA, which lacks access to clean water and adequate sanitation and found on 14.8% of pregnant women [40,41]. However, the efficiency of the Widal test in diagnosing typhoid fever without other confirmatory tests is not of diagnostic value; thus, it should not be performed as a routine antenatal care practice in STP [53]. ...
Antenatal screenings and maternal diagnosis among pregnant women in Sao Tome & Principe—Missed opportunities to improve neonatal health: A hospital-based study
Article
Full-text available
  • Dec 2022
Newborn mortality and adverse birth outcomes (ABOs) in Sao Tome & Príncipe (STP) are overwhelmingly high, and access to quality-antenatal care (ANC) is one of the strategies to tackle it. This study aimed to fill the gaps in ANC screenings with a focus on how to improve neonatal outcomes. We conducted a retrospective hospital-based study in which ANC pregnancy cards were reviewed. Screenings were described and compared according to the total number of ANC contacts: 1–3 (inadequate), 4–7 (adequate), and ≥8 (complete). The collected data were entered into QuickTapSurvey and exported to SPSS version 25 for analysis. Statistical significance was considered at a p-value ≤0.05. A total of 511 ANC pregnancy cards were reviewed. Mothers’ mean age was 26.6 (SD = 7.1), 51.7% had a first trimester early booking, 14.9% (76) had 1–3 ANC contacts, 46.4% (237) had 4–7 and 38.7% (198) ≥8. Screening absence was found in 24%-41%, lack of money was registered in 36%. Pregnant women had no screening performed for HIV in 4.5%, syphilis in 8.8%, HBV 39.3%, malaria 25.8%, hemoglobin 24.5%, blood glucose 45.4%, urine 29.7%, stool exams 27.8% and 41.1% had no ultrasound. Screening completion for blood group, HIV, malaria, urine, hemoglobin, and coproparasitological exam were found to have a statistically significant difference (p<0.001) for the complete ANC group when compared to other groups. Antenatal problems identified were: 1) bacteriuria (43.2%); 2) maternal anemia (37%); 3) intestinal parasitic infections (59.2%); 4) sickle cell solubility test positive (13%); and 5) a RhD-negative phenotype (5.8%). Missed-ANC treatments were up to 50%. This study reveals a coverage-quality gap in STP since no pregnant woman is left without ANC contact, although most still miss evidence-based screenings with an impact on neonatal outcomes. Strategies such as implementing a total free ANC screening package in STP would enhance maternal diagnosis and prompt treatments.
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... This low S. Typhi isolation rate from patients considered to have typhoid fever by positive Widal test (≥1:80) and the high rate of isolation of other enteric pathogens (Shigella spp) aside S. Typhi emphasizes the low sensitivity and specificity (from possible cross-reactivity from other enteric pathogens) of the Widal test in the diagnosis of typhoid fever (5,15). Although, several studies have documented inherent variabilities of the Widal test, difficulty in establishing a steady state baseline titre, and lack of reproducibility of the test result (16,17,18), evidence from our study might suggest that a positive Widal test correlates more with infections caused by other enteric bacteria aside typhoid fever. ...
Widal antibody titre test versus blood culture; which is a better diagnostic for typhoid fever?: Test de titre d'anticorps Widal versus hémoculture; quel est le meilleur diagnostic pour la fièvre typhoïde?
Article
Full-text available
  • Oct 2022
Background: The importance of accurate diagnosis of infectious diseases is central and crucial to the effectiveness of treatment and prevention of the associated long-term complications of such infections. The objective of this study was therefore to determine the accuracy of the Widal antibody titre test in the diagnosis of typhoid fever relative to the gold standard blood culture technique.Methodology: A total of 40 students attending the Olabisi Onabanjo University Health Services, Ago-Iwoye, Ogun State, Nigeria on account of suspected typhoid fever by positive Widal test (≥ 1/80) and not on antibiotic therapy, were recruited for the study. Stool and blood samples were collected from each participant and analysed at the medical laboratory of the health center using conventional culture techniques and confirmation of isolates by simplex and multiplex polymerase chain reaction (PCR) amplification assays of hilA (Salmonella enterica), ipaH (Shigella spp), rfc (Shigella flexneri) and wbgZ (Shigella sonnei) genes. Antibiotic susceptibility testing (AST) of isolated bacteria to 10 panel of antibiotics was done using the Kirby Bauer disk diffusion test and interpreted according to the Clinical and Laboratory Standards Institute (CSLI) guideline.Results: Of the 40 patients with suspected typhoid fever by the Widal test, 9 yielded Salmonella enterica giving a 22.5% isolation rate, with Salmonella enterica serovar Typhi (Salmonella Typhi) confirmed as sole bacterium from blood cultures in 5 (12.5%) patients and co-infection of Salmonella and Shigella from stool samples in 4 (10.0%) patients. A total of 52 enteric bacteria isolates were recovered from blood and stool samples of the 40 patients made of Salmonella enterica 9 (17.3%), Shigella spp 20 (38.5%), S. flexneri 9 (17.3%) and S. sonnei 14 (26.9%). All the enteric isolates were multi-drug resistant (MDR), with resistance rates to the antibiotic panel ranging from 33.3%-100%, and all the isolates were resistant to ceftriaxone and pefloxacin. Salmonella isolates were also 100% resistant to nitrofurantoin, ofloxacin and ciprofloxacin; S. flexneri were 100% resistant to nitrofurantoin, amoxicillin, cotrimoxazole, ofloxacin and ciprofloxacin; and S. sonnei were 100% resistant to nitrofurantoin and cotrimoxazole.Conclusion: These results showed that only 12.5% of typhoid fever diagnosis by Widal test had Salmonella Typhi isolated from their blood cultures while Salmonella enterica and Shigella spp were isolated from stool samples of other cases. There is need to adopt culture techniques for laboratory diagnosis of febrile illnesses in order to improve treatment regimen. The fact that AST can also be performed with culture technique could further guide antibiotic prescription and reduce the risk of emergence of resistant bacteria. Contexte: L'importance d'un diagnostic précis des maladies infectieuses est centrale et cruciale pour l'efficacité du traitement et la prévention des complications à long terme associées à ces infections. L'objectif de cette étude était donc de déterminer la précision du test de titre d'anticorps de Widal dans le diagnostic de la fièvre typhoïde par rapport à la technique d'hémoculture de référence.Méthodologie : Un total de 40 étudiants fréquentant les services de santé de l'Université Olabisi Onabanjo, Ago-Iwoye, État d'Ogun, Nigéria en raison d'une fièvre typhoïde suspectée par un test Widal positif (≥ 1/80) et non sous antibiothérapie, ont été recrutés pour l'étude. Des échantillons de selles et de sang ont été prélevés sur chaque participant et analysés au laboratoire médical du centre de santé à l'aide de techniques de culture conventionnelles et de confirmation des isolats par des tests d'amplification par réaction en chaîne par polymérase (PCR) simplex et multiplex de hilA (Salmonella enterica), ipaH (Shigella spp), les gènes rfc (Shigella flexneri) et wbgZ (Shigella sonnei). Les tests de sensibilité aux antibiotiques (AST) des bactéries isolées à 10 groupes d'antibiotiques ont été effectués à l'aide du test de diffusion sur disque de Kirby Bauer et interprétés conformément aux directives du Clinical and Laboratory Standards Institute (CSLI).Résultats: Sur les 40 patients suspects de fièvre typhoïde par le test de Widal, 9 ont révélé Salmonella enterica donnant un taux d'isolement de 22,5%, avec Salmonella enterica sérovar Typhi (Salmonella Typhi) confirmée comme bactérie unique à partir d'hémocultures chez 5 (12,5%) patients et co-infection de Salmonella et Shigella à partir d'échantillons de selles chez 4 (10,0%) patients. Un total de 52 isolats de bactéries entériques ont étérécupérés à partir d'échantillons de sang et de selles des 40 patients constitués de Salmonella enterica 9 (17,3%), Shigella spp 20 (38,5%), S. flexneri 9 (17,3%) et S. sonnei 14 (26,9%). Tous les isolats entériques étaient multirésistants (MDR), avec des taux de résistance au panel d'antibiotiques allant de 33,3% à 100%, et tous les isolats étaient résistants à la ceftriaxone et à la péfloxacine. Les isolats de Salmonella étaient également résistants à 100% à la nitrofurantoïne, à l'ofloxacine et à la ciprofloxacine; S. flexneri était résistant à 100% à la nitrofurantoïne, à l'amoxicilline, au cotrimoxazole, à l'ofloxacine et à la ciprofloxacine; et S. sonnei étaient 100% résistants à la nitrofurantoïne et au cotrimoxazole.Conclusion: Ces résultats ont montré que seuls 12,5% des diagnostics de fièvre typhoïde par le test de Widal avaient Salmonella Typhi isolée à partir de leurs hémocultures, tandis que Salmonella enterica et Shigella spp ont été isolées à partir d'échantillons de selles d'autres cas. Il est nécessaire d'adopter des techniques de culture pour le diagnostic en laboratoire des maladies fébriles afin d'améliorer le schéma thérapeutique. Le fait que l'AST puisse également être réalisée avec une technique de culture pourrait guider davantage la prescription d'antibiotiques et réduire le risque d'émergence de bactéries résistantes.
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Evaluating alternatives to the Widal test for typhoid fever diagnosis in developing countries: A targeted literature review
Article
Full-text available
  • Feb 2025
Background: Typhoid disease, caused by Salmonella typhi, is prevalent in developing countries with poor sanitation. The Widal test, despite its century-old history, has drawbacks in diagnostic capacity because of inherent characteristics, cross-reactivity and repeated exposure to the pathogen in endemic regions.Aim: The study evaluates the utility of the Widal test for the diagnosis of typhoid infections and emphasises the need for a better diagnostic modality in endemic regions.Setting: The study included research conducted in developing countries where typhoid fever is endemic.Method: A targeted literature review was conducted utilising the MEDLINE and Embase databases on 19 October 2022, encompassing publications from the preceding 10 years. Manual searches were executed using Google Scholar and the Google Search Engine on 02 November 2022. The initial search yielded 657 articles, of which 20 met the inclusion criteria and were subsequently incorporated into the final review.Results: The mean sensitivity, specificity, positive predictive value and negative predictive value of the Widal test in this study were 62.94 ± 17.83 (95% confidence interval [CI]: 49.23–76.64); 73.31 ± 18.75 (95% CI: 58.89–87.73); 58.85 ± 40.07 (95% CI: 16.80–100.90) and 75.96 ± 25.93 (95% CI: 46.08–100.45), respectively.Conclusion: The different studies in this review have shown that the Widal test performs poorly in identifying typhoid infections compared to other rapid diagnostic tests (RDTs). In addition, the current alternative RDTs are not accurate enough to reliably identify or rule out typhoid infection.Contributions: A shift in diagnostic approach for typhoid fever in developing countries is required and an accurate and feasible point-of-care test is urgently needed.
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Evaluation of Real Time Polymerase Chain Reaction for Salmonella Invasion Gene A and Salmonella Tetrathionate Respiration Gene as a Diagnostic Test for Typhoid Fever
Article
Full-text available
  • Jan 2023
Background: Enteric (typhoid and paratyphoid) fever is a serious systemic disease caused by Salmonella enterica (S. enterica) that needs appropriate microbiological diagnosis mainly with atypical clinical signs due to antibiotics misuse. In Egypt, there are insufficient data about molecular detection of enteric fever. Objectives: To evaluate the quantitative real-time polymerase chain reaction (qPCR) for Salmonella invasion gene A (Inv A) and Salmonella tetrathionate respiration gene (ttr) of S. enterica in typhoid fever patients. Methodology: This was a case-control study that included 100 patients with typhoid fever and 100 control subjects. Ten ml blood were obtained for blood culture, Widal testing and enrichment on tryptic soya broth (TSB) with bile. Positive blood culture was sub cultured, identified and serotyped for isolation of S. enterica. Finally, qPCR was applied for detection of Inv A and ttr genes from blood samples and after enrichment. Results: Blood culture was positive in 51% and Widal test was positive in 70% of patients. Combination of Widal and/or blood culture increased their sensitivity, specificity and accuracy to 82%, 89.2% and 85.5% respectively. qPCR was positive in 95% of patients (95 for ttr and 89 for Inv A) while, pre-enriched blood qPCR was positive in 99%. The highest sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy was for qPCR for pre-enriched blood (99%, 100%, 100%, 99.01%, 99% respectively). Conclusion: The study highlighted the high accuracy of qPCR for genes Inv A and ttr in diagnosis of S. typhi from blood.
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A SYSTEMATIC EVALUATION OF RAPID DOT-EIA, BLOOD CULTURE AND WIDAL TEST IN THE DIAGNOSIS OF TYPHOID FEVER
Article
Full-text available
  • Mar 2013
Background: Typhoid fever, caused by Salmonella enterica serotype Typhi, is endemic in the Indian sub-continent including Bangladesh, South-east and Far-east Asia, Africa and South Central America. The disease can occur in all age group with highest incidence among children. Blood culture is regarded as the gold standard for diagnosis and carry 70-75% diagnostic yield in the first week of illness. However, this requires laboratory equipment and technical training that are beyond the means of most primary health care facilities in the developing world. Typhidot is a rapid dot-enzyme immune assay (EIA), which detects IgG and IgM antibodies to a specific 50 kD outer membrane protein (OMP) antigen of Salmonella enterica serotype Typhi. Typhidot becomes positive as early as in the first week of fever. The results can be visually interpreted and is available within one hour. Materials and method: Fifty blood samples, collected aseptically from patients clinically diagnosed of Typhoid fever, were evaluated by blood culture, Widal test and Typhidot. Results: Of the 50 patients, 33 (66%) were positive by blood culture. Widal test was positive in 33(66%) patients which included 26 in blood culture positive patients and 7 in blood culture negative patients. Typhidot was positive in 37 (74%) patients. Thus, in comparison to the gold standard test i:e blood culture, Typhidot and Widal test had sensitivity and specificity of 100% & 76% and 78.78% & 58.82% respectively. Conclusion: Typhidot is found to have high sensitivity and good specificity and could be applied as a good alternate in resource poor nation. Further, it is simple to perform, reliable when compared to Widal test, and rapid, with results being available in one hour when compared to 48 hours for blood culture and 18 hours for Widal test.
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Role of Widal Test in the Diagnosis of Typhoid Fever in Context to Other Test
Article
Full-text available
  • Aug 2012
Typhoid is one of the infectious diseases of human. Outbreaks of typhoid fever caused by S. typhi and S. paratyphi A are still a serious health problem worldwide. There are number of test available now days from molecular to immunological and biochemical to microbiological. In our study we have tried to establish the relevance of widal test in the diagnosis of typhoid fever. Both the tube and slide agglutination widal test were used to investigate the incidence of ty- phoid fever in 80 test individuals comprising 60 typhoid fever patients and 20 apparently healthy individuals comprised of adult and children. The test results were compared with those of standard blood culture tests. We tested different individu- als and were categorized according to their age above 10 years (20), and between 5- 10 years (20), and children under 5 years (20). Results showed that the accuracy of the widal tube and slide agglutination tests as used in the study in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 71%, 62%, 91% and 31%, respectively. It is concluded that widal test will remains relevant as a diagnosis tool for typhoid fever, which is more con- venient, cheaper and faster than the other molecular and serological test.
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Comparative Study on the Use of Widal Test and Stool Culture in the Laboratory Diagnosis of Salmonella Infection in Adult and Children in Jos
Article
Full-text available
  • Dec 2013
Background-Salmonella infection is a common bacteria disease that causes enteric fever in humans which are shed in faeces. Presently, Widal test, Stool culture, blood culture and urine culture are the most diagnostic means of confirming salmonella infection in humans since they are based on the isolation, identification, detection and demonstration of the presence of antibodies in the serum. However, the stool and serum sample of an infected patient against the O (somatic) and H (flagella) antigents of the bacteria requires thorough laboratory analysis. This study aimed to compare the diagnostic performance of Widal test and Stool culture in the laboratory diagnosis of salmonella infection in children (0-14 yrs) and Adult (18 yrs and above). Methods: A random selection of Adult and Children with symptoms clinically suspected to be typhoid visiting the Hospital (Bingham University Teaching Hospital) at the period of the study were recruited. Informed consent of volunteers and guardians were obtained and in addition confidentially of the result was ensured. A total of 91 patients samples were tested and cultured including Adults and Children. The bacteria isolated were identified by gram's reaction and biochemical characteristics. Evaluation of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of both adult and children were calculated. Results: Of the 91 patients among whom were 48 adults and 43 children. The total number of adults positive for stool culture was 12 (25%) among which were 10 (31.2%) males, 2 (12.5%) females, while the total number of children positive to culture were 9 (20.9%) among which were 7 (26.9%) males and 2 (11.7%) females respectively. The Widal test shows that 30 (62.5%) were positive among which were 17 (53.1%) males and 13 (81.2%) females, while for children, out of 13 (30.2%) who were positive, 8 (30.7%) were males and 5 (29.4%) were females respectively. Adults stool culture were found to be sensitive to Offloxacin, Ciprofloxacin, Ceffraxole and Cefuroxime while children stool culture were also found to be sensitive to Ciprofloxacin, Amoxicillin/Clavulinate, Ampicillin, Ceftazidinme and Clozacillin making them the drugs of choice. Conclusions: From the results obtained, adults were more affected than children; and the males in general were affected more than the females. The widal test therefore was found to be more sensitive while the stool culture more specific in adults and children, but salmonella infection could still occur irrespective of age or gender. Hence, Health care personnel should not totally depend on the widal test alone for the diagnosis of enteric fever, but should use other diagnostic methods to differentiate salmonella infection from other infections.
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Evaluation of sensitivity and specificity of ELISA against Widal test for typhoid diagnosis in endemic population of Kathmandu
Article
Full-text available
  • Nov 2015
  • BMC INFECT DIS
Background: Widal test, which has poor predictive outcomes in predominant typhoid population, is not standard enough to predict accurate diagnosis. This study aims to compare the diagnostic accuracy of Widal test to ELISA using blood culture as gold standard. Methods: The blood samples were collected in Capital Hospital, Kathmandu, Nepal from febrile patients having ≥48 h fever in 3 years study period for blood culture, Widal test and IgG-IgM ELISA. Results: Amongst 1371 febrile cases, 237 were Salmonella typhi positive to blood culture and 71.4 % typhoid fever patient were of 46-60 years old with male to female ratio of 2:1. Blood culture confirmed patients had ≥1:40 anti-TH and anti-TO titre in 45.56 % (n = 108) and 43.88 % (n = 104) patients respectively. The sensitivity and specificity of IgG (0.96 and 0.95) and IgM (0.95 and 0.94) at 95 % confidence level were significant compared to Widal anti-TH (0.72 and 0.58) and TO (0.80 and 0.51) test (p value, 0.038) at titre level ≥1:200. Further the PPV of Widal TH and TO (0.38 and 0.23) was low compared to IgG and IgM ELISA (0.78 and 0.77) (p value, 0.045). Conclusion: Widal test is not sensitive enough for an endemic setting like Nepal and thus should be either replaced with more accurate test like ELISA or follow an alternative diagnostic methodology.
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Diagnosis and Treatment of Typhoid Fever and Associated Prevailing Drug Resistance in Northern Ethiopia
Article
Full-text available
  • Apr 2015
To determine diagnostic value of Widal test, treatment pattern of febrile patients and antimicrobial drug susceptibility pattern of blood isolates. Using cross sectional methods, blood samples were collected for culture and Widal test from 502 febrile outpatients attending Mekelle hospital and Mekelle health center with similar symptoms to typhoid. Sensitivity, specificity for anti-TH and anti-TO titers using culture confirmed typhoid fever cases, and Kappa agreement between Titer and slide Widal tests were calculated. Treatment pattern of patients and antimicrobial susceptibility pattern of the blood isolates was assessed. From the 502 febrile patients, 8(1.6%) of them had culture-proven typhoid fever. However, patients who have indicative of recent infection by O and H antigens of Widal slide agglutination test were 343 (68.5%), with specificity and sensitivity of 33% and 100%, respectively. Over prescription of antibiotics was seen by Widal slide test for Ciprofloxacin 268 (76.1%), Amoxicillin- Clavulanic acid 9(2.6%), Amoxicillin 8(2.4%) and Chloranphenicol 8(2.4%). Tube titer positive was seen among in 23(5.3%) patients with 75% sensitivity and 95.8% specificity. Widal slide and Tube titer tests showed poor agreement for both antigens (kappa=0.02 for O) and (Kappa=0.09 for H). A single anti-TH titer of ≥ 1:160 and anti-TO titer ≥ 1:80 higher in our study showed indicator for typhoid fever infection. Drug resistance pattern of blood isolates ranges from 0-89.7% for gram positive and 0-100% for Gram negative, with an overall multi-drug resistance rate of 61.7%. Patients were wrongly diagnosed and treated for typhoid fever by Widal test. Tube titration method was relatively good but still with poor sensitivity. Blood isolates showed multi drug resistance, which may be due to the indiscriminate prescription as seen in this study. Based on our result slide Widal test is not helpful in the diagnosis of typhoid, hence other tests with rapid, feasible, better sensitivity and specificity is urgently needed in Ethiopia. Copyright © 2015. Published by Elsevier Ltd.
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Manson's Tropical Diseases
Article
  • Feb 1983
  • Arch Pediatr Adolesc Med
The 18th edition of Manson's Tropical Diseases has recently been published. Since Sir Patrick Manson first published his book Tropical Diseases in 1898, this textbook has served as the standard tropical medicine reference in many areas throughout the world. The expressed purpose of the 18th edition, now written in part by P. E. C. Manson-Bahr, is to provide a general reference text for practitioners, as well as students, and the book remains the best available for clinical aspects of the practice of medicine in the tropics. The text is well illustrated with many photomicrographs provided by The Wellcome Museum of Medical Science. Several major chapters of the book are specially written by experts in the particular area. For example, the presentation of hemoglobinopathies as part of anemia in the tropics, by Dr David Weatherall, is clear, concise, and comprehensive. Similarly, the discussion of ophthalmologic problems in the tropics is excellent.
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Diagnostic efficacy of Widal slide agglutination test against Widal tube agglutination test in enteric fever
Article
  • Jul 2014
Introduction: Enteric fever is an endemic disease in India and warrants rapid and affordable diagnosis. The Widal slide agglutination test is a commonly used rapid screening test for this purpose. The literature available on its diagnostic ability in comparison to the tube agglutination test is however scanty. Hence, this study aims to evaluate the efficacy of the Widal slide agglutination test and the tube agglutination test for the diagnosis of enteric fever. Materials and Methods: A total of 1470 sera were collected during the study period of one year from patients having pyrexia of unknown origin. All the samples were tested for the presence of anti O and anti H agglutinins against S. typhi and S. paratyphi A by semi quantitative slide and quantitative tube agglutination tests as per standard protocols. The titers of 1:80 (O agglutinins) and 1:160 (H agglutinins) were taken as the significant titer for the diagnosis of enteric fever. The results of the slide agglutination test were compared with the tube agglutination test and analyzed using Fisher's exact test. The sensitivity, specificity, positive and negative predictive values of slide agglutination were calculated using the tube agglutination method as a standard for comparison. Results: Of the 294 slide positive samples, 209 (71.1%) samples tested negative by the tube agglutination test. The sensitivity, specificity, positive and negative predictive values for the slide agglutination test were observed to be 100 % (CI 95.75-100%), 84.91% (CI 82.93-86.73%), 28.91% (CI 23.84-34.45%) and 100% (CI 99.69-100%) respectively. Conclusion: Serological diagnosis of enteric fever should always be confirmed by the tube agglutination test rather than depending solely upon the rapid slide agglutination test results.
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Utility of A Single Widal Test in The Diagnosis of Typhoid Fever
Article
  • Apr 2012
Background & objectives: The clinical diagnosis of typhoid fever is difficult, as the presenting symptoms are often diverse and similar to those observed with other febrile illnesses. The definitive diagnosis of typhoid fever requires the isolation of Salmonella typhi or paratyphi from the patient concerned. Since patients often receive antibiotics prior to a confirmatory diagnosis, there is uncertainty that bacteria can be isolated from the blood cultures. Besides this, the facilities for blood culture are not always available or feasible. All these limitations have made Widal test the most utilized diagnostic test for typhoid fever. Many studies have produced data which had cast serious doubts on the value of the Widal Test and thus reappraisal of the role of a single Widal test is needed. Methods & materials: This study was carried out to determine the changes in clinical pattern of enteric fever. A total of 153 children, aged 0 to 14 years, diagnosed as typhoid fever (either positive blood culture for Salmonella typhi or paratyphi) were induced in the study. Of them, 86 children were with a definitive diagnosis of typhoid or paratyphoid fever as indicated by the isolation of S. typhi or S. paratyphi from the blood and 17 had negative blood culture but were clinically suspected of having typhoid fever. The control group was comprised of 50 children with non-typhoidal fevers The Widal test was carried out using rapid slide agglutination method and its accuracy was assessed by comparing the findings with that obtained through blood culture. Result: The mean age of the patients was 5.2 ± 2.8 years and the youngest and oldest patients were 0.7 and 14 years respectively and male to female ratio was roughly 1:1. Nearly one-quarter (24.6%) of the patients had been suffering from the disease for >10 days and the mean duration of illness was 8.2 ± 3.3 days. Widal Test result showed that an ‘O’ agglutinin titer of cut-off value e”1:40 gave a sensitivity of 87.2%, a specificity of 47.1%, a positive predictive value (PPV) of 89.2% and a negative predictive value (NPV) of 42.1%. The sensitivity and NPV decreased with the increase in titer levels and were 56.9% and 31.5% at cut-off value of e” 1:320, while the specificity and PPV increased with the increase in titer levels from 47.1% and 89.2% respectively at a titer of e”1:40 to 100% at a titer of e” 1:320. The ‘titer behaved in the same way as did the ‘O’ agglutinin titer. Similarly when H’ agglutinin was used the sensitivity and NPV decreased from 65% and 31.7% at a titer of e”1:40 to only 25% and 20% respectively at a titer of > 1:320, while specificity and PPV increased from 76.4% and 81.1% at >1:40 to 94.1% and 95.6% respectively at e” 1:320. When either ‘O’ or ‘H’ antibody titer of e”1:160 was used, a good sensitivity (71%), specificity (70.6%) and PPV (92.4%) resulted, though NPV decreased to 32.4%. Conclusion: The Widal test can be of diagnostic value when blood cultures are not available nor practically feasible. DOI: http://dx.doi.org/10.3329/bjch.v35i2.10377 Bangladesh J Child Health 2011; Vol 35 (2): 53-58
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