Editor’s Note: This week’s blog is a personal story from a Nigeria Health Watch team member, Patience Adejo. She writes about her experience being diagnosed with Typhoid Fever multiple times using the Widal test, only to recently learn that the test does not give the most accurate diagnosis for typhoid fever. She delves into the standard procedure for diagnosing typhoid fever in Nigeria and the need for renewed scrutiny and adherence to diagnosis guidelines.
Growing up in a family of five children, I was tagged with the nickname ‘Healthy Patty’ because I was so full of energy and hardly ever got sick. All that changed in May 2017 when I started to have constant headaches every day, coupled with a general feeling of malaise, dizziness and a high temperature. I visited the hospital many times and each time I was asked to do a Widal test, this always produced very high titre values. Widal Test is a simple laboratory test used to determine if a patient has typhoid. It works by forming tiny clumps which show the presence of the bacterial agent in the patient’s blood. The amount of clumps formed is used to determine the severity of the infection.
The doctors repeatedly diagnosed me with typhoid fever following the results of the Widal test. This was until February 2019 when a follow-up stool, blood and urine culture was done to confirm the diagnosis. Imagine my surprise when the results from the culture contradicted the most recent Widal test that had been carried out just four days before! The Widal test was positive for typhoid, and the stool urine and blood culture tests were negative for typhoid. My ordeal at being repeatedly misdiagnosed with typhoid following 10 Widal tests over a 22-month period is an indication that the Widal test, while easy and low cost to administer, is not reliable in the diagnosis of typhoid fever and this has most likely led to a large number of patients being misdiagnosed and treated for a disease they never had.
Dr Ada Amajor, a general practitioner who used to work in Maitama General Hospital, Abuja said that the Widal test was never designed for diagnosis, but was initially used as a presumptive test for enteric fever, also known as typhoid fever. It was used to identify people who had been exposed to the Salmonella entericaserotype Typhi (S. typhi) bacterium, usually spread through contaminated food and drink, as well as faeces.
Slide and tube agglutination tests are commonly used to diagnose typhoid fever in Nigeria. Image source: onlinebiologynotes.com
There is widespread misuse of the Widal test as many physicians diagnose and treat typhoid cases based on results from a single Widal test that they administer when previous episodes of typhoid have been treated. In addition, exposure to the typhoid vaccination can cause a Widal test to give a false positive result. False diagnoses and treatment of typhoid fever with antibiotics does not help in the battle against antimicrobial resistance, a major challenge in the world today. Research suggests that in typhoid-endemic regions like Nigeria, single testing of a serum specimen for Widal agglutination cannot provide a reliable diagnosis.
Studies have shown that patients who present with symptoms similar to typhoid may have diseases like malaria or urinary tract infections. One study actually showed a significant association between the severity of malaria parasitemia and a positive Widal agglutination test. If these infections are not first ruled out before clinicians diagnose for typhoid, false positive Widal reactions are inevitable.
In a study published by a Nigerian Medical Journal in June 2016, 271 blood samples from consecutive adults (>18 years) with febrile illness attending the General Practice Clinic of the University of Benin Teaching Hospital were tested using the Widal agglutination test, blood culture, and malaria parasite test on each sample to establish the diagnosis of typhoid fever. Of the 271 blood samples 124 (45.76%) were positive following a Widal agglutination test, 60 (22.10%) blood samples grew Salmonella organisms on blood culture while 55 (20.29%) blood samples showed a co-infection of typhoid fever and malaria.
The World Health Organisation (WHO) has stated that the Widal test, should not be used as a diagnostic tool for typhoid. WHO suggests that a blood culture before initiating antimicrobial therapy remains the diagnostic method of choice, although the isolation of Salmonella typhi from the bone marrow is the standard method for confirming a typhoid case.
Dr Amajor agrees that the standard tests for typhoid are blood culture, stool culture, and urine culture. She said that these tests are seldom done due to issues around lack of efficient laboratories or diagnostic centres; delays in producing results; the patient’s inability to pay for tests; and physicians poor knowledge of the uses of the Widal test and its limitations. Health Maintenance Organisations (HMOs) in addition have declined to cover the cost of the Widal test as they do not view them as a reliable test for typhoid diagnosis.
Many health practitioners that we spoke to, did not seem to be aware of any national guideline for the diagnosis and treatment of typhoid in Nigeria and so they relied on the WHO guidelines for the diagnosis and treatment of typhoid fever. Even though the WHO guidelines state clearly that the Widal test is not a diagnostic test, it is still widely used in many health facilities.
Image source: Nigeria Health Watch
The Standard Treatment Guideline developed by the Federal Ministry of Health in 2008 also states clearly that “A positive culture is the ‘gold standard’ for the diagnosis of typhoid fever. Specimens for culture may be obtained from the blood, stool, urine, bone marrow, gastric and intestinal secretions.” It lists the Widal test as a non-specific investigation stating that the ‘Widal test gives high rates of false positives and negatives, and the guidelines
The thought of being on antibiotics almost every two months for almost two years is harrowing for most people. Yet this was my experience until stool, urine and blood cultures were taken that contradicted the Widal test. This experience is even more unpleasant as I realise that I may never even have had typhoid. The urine culture eliminated typhoid, but an infection was diagnosed which according to the doctor could have been the cause of the high titres the Widal tests showed.
Still, millions of Nigerians are being misdiagnosed with typhoid due to the use of the Widal test. Clearer diagnosis and treatment protocols should be given to health professionals at all levels. The Standard Treatment Guidelines are over 10 years old and have not been updated since. More responsibility and leadership is needed in this area. Although many doctors and hospitals in Nigeria do not rely on a single Widal test to diagnose and treat typhoid, many, like the hospital I went to, still do. The Nigerian Standard Treatment Guideline as regards the treatment of typhoid needs to be enforced in every treatment and diagnostic centre in Nigeria.
The danger of an incorrect typhoid diagnosis is that the symptoms of typhoid fever are difficult to distinguish from other viral haemorrhagic fevers like Lassa fever, malaria or yellow fever. Health professionals are advised to maintain a high index of suspicion for infectious diseases like Lassa fever, especially when a patient presents with a high temperature, muscle pain, vomiting or diarrhea, similar symptoms as typhoid fever.
Shortages of health professionals in many primary health centres in Nigeria and the absence of diagnostic facilities and laboratory scientists makes it harder for health professionals to correctly diagnose typhoid, resulting in the reliance on the Widal test. State governments need to provide the necessary equipment in at least each Local Government Area (LGA) in every state, so more hospitals and health centres are able to diagnose typhoid and other infectious diseases. To stop the widespread misdiagnoses of typhoid fever, continuous and vigorous continuous training of health workers needs to take place in every state and LGA. Professional associations should also play a larger role in ensuring all health professionals take part in continuous professional development training to ensure they continue to enhance their skills so as to deliver quality healthcare.
I am glad that after close to two years of being misdiagnosed and treated for typhoid fever using only a Widal test, I now have the knowledge to understand that the next time my doctor wants to diagnose me using only a Widal test, I can insist that a blood, stool, and urine culture be done. Many others need to have this knowledge, we all want to have access to quality healthcare, we also want to have confidence that our illnesses are being correctly diagnosed.
Have you ever been diagnosed with typhoid only with a widal test? Share your story with us
This article was overdue! In my opinion, the WIDAL test should be banned all together because it has no clinical diagnostic relevance in times when antibiotics are used. In the pre-antibiotic area a multiple increase of the titer over a certain time period had an acceptable sensitivity for confirming the diagnosis still hampered by cross-interferences with other immunological reactions. Sine the usage of antibiotics WIDAL is not to be used at all anymore and only confirms the diagnosis of “uneducated physician”!
Dr Engelking,
Thank you for your input. This is a challenge we continue to face with clinicians diagnosing patients with malaria or typhoid. The Rapid Diagnostic Tests (RDT), should be used at first to rule out malaria. There seems to be a tendency to diagnose typhoid and prescribe antibiotics when unsure what is wrong with the patient. In your experience, what then is the best way to address this? Specific training/retraining of clinicians? Public awareness campaigns?
Dear Readers,
Professors Aboderin and Gyoh Provide us with the detailed advice needed. Implementation remains a challenge.
Please permit me to share a perspective of the five years of work in Nigeria: What struck me in the OPD was the abundant number of patients stating they were suffering from “Malaria-n’-Typhoid” as if it was a standing diagnosis. Clinical investigations (and if needed further observation) could yield anything from a viral flu, pneumonia, dengue, in season often malaria and in most cases no typhoid. Never in those five years was I able to establish the diagnosis of a single patient suffering from malaria and typhoid at the same time.
In my opinion, “Malaria-n’-Typhoid” has become a jargon adopted by the population (and probably plenty of physicians) promoting over-treatment. I could imagine that a broad awareness campaign “Malaria-n’-Typhoid is a myth!” (or something similar) could break a cycle of misconceptions. My observation is that most patients were able to follow the argument that it is highly unlikely to suffer from both diseases at the same time since the mode of transmission is completely independent.
What would it be like if we could engage the many outstanding Nigerian comedians to take this topic to the top of their list? What would it be like if snappy jokes would be spread over social media breaking the myth of “Malaria-n’-Typhoid”?
Another more concerning implication of failure to make a diagnosis and repeated courses of antibiotics every two months, for almost two years in this index case is antimicrobial resistance. Antimicrobial resistance has become a threat not only to global health security but also development. Use of antibiotics exert a selective pressure on bacteria to become resistant and thus difficult or impossible to killing by the drugs. Resistance is becoming a threat not only to ability to treat common infections but all of modern healthcare including surgeries, transplantations and chemotherapies.
Dear Prof. Aboderin,
Thank you for your input and for highlighting the threat of antimicrobial resistance. It really is a threat and it is clear that many Nigerians are not aware of this. What are your thoughts on the ease of access of antibiotics? They are so easily available over-the-counter like cough syrup. Should there be more restrictions placed on them? Beyond antibiotics awareness (and antibiotics awareness week), should clinicians be retrained on prescribing antibiotics?
The prevention of antimicrobial resistance needs a One Health approach which includes public health, human and veterinary, environmental sciences, etc, should these all be involved in a public education campaign?
It is most demoralising after we, the medical teachers have been teaching for the last 40 years that doctors “diagnose” typhoid in most cases of persistent severe malaria, and when they have no idea what is ailing the patient. This results in the misuse of antibiotics, contributing to so many organisms developing resistance that we are in danger of being taken back to helplessness in infections similar to pre-antibiotic era.
http://africahealth.co.uk/articles/march_2011/4.%20Gyoh%20opinion.pdf
An islolated Widal test is not specific for typhoid; it will be positive in malaria and several other severe fevers common in our environment. It has already been, for several years, abandoned by many countries. I think the problem is that most of our practitioners do not keep up-to-date with the developments in their profession. At this age of internet, no doctor can be excused for failure to keep at the cutting edge of their specialties, and that includes general practitioners.
Shima K Gyoh, retired surgeon.
Dear Prof Gyoh,
We appreciate your very experienced input. It is evident from the responses we have received from this article that the experience of being diagnosed with typhoid is a pain point for many Nigerians. We mentioned at the end of the article the need for continuous professional development for our medical professionals. This is critical in this age where treatment guidelines and protocols continue to change (and improve). Despite what seems to be widely known in the medical profession, the inappropriate use of the Widal test continues. How best can this issue be tackled then? Given the size of the issue in Nigeria, can this be done through the Medical and Dental Council of Nigeria? Maybe medical professionals in general practice could be required to complete a CPD course specific to this problem to guarantee their continued accreditation? Can the Nigerian Medical Association take this on, especially regarding patient education? So if a patient is diagnosed with just a Widal test, they know to insist on the gold standard (stool, urine and blood cultures). The latter may prove difficult given the level of health literacy in the country. Should NCDC be doing more, to inform the public?
INAPPROPRIATE DIAGNOSIS OF TYPHOID AND MISUSE OF ANTIBIOTICS.
This is a deep problem which I particularly noticed in the young Consultants teaching and supervising residents and medical students! The bad habits are being transmitted across the generations of upcoming medical professionals, and has been going on for quite a while. Many of the clinicians probably subconsciously think antibiotics have a salutary effect on people’s health, rather similar to their use in farm animals, and in their hurry to get through large crowds in outpatients, or investigate cases where the diagnosis is difficult, they prescribe antibiotics with the hope of hitting whatever hidden infection might be responsible for the ill-health.
All avenues of tackling the problem must be applied. I agree with you that the Medical Council, The Nigeria Medical Association, Medical Faculties, under and post-graduate medical colleges should all put this topic on the front burner
1. CPD seminars should emphasise the problem of infections and antibiotics.
2. Undergraduate and the Fellowship examiners should ensure that questions designed to correct poor impressions on the topic are always asked.
3. Special committees to undertake publicity on “Infections and antibiotics” should be considered at institutions and conferences.
4. Inappropriate prophylactic antibiotics, such as given to everyone going for any operation, including hernias, must be stopped in favour of strengthening aseptic procedures.
It would be a good move for the Nigeria Medical Association to undertake this as a special project. A committees could determine the rate of prescription before and after the advocacy. Useful publications can be produced.
I can only imagine. How many health facilities in Nigeria can perform blood culture. Our government need to prioritize health. If only we can invest more in health, the precarious situation as is obtainable in most rural areas can be ameliorated. Most rural areas do not have qualified health personnel not to talk about a functional comprehensive health care center.
the issue of misdiagnosis of Typhoid fever is somewhat deliberate. The first culprit is the desperation on the part of practitioners (medical and dental) to make money. The patient is likely to pay more for services when he is told he has 2 infections (typhoid and malaria) rather than just one (malaria).
the other reason is that our clinical laboratory services are far from optimum. Most clinical laboratories are not equipped to carry out any good diagnostic procedure like a good blood culture let alone a sensitivity test.
Sad to say, even at Teaching Hospital Laboratories, Widal test is used as a means to diagnose Typhoid fever. A case in point was when a Head of Department (Pathologist) made some procurements without including Typhoid antisera. He was attacked by the very senior laboratory Scientists that he omitted the vey test that serves as a ‘money spinner’! The HOD politely explained that its not needed, but the Lab Scientist insisted.
I all, I think its system failure. If there are guidelines available, why are they not being followed. What is done to those persons who go contrary to set guidelines?
The teaching in Medical schools is very clear and understood. But the practice is far from the standard. My suggestion is that there should be a way to ensure that guidelines are followed and those who err should be made to answer.
Finally, all Medical Laboratories should enlist the services of at least one visiting Pathologist who will ensure that the right investigations are carried out and results issued are reliable and authenticated.
Apt
Many Nigerian Physicians are aware that single widal test isn’t diagnostic of Typhoid. However, in Nigeria, most times patients push Drs and usually have their way. For instance, most patients will visit a Dr and insist they want “Typhoid test” and by that, they mean widal test. Also, many patients don’t appreciate what a Dr is doing for them until they are told they are being treated for Typhoid.
Typhoid is a rare and severe infection and shouldn’t be seen to always “accompany” malaria.
This assessment of the misuse of the Widal test is so true! My latest instance, one of many–only yesterday I went to a hospital in Enugu for malaria treatment. The doctor immediately wanted to do a Widal test. I declined, because when I went to the same hospital a couple of months ago, my Widal test was positive and I was loaded with antibiotics, even though I suggested a stool culture was necessary to confirm typhoid. Turns out when I went elsewhere for the stool and urine cultures, there was no typhoid. This time the doctor prescribed antibiotics along with anti-malarial drugs, just in case. I don’t plan to take them.
This has happened to me numerous times; it’s almost routine. Fortunately, the doctors I encountered in Nsukka were a little more aware and always followed up a seeming positive with the cultures. They mentioned that a previous history of typhoid could affect the result and the positive could mean
several things, not just typhoid. So the problem is real and prevalent.
Prof. Virginia Dike
Dear Prof Dike,
Thank you for your comment.
It is clear that we have a challenge with the over-prescription of antibiotics as a “catch-all” solution when physicians are unsure what ailment a patient has. We are aware of the dangers of antimicrobial resistance and the problem just seems to be getting worse. As mentioned in the comments by a few others including Prof Shima Gyoh, health practitioners need to take part in continuous professional development to keep their skills up to date, in addition, patient education helps, especially where there is awareness about the efficacy (or lack efficacy) of the Widal test.
The difficulties with the diagnosis of typhoid and the window and time lag to get results means that physicians start treating for typhoid with antibiotics (and malaria), rather than wait for results. So, we have issues in the technology to diagnose typhoid and governance around clinics and hospitals which puts us in the current situation we are in.
good research
This is so insightful.
Interesting.
thanks for the interesting blog.
thanks for the value of blog.