Typhoid intestinal perforations in Ghana
In many developing countries, typhoid fever; a severe febrile illness primarily caused by Salmonella typhi, is still a disease of enormous public health concern, even though it is almost eliminated in developed countries. Typhoid fever is generally transmitted by faecal-oral route and may occasionally lead to an epidemic, particularly in areas with poor waste disposal system, and limited availability of clean drinking water. It has been estimated that 22 million cases of typhoid fever and 216 000 deaths occur annually worldwide. In Africa, population based incidence of typhoid fever is reported to range from 13 to 845 cases per 100000 population annually.
Effective public health measures such as the provision of clean, potable water and good waste disposal systems have led to a dramatic decrease of the disease in developed countries. Developing countries on the other hand still bear the burden of the disease, due to the fact that most communities still fall short of standards for good drinking water, hygiene and sanitation.
Clinical signs and symptoms of typhoid fever include malaise–a general feeling of discomfort, headache, sustained fever, constipation and/or diarrhea, abdominal pain, and other gastrointestinal symptoms, cough and loss of appetite. Confirmatory laboratory findings are conducted by the isolation of Salmonella Typhi from bone marrow, blood, or other site in a patient with compatible illness.
With a case mortality rate approaching 30% – 40%, typhoid intestinal perforations (TIPs) and intestinal bleeding arising from necrosis of Peyer’s patches in the terminal ileum is the most lethal complications of typhoid fever. Just like typhoid fever, TIP is the most common surgical problem in developing countries, where it is associated with high mortality and morbidity, due to lack of clean drinking water, poor sanitation and lack of medical facilities in remote areas and delay in hospitalization. The high incidence of TIP has also been attributed to the emergence of multi-drug resistant and virulent strains of Salmonella typhi.
TIP affects mostly children and young adults who are the future leaders and would contribute greatly to the economy of developing countries in the future. This results in devastating effects (socially and economically) on resource poor countries due to loss of productive hours as due to hospitalization of patients with acute disease and the complications and loss of income attributable to the duration of the clinical illness. In resource-poor countries like Ghana, the management of the TIP which requires surgery has peculiar challenges relating to diagnostic and therapeutic measures. Some of these unique challenges include late presentation of the disease coupled with lack of clean drinking water, poor sanitation, and lack of diagnostic facilities and emergence of multi-drug resistant (MDR) strains of S. typhi. This may result in poor treatment outcomes. Many factors such as late presentation, inadequate pre-operative resuscitation, delayed operation, the number of perforations, and the extent of faecal peritonitis, have been found to have a significant effect on the prognosis.
There should be access to clean portable water, people must make it a point to keep their surroundings clean at all times and health facilities and equipment must be made available to help detect this disease at the early stage.
Source: US National Library of Medicine enlisted journal