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Typhoid Fever in Nigeria

Causes, treatment and prevention of enteric fever in Nigerian communities

Typhoid fever, caused by Salmonella Typhi, is one of the most common serious bacterial infections in Nigeria, with an estimated 4-5 million cases annually. It is transmitted through contaminated food and water — sachet water from unhygienic sources, street food, and poor sanitation are major transmission routes. Typhoid causes a prolonged febrile illness that, if untreated, can cause intestinal perforation and death. Overdiagnosis based on the Widal test without clinical correlation leads to massive antibiotic overuse in Nigeria.

Signs and Symptoms

✓ Sustained high fever (39-40°C) building up over 5-7 days — unlike malaria which causes intermittent fever
✓ Relative bradycardia: pulse slower than expected for the degree of fever
✓ Headache, malaise, and fatigue
✓ Abdominal pain, constipation in the first week; diarrhoea may develop in the second week
✓ Rose spots: faint salmon-coloured spots on the trunk — rarely noticed in dark-skinned patients
✓ Hepatosplenomegaly: enlarged liver and spleen
✓ Complications (week 3-4): intestinal perforation (sudden severe abdominal pain — emergency), intestinal bleeding, encephalopathy

Risk Factors

When to Seek Help

Seek testingAny fever lasting more than 5 days without a clear diagnosis — typhoid should be actively considered and cultured, not presumptively treated
EmergencySudden severe abdominal pain in a patient with typhoid — intestinal perforation; go to A&E immediately; this is a surgical emergency with high mortality
Hospital admissionComplicated typhoid, inability to take oral medications, or very high fever unresponsive to paracetamol — inpatient IV antibiotics required

Tests & Diagnosis

🧪 Blood culture
Gold standard for diagnosis — bacteria grown from blood; sensitivity 40-80% in untreated patients; must be done BEFORE starting antibiotics; results take longer to come back; available at all teaching hospital microbiology labs
🧪 Bone marrow culture
Most sensitive test (90%+) — but invasive and rarely needed in practice
🧪 Widal test (agglutination test)
Widely used in Nigeria but highly unreliable — very poor sensitivity and specificity; cross-reacts with other Salmonella species, malaria, hepatitis, and other infections; a positive Widal test without blood culture confirmation should NOT be the sole basis for typhoid diagnosis and treatment
🧪 FBC
Leukopenia (low white cell count) is characteristic — unlike most infections which cause leukocytosis
🧪 Rapid typhoid antigen tests (Typhidot, True NS1)
More specific than Widal; useful where culture is unavailable; negative result in early illness does not exclude typhoid

Treatment Options

1
Azithromycin
First-line for uncomplicated typhoid in Nigeria — 1g on day 1, then 500mg daily for 6 days; good oral bioavailability; effective against many Nigerian strains; available at most pharmacies
2
Ceftriaxone
For complicated typhoid requiring hospitalisation — IV 2g once daily for 10-14 days; also for multidrug-resistant strains
3
Ciprofloxacin
Previously first-line but increasingly resistant in Nigerian strains — sensitivity testing essential; still used when susceptibility confirmed
4
Chloramphenicol/ampicillin/cotrimoxazole
Older agents with widespread resistance — no longer recommended empirically
5
Supportive care
Adequate oral hydration; paracetamol for fever; soft diet; strict hand hygiene to prevent spread to household contacts; isolate if possible
6
Prevention
Safe drinking water; handwashing with soap before eating and after toilet; typhoid Vi polysaccharide vaccine (available in Nigeria; recommended for travellers and high-risk communities)

Frequently Asked Questions

Is the Widal test reliable for diagnosing typhoid in Nigeria?
No — the Widal test is notoriously unreliable in Nigeria and causes massive overdiagnosis. A single positive Widal test without clinical context and blood culture confirmation should not be used to diagnose typhoid. Blood culture is the gold standard.
How long does typhoid last with treatment?
Fever typically improves within 3-5 days of starting appropriate antibiotics. The complete course should be finished (6-14 days depending on antibiotic) to prevent relapse.
Can typhoid recur after treatment?
Yes — typhoid relapse occurs in 5-10% of patients, usually 2-3 weeks after apparent recovery. A more prolonged course of antibiotics reduces but does not eliminate this risk. Retreatment with the same antibiotic is usually effective.
Is there a vaccine against typhoid in Nigeria?
Yes — the Vi polysaccharide typhoid vaccine is available at private hospitals and travel clinics in Nigeria. It provides 50-80% protection for 2-3 years. A newer typhoid conjugate vaccine (TCV) provides longer-lasting protection and is being introduced in Nigeria's routine immunisation schedule.
Can typhoid cause serious complications?
Yes — untreated or late-treated typhoid can cause intestinal perforation (hole in the gut — life-threatening), intestinal bleeding, encephalopathy (brain confusion), and rarely heart inflammation, hepatitis, or meningitis. This is why prompt diagnosis and complete treatment are essential.

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