PLOS ONE

RESEARCH ARTICLE

Validation of the Nelwan Score as a screening

tool for the diagnosis of typhoid fever in
adults in Indonesia
Erni Juwita Nelwan ID1,2*, Luh Putu Listya Paramita3, Robert Sinto1, Decy Subekti4,
Fransiscus Nikodemus Hosea3, Pringgodigdo Nugroho5, Herdiman T. Pohan1
1 Division of Tropical and Infectious Disease, Department of Internal Medicine, Cipto Mangunkusumo
Hospital, Jakarta, Indonesia, 2 Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia, 3 Department
of Internal Medicine, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, Indonesia, 4 Oxford
University Clinical Research Unit, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia, 5 Division of
Nephrology and Hypertension, Department of Internal Medicine, Cipto Mangunkusumo Hospital, Jakarta,
Indonesia
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* [email protected]
a1111111111
a1111111111
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a1111111111 Abstract

Introduction
OPEN ACCESS
Typhoid fever diagnosis is challenging for clinicians in areas with limited laboratory facilities.
Citation: Nelwan EJ, Paramita LPL, Sinto R,
Scoring methods based on signs and symptoms are useful for screening for probable cases
Subekti D, Hosea FN, Nugroho P, et al. (2023)
Validation of the Nelwan Score as a screening tool of typhoid fever. The Nelwan Score variables are derived from the clinical signs and symp-
for the diagnosis of typhoid fever in adults in toms of patients with suspected typhoid. We validated the Nelwan Score compared to labo-
Indonesia. PLoS ONE 18(5): e0256508. https://doi. ratory tests as the gold standard.
org/10.1371/journal.pone.0256508

Editor: Bachti Alisjahbana, Universitas Padjadjaran,

INDONESIA Methods
Received: August 3, 2021 This cross-sectional study was conducted between July 2017 and January 2018 in five hos-
Accepted: April 27, 2023 pitals and two primary health care centers in Jakarta and Tangerang, Indonesia. Patients
Published: May 12, 2023 with fever for 3–14 days and gastrointestinal symptoms were evaluated using the Nelwan
Score. Blood cultures, samples for polymerase chain reaction testing, and additional rectal
Copyright: © 2023 Nelwan et al. This is an open
access article distributed under the terms of the swab cultures were collected simultaneously to confirm the diagnosis of typhoid. Data were
Creative Commons Attribution License, which analyzed using a contingency table to measure sensitivity, specificity, positive predictive
permits unrestricted use, distribution, and value (PPV), and negative predictive value (NPV), and the optimal cut-off of the Nelwan
reproduction in any medium, provided the original
author and source are credited.
Score for typhoid diagnosis was determined using a receiver-operating characteristic curve.

Data Availability Statement: All relevant data are

within the paper and its Supporting Information
files. Result
Funding: The author(s) received no specific Typhoid was confirmed in 11 of the 233 patients (4.7%) with suspected typhoid. Among lab-
funding for this work. oratory-confirmed typhoid cases, the median Nelwan Score was 11 (range: 9–13) and the
Competing interests: The authors have declared optimal cut-off value was 10, with an area under the curve of 71.3%, sensitivity of 81.8%,
that no competing interests exist. specificity of 60.8%, PPV of 9.3%, and NPV of 98.5%.

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PLOS ONE Validation of nelwan score

Conclusion
A Nelwan Score of 10 is the best cut-off value for screening for typhoid fever. It is useful as
screening tool for typhoid fever, where laboratory resources are limited, and could help to
decrease irrational antibiotic use.

Introduction
Typhoid fever, caused by Salmonella typhi and Salmonella paratyphi, is an infectious disease
with a heavy public health burden. Globally, 14.3 million cases were reported in 2017, with a
case fatality rate of 0.95% (95% Uncertainty Interval [UI] (0.54–1.53%)) [1]. Typhoid fever is
endemic in Indonesia and needs active attention because of the increasing annual incidence
(500/100.000 population) and mortality rate of 0.6–5% [2]. In addition, screening for typhoid
fever in 2013 showed that 2.9% of food vendors in Jakarta were typhoid carriers [2, 3].
The nonspecific clinical presentation of typhoid fever adds to the diagnostic difficulties
because it mimics other febrile illnesses such as malaria, dengue fever, and influenza [4–7].
Nonetheless, characteristic presentations, such as “step-ladder” fever, relative bradycardia, and
coated tongue, aid in clinical diagnosis. These features were described by Haq et al. [5] to have
good specificity (100%, 94%, and 94% for “step-ladder” fever, relative bradycardia, and coated
tongue, respectively). However, fever and abdominal pain were the most reported symptoms
[8, 9]. In resource-limited settings, diagnosis is highly dependent on the clinical presentation.
Therefore, careful evaluation is needed to distinguish typhoid fever from other diseases.
Laboratory investigations are important for screening and diagnosis of typhoid fever. How-
ever, serological tests, culture, and polymerase chain reaction (PCR) have diagnostic limita-
tions, and investigations such as blood and bone marrow culture are not readily available in
most typhoid-endemic countries. Likewise, the Widal test, which is more commonly used in
endemic countries, has poor specificity and titer cut-off limitations. Another drawback is that
laboratory investigations are costly and not always available, and this contributes to delayed
diagnosis and inappropriate treatment [3, 8, 10, 11]. To overcome these diagnostic difficulties,
several rapid diagnostic tests have recently been evaluated [12, 13]. However, their acceptance
and widespread use in laboratories in typhoid-endemic developing countries are limited.
In Indonesia, antibiotics are prescribed for patients with clinically suspected typhoid
because adequate laboratory diagnosis is lacking in most rural health facilities. Symptom-
based treatment with antibiotics leads to an increased rate of antimicrobial resistance [14]. The
WHO listing of Salmonella spp. as a high-priority pathogen facing antibiotic resistance is evi-
dence of the administration of treatment on a clinical basis [15]. Despite efforts to support dif-
ferent methods of diagnosing and managing typhoid fever, the incidence, morbidity, and
mortality rates remain high [2, 3, 9, 16]. Thus, prompt, accurate diagnosis is needed to
decrease the typhoid fever burden, including a decrease in costly laboratory investigations and
antimicrobial resistance.
The Nelwan Score, which was first developed by Nelwan in 1991 is a clinical scoring system
that aids in the diagnosis of typhoid fever [17]. With this method, points are assigned to the
signs and symptoms obtained from the history and physical examination. This scoring method
has been used as a research tool in the diagnosis of typhoid fever in Indonesia and has not yet
been applied in clinical case diagnosis in health facilities.
With the Nelwan Score, the points obtained are totaled, and the score corresponds to the
probability of a clinical diagnosis of typhoid fever: a score of 13 or more is rated highly likely
to be typhoid fever, and typhoid fever is unlikely if the score is < 7. Although the Nelwan

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PLOS ONE Validation of nelwan score

Score can help in the diagnosis of typhoid fever, this scoring method has not been validated
compared with blood culture and PCR as the reference standard for typhoid diagnosis. In this
study, we validated the Nelwan Score for the diagnosis of typhoid fever in adults compared
with laboratory tests.

Methods
Study design
A cross-sectional study was conducted between July 2017 and January 2018 using primary data
of patients who visited the emergency department, outpatient clinic, and internal medicine
ward in five hospitals (Persahabatan Hospital, Budhi Asih Hospital, South Tangerang Hospital,
Hermina Ciputat Hospital, and Metropolitan Medical Center Hospital) and two primary health
care centers (Jatinegara Primary Health Center and Gambir Primary Health Center) in the
Jakarta area. The inclusion criteria were adult patients (aged 18–65 years) with fever � 37.5˚C,
for 3 to 14 days, and at least one abdominal manifestation indicative of typhoid fever. Pregnant
women, those with known causes of fever, and those treated with antibiotics were excluded.
Clinical history and physical examination were performed on all study participants with
routine laboratory investigations (complete blood count and differential count). In addition,
blood culture and PCR were carried out, and rectal culture was performed in participants who
had fever for more than 7 days.
All participants were interviewed and the Nelwan Score was calculated (Table 1). Patients
with fever and abdominal symptoms were considered clinically probable cases of typhoid
fever, and the clinical diagnosis was confirmed by positive blood culture, rectal swab culture,
or PCR of a blood sample.
Nelwan Score: The score was calculated by assigning a point to each of the following symp-
toms: fever for less than one week, headache, weakness, nausea, abdominal pain, anorexia,

Table 1. Symptoms and signs of the Nelwan Score for typhoid fever.
Score
Symptom
Fever � 1 week 1
Fever >1 week 2
Headache 1
Weakness 1
Nausea 1
Abdominal pain 1
Anorexia 1
Vomiting 1
Motility Disorder 1
Insomnia 1
Sign
Hepatomegaly 1
Splenomegaly 1
Relative bradycardia 2
Typhoid tongue 2
Melena stools 2
Impaired consciousness 2
Total score 20
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vomiting, disturbed gastrointestinal motility, insomnia, hepatomegaly, and splenomegaly

(Table 1). Two points were assigned for fever for more than one week, relative bradycardia,
typhoid tongue, melena stools, and impaired consciousness. The maximum possible score was
20. When first developed, a score of 13 or more indicated that a patient was highly likely to be
positive for typhoid fever, a score ranging between 8 and 12 provided a 50% probability of
typhoid fever positivity, and a score of 7 or less indicated that typhoid fever was unlikely.

Laboratory investigations
Blood culture. An 8–10 mL sample of blood was collected using a universal standard antisep-
tic procedure and injected into BACTEC Plus Aerobic bottles, which were transported daily to
the Eijkman Oxford Clinical Research Unit laboratory and processed according to standard
procedures for the isolation and identification of S. typhi [18, 19]. The inoculated bottles were
incubated in a BD BACTEC 9050 system instrument at 37˚C for 7 days, or until they were
detected as positive by the instrument. When bacterial growth was detected, small aliquots of
medium were subcultured on MacConkey and Salmonella-Shigella (SS) agar plates. MacCon-
key and SS agar plates were incubated at 37˚C for 18 to 24 hours. On MacConkey agar, S. typhi
was identified as smooth, non-lactose-fermenting colonies. On SS agar, S. typhi was identified
as a non-lactose-producing, non-fermenting colonies with a black center. Suspected colonies
were screened using Kligler iron agar, motility indole ornithine, and citrate utilization tests.
Colonies showing biochemical reactions suggestive of S. typhi were confirmed serologically by
a slide agglutination test with Vi antiserum, Salmonella D1 group-specific antiserum, Salmo-
nella O factor 9 antiserum (Becton Dickinson Laboratories, Franklin Lakes, NJ, USA).
Rectal swab culture. Rectal swabs were transported to the laboratory in Cary and Blair
medium and plated directly on SS and MacConkey agar plates. Swab samples were also placed
in Salmonella-selective enrichment broth (selenite cystine broth). After 18 to 20 h of incuba-
tion in the broth at 37˚C, these swabs were plated on fresh sets of the same two agar media.
Agar plates were also incubated at 37˚C for 20 to 24 h. Identification of S. typhi was performed
by selecting isolated colonies with characteristics of S. typhi as described in the previous sec-
tion on blood culture examination [19].
DNA extraction and polymerase chain reaction. DNA was extracted from 200-μL blood
samples using the QIAmp DNA mini kit (Qiagen, Hilden, Germany) according to the manu-
facturer’s instructions. PCR testing was performed using primer sets for flagellin genes of S.
typhi: fliC and fliB (z66). The fliC gene was amplified with primers fliC_F: 5'-TTA-AC
G-CAG-TAAAGA-GAG-3' and fliC_R: 5'-ATGGCA-CAA-GTC-ATT-AAT-AC-3',
which produced 1521 base pairs for the d-allele and 1273 bp for the j-allele. Amplification of
the fliB (z66) gene was performed with z66 flag_F: 5'-ATG-GCA-CAA-GTC-ATC-A
AT-AC-3' and z66 flag_R: 5'-TTA-ACG-CAG-CAG-AGA-CAG-TAC3' produced 1479
bp amplicons [20, 21]. PCR was carried out with PCR toptaq DNA polymerase (Qiagen, Hil-
den, Germany) with a DNA concentration of 20 ng/mL, cycled 35 times on a Thermocycler
PCR System 9700 (Applied Biosystems, Foster City, CA, USA), and the resulting products
were analyzed on a 1% agarose gel with 2 μL loading dye (Promega, Madison, WI, USA), for
each 5 μL sample. The size was measured by comparing the migration available with the 100
bp DNA ladder (Promega, Madison, WI, USA).

Data analysis
Data analysis was performed using Stata version 15.0 (StataCorp, College Station, TX, USA).
Descriptive analysis was performed on demographic data and clinical manifestations. The
diagnostic value of the Nelwan Score was assessed by calculating the sensitivity, specificity,

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PLOS ONE Validation of nelwan score

predictive value, and likelihood ratio, and cut-off analysis was performed by plotting the
receiver-operating characteristic (ROC) curve with 95% confidence intervals (CI).

Ethical considerations
Written informed consent was obtained from all participants prior to data collection. Ethical
approval was obtained from the Ethical Board of Universitas Indonesia (approval number:
641/UN2). F1/ETIK/2017). All data collected were kept confidential.

Results
A total of 233 participants were enrolled and assessed using both the Nelwan score and refer-
ence tests. The signs and symptoms reported by the participants are presented in Table 2. Of
the 233 participants, 11 (4.7%) had typhoid confirmed by positive blood culture. However,
none of the rectal cultures or blood PCR results were positive. Of the 11 participants with con-
firmed typhoid, six (55%) were female. The median age of all study participants was 38 years,
whereas the median age of the patients with confirmed typhoid was 26 years.
The symptoms of fever for less than a week, headache, weakness, nausea, abdominal pain,
anorexia, motility disorder, and insomnia were present in all patients with laboratory-con-
firmed typhoid, thus, no participants with confirmed typhoid fever had a Nelwan Score less
than 9.
Fig 1 shows the ROC curve analysis. The diagnostic prediction according to the area under
the curve (AUC) was 77.3% (95% CI: 65.9–88.7%).

Table 2. Clinical characteristics of study subjects (clinical and confirmed cases).

Clinical characteristics Total Typhoid confirmed Typhoid not confirmed
n = 233 n = 11 n = 222
Sex
Male 110 5 (4.5%) 105 (95.5%)
Female 123 6 (4.88%) 117 (95.12%)
Age (years), median (range) 26 (20–45) 38 (18–81)
Fever � 1 week 202 (86.7) 11 (100) 191 (86)
Fever > 1 week 31 (13.3) 0 (0) 31 (13.9)
Headache 209 (89.7) 11 (100) 198 (89.2)
Malaise 221 (94.8) 11 (100) 210 (94.6)
Nausea 222 (95.3) 11 (100) 211 (95)
Abdominal pain 207 (88.8) 11 (100) 196 (88.3)
Anorexia 211 (90.6) 11 (100) 200 (90.1)
Vomiting 168 (72.1) 10 (90.9) 160 (72.1)
Motility disorder 177 (76) 11 (100) 166 (74.8)
Insomnia 174 (74.7) 11 (100) 163 (73.4)
Hepatomegaly 7 (3) 0 7 (3.2)
Splenomegaly 0 0 0
Relative bradycardia 21 (9) 7 (63.6) 14 (6.3)
Typhoid tongue 94 (40.3) 10 (90.9) 84 (37.8)
Melena 21 (9) 0 21 (9.5)
Impaired consciousness 7 (3) 1 (9.1) 6 (2.7)
Nelwan Score, median (range) 9 (4–15) 11 (9–13) 9 (4–15)

Values are reported as n (%), unless indicated otherwise.

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Fig 1. Receiving-operating characteristic (ROC) curve of the Nelwan Score for diagnosing typhoid fever.
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The corresponding cut-off values to estimate the typhoid fever diagnosis and risk in
patients with fever are shown in Fig 2.
To explore the best diagnostic value of the Nelwan Score, we calculated different cut-off val-
ues. A value of 10 had the highest sensitivity (81.8%) with a negative predictive value (NPV) of
98.5% and reliability of 42.6%, whereas a sensitivity of 100% was obtained using at a cut-off
value of 9, and specificity of 88.7% was observed using a cut-off value of 12 (Table 3).

Discussion
The Nelwan Score for the diagnosis of typhoid fever was evaluated based on the clinical signs
and symptoms of patients who presented to five hospitals and two community health facilities
in the greater Jakarta area. A Nelwan Score of 10 had an acceptable sensitivity (81.8%) and
NPV (98.5%), and was the optimal cut-off value for diagnosing typhoid fever. These results
suggests that the Nelwan Score has practical value as a screening tool that could benefit clini-
cians working in health facilities with limited laboratory facilities [17, 22]. A tool that aids in
early diagnosis and prompt treatment of typhoid fever is essential in Indonesia to reduce mor-
bidity and prevent transmission. As the treatment of typhoid fever includes the administration
of antibiotics, making a reliable clinical diagnosis at presentation would prevent the irrational
use of antibiotics that might contribute to antimicrobial resistance. Indonesia has already been
identified as an epicenter for antimicrobial resistance [14].
The usefulness of the Nelwan Score was determined using an ROC curve. A cut-off value of
10 provided the best trade-off between sensitivity and specificity. As this is the first study to
assess the optimal cut-off value of the Nelwan Score, a comparison could not be evaluated.
We compared our findings with those of several studies that focused on the clinical features
of aiding typhoid fever diagnosis. Haq et al [5]. reported that clinical manifestations promoted
a good diagnostic value for typhoid fever. However, their study reported the specificity of each
separate clinical manifestation compared to microbiological results. Kuvandik et al. [6],

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Fig 2. Receiver-operating characteristic curve of the Nelwan Score showing the intersection between sensitivity
and specificity.
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reported that several relevant clinical manifestations might aid clinicians in diagnosing
typhoid fever, combined with laboratory investigation. Kuvandik et al. [6] reported that clini-
cal manifestations (splenomegaly, rose spots, and relative bradycardia) alone provided a high
sensitivity (91.7%) but limited specificity (34.5%) for typhoid diagnosis in the absence of
microbiological confirmation [6]. Hosoglu et al. [7], tried to develop a prediction rule as an
alternative to microbiological tests to aid clinicians in diagnosing typhoid fever. The sensitivity
and specificity of their prediction rule were 83.8% and 82.4%, respectively; however, their pre-
diction rule included the Widal test result and leukocyte count [7]. Compared to other studies,
this study showed that the Nelwan Score, a scoring system based on clinical manifestations,
had acceptable diagnostic value and better practicality in the absence of laboratory
investigations.
We then compared our study with the study conducted by Neopane et al. [8], who also
developed diagnostic criteria for typhoid fever based on clinical manifestations. The sensitivity
and specificity of their diagnostic criteria were 72.2% and 98.3%, respectively. They pointed
out that their diagnostic criteria were unique, as they avoided laboratory investigations. This
study, which has a larger sample size, also evaluated a scoring system based on clinical mani-
festations, and found that the Nelwan Score, had good diagnostic value with better sensitivity
(81.8%). This suggests that the Nelwan Score might be a better clinical screening tool for

Table 3. Diagnostic value of Nelwan Score.

Cut-off Value Sensitivity % (95% CI) Specificity % (95% CI) PPV % (95% CI) NPV % (95% CI) LR+ (95% CI) LR− (95% CI) Reliability %
10 81.8 (52–95) 60.8 (54–67) 9.3 (5–17) 98.5 (95–100) 2.09 (1.66–2.62) 0.30 (0.19–0.47) 42.6
11 54.5 (28–79) 73.4 (67–79) 9.2 (4–19) 97 (93–99) 2.05 (1.47–2.87) 0.62 (0.47–0.82) 27.9
12 45.5 (21–72) 88.7 (84–92) 16.7 (7–34) 97 (94–99) 4.04 (2.33–7.00) 0.61 (0.44–0.86) 34.2

LR, likelihood ratio; NPV, negative predictive value; PPV, positive predictive value.

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patients with suspected typhoid fever. Furthermore, this score can be extensively implemented
as a typhoid fever screening tool in healthcare facilities with limited resources.
Statistically, patients with a total score of 10 were estimated to have a confirmed typhoid
fever case with sensitivity, specificity, positive predictive value (PPV), and NPV of 81.8%,
60.8%, 9.3%, and 98.5%, respectively. The positive and negative likelihood ratios of the Nelwan
Score in this setting are 2.086 and 0.299, respectively. The PPV was very low due to the low
proportion of patients with typhoid fever in this study. However, our findings suggest that
when a patient with suspected typhoid fever has consistent clinical signs and symptoms with a
Nelwan Score of � 10, clinicians can promptly initiate treatment in setting where laboratory
investigations such as culture are not available. In patients in whom the Nelwan Score is < 10,
laboratory investigations should be performed to confirm the typhoid diagnosis. Using cut-off
values of 11 and 12 showed no statistically significant increase in the sensitivity, specificity,
and AUC value, compared with a cut-off value of 10, and therefore we suggest a cut-off value
of 10 should be used to diagnose typhoid based on the Nelwan Score.
Our study has some limitations. The proportion of confirmed typhoid fever cases was low
(4.72%), similar to a recent study by Gasem et al. [23]. Although this may not be a representa-
tive figure of typhoid fever in Indonesia, it is comparable to the proportion reported by Pun-
jabi et al. [24] in a study conducted in North Jakarta hospitals in patients admitted with a
history of fever for 3 days or more accompanied by abdominal complaints. To date, few studies
have reported the prevalence of typhoid fever. This is probably due to difficulties in confirming
the diagnosis, because PCR testing is not recommended as a routine diagnostic procedure.
The low incidence of typhoid fever may also be influenced by antibiotic administration
prior to conducting laboratory investigations. Several studies have reported that antibiotic
administration and the duration between the onset of the disease and sample collection con-
tributed to the low detection rate of typhoid cases [25, 26]. To prevent this from biasing our
results, we restricted the eligibility criteria to patients without current antibiotic use. However,
we learned that it is essential to ask for more specific information regarding current antibiotic
exposure because patients might have already visited the outpatient clinic before being
included in our study.
Another reason why only a small proportion of participants were confirmed with typhoid
fever is that culture (especially rectal swab culture) has limited sensitivity, which varies
throughout the course of the disease (40–80% during the incubation period) [25, 27]. The
same factors also apply to PCR. Although some studies have shown that PCR has high sensitiv-
ity and specificity, false-negatives may still occur [28–30]. False-negative PCR results may
result from the small numbers of bacteria, gene mutations, and inhibitory substances in the
sample [30].
Another limitation of this study is that it did not evaluate the items of the Nelwan Score as a
scoring system. Nevertheless, this study showed that the Nelwan Score as an appropriate
method in which clinical signs and symptoms may be appropriately recognized to diagnose
typhoid fever.

Conclusion
The clinical features used in the Nelwan Score showed that a cut-off value of 10 was the score
with the best diagnostic value. Taking this into consideration, the Nelwan Score is applicable
as a screening tool for patients presenting with suspected typhoid fever features in settings
where laboratory resources are limited and could reduce the inappropriate use of antibiotics in
patients with suspected typhoid.

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Supporting information
S1 Dataset. Original dataset.
(XLSX)
S1 File. STARD flow diagram.
(DOCX)

Acknowledgments
We acknowledge Dr. Rukhsana Ahmed for reviewing the final draft and thank the Division of
Tropical and Infectious Disease Department of Internal Medicine Universitas Indonesia/Cipto
Mangunkusumo Hospital, Persahabatan Hospital, Budhi Asih Hospital, South Tangerang
Hospital, Hermina Ciputat Hospital, Metropolitan Medical Center Hospital, Jatinegara Pri-
mary Health Center, and Gambir Primary Health Center for accommodating and supporting
this study. We thank Rois Muqsith Fatawy for performing the final revision of the manuscript.
We also thank the study participants for their voluntary participation.

Author Contributions
Conceptualization: Erni Juwita Nelwan, Robert Sinto, Decy Subekti, Pringgodigdo Nugroho,
Herdiman T. Pohan.
Data curation: Decy Subekti, Herdiman T. Pohan.
Formal analysis: Erni Juwita Nelwan, Luh Putu Listya Paramita, Robert Sinto, Decy Subekti.
Investigation: Luh Putu Listya Paramita, Decy Subekti.
Methodology: Luh Putu Listya Paramita, Robert Sinto, Fransiscus Nikodemus Hosea.
Project administration: Luh Putu Listya Paramita.
Resources: Luh Putu Listya Paramita.
Supervision: Erni Juwita Nelwan, Robert Sinto, Pringgodigdo Nugroho, Herdiman T. Pohan.
Validation: Erni Juwita Nelwan, Decy Subekti, Fransiscus Nikodemus Hosea, Pringgodigdo
Nugroho, Herdiman T. Pohan.
Visualization: Erni Juwita Nelwan.
Writing – original draft: Erni Juwita Nelwan, Luh Putu Listya Paramita.
Writing – review & editing: Erni Juwita Nelwan, Robert Sinto, Fransiscus Nikodemus Hosea.

References
1. Stanaway JD, Reiner RC, Blacker BF, Goldberg EM, Khalil IA, Troeger CE, et al. The global burden of
typhoid and paratyphoid fevers: a systematic analysis for the Global Burden of Disease Study 2017.
Lancet Infect Dis. 2019; 19(4):369–81. https://doi.org/10.1016/S1473-3099(18)30685-6 PMID:
30792131
2. Mogasale V, Mogasale V V., Ramani E, Lee JS, Park JY, Lee KS, et al. Revisiting typhoid fever surveil-
lance in low and middle income countries: lessons from systematic literature review of population-
based longitudinal studies. BMC Infect Dis. 2015 Dec 29; 16(1):35.
3. Azmatullah A, Qamar FN, Thaver D, Zaidi AKM, Bhutta ZA. Systematic review of the global epidemiol-
ogy, clinical and laboratory profile of enteric fever. J Glob Health. 2015; 5(2). https://doi.org/10.7189/
jogh.05.020407 PMID: 26649174

PLOS ONE | https://doi.org/10.1371/journal.pone.0256508 May 12, 2023 9 / 11

PLOS ONE Validation of nelwan score

4. Elisabeth Purba I, Wandra T, Nugrahini N, Nawawi S, Kandun N. Program Pengendalian Demam Tifoid
di Indonesia: Tantangan dan Peluang. Media Penelitian dan Pengembangan Kesehatan. 2016; 26
(2):99–108.
5. Haq SA, Alam MN, Hossain SM, Ahmed T, Tahir M. Value of clinical features in the diagnosis of enteric
fever. Bangladesh Med Res Counc Bull. 1997 Aug; 23(2):42–6. PMID: 9465434
6. Kuvandik C, Karaoglan I, Namiduru M, Baydar I. Predictive value of clinical and laboratory findings in
the diagnosis of the enteric fever. New Microbiologica. 2009; 32(1):25–30. PMID: 19382666
7. Hosoglu S, Geyik MF, Akalin S, Ayaz C, Kokoglu OF, Loeb M. A simple validated prediction rule to diag-
nose typhoid fever in Turkey. Trans R Soc Trop Med Hyg. 2006; 100(11):1068–74. https://doi.org/10.
1016/j.trstmh.2005.12.007 PMID: 16697432
8. Neopane A, Panta S. Validation of the proposed clinical diagnostic criteria of enteric fever. Kathmandu
University Medical Journal. 2012; 10(40):8–11. https://doi.org/10.3126/kumj.v10i4.10986 PMID:
23575044
9. Baker S, Favorov M, Dougan G. Searching for the elusive typhoid diagnostic. BMC Infect Dis. 2010; 10
(Figure 1):1–8. https://doi.org/10.1186/1471-2334-10-45 PMID: 20205702
10. Adhikari A, Rauniyar R, Raut PP, Manandhar K Das, Gupta BP. Evaluation of sensitivity and specificity
of ELISA against Widal test for typhoid diagnosis in endemic population of Kathmandu. BMC Infect Dis.
2015; 15(1):1–7. https://doi.org/10.1186/s12879-015-1248-6 PMID: 26573629
11. Andualem G, Abebe T, Kebede N, Gebre-Selassie S, Mihret A, Alemayehu H. A comparative study of
Widal test with blood culture in the diagnosis of typhoid fever in febrile patients. BMC Res Notes. 2014;
7(1):1–6. https://doi.org/10.1186/1756-0500-7-653 PMID: 25231649
12. Hamdy MS, Abdel-Rahman S, Mostafa A, Abd-El Hameed S. Evaluation of enterocheck WB® test in
diagnosis of typhoid fever among Egyptian adults. Egypt J Med Microbiol. 2014; 23(4):47–50.
13. Salama RI, Said NM. A Comparative Study of the Typhidot (Dot-EIA) versus Widal Test in Diagnosis of
Typhoid Fever among Egyptian Patients. Open J Gastroenterol. 2019; 09(06):91–8.
14. World Health Organization (WHO). GLASS Report: Early Implementation 2020. 2020. 134 p.
15. World Health Organization (WHO). Global priority list of antibiotic-resistant bacteria to guide research,
discovery, and development of new antibiotics. 2017.
16. Hatta M, Ratnawati. Enteric fever in endemic areas of Indonesia: An increasing problem of resistance. J
Infect Dev Ctries. 2008; 2(4):279–82.
17. Nelwan R, Chen Lie K, Hadisaputro S, Suwandoyo E, &nbsp S, &nbsp N, et al. A Single Blind Compara-
tive Randomized Non-Inferior Multicenter Study for Efficacy and Safety of Levofloxacin versus Cipro-
floxacin in the Treatment of Uncomplicated Typhoid Fever. Adv Microbiol. 2013; 03(01):122–7.
18. World Health Organization. Background document: The diagnosis, treatment and prevention of typhoid
fever. 2003.
19. Ballows A, Hausler WJ Jr, Hermann KL, Isenberg HD, Shadony HJ. Enterobacteriaceae. In: Manual of
Clinical Microbiology. 1991. p. 360–83.
20. Baker S, Holt K, Van De Vosse E, Roumagnac P, Whitehead S, King E, et al. High-throughput genotyp-
ing of Salmonella enterica serovar Typhi allowing geographical assignment of haplotypes and patho-
types within an urban district of Jakarta, Indonesia. J Clin Microbiol. 2008; 46(5):1741–6. https://doi.org/
10.1128/JCM.02249-07 PMID: 18322069
21. Frankel G, Newton SMC, Schoolnik GK, Stocker BAD. Intragenic recombination in a flagellin gene:
characterization of the H1-j gene of Salmonella typhi. EMBO Journal. 1989; 8(10):3149–52. https://doi.
org/10.1002/j.1460-2075.1989.tb08468.x PMID: 2583095
22. Khosla S. Severe typhoid fever and appraisal of its profile. In: Nelwan RHH:Typhoid fever profile, diag-
nosis, and treatment in the 1990’s. Jakarta: FKUI Press; 1992. p. 51–82.
23. Gasem MH, Id HK, Tjitra E, Alisjahbana B, Karyana M, Lokida D, et al. An observational prospective
cohort study of the epidemiology of hospitalized patients with acute febrile illness in Indonesia. 2020;
486:1–17. Available from: https://doi.org/10.1371/journal.pntd.0010530
24. Punjabi NH, Agtini MD, Ochiai RL, Simanjuntak CH, Lesmana M, Subekti D, et al. Enteric fever burden
in North Jakarta, Indonesia: A prospective, community-based study. J Infect Dev Ctries. 2013; 7
(11):781–7. https://doi.org/10.3855/jidc.2629 PMID: 24240034
25. Gilman Robert H, Terminel M, Levine Myron M, Hernandez-Mendoza P, Hornick Richard B. Relative
Efficacy of Blood, Urine, Rectal Swab, Bone-Marrow, and Rose-Spot Cultures for Recovery of Salmo-
nella Typhi in Typhoid Fever. The Lancet. 1975 May; 305(7918):1211–3.
26. Al-Emran HM, Hahn A, Baum J, Cruz Espinoza LM, Deerin J, Im J, et al. Diagnosing Salmonella enter-
ica Serovar Typhi Infections by Polymerase Chain Reaction Using EDTA Blood Samples of Febrile

PLOS ONE | https://doi.org/10.1371/journal.pone.0256508 May 12, 2023 10 / 11

PLOS ONE Validation of nelwan score

Patients From Burkina Faso. Clinical Infectious Diseases. 2016 Mar 15; 62(suppl 1):S37–41. https://
doi.org/10.1093/cid/civ770 PMID: 26933018
27. Darton TC, Zhou L, Blohmke CJ, Jones C, Waddington CS, Baker S, et al. Blood culture-PCR to opti-
mise typhoid fever diagnosis after controlled human infection identifies frequent asymptomatic cases
and evidence of primary bacteraemia. Journal of Infection. 2017 Apr; 74(4):358–66. https://doi.org/10.
1016/j.jinf.2017.01.006 PMID: 28130144
28. Sánchez-Jiménez MM, Cardona-Castro N. Validation of a PCR for diagnosis of typhoid fever and sal-
monellosis by amplification of the hilA gene in clinical samples from Colombian patients. J Med Micro-
biol. 2004 Sep 1; 53(9):875–8. https://doi.org/10.1099/jmm.0.45630-0 PMID: 15314194
29. Mawazo A, Bwire GM, Matee MIN. Performance of Widal test and stool culture in the diagnosis of
typhoid fever among suspected patients in Dar es Salaam, Tanzania. BMC Res Notes. 2019 Dec 5; 12
(1):316. https://doi.org/10.1186/s13104-019-4340-y PMID: 31167646
30. Millar BC, Xu J, Moore JE. Risk Assessment Models and Contamination Management: Implications for
Broad-Range Ribosomal DNA PCR as a Diagnostic Tool in Medical Bacteriology. J Clin Microbiol. 2002
May; 40(5):1575–80. https://doi.org/10.1128/JCM.40.5.1575-1580.2002 PMID: 11980924

PLOS ONE | https://doi.org/10.1371/journal.pone.0256508 May 12, 2023 11 / 11