TYPE Original Research

PUBLISHED 16 August 2024

DOI 10.3389/fpubh.2024.1357131

Prevalence of typhoid fever and

OPEN ACCESS its associated factors among
febrile patients visiting Arerti
EDITED BY
Juarez Antonio Simões Quaresma,
Federal University of Pará, Brazil

REVIEWED BY
Hemant Khuntia,
Primary Hospital, Amhara Region,
Siksha ’O’ Anusandhan University, India
Rashid Jan,
University of Swabi, Pakistan
north east Ethiopia
*CORRESPONDENCE
Fekade Demeke Bayou Genet Muche1 , Asmamaw Tesfaw1 and Fekade Demeke Bayou2*
[email protected]
1
RECEIVED 26 January 2024 Department of Biology, Debre Berhan University, Debre Berhan, Ethiopia, 2 Department of
ACCEPTED 05 August 2024
Epidemiology and Biostatistics, School of Public Health, Colleges of Medicine and Health Science,
PUBLISHED 16 August 2024
Wollo University, Dessie, Ethiopia

CITATION
Muche G, Tesfaw A and Bayou FD (2024)
Prevalence of typhoid fever and its associated Background: Typhoid fever is one of the major public health concerns in
factors among febrile patients visiting Arerti developing countries, including Ethiopia. Understanding the burden and factors
Primary Hospital, Amhara Region, north east
Ethiopia. Front. Public Health 12:1357131.
contributing to the transmission and development of the disease is crucial to
doi: 10.3389/fpubh.2024.1357131 applying appropriate preventive and therapeutic interventions.
COPYRIGHT Objective: To assess the prevalence of typhoid fever and its associated factors
© 2024 Muche, Tesfaw and Bayou. This is an among febrile patients visiting Arerti Primary Hospital from 1 March to 30
open-access article distributed under the
terms of the Creative Commons Attribution May 2022.
License (CC BY). The use, distribution or Methods: A facility-based cross-sectional study was employed among 326
reproduction in other forums is permitted,
provided the original author(s) and the febrile patients visiting Arerti Primary Hospital for health services. The data were
copyright owner(s) are credited and that the collected using laboratory procedures (widal test) and a structured interviewer-
original publication in this journal is cited, in administered questionnaire. The data were entered using Epi Data version 3.1
accordance with accepted academic practice.
No use, distribution or reproduction is and analyzed by SPSS version 25. Logistic regression was used to determine
permitted which does not comply with these associations between variables. P-value < 0.05 and adjusted odds ratio with
terms. 95% confidence interval were used to measure the presence and strength
of associations.
Results: In this study, of the total 317 cases that participated, the majority
(64.4%) of them were males with age ranges from 13 to 63 years. The overall
prevalence of positive antigen tests for typhoid infection was 30.0% (95% CI:
25.0%−35.3%). About 66.9% of the study participants had good knowledge, 75.7%
had favorable perception, and 42.3% had good infection prevention practice.
Being unemployed [AOR = 7.57, 95% CI (1.98, 28.93)], being a farmer [AOR =
2.73, 95% CI (1.01, 7.41)], and having a body mass index (BMI) below 18.5 kg/m2
[AOR = 5.12, 95%CI (2.45, 10.68)] were significantly associated with typhoid
fever infection.
Conclusion: The prevalence of typhoid fever among febrile patients was
high. Typhoid fever infection was significantly associated with occupational
status (being unemployed and being a farmer) and lower BMI. The level of
knowledge, perception, and practice of typhoid fever infection prevention were
found inadequate. Therefore, behavioral change interventions are needed at the
community level.

KEYWORDS

prevalence, typhoid fever, Arerti, Ethiopia, associated factors

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Muche et al. 10.3389/fpubh.2024.1357131

Introduction of typhoid fever was 68.75% (15), while it was found at 943
per 100,000 in Ghana (16). In Ethiopia, limited studies found
Typhoid fever is a life-threatening acute febrile illness caused that 13.2, 10, and 25.7% of the study population in the Afar
by Salmonella typhi and paratyphi (with a 10:1 case ratio) Region, West Wollega Zone, and Injibara, Northwest Ethiopia,
(1–3). After ingestion in contaminated food or water, typhoid respectively, had S. Typhi infection (17–19). In general, the
organisms pass through the pylorus, reach the small intestine, estimated pooled prevalence of typhoid fever from blood and
penetrate the mucosal epithelium, cause acute infection, and are stool culture diagnosis was 3% and Widal test examination 33%
released into the bloodstream by lymph drainage from mesenteric (20). Socio-demographic and clinical conditions including the
nodes. Incubation periods ranging from 3 days to more than 60 duration and severity of typhoid fever disease, sex, age, personal
days have been reported (1). After infection with the bacteria, and environmental hygiene (11, 21), income (15, 16), sharing
symptoms usually start 8–14 days later for typhoid fever and 1– food, ownership/utilization of toilets (22, 23), residence (24),
10 days later for paratyphoid fever (3). The clinical presentation educational level, and misconception about the transmission of
of typhoid fever varies from a mild illness with low-grade fever, typhoid fever (18, 25–27) were found to be significantly associated
malaise, and a slight dry cough to a severe clinical picture with with typhoid prevalence.
abdominal discomfort and multiple complications. Depending To combat the impact of typhoid fever on the health,
on the clinical setting and the quality of available medical care, economic, and social activities of the community, there should
a significant portion of typhoid patients may develop serious be clear information regarding the magnitude of the disease and
complications like intestinal perforation, hemorrhage, hepatitis, its socio-demographic, economic, cultural, and geographic risk
altered mental status (confusion and delirium), etc. (1, 3). The factors contributing to the transmission and development of the
definitive diagnosis of typhoid fever depends on the isolation of disease. To evaluate the impact of this infectious disease in a
S. typhi from blood, bone marrow, or a specific anatomical lesion. particular area, one must be aware of the prevalence of typhoid
Blood culture is the mainstay of the diagnosis of this disease (1). fever. For public health officials to deploy focused interventions
Transmission of typhoid fever can be prevented by maintaining and allocate resources efficiently, this information is essential.
food safety, safe water supply, proper sanitation, vaccination, Understanding associated risk factors facilitates understanding the
and health education to create public awareness and induce mechanisms underlying the transmission of typhoid fever. This
behavioral change after identifying socio-demographic, cultural, information can direct the creation of approaches to stop the
and economic risk factors contributing to the transmission of the spread, like strengthening immunization campaigns and enhancing
disease (1, 3). food safety, water quality, sanitation, and hygiene. Understanding
Globally, there were more than 14 million cases of typhoid and the prevalence and risk factors helps medical professionals diagnose
paratyphoid fevers, with an estimated 136,000 deaths. Moreover, and treat patients more accurately. It can result in faster, more
typhoid and paratyphoid fevers were responsible for 9.8 million precise patient care, better recovery rates, and a decrease in typhoid
disability-adjusted life years (DALYs) in 2017 (4, 5). In Africa, fever-related complications or deaths. However, such relevant
typhoid fever remains a higher endemic tropical disease of public information is limited in Ethiopia, particularly in the study area.
health significance due to its faster transmission rates (6, 7). Hence, this study was aimed at assessing the prevalence of typhoid
The reported figures on typhoid fever cases show that the trend fever and its associated factors among febrile patients attending
of typhoid-related morbidity is in rapid increment over time in Arerti Primary Hospital.
Africa. Outbreaks of typhoid fever were reported in 15 countries
(6). The estimated case fatality rate among non-surgical patients
was 5.4% for the Africa region, which is six times higher than
Methods and materials
that of the Asia region (5). The burden of the disease was more
pronounced in sub-Saharan Africa (SSA), with 7.2 million cases of Study setting, design, and period
typhoid fever annually and an incidence rate of 762 per 100,000
person-years. Recent studies show that almost all regions of SSA This study was conducted at Arert Primary Hospital located in
are tending toward high incidence rates, especially Central and Minjar Shenkora woreda, Amhara Regional State, Ethiopia. Minjar
Western Africa (7). Shenkora Woreda is located 130 km from Addis Ababa. The woreda
Typhoid and paratyphoid fever was endemic in many countries is populated with an estimated number of 156,040 people (80,729
in South Asia, sub-Saharan Africa, and East Asia and the Pacific male) and (75,311 female) (28). There are five health centers, 27
(8–10). In Africa, a study done in Kaduna State and South-East health posts, and one primary hospital providing health services
Nigeria showed that the prevalence of typhoid fever was 33.3% for the catchment population. A facility-based cross-sectional study
and 14.1%, respectively (11, 12). In the Democratic Republic was conducted from March 01 to May 30, 2022.
of Congo and South Africa, the annual incidence of typhoid
fever ranged from 1.7 to 9.1% and 0.11 to 0.39 per 100,000
populations, respectively (13, 14). In Cameroon, the prevalence
Population

Abbreviations: AOR, adjusted odds ratio; APH, Arerti Primary Hospital; CI, Source population
Confidence Interval; OPD, Out Patient Department; SPSS, Statistical Package The source population was all febrile patients attending Arerti
for Social Sciences; TF, Typhoid Fever. Primary Hospital during the study period.

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Study population education, residence, marital status, dietary habits, safe water
Selected febrile patients clinically suspected for typhoid fever in source, and toilet access were collected by face-to-face interview
the study period were considered as the study population. using a structured questionnaire. After the interview, a 5 ml
blood specimen was collected from each study participant in the
laboratory department using a test tube without anticoagulant.
Inclusion and exclusion criteria The blood samples were collected by puncturing superficial veins
(mainly from median cubital veins) of the upper limb using
Inclusion criteria a 5 cc needle. The collected blood samples were processed to
All febrile patients clinically suspected for typhoid fever in the get serum, and the Widal slide agglutination tests were done to
study period were included in the study. detect S. Typhi using known S. Typhi flagella (H) and somatic
(O) antigens.
The slide-agglutination tests were performed as per the
Exclusion criteria manufacturer’s instruction. Briefly, the antigen vials were gently
Patients with impaired mental status (unconscious) during the mixed with saline by an aspirate dropper multiple times to make
study period were excluded. a thorough mixture. A 50 µl serum sample was added to a row
of circles on the test card. Drops (one drop each) of positive
and negative control sera were dispensed into respective circles.
Sample size determination A drop of the appropriate well-shaken suspension of the antigen
was added to each circle next to each sample to be tested and
The sample size for this study was determined using a single mixed with the content of each circle with a disposable stirrer
population proportion formula by taking the proportion (p) of and spread over the entire area enclosed by the ring with separate
typhoid fever of 25.7% from the previous study (18), the confidence applicators for each mixture. After that, the slides were shaken
level of 95%, the marginal error of 5%, and adding 10% non- gently by hand or using a mechanical rotator (100 rpm) for 1 min.
response rate. It was calculated as follows: Finally, the test was observed immediately under a suitable light
source for any degree of agglutination, and qualitative results
Zα/ 2 2 (P) (1 − P) (1.96)2 (0.26) (0.74) were recorded.
n=
2 n= .
d (0.05)2

After adding 10% non-response rate, the total sample size for
this study was 326 individuals. Study variables
Dependent variable
Sampling technique Typhoid fever status (positive or negative).

A systematic random sampling technique was used to select

study participants. First, we classified the hospitals into four Independent variable
outpatient departments (OPD) as OPD1, OPD2, OPD3, and OPD4. Independent variables include socio-demographic variables
Then patients were distributed into each OPD. Then, systematic (like sex, age, educational status, occupational status, marital
random sampling was used to select respondents from each OPD. status, residence, sources of water, etc.), history or current chronic
Sampling interval (K) was calculated by dividing total estimated medical illness and recurrent infection, knowledge about TF cause,
febrile patients visiting the hospital during the study period (N) route of transmission, and preventive measures to be taken,
by the sample size (n). It gave a value of K = 11, hence the perception about TF cause, route of transmission, and preventive
first individual was selected by lottery method, and then the next measures to be taken, and practice of febrile patients to prevent
participants were chosen in every 11th interval until the total sample TF infection.
size was reached.

Operational definitions
Data collection, clinical sample processing,
and serological testing Case definition of typhoid fever
According to the Ethiopian Ministry of Health, typhoid fever is
All febrile patients visiting Arerti Primary Hospital outpatient defined as: A probable or suspected case of typhoid fever: A patient
department (OPD) during the study period were examined with documented fever (38◦ C and above) for at least 5 days prior
clinically by physicians or health professionals. Patients presenting to presentation with a rising trend AND having no other focus to
with fever (axillary temperature >37.5◦ C) and any of the explain the cause of the fever (e.g., malaria, meningitis, pneumonia,
complaints like abdominal pain or discomfort, headache, abscess, pyelonephritis, etc.). A confirmed case of typhoid fever: A
constipation, or diarrhea were requested for a Widal test. After patient with persistent fever (38◦ C or above) lasting three or more
getting informed consent, data on individual and household days and S. Typhi isolated on culture (blood, bone marrow culture,
socio-demographic data such as age, sex, family size, occupation, stool, or urine) (29).

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TABLE 1 Socio-demographic characteristics of febrile patients visiting

Knowledge about typhoid fever APH, Arerti town, Ethiopia, 2022.
Patients’ knowledge about typhoid fever was assessed using
11 yes or no item questions concerned with the cause, mode Characteristics Categories Frequency Percentage
of transmission, and preventive measures of typhoid fever. Each (n) (%)
correct answer was scored “1” and the incorrect answer was “0,”
Sex of the Male 204 64.4
with the sum ranging from 0 to 11. The mean score was calculated respondents
to determine their level of knowledge, and participants who scored
Female 113 35.6
the mean and above were considered to have good knowledge,
while those scored below the mean score were regarded as having Age in years of the <20 40 12.6
poor knowledge. respondents

20–29 86 26.5

30–39 100 31.5

Perception toward typhoid fever
Patients perception of being exposed to or at risk of acquiring 40–49 53 16.7
typhoid fever, susceptibility, preventability, and severity of typhoid
50–59 22 6.9
fever were asked to assess their perception toward typhoid fever.
≥60 18 5.7

Practice of typhoid infection prevention Educational status of Cannot read and 34 10.7
the respondents write
A total of 14 practice-related questions were used to assess
participants’ practice of typhoid infection prevention. The average Can read only 13 4.1

score was calculated to determine their level of prevention practice, Can read and 67 21.1
and participants who scored the mean and above were considered write
to have good prevention practice, while those scored below the Completed 34 10.7
mean score were regarded as having poor prevention practice. primary
education

Secondary 70 22.1
Data quality control education

Diploma 24 7.6
The questionnaire was pretested on 5% of the sample
Degree and 75 23.7
population in Arerti health center. During the pre-test, the above
questionnaire was evaluated for its clarity, sensitivity, and cultural
Average monthly <5,000 142 44.7
acceptability. Confusing questions were identified based on the
income in birr
obtained results from the pretest, and necessary modifications have
5,000–10,000 166 52.4
been made to the questions. Training was given for data collectors
on the portion of the questionnaire and data collection procedures. 10,001–15,000 4 1.3
The questionnaire was translated from English to Amharic by
15,001–20,000 5 1.6
language experts to ease the data collection process. During
data collection, on-site supervision and technical assistance were Religion of the Orthodox 260 82
provided by the principal investigator. Finally, the questionnaire respondents
was checked daily for its completeness and consistency by Protestant 10 3.2
the principal investigator, and any incomplete information was
excluded from analysis after data collection. Muslim 47 14.8

Marital status of the Single 120 37.8

respondents
Data processing and analysis Married 193 60.9

The collected data were entered into the computer using Epi Divorce/widowed 4 1.3

Data version 3.1 and then exported to SPSS version 25 for further Occupation of Farmer 111 35
analysis. The data was cleaned, edited, sorted, and coded before respondents
analysis. Descriptive statistics such as mean, median, and standard Merchant 52 16.4
deviation were carried out for continuous variables. Participants’
responses to knowledge and practice-related questions were coded, Government 65 20.5
employ
scored, summed, and averaged. Eleven (11) questions were asked
for the participants to assess their level of knowledge about typhoid Student 74 23.3

fever. Those who answered the correct answer were scored “1” Other 15 4.8
and “0” if not. The summed scores ranged from 0 to 11. The

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TABLE 2 Source of water and comorbidity status of febrile patients

Concerning the type of water sources, most (89.6%) of the study
visiting Arerti Primary Hospital, Ethiopia, 2022.
participants were getting pipe water. For more than half (53.3%)
Variables Categories Frequency Percent of the respondents, the time taken to reach the water sources was
<5 min. About 26 (8.2%) of the study participants had any chronic
Source of water Pipe line 284 89.6
health problem (comorbidities), and hypertension was the most
Spring 33 10.4 frequently seen comorbidity (Table 2).
Traveling time to get <5 169 53.3
water source in minutes

5–10 63 19.9 Knowledge, perception, and preventive

11–15 39 12.3 practice of typhoid infection
16–20 8 2.5
Knowledge about typhoid fever
21–25 9 2.8
The patients’ knowledge about preventive measures,
≥26 15 4.7 transmission route, and signs and symptoms of TF was assessed
Weight of respondents <50 7 2.2 using 11 yes/no questions. The scores were ranging from zero (0) to
in kg eleven (11) with a mean of 9.15. Participants who scored more than
50–65 169 53.3 or equal to the mean were considered to have good knowledge. The
overall proportion of participants who had good knowledge about
66–75 92 29.1
typhoid fever was 66.9% (212). Most (91.2%) of the respondents
76–85 40 12.6 know that fever can be a sign of typhoid fever infection (Table 3).
≥86 9 2.8

Presence of chronic Yes 26 8.2

diseases Participants perception toward typhoid fever
In this study, the majority (64.4%) of the study participants
No 291 91.8
perceived themselves as they were exposed (at risk) to typhoid
What type of chronic Hypertension 13 50.0
fever infection. The mean score of the perception-related
disease do you have?
question was 3.0; participants who scored the mean and
Diabetes mellitus 9 34.6 above were regarded as having positive perception. Three-
Others 4 1.3 fourths (75.7%) of respondents had scored the mean and above
out of four perception-related questions, which implies that
they had a good perception about the TF disease source of
infection, route of transmission, and its preventive measures
mean (average) value of scores was calculated (which was 9.15) (Table 4).
and used to categorize participants’s level of knowledge. Hence,
respondents who scored below the 9.15 in the knowledge-related
question were regarded as having poor knowledge, while those who Participants’ practice to typhoid fever infection
scored 9.15 and above were considered to have good knowledge. prevention
The same method was applied to assess the level of typhoid fever In this study, participants’ practice of typhoid fever infection
infection prevention practice. Bivariable and multivariable logistic prevention was assessed using 14 diverse closed-ended questions.
regression models were fitted to determine factors associated with The minimum and maximum scores were 3.0 and 13.0, with a
the occurrence of typhoid fever. A P-value of <0.05 was used to test mean of 7.42. Of those 317 febrile patients, 134 (42.3%) were
statistical significance and adjusted odds ratio (AOR) with its 95% scored the mean and above on the TF infection practice-related
CI as a measure of strength of association between variables. questions. More than half (57.7%) of the study participants did
not have proper waste disposal practice, and only 11.0% were
adequately practicing hand washing practice after using the toilet
(Table 5).
Result
Socio-demographic characteristics of
participants Prevalence of typhoid fever among febrile
patients
In this study, about 317 febrile patients participated, giving a
response rate of 97.2%. Out of which the majority (64.4%) of them Of those 317 febrile patients who got the Widal diagnostic test,
were males. The age of study participants ranged from 13 to 63 O antigen was detected among 95 (30.0%) of the respondents. Both
years, with a mean ± SD of 34.59 to 12.07 years. Nearly one- H antigen and O antigen were detected among 201 (63.4%) of
fourth of the participants were university degree holders. Regarding the respondents. Since the flagellated H antigen may not indicate
their occupational status, more than one third of them (35%) were the current typhoid fever infection, we didn’t rely on this antigen
farmers, followed by merchants 65 (20.5%) (Table 1). result to estimate typhoid fever infection status. Hence the overall

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TABLE 3 Febrile patient knowledge about the preventive measure of TF, route of transmission, and clinical presentation of TF in APH, Arerti town,
Ethiopia, 2022.

Knowledge assessment items Response Frequency Percentage

TF is caused by microorganisms No 45 14.2

Yes 272 85.8

Fever is one sign of TF No 28 8.8

Yes 289 91.2

Typhoid fever can kill infected individuals No 27 8.5

Yes 290 91.5

Typhoid fever is transmitted from an infected person to other healthy persons No 65 20.5

Yes 252 79.5

Typhoid fever is transmitted by eating contaminated food No 46 14.5

Yes 271 85.5

Typhoid fever is transmitted by drinking contaminated water No 58 18.3

Yes 259 81.7

Typhoid fever carriers can act as a source of TF infection No 110 34.7

Yes 207 65.3

Hand washing before meals can prevent TF infection No 47 14.8

Yes 270 85.2

Hand washing after the toilet can prevent TF infection No 56 17.7

Yes 261 82.3

Typhoid fever can be prevented by proper food cooking No 53 16.7

Yes 264 83.3

Typhoid fever can be prevented by washing table fruits and vegetables No 52 16.4

Yes 265 83.6

Knowledge of study participants about typhoid fever infection Poor knowledge 105 33.1

Good knowledge 212 66.9

prevalence of typhoid fever in the study setting was 30.0%, 95% CI likely to have typhoid fever infection than merchants. Likewise, as
(25.0%−35.3%; Figure 1). compared with the same group, farmers were nearly three times
more likely to have a positive antigen test for typhoid infection.
Moreover, study participants whose body mass index (BMI) was
Factors associated with typhoid fever <18.5 kg/m2 were more than five times more likely to have typhoid
infection as compared with their counterparts (Table 6).
infection

A bi-variable and multivariable logistic regression model

was fitted to assess the relationship between dependent and Discussion
independent variables. Accordingly, preliminary assessment was
done using bivariable analysis to select the candidate variables In this study, the prevalence of typhoid fever and its associated
for multivariable logistic regression, the final model. Variables variables were assessed among febrile patients visiting Arerti
including sex of the respondents, occupational status, educational Primary Hospital for health services. Accordingly, the overall
status, marital status, body mass index, knowledge about typhoid prevalence of positive antigen tests for typhoid infection was 30%
infection, perception, and practice of typhoid infection prevention (95% CI: 25.0%−35.3%). Nearly two-thirds (66.9%) of the study
were moved to the multivariable logistic regression model. After participants had good knowledge about the cause, transmission,
controlling the effect of confounding variables, occupational status and prevention methods of typhoid fever infection. Similarly,
being unemployed [AOR = 7.57, 95% CI (1.98, 28.93)], being a three-fourths (75.7%) of the participants had favorable perceptions
farmer [AOR = 2.73, 95% CI (1.01, 7.41)], and having a BMI for typhoid fever infection prevention. However, only 42.3% of
<18.5 kg/m2 [AOR = 5.12, 95% CI (2.45, 10.68)] were statistically them had good infection prevention practices. Being unemployed, a
significantly associated with typhoid fever infection. In this study, farmer, and having a BMI <18.5 kg/m2 were significantly associated
unemployed study participants were more than seven times more with typhoid fever infection.

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TABLE 4 Perception of the study participants about the preventive TABLE 5 Febrile patients’ practices to prevent TF infection among febrile
measure of TF and route of transmission of TF in APH, Arerti town, patients who were visiting APH, Arerti town, Ethiopia, 2022.
Ethiopia, 2022.
Practice Response Frequency Percentage
Perception Response Frequency Percent assessment
assessment items
items
Do you consume raw Yes 138 43.5
Do you believe that you No 113 35.6 meat in the last month?
are exposed to TF
infectious sources? No 179 56.5

Do you consume raw Yes 119 37.5

Yes 204 64.4
milk in the last month?
Do you think that TF is a No 72 22.7
No 198 62.5
preventable disease?
Do you use pipeline Yes 312 98.4
Yes 245 77.3
water?
Do you think that No 47 14.8
No 5 1.6
washing your hands
before a meal can Do you have a garbage Yes 134 42.3
prevent you from getting can for waste collection
a TF infection? at your home?

Yes 270 85.2 No 183 57.7

Do you think consuming No 81 25.6 Do you have a toilet and Yes 289 91.2
raw fruit and vegetables use it properly?
can expose you to TF
infection? No 28 8.8

Do you usually wash Always 35 11.0

Yes 236 74.4
your hands using soap
Perception of the study Negative 77 24.3 after toilet usage?
participants about the perception
Sometimes 282 89.0
preventive measure of
TF Do you have an animal Yes 86 27.1
living in the same house?
Positive 240 75.7
perception No 231 72.9

Do you store food for Yes 268 84.5

later consumption after
The figure reported in this study, 30.0%, was in line with the use?
findings reported in Pakistan (29.34%) (11), China (29.3%) (8), No 49 15.5
and Kaduna State, Nigeria (33.3%) (12). The observed concordance
Do you share food from Yes 258 81.4
might be due to similarity in study population and method of the same plate?
assessment. For instance, the study conducted in Pakistan assessed
No 59 18.6
the prevalence of typhoid fever among febrile patients using
Do you eat uncooked Never 15 4.7
widal tests, which applied a similar approach with our study. The
food?
study conducted in Injibara, Northeast Ethiopia, reported that
Some times 302 95.3
the prevalence of typhoid fever was 25.7%, which was consistent
with our study finding (18). This consistency might be justified Do you wash your hands Always 54 17.0
before preparing food?
by the similarity of the two studies in terms of study setting,
socio-demographic factors, and methods used to measure the Some times 263 83.0
outcome variable. Are you smoking a Yes 9 2.8
However, the current figure was higher than findings reported cigarette?
in the Democratic Republic of Congo (9.1%) (14), Lagos, Nigeria No 308 97.2
(15.9%) (30), and Zaria (4.9% among children) (31). This
Are you drinking Yes 114 36.0
discrepancy might be due to the difference in study population, alcohol?
time of the study, laboratory modalities used, health facility settings,
No 203 64.0
and socio-demographic characteristics of the study participants.
Did you get a health Yes 192 60.6
For example, the study conducted in Zaria included only children
education?
(<15 years old; nearly one third were under 5 years old) as study
No 125 39.4
participants; this group would most probably be affected by other
etiologic agents like the Rota virus rather than typhoid fever. Overall practice for Poor 183 57.7
typhoid infection practice
Moreover, the study conducted in Lagos, Nigeria, used culture to
prevention
detect the salmonella species, whereas the Widal test was used in
Good 134 42.3
this study. The difference in measuring tool (diagnostic tool) might
practice
contribute to the observed discrepancy of the outcome variable.

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FIGURE 1
Typhoid fever infection based on an antigen test using the Widal test among febrile patients visiting Arerti Primary Hospital, Amhara, 2022.

In Ethiopia, studies conducted in the Afar (17), West environmental determinants of health. The mentioned study
Wollega, and Oromia (19) regions reported that the prevalence was a type of trend analysis using secondary data (health
of typhoid fever was 13.2 and 10.0%, respectively. Which is facility records), which assessed typhoid fever diagnosed
lower as compared to the figure found by this study (30.0%). by using both clinical and laboratory diagnosis methods.
The probable reason for the observed difference in terms of This measurement difference might be the reason for the
typhoid fever prevalence could be a difference in study settings; observed discordance.
the above studies were community-based studies while ours was In this study, being unemployed, a farmer, and having
a facility based study. The community-based studies identified a lower body mass index (BMI) were significantly associated
the prevalence of typhoid fever among a healthy population, with the occurrence of typhoid fever infection. Although not
whereas the facility-based studies assessed the same outcome supported by previous studies, unemployed (daily labor) and
among patients manifested with apparent clinical manifestations. farmers would be more likely to be involved in risky conditions
Hence, this might end up with a significant difference in the for typhoid fever transmission. Since most farmers reside in
disease magnitude. rural areas, they might also face inadequate access to safe water,
On the other hand, the finding from this study was lower and late healthcare-seeking behavior may speed transmission.
as compared with the figures found by the studies conducted Having a lower body mass index (BMI) may indicate a state
in Littoral, Cameroon (68.75%) (16), Akure, Nigeria (80.5%) of undernutrition; hence, undernourished individuals might be
(32), Ghana (66.9%) (16), and Karu, Nigeria (69.6%) (33). highly susceptible for infection and other comorbidities. This study
This discordance might result from discrepancies in study might have the following limitation: since we conducted it at a
populations, sample size, study settings, and socio-demographic single health facility, the result may not be generalizable to the
variability of the study participants. For instance, the study whole community.
conducted in Cameroon included a small sample size of study
participants who were clinically diagnosed with typhoid fever.
This might overestimate the outcome as included already clinically Conclusions and recommendations
diagnosed cases for the confirmation purpose. Moreover, in
Ethiopia, studies done in Arba Minch, SNNPR, Ethiopia (25) The prevalence of TF among febrile patients in the study area
found higher prevalence of typhoid fever (47.37% among males was high. Typhoid fever infection was significantly associated
and 52.3% among females) as compared with the reported with occupational status (being unemployed and being a
figure by this study. This difference might be due to differences farmer) and body mass index (BMI). The level of knowledge,
in study designs, study population, measurement tools, and perception, and practice for typhoid fever infection prevention

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Muche et al. 10.3389/fpubh.2024.1357131

TABLE 6 Multivariable analysis of factors significantly associated with the prevalence of TF among febrile patients visiting APH at Arerti town, Amhara,
Ethiopia, 2022.

Variables TF test results COR (95% CI) AOR (95% CI) P-value
Positive Negative
Sex of the respondent Male 63 141 1.13 (0.68, 1.88) 0.99 (0.55, 1.76) 0.963

Female 32 81 1 1

Occupation of the Unemployed 31 53 1.38 (0.67, 2.83) 7.57 (1.98, 28.93) 0.003
respondent

Farmer 34 77 1.04 (0.52, 2.09) 2.73 (1.01, 7.41) 0.048

Gov’t employee 13 52 0.59 (0.26, 1.35) 0.82 (0.23, 2.91) 0.755

Merchant 17 40 1 1

Educational status Uneducated 24 90 0.71 (0.38, 1.34) 0.35 (0.09, 1.38) 0.132

Primary/secondary 44 60 1.96 (1.09, 3.52) 1.12 (0.44, 2.84) 0.807

Diploma & above 27 72 1 1

Marital status Married 58 135 0.99 (0.61, 1.62) 0.39 (0.15, 1.04) 0.060

Unmarried 37 87 1 1

BMI <18.5 18 104 3.77 (2.12, 6.71) 5.12 (2.45, 10.68) <0.01

18.5 and above 77 118 1 1

Practice categorized Poor practice 61 122 0.68 (0.41, 1.12) 1.06 (0.57, 1.98) 0.845

Good practice 34 100 1 1

Perception toward Negative perception 19 58 1.42 (0.80, 2.54) 1.52 (0.59, 3.94) 0.384
typhoid fever prevention

Positive perception 76 164 1 1

Knowledge about TF Poor knowledge 24 81 1.70 (0.99, 2.91) 0.69 (0.24, 1.95) 0.482

Good knowledge 71 141 1

Bold values indicate statistically significant (p < 0.05).

was not adequate. Our findings may inform health planners Author contributions
and administrators in developing relevant interventions that
promote TF preventive practice toward TF disease among GM: Conceptualization, Data curation, Formal analysis,
the population. Investigation, Methodology, Project administration, Software,
Supervision, Validation, Visualization, Writing – original
draft, Writing – review & editing, Funding acquisition,
Data availability statement Resources. AT: Data curation, Methodology, Supervision,
Validation, Visualization, Writing – review & editing. FB: Data
The original contributions presented in the study are included curation, Methodology, Supervision, Validation, Visualization,
in the article/supplementary material, further inquiries can be Writing – review & editing, Conceptualization, Formal analysis,
directed to the corresponding author. Investigation, Project administration, Software, Writing –
original draft.
Ethics statement
This study was reviewed and approved by the Debre
Berhan University Ethical Review Committee. The study was Funding
conducted in accordance with the local legislation and institutional
requirements. Written informed consent for participation in this The author(s) declare that no financial support was
study was provided by the participants’ legal guardians/next received for the research, authorship, and/or publication of
of kin. this article.

Frontiers in Public Health 09 frontiersin.org

Muche et al. 10.3389/fpubh.2024.1357131

Acknowledgments that could be construed as a potential conflict

of interest.
Authors would like to thank study participants, Debre
Berhan University and Arerti Primary Hospital staff for
technical assistance. Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
Conflict of interest organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
The authors declare that the research was conducted claim that may be made by its manufacturer, is not guaranteed or
in the absence of any commercial or financial relationships endorsed by the publisher.

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