THE PREVALENCE OF MALARIA AND TYPHOID FEVER AMONG PATIENTS ATTAINING HOSPITAL
THE PREVALENCE OF MALARIA AND TYPHOID FEVER AMONG PATIENTS ATTAINING HOSPITAL IN NIGERIA: A CASE STUDY OF GENERAL HOSPITAL ETINAN, AKWA IBOM STATE
TABLE OF CONTENTS
Title Page
Approval Page
Certification
Dedication
Acknowledgements
Table of Contents
Lists of tables
List of Diagram
Abstract
CHAPTER ONE – INTRODUCTION
1.1Â Â Â Â Â Â Introduction
1.2Â Â Â Â Â Â Aims and Objectives of the Study
CHAPTERTWO – LITERATURE REVIEW
2.1 Â Â Â Â Â Malaria and Typhoid Fever as causes of Febrile Illnesses
2.2Â Â Â Â Â Â Co-infections of Malaria and Typhoid Fever
2.3Â Â Â Â Â Â Antibiotic Susceptibility of Salmonella
2.4Â Â Â Â Â Â Risk Factors for Infections with Malaria and Typhoid Fever
CHAPTER THREE – MATERIALS AND METHODS
3.1 Â Â Â Â Â The Study Area
3.2Â Â Â Â Â Â Study population
3.3Â Â Â Â Â Â Ethical Considerations
3.4Â Â Â Â Â Â Sample collection and laboratory investigations
3.5Â Â Â Â Â Â Identification of Salmonella typhi and paratyphi
3.6      Statistical Analysis    Â
CHAPTER FOUR – RESULTS
4.1 Â Â Â Â Â Prevalence of malaria parasites among subjects attending
General Hospital Etinan with respect to age and gender
4.2 Â Â Â Â Â The prevalence of typhoid fever among the subjects with respect
to age and gender
4.3 Â Â Â Â Â Prevalence of co-infections of both malaria and typhoid fever
among subjects attending General Hospital Etinan with respect
to age and gender
4.4Â Â Â Â Â Â Prevalence of malaria and typhoid fever among pregnant female
subjects attending General Hospital Etinan with respect to
gravidity and trimester
CHAPTER FIVE – DISCUSSION
Conclusion
Recommendations
References
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ABSTRACT
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Malaria and typhoid fever cause major health problems especially in low and middle income countries. People in endemic areas are at risk of developing both infections concomitantly. This study was conducted to provide an epidemiological data on infection of malaria and typhoid fever among patients attending General Hospital, Etinan. A cross-sectional study involving two hundred (200) patients attending General Hospital, Etinan from December 2020 to February, 2021 for check-up and medical examination. Blood samples were collected for Widal test and blood film preparation for identification of malaria parasite microscopically. Data were analyzed using chi-square statistical analysis.
A total of 92 (46%) of the study participants were males and 108 (54%) female. age is significantly dependent on the prevalence of malaria parasite among subjects attending General Hospital, Etinan (X2(7) = 30.0764, p = 14.067). gender is not significantly dependent on the prevalence of malaria parasite among subjects attending General Hospital, Etinan (X2(1) = .094, p = 3.841). age is significantly dependent on the prevalence of typhoid fever among subjects attending General Hospital, Etinan (X2 = 49.662, p = 14.067) at 7 degrees of freedom. gender is significantly dependent on the prevalence of typhoid fever among subjects attending General Hospital, Etinan (X2(1) = .094, p = 3.841).
Age is significantly dependent on the prevalence of co-infections of both malaria and typhoid fever among subjects attending General Hospital, Etinan (X2(7) = 28.911, p = 14.067). gender is not significantly dependent on the prevalence of co-infections of both malaria and typhoid fever among subjects attending General Hospital, Etinan (X2(1) = 2.764, p = 3.841*). gravidity is not significantly dependent on the prevalence of malaria among subjects attending General Hospital, Etinan (X2(2) = 1.0, p = 5.991*).
Gravidity is not significantly dependent on the prevalence of typhoid fever among subjects attending General Hospital, Etinan (X2(2) = 0.799, p = 5.991*). gravidity is not significantly dependent on the prevalence of malaria among subjects attending General Hospital, Etinan (X2(2) = 2.5, p = 5.991*). trimester is not significantly dependent on the prevalence of typhoid fever among subjects attending General Hospital, Etinan (X2(2) = 3.202, p = 5.991*). Based on this it was recommended that due to the low prevalence of malaria and typhoid fever co-infection, clinicians should not treat concurrently but rather stick to differential diagnosis. This would help reduce the development of drug resistance among the population.
CHAPTER ONE
INTRODUCTION
1.1Â Â Â Â Â Â Introduction
Malaria is the number one killer of all the parasite disease. More than 90% of the death worldwide in sub-Saharan Africa (Jawetzetal, 2016). Nigeria is known for high prevalence of malaria and it is a leading cause of morbidity and mortality in the country (Olasehinde et al., 2010). Available records show that at least 50 per cent of the population of Nigeria suffers from at least one episode of malaria each year and this accounts for over 45 per cent of all outpatient visits (Olasehinde et al., 2010).
Malaria accounts for 25 to 30 percent of mortality rates in Nigeria thereby imposing great burden in the country in terms of pains and trauma suffered by its victims as well as loss in outputs and cost of treatments (Ukaegbu et al., 2014). Malaria is one of the febrile illnesses and the most common fatal disease caused by one or more species of the Plasmodium. These species are P. falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi (Singh and Daneshvar, 2013; Samathaet al., 2015).
THE PREVALENCE OF MALARIA AND TYPHOID FEVER AMONG PATIENTS ATTAINING HOSPITAL
Occasionally, humans become infected with a zoonotic species, P. knowlesi found in Asia (Singhetal., 2004;Daneshvar et al., 2009). The life cycle of the malaria parasite takes place in humans and in the female Anopheles mosquito. In human life cycle, the sporozoites are infective form of parasite. They are present in salivary gland of female anopheles mosquito, magnet infection by bite of infected mosquito (Arora, 2014). The parasite first enters the blood stream through bite of an infected female anopheles mosquito (Willey et al., 2017).
Malaria infection develops via two phases: one that involves the liver (exo-erythrocytic phase), and one that involves red blood cells or erythrocytes (erythrocytic phase). When an infected mosquito pierces a person’s skin to take a blood meal, sporozoites in the mosquito’s saliva enter the blood stream and migrate to the liver where they infect hepatocytes, multiplying asexually and asymptomatically for a period of 8–30days (Ubandoma, et al 2017). The cycle in man comprises of the following stage, the pre-erythrocytic Schizogony, erythrocytic Schizogony, gametogony and secondary exo-erythrocytic (Arora, 2014).
In pre-erythrocytic or primary exo-erythrocytic Schizogony, man is reservoir of infection. Transmission of the disease to man occurs when and infected female Anopheles mosquito bites and inject it sporozoite in its saliva onto humans cutaneous capillaries while taking blood mill (Adeoye, 2007). Infection can also occur by transfusion of infected donor blood, by injection through the use of needle and syring contaminated with infected blood and occasionally congenitally, usually when a mother is not immune (Cheesbrough, 2010).
The sporozoite circulate in man’s blood for about 30 minutes before migrating into the parenchyma cells of the liver (Adeoye, 2007). The sporozoite which are elongated, spindle-shape bodies becomes rounded inside the liver cells. They undergo a process of multiple nuclear division followed by cytoplasmic division and developed into pre-erythrocytic Schizongony (Arora, 2014).
The Schizont contains numerous merozoites and are much larger than erythrocyte Schizonts. When mature, the Schizont rupture and release the merozoites into the blood stream. They must enter red cell within 30 minutes for survival (Adeoye, 2007). Erythrocytic Schizogony is the second phase of the cycle in human host when the merozoites enters the red cells, grow into trophozoite which eventually forms a mature Schizont. The schizont rupture to released the merozoites. They parasitize new red cells and continues the erythrocytic cycle (Ochei and kolhatker, 2010).
The parasite multiplication during the erythrocytic phase is responsible for bringing on a clinical attack of malaria. Erythrocytic Schizogony may be continued for a considerable period, but in the course of time the infection tends to die out. P. falciparum differs from other forms of malaria parasites in that developing erythrocytes schizonts aggregate in the capillaries of the brain and other intestinal organs, so that only young ring form are found in peripheral blood (Arora, 2014).
In gametogony, the merozoites released from Schizont that are not destroyed by host immune system infect new red cells for another cycle of Schizogony. After erythrocytic Schizogony cycle some of the merozoites developed into male and female gametocytes. Gametocytes appear in the blood stream usually after a few or several cycles of erythrocytic Schizogony (Adeoye, 2007). After several erythrocytic generation some of the merozoites instead of producing Schizonts begins to undergo development into male and female gametocytes. These gametocytes form part of sexual cycle that takes place in mosquito (Ochei and kolhatker, 2010).
Malaria can also be diagnosed using polymerase chain reaction (PCR). Confirming clinical diagnosis with appropriate laboratory test is very vital. Malaria is a preventable and curable disease. Artemisinin-based combination therapies (ACTs) for uncomplicated malaria is highly effective against P. falciparum (WHO, 2016). In Nigeria, artermether-lumefantrine, artesunate-amodiaquine, or dihydroartermisinin-piperaquine are among the recommended ACTs (Sharma et al 2016).
Pregnant women are three times more likely to suffer from severe diseases as a result of malarial infection compared with their non-pregnant counterparts, and have a mortality rate that approaches 50% (Desai et al., 2007). The principal impact of malaria infection is due to the presence of parasites in the placenta, which causes maternal anaemia and low birth weight. Beyond the post-partum period, the long term consequences of malaria during pregnancy on the infant include poor development, behavioural problems, short stature and neurological deficits (Desai et al., 2007).
Protection of pregnant women living in malaria endemic countries has been of particular interest to many malaria control programmes because of this group’s higher susceptibility and reduced immunity. Nigeria, accounts for one fourth of all malaria cases in the 45 endemic countries in Africa, and 11% of maternal deaths in the country are attributed to malaria (Agomo et al., 2013).
Positively, Malaria control measures have received a greater attention in the last decade as increased funding has resulted in the scaling up of malaria control programmes. Use of insecticide-treated nets (ITNs) is one of the key components of malaria prevention and control as recommended by the World Health Organization (WHO, 2010). The nets reduce human contact with mosquitoes, thus leading to a significant reduction in the incidence of malaria, associated morbidity, and mortality; as well as in the adverse effects during pregnancy in areas of intense malaria transmission. The prevalence of malaria and typhoid fever among patients attaining hospital.
Therefore, the WHO recommends IPT with sulfadoxine-pyrimethamine in areas with moderate to high malaria transmission in Africa. .
Enteric fever is a systemic prolonged febrile illness caused by certain Salmonella serotypes. Salmonella enterica serotype typhi (S. typhi) and Salmonella enterica serotype paratyphi (S. paratyphi A, S. paratyphi B, and S. paratyphi C) are species that cause typhoid fever. S. typhi is the most common serotype of salmonella that causes typhoid fever (Andualem et al., 2014).
Genus salmonella includes 2000 serotypes and biotypes according to the Kauffman white classification (Ochei and kolhatker, 2010). Salmonella was formerly classified as separate species, DNA hybridization studies have shown that all pathogenic salmonella belong to single species, Salmonella enteric which is subdivided into seven sub-species (Cheesbrough, 2010).
Currently, the genus salmonella is divided into two species each with multiple sub-species and serotypes. The two species are salmonella enteric and salmonella bongori (formally sub-species v) (Jawetz et al 2016). The four serotypes of salmonella that cause enterica fever are S. paratyphi A (sero group A), S. paratyphi B (sero group B), S. choleraesu (sero group C1) and S. typhi (sero group D) (Jawetz et al., 2016). Three main antigens associated with salmonellae (Ochei and kolhatker, 2010), they are O, H and Vi antingens. O (somatic) antigens, the O antingens are found on the body of the organism in both motile and non-motile strains.
They are heat stable, alcohol and weak acid stable and give less immune logic response than H antigen. H (flagella) antigen are found on the flagella, they are heat labile and are destroyed by alcohol. The antigens trigger off immune response and give high titre following infection or vaccination. Vi antigen (for virulence) is present on the typhi, the antingen forms covering layer on the outside cell wall when fully developed, it is agglutin able with the specific Vi anti serum and mask the O antigen (Ochei and kolhatker, 2010).
Typhoid fever causes serious morbidity in many regions of the world, accounting for 21 million cases and 222,000 deaths annually (WHO, 2015).
Typhoid fever is common in malaria endemic settings, usually leading to mixed-infection. South and Central Asia, Africa and South and Central America are considered endemic, with rates exceeding 100 per 100,000 populations per year (Bhan et al., 2005).
In Africa, due to scarce resources and limited laboratory capacity to diagnose the disease accurately, most data on typhoid fever are not credible. A survey conducted in Egypt found an incidence of 59 cases per 100,000 persons per year for typhoid fever (Srikantiah et al., 2006).
Salmonella are often pathogenic for human or animals when acquired by the oral route (Jawetz et al., 2016). S. typhi belongs to the Enterobacteriaceae family and genus Salmonella. It affects only human and caused typhoid fever (Igharo et al., 2012).
Salmonella is a gram-negative aerobic and facultative anaerobic rod-shaped bacterium (Todar, 2008). They are non-sporing and with the exception of Salmonella typhi, non-capsulate (Cheesbrough, 2010). It grows optimally at 35-37°C, rod-shaped with a length of 2-3μm and a diameter of 0.4-0.6μm (Cheesbrough, 2010). It moves with the aid of its flagella (H-d antigen). S. typhi contains somatic or O, antigens associated with toxin, H-d associated with flagella; and Vi-antigen for virulence. The prevalence of malaria and typhoid fever among patients attaining hospital.
It interferes with the complement (C3b) mediated opsonization of S. typhi. This prevents it from binding with the phagocytes and subsequently inhibits phagocytosis (Moses et al., 2016).
Typhoid fever is spread through ingestion of contaminated food and water. Humans excrete the bacteria in their faeces during the infection and usually persist if they become carriers. Other medium of transmission is by eating raw fruits and vegetables contaminated with infected human faeces, milk products and shellfish. The bacterium can be viable for a long duration on food surface, sea water and sewage water. It can survive in freezing temperature for 3 months (Opara et al., 2011).
Foods are usually contaminated by flies which act as mechanical carriers and the bacteria can proliferate to cause typhoid in human (Guzman et al., 2006). It usually enters the blood stream to the intestinal mucosa and subsequently multiplying in the lymph nodes. Most often the incubation period varies between 7 to 21 days. The main clinical symptoms related to typhoid fever are prolonged fever, malaise, anorexia, vomiting, severe headache, bradycardia, splenomegaly (Heymann et al., 2008).
Initially the fever is minimal but rises gradually until second week where it can be high and persistent (39-400C). Other symptoms include abdominal discomfort, dry cough, myalgia and constipation is more common in adults than diarrhea seen in children. A transient, macular rash of rose-colored spots can occasionally be seen on the trunk (Holmberg, 2012). Physical manifestations that are normally seen are coated tongue, tender abdomen, hepatomegaly or splenomegaly.
Most often nausea and vomiting are not common but can be present in severe cases. Complications occur in about 15% of all cases, and include intestinal haemorrhage or perforation, psychosis, meningitis, and hepatosplenomegaly. Prior to the discovery of antibiotics case fatality rates were high in untreated cases (10─20%).
With the advent of antibiotics, case fatality rate is only about 1% although relapse may occur in 15-20% of patients while 10% of untreated patients would be infectious within 3 months and 2-5% would turn out to be chronic carriers (Heymann et al., 2008). Generally, re-infection of typhoid is rare because of the development life long immunity after primary infection.
The presence of clinical symptoms characterized by fever is indicative of typhoid fever but needs laboratory confirmation (WHO, 2010). The S. typhi can be isolated from blood within a week and in urine and faeces after first week. Even though blood culture is mostly used for diagnosis, bone marrow culture can also be used to isolate S. typhi. The sensitivity and specificity of the conventional Widal test are low due to cross-reactivity with other microorganisms.
Malaria and typhoid fever co-infection was first described during the American civil war by Woodward in 1862 among young soldiers presenting with intermittent pyrexia (Sabina, 2017). People with poor hygiene can contract both diseases. Patients with co-infection mostly associated with nausea, vomiting, abdominal pain, diarrhea and continuous fever (Khan et al., 2005). Anaemia due to massive haemolysis or dyserythropoesis can occur during malaria infection which can lead to increase iron in the liver and which support the growth of Salmonella (Bashyam, 2007). Some studies have shown that Complement C1q and C4b deficiency can make a person susceptible to typhoid fever infection (Warren et al., 2002).
The common detection of high antibody titre of these Salmonella serotypes in malaria patients has made some people to believe that malaria infection can progress to typhoid or that malaria always co-infect with typhoid/paratyphoid in all patients.
Hence, some people treat malaria and typhoid concurrently once they have high antibody titre for Salmonella serotypes, even without adequate laboratory diagnoses for malaria and vice versa. Considering the above complications associated with malaria and typhoid fever infections in Nigeria, this study therefore was carried out to assess the prevalence of malaria and salmonella parasite infection among patients attending Etinan General Hospital in relation to gender and social pattern of living as factors affecting their exposure to malaria parasite infection.
1.2Â Â Â Â Â Â Aims and Objectives of the Study
The aim of the study is to determine the prevalence of malaria and typhoid fever among patients attaining Etinan General Hospital, Etinan Local Government Area, Akwa Ibom State, Nigeria.
The specific objectives of the study are to:
(i)Â Â Â Â Â Â Â Â determine the prevalence of malaria among the subjects with respect to age and gender;
(ii)Â Â Â Â Â Â Â determine the prevalence of typhoid fever among the subjects with respect to age and gender;
(iii)Â Â Â Â Â Â determine the prevalence of co-infections of both malaria and typhoid fever among the subjects with respect to age and gender; and
(iv)Â Â Â Â Â Â determine the prevalence of malaria and typhoid fever among pregnant female participants with respect to gravidity and trimester.
CONCLUSION
This study established a high prevalence rate of malaria and typhoid fever prevalence of 34% and 62.5% respectively, found in the General Hospital Etinan with a likelihood of further expansion in the disease rate if appropriate interventions are not urgently initiated.
The increase vulnerability of adult population and pregnant women to malaria and typhoid fever infection found in this study suggest an urgent need for institution of prevention and control measures in this locality in order to reduce the high rate of maternal and fetal mortality associated with pregnancy. The prevalence of malaria and typhoid fever among patients attaining hospital.
The present study showed that there is a high prevalence of typhoid fever parasite among female populations in Etinan. Also, it shows that the prevalence of co-infection among adult populations in General Hospital, Etinan was higher within the age range of 31- 40years when compared to their counterparts. The gravidity and trimester does not influence the prevalence of malaria and typhoid fever among pregnant women who attended General Hospital, Etinan. The prevalence of malaria and typhoid fever among patients attaining hospital.
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