John A. Crump
In this issue of Clinical Infectious Diseases, 2 papers shed important light on the problem of typhoid fever in Sub-Saharan Africa and stimulate reflection on the challenges raised by the syndrome of fever in low-resource settings. Neil et al  report the investigation of an increase in intestinal perforations from rural western Uganda. By improving the clinical microbiology services available in the outbreak area and by implementing active surveillance at healthcare facilities in the district, the research team was able to confirm Salmonella enterica serovar Typhi as the etiologic agent and estimate the typhoid fever annual incidence in the study area at 8092 cases per 100 000 persons. This very high typhoid fever incidence rate was associated not only with hundreds of hospitalizations and intestinal perforations but also with 47 deaths. Lutterloh and colleagues  investigated an outbreak of unexplained febrile illnesses with neurologic findings along the Malawi–Mozambique border. Again, making diagnostic services available in the rural and remote outbreak area allowed Salmonella Typhi to be established as the cause. A careful clinical and epidemiologic investigation, including enhanced surveillance of suspected, probable, and confirmed cases of typhoid fever, characterized 40 patients with debilitating focal neurologic manifestations, including upper motor neuron signs, ataxia, and Parkinsonism, and 11 deaths.
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