Authors
Laura Hobbs, Leah Sukri, Katherine Shafer, Shrimati Datta, Saqib Qazi, Andrew Avery, Audry Banza, Yves Mpongo, Joshua Eby, Katie Howe, Sadock Irankunda, Emmanuel Ikwutah, Clarisse Girincuti, Louisa Nwachukwu, Aminat Fagbenro, Brad-Lot Igiraneza, Amie Mugisha, Melance Kabanyegeye, Che Innocent Abong, Christian Mutunzi, Glory Masango, Jonathan Traore, Samaila Yusuf, Ousmane Sani, Céline Langendorf, Matthew B. Laurens, Yakoubou Sanoussi, Kathleen Neuzil
Background
Typhoid fever remains a major public health challenge in low-income and middle-income countries, where limited diagnostic capacity leads to substantial underestimation of disease burden. In many endemic settings, blood culture, the diagnostic gold standard, is unavailable, and policy decisions regarding typhoid conjugate vaccine (TCV) introduction are often made in the absence of robust data. Typhoid intestinal perforation (TIP), a severe complication of infection, may serve as a pragmatic surveillance indicator of disease burden, particularly among children.
Methods
We conducted a prospective hospital-based study of children aged 3–17 years presenting with non-traumatic acute abdomen requiring surgical evaluation at a regional referral hospital in rural Niger between Aug 31, 2023, and Dec 31, 2024. Clinical, operative, microbiological, and pathological data were collected using standardised protocols. Patients were classified as having typhoid-related disease based on blood culture confirmation and/or intraoperative findings consistent with typhoid perforation. Descriptive analyses were performed to characterise disease burden, clinical outcomes, and antimicrobial resistance patterns.
Findings
Among 459 enrolled patients, 426 underwent surgical intervention, of whom 425 met inclusion criteria. Of these, 346 (81·4%) met criteria for typhoid-related disease, including 61 (17·6%) with S. Typhi isolated from blood cultures, highlighting the limited sensitivity of microbiologic confirmation in this setting. Typhoid accounted for the vast majority of paediatric surgical abdominal emergencies. Patients with typhoid-related disease experienced substantial morbidity, including high rates of surgical complications, and 57·5% underwent reoperations; the mortality rate was 20·5%. Blood culture S. Typhi isolates demonstrated high levels of ciprofloxacin resistance but retained susceptibility to azithromycin. Temporal trends in surgical cases paralleled patterns of blood culture positivity, suggesting seasonal transmission.
Interpretation
TIP represents a major and under-recognised cause of paediatric morbidity and mortality in this setting. In the absence of routine laboratory surveillance, surgical data may provide a feasible and informative proxy for estimating typhoid burden. These findings suggest that TIP could serve as a pragmatic surveillance indicator in similar high-burden settings. Results provide context-specific evidence to inform and prioritise TCV introduction. The broader applicability of this approach could improve burden estimation and accelerate vaccine policy decisions in other endemic regions.
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