Typhoid and Malaria Co-Infection – An

Interesting Finding in the Investigation of a

Tropical Fever
Brian Cheong Mun Keong and Wahinuddin Sulaiman
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This article has been cited by other articles in PMC.
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Abstract
In the investigation of fever in the tropics, two important diagnoses to be ruled out are typhoid
and malaria. Both cause significant morbidity, mortality and economic loss. An estimated 17
million cases of typhoid are reported worldwide each year, resulting in 0.6 million deaths.
Seventy five to eighty percent of these cases occur in Asia alone. Malaria affects 1 billion people
each year; out of which 1–3 million die. Although caused by very different organisms – one a
Gram negative bacilli, the other a protozoa, and transmitted via different mechanisms – ingestion
of contaminated food and water and via the bite of an insect vector respectively, both typhoid
and malaria share rather similar symptomatology and epidemiology. Malaysia is endemic for
both these diseases and one should not be too surprised when faced with a diagnosis of co-
infection of typhoid and malaria, as have been described in India and Canada. Here we describe
one such case of Salmonella typhi and Plasmodium vivax infection.

Keywords: typhoid, malaria, co-infection

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Introduction
Case Report

A 41-year-old Malay man, working as a logger, presented with two weeks of fever, myalgia and
abdominal pain. He had been diagnosed and treated for malaria 20 years ago. He remained
asymptomatic until now. He had no other history of traveling to other malaria endemic country
and not taking any malarial chemoprophylaxis. On examination, he was febrile with
temperatures swinging between 37°C and 39.3°C and relative bradycardia. He was not jaundiced
and neither were any rashes noted. There was no hepatosplenomegaly.

His full blood count showed normal Hb (14.2 g/dl) and platelet count (201 × 109/l). The white
cell count, however was within normal range (5.2 × 109/l) with neutrophil predominance. Serum
albumin was 34.9 g/l, alkaline phosphatase 178 IU/l, aspartate transaminase 63 IU/l, alanine
transaminase 63.9 IU/l and total bilirubin 9.4 umol/l.
Ultrasonography of the abdomen showed hepatomegaly with a mildly echogenic parenchyma.
The spleen was at the upper limit of normal (13.8 cm). Blood cultures isolated Salmonella typhi.
The first Widal test was not significant (T(O) 1:50 and T(H) 1:50). The second Widal test taken
nine days later showed T(O) 1:100 and T(H) 1:200. Serial blood smears for malaria parasites was
positive for Plasmodium vivax (160/ul blood) on the fifth smear.

He was treated with chloramphenicol 500mg qid for 14 days and a course of chloroquine and
primaquine with uneventful recovery.

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Discussion
Typhomalaria was first described by an army doctor, J J Woodward (1833–1884) in 1862 among
young soldiers during the American Civil War who were suffering from febrile illness that
seemed to be typhoid (including intestinal lesions found at postmortem) but with fever patterns
also suggestive of intermittent fever. He believed that it might be a hybrid rather than a new
species of disease (1 – 3). However, by the end of 19th century, laboratory tests had eliminated
this theory as they found that it was either one thing or the other, or in rare instances, co-
infection with both S. typhi and the plasmodium of malaria.

Both typhoid and malaria share social circumstances which are imperative to their transmission.
Therefore, a person living in such an environment is at risk of contracting both these diseases,
either concurrently or an acute infection superimposed on a chronic one. A high index of
suspicion is necessary to diagnose a co-infection as most clinicians are used to linking every
symptom and sign to a single pathology.

-- Typhomalaria pertama kali dijelaskan oleh dokter tentara, JJ Woodward

(1833–1884) pada tahun 1862 di antara prajurit muda selama Perang Sipil
Amerika yang menderita penyakit demam yang tampaknya tifus (termasuk lesi
usus yang ditemukan pada postmortem) tetapi dengan pola demam juga. sugestif
demam intermiten. Dia percaya bahwa itu mungkin hibrida daripada spesies baru
penyakit (1 - 3). Namun, pada akhir abad ke-19, uji laboratorium telah
menghilangkan teori ini karena mereka menemukan bahwa itu adalah salah satu
hal atau yang lain, atau dalam kasus yang jarang, koinfeksi dengan S. typhi
dan plasmodium malaria.
Baik tifoid dan malaria berbagi keadaan sosial yang sangat penting untuk
transmisi mereka. Oleh karena itu, seseorang yang tinggal di lingkungan
seperti itu berisiko terkena kedua penyakit ini, baik secara bersamaan atau
infeksi akut yang terjadi pada yang kronis. Indeks kecurigaan yang tinggi
diperlukan untuk mendiagnosa koinfeksi karena sebagian besar dokter digunakan
untuk menghubungkan setiap gejala dan menandatangani satu patologi.

In co-infections, the diagnosis of typhoid should be made from a culture specimen as false
positives and overestimation occur with the use of the Widal test. Ammah et al reported that in
200 patients with fever, 17% had concurrent malaria and typhoid fever based on bacteriological
proven diagnosis as compared to 47.9% based on the Widal test (4). This is to be expected as the
Widal test being a serological test, only proves exposure to a certain antigen. It does not tell if an
infection is recent or not. Samal et al, described 52 patients with malaria positive in the
peripheral blood smear (cases consisted of vivax, falciparum or mixed vivax and falciparum), out
of whom eight cases had a positive Widal test but blood cultures were negative for S. typhi in all.
All of the cases were cured with antimalarial therapy (5). There were no complications attributed
to these infections documented in the previous reported cases. Nevertheless, complications may
occur even if the patients received adequate treatment. Hence, monitoring for the complications
is essential especially for travelers traveling to endemic areas.

--Dalam koinfeksi, diagnosis tifus harus dibuat dari spesimen kultur sebagai
positif palsu dan terlalu tinggi terjadi dengan penggunaan tes Widal. Ammah
dkk melaporkan bahwa pada 200 pasien dengan demam, 17% mengalami malaria
bersamaan dan demam tifoid berdasarkan diagnosis terbukti bakteriologis
dibandingkan dengan 47,9% berdasarkan tes Widal (4). Ini diharapkan karena
tes Widal sebagai tes serologis, hanya membuktikan paparan antigen tertentu.
Itu tidak memberitahu apakah infeksi baru atau tidak. Samal et al, dijelaskan
52 pasien dengan malaria positif di apusan darah perifer (kasus terdiri dari
vivax, falciparum atau campuran vivax dan falciparum), dari siapa delapan
kasus memiliki tes tapi darah positif budaya Widal negatif untuk S. typhi di
semua . Semua kasus disembuhkan dengan terapi antimalaria (5). Tidak ada
komplikasi yang dikaitkan dengan infeksi ini didokumentasikan dalam kasus
yang dilaporkan sebelumnya. Namun demikian, komplikasi dapat terjadi bahkan
jika pasien menerima perawatan yang memadai. Oleh karena itu, pemantauan
untuk komplikasi sangat penting terutama bagi wisatawan yang bepergian ke
daerah endemik

The actual and precise underlying mechanisms to explain the association between malaria and
Salmonella species infection is still uncertain. However, there are few postulations which may
explain why malaria may predispose to salmonella bacteremia and sepsis. It has been shown that
antibody response to O antigen of S. typhi was markedly reduced in acute episode of malaria
compared with that in controls where humoral immunity is transiently impaired (6). It has been
demonstrated in a murine model of infection with Salmonella murium that hemolysis which
occur in malaria may predispose to gram-negative organism as what has been seen in hemolytic
disease caused by sickle cell disease and bartonellosis (7).

In the case illustrated above, the diagnosis was from a blood smear and a blood culture, both
providing objective evidence of the on-going dual infection. Fortunately, he did not developed
any complications such as hemolysis.

-- Mekanisme yang mendasari aktual dan tepat untuk menjelaskan hubungan antara
malaria dan infeksi spesies Salmonella masih belum pasti. Namun, ada beberapa
postulasi yang dapat menjelaskan mengapa malaria dapat menjadi predisposisi
bakteremia salmonella dan sepsis. Telah ditunjukkan bahwa respon antibodi
terhadap antigen O dari S. typhi sangat berkurang pada episode akut malaria
dibandingkan dengan pada kontrol dimana imunitas humoral mengalami gangguan
sementara (6). Telah dibuktikan dalam model murine infeksi dengan Salmonella
murium bahwa hemolisis yang terjadi pada malaria dapat mempengaruhi organisme
gram negatif seperti apa yang telah terlihat pada penyakit hemolitik yang
disebabkan oleh penyakit sel sabit dan bartonellosis (7).
Dalam kasus yang digambarkan di atas, diagnosis berasal dari hapusan darah
dan kultur darah, keduanya memberikan bukti objektif dari infeksi ganda yang
sedang berlangsung. Untungnya, dia tidak mengalami komplikasi seperti
hemolisis

Although cases which had been reported were common among travelers, certain areas in our
country is still considered endemic for both malaria and typhoid infections and our patient
demonstrated that although he is not a traveler, these co-infection may still occur. Thus, in
malarial patient with persistent fever in spite of therapy, one should consider drug resistant as
well as concomitant gramnegative infection such as typhoid fever.

-- Meskipun kasus yang telah dilaporkan umum di kalangan wisatawan, beberapa

daerah di negara kita masih dianggap endemik baik untuk infeksi malaria dan
tipus dan pasien kami menunjukkan bahwa meskipun ia bukan seorang musafir,
koinfeksi ini mungkin masih terjadi. Dengan demikian, pada pasien malaria
dengan demam persisten meskipun terapi, orang harus mempertimbangkan
resistansi obat serta infeksi gramnegatif bersamaan seperti demam tifoid.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3347907/

2. Malaria and Typhoid Co-infection: Need to

Interpret Serological Results Cautiously
1
Monika Matlani, Bhavna Sharma,2 and Rajni Gaind3

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To,

The Editor,

This is in reference to the article “Comparative evaluation of various tests for diagnosis of
concurrent Malaria and Typhoid fever in a tertiary care hospital of Northern India” published by
Deepika verma et al., in the Journal of Clinical and Diagnostic Research, 2014, May, Vol-8(5),
in which the prevalence of malaria and typhoid co-infections have been reported to be 8.5%
using serological tests and 1.6% using blood culture for enteric fever and peripheral smear for
Malaria [1]. We would like to add to the existing knowledge by sharing our findings using
various serological and gold standard tests for Malaria and Enteric fever. This is also to highlight
the epidemiological differences in both the diseases as well as confections in different regions of
Northern India.

-- Hal ini mengacu pada artikel “Evaluasi komparatif dari berbagai tes untuk
diagnosis bersamaan Malaria dan demam tifoid di rumah sakit perawatan tersier
India Utara” yang diterbitkan oleh Deepika verma et al., Dalam Journal of
Clinical and Diagnostic Research, 2014, Mei , Vol-8 (5), di mana prevalensi
malaria dan koinfeksi tifoid telah dilaporkan menjadi 8,5% menggunakan tes
serologis dan 1,6% menggunakan kultur darah untuk demam enterik dan apusan
perifer untuk Malaria [1]. Kami ingin menambah pengetahuan yang ada dengan
membagikan temuan kami menggunakan berbagai tes standar serologis dan emas
untuk Malaria dan demam enterik. Ini juga untuk menyoroti perbedaan
epidemiologi pada kedua penyakit serta permen di berbagai daerah di India
Utara.

Both typhoid and malaria are diseases of epidemiological importance globally. Though caused
by different organisms – one Gram negative bacilli, the other protozoa, and transmitted via
different mechanisms, both present with acute febrile illness which requires workup for both.
Co-infections can lead to misdiagnosis usually resulting in either under treatment or over
treatment. This predisposes transmission of infection from untreated patient to new host and
further irrational use of antibiotics/anti malarial results in increasing surge of drug resistance
[2,3]. The present study was conducted in VMMC & Safdarjung hospital, New Delhi from July
2014 to June 2015. A total of 1464 samples collected from the patients attending the outpatient
department and admitted in the wards of our hospital were tested for the diagnosis of malaria and
enteric fever both. The inclusion criteria followed for the study were-

a. Patients presenting with undifferentiated fever of minimum 5 days with clinical suspicion of
typhoid or malaria.
b. Patients of age from >2 years onwards.

The patients having history of intake of anti-malarial drug, or antibiotics were excluded from the
study.

-- Baik tifoid maupun malaria adalah penyakit yang penting secara

epidemiologis secara global. Meskipun disebabkan oleh organisme yang berbeda
- satu Gram negatif bacilli, protozoa lainnya, dan ditularkan melalui
mekanisme yang berbeda, keduanya hadir dengan penyakit demam akut yang
membutuhkan pemeriksaan untuk keduanya. Co-infection dapat menyebabkan
misdiagnosis yang biasanya berakibat pada perawatan atau pengobatan. Ini
predisposisi penularan infeksi dari pasien yang tidak diobati ke host baru
dan penggunaan antibiotik lebih lanjut / hasil anti malaria dalam
meningkatkan lonjakan resistensi obat [2,3]. Penelitian ini dilakukan di
rumah sakit VMMC & Safdarjung, New Delhi dari Juli 2014 hingga Juni 2015.
Sebanyak 1464 sampel yang dikumpulkan dari pasien yang menghadiri departemen
rawat jalan dan dirawat di bangsal rumah sakit kami diuji untuk diagnosis
malaria dan enterik demam keduanya. Kriteria inklusi yang diikuti untuk studi
adalah-
Sebuah. Pasien yang datang dengan demam tidak terdiferensiasi minimal 5 hari
dengan kecurigaan klinis tifus atau malaria.
b. Pasien usia dari> 2 tahun ke depan.
Pasien yang memiliki riwayat asupan obat anti malaria, atau antibiotik
dikeluarkan dari penelitian.

Blood smear examination, Rapid malaria antigen test, blood culture, and Widal test were done
for the diagnosis of Malaria and typhoid respectively. Out of 1464 samples 14(1%) were positive
by both Widal and rapid malaria antigen test. However, out of 14 samples positive by Widal and
rapid malaria test, only 6 (5 S. typhi and 1 S. paratyphi) were confirmed by blood culture and ten
were confirmed for malaria by peripheral smear. Hence co-infection cases confirmed by gold
standard tests were only six (0.40%). These results are similar to the findings obtained by the
authors and establish that the results obtained by Widal and Malaria rapid tests should be
interpreted carefully especially while reporting Malaria and typhoid co-infections.

To the best of our knowledge and as per pubmed search there is no published data on the
prevalence of malaria typhoid co-infection from Delhi. Hence this study was done to determine
the prevalence of malaria typhoid co-infections in our region. On comparing the data with the
above mentioned authors and some other and the other reports from Uttar Pradesh, prevalence of
confection cases in our study was found to be very less [1,4]. However, this may be attributed
higher prevalence of typhoid and malaria in Uttar Pradesh as evident by the website of National
Vector Born Disease Control Programme [5]. Hence it is important to consider endemicity of the
infections, while interpreting the results of serological tests where typhoid and Malaria co-
infection are suspected.

-- Pemeriksaan apus darah, tes antigen malaria cepat, kultur darah, dan tes
Widal dilakukan untuk diagnosis Malaria dan tifoid. Dari 1464 sampel 14 (1%)
positif dengan tes antigen malaria Widal dan cepat. Namun, dari 14 sampel
positif oleh Widal dan tes malaria cepat, hanya 6 (5 S. typhi dan 1 S.
paratyphi) yang dikonfirmasi oleh kultur darah dan sepuluh dikonfirmasi untuk
malaria oleh perifer BTA. Oleh karena itu, kasus koinfeksi yang dikonfirmasi
oleh tes standar emas hanya enam (0,40%). Hasil ini mirip dengan temuan yang
diperoleh oleh penulis dan menetapkan bahwa hasil yang diperoleh dengan tes
cepat Widal dan Malaria harus ditafsirkan secara hati-hati terutama saat
melaporkan Malaria dan koinfeksi tifoid.
Untuk yang terbaik dari pengetahuan kita dan sesuai dengan pencarian yang
dipublikasikan tidak ada data yang dipublikasikan tentang prevalensi
koinfeksi malaria tifoid dari Delhi. Oleh karena itu penelitian ini dilakukan
untuk menentukan prevalensi koinfeksi malaria tifoid di wilayah kita. Pada
membandingkan data dengan penulis yang disebutkan di atas dan beberapa
lainnya dan laporan lain dari Uttar Pradesh, prevalensi kasus konpeksi dalam
penelitian kami ditemukan sangat kurang [1,4]. Namun, ini dapat dikaitkan
dengan prevalensi tifoid dan malaria yang lebih tinggi di Uttar Pradesh
sebagaimana terbukti oleh situs National Vektor Born Disease Control Program
[5]. Oleh karena itu penting untuk mempertimbangkan endemisitas infeksi,
sementara menafsirkan hasil tes serologis di mana tifoid dan koinfeksi
malaria diduga

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Notes
Financial or Other Competing Interests

None.

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References
[1] Verma D, Kishore S, Siddique ME. Comparative Evaluation of Various Tests for Diagnosis of
Concurrent Malaria and Typhoid Fever in a Tertiary Care Hospital of Northern India. Journal of Clinical
and Diagnostic Research. 2014;8(5):41–44. [PMC free article] [PubMed]

[2] WHO. World Malaria Report 2013. In Book World Malaria Report. 2013;2013

[3] Leslie T, Mikhail A, Mayan I, Anwar M, Bakhtash S, Nader M. Overdiagnosis and mistreatment of
malaria among febrile patients at primary healthcare level in Afghanistan: observational study. British
Medical Journal. 2012;3:45. [PMC free article] [PubMed]

[4] Shukla S, Pant H, Sengupta C, Chaturvedi P, Chaudhary BL. Malaria and typhoid, do they co-exist as
alternative diagnosis in tropics? A tertiary care hospital experience. Int J Curr Microbiol App Sci.
2014;3(5):207–14.

[5] http://nvbdcp.gov.in/malaria-new.html accessed on 30th September.

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Vol. 3, No. 4, 2015, pp 162-166. doi: 10.12691/ajphr-3-4-6 | Research Article

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Prevalence of Malaria and Typhoid Fever Co-Infection:

Knowledge, Attitude and Management Practices among
Residents of Obuda-Aba, Abia State, Nigeria
Okore Oghale O’woma1, Ubiaru Prince. Chigozirim.1, , Nwaogwugwu Uzoamaka Gloria1
1
Department of Zoology and Environmental Biology, Michael Okpara University of Agriculture,
Umudike, Abia State, Nigeria

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Abstract

1. Introduction

2. Materials and Methods

3. Results

4. Discussion

5. Conclusion
 References

Abstract

A study of prevalence, knowledge, attitude and management practices of malaria and typhoid
fever co-infection was carried out among residents of Obuda-Aba, Abia State, Nigeria, between
July and September, 2014. Venepuncture technique was used for collection of the blood samples.
A total of 245 persons comprising 120 males and 125 females were examined. Field stained thick
and thin blood films were used to detect malaria parasites in the samples. Typhoid fever was
diagnosed from each blood sample using Widal test kit. Out of the 245 persons sampled,
95(38.78%) tested positive for malaria, 105 (42.86%) tested positive for typhoid fever,
45(37.50%) were co-infected with malaria and typhoid fever among the males and 55(44.00%)
were co-infected with malaria and typhoid fever among the females. Co-infection of malaria and
typhoid fever was highest in the age group of 61-75 years, 4(100%) among the males and highest
in the age group of 16-30 years, 15(83.33%) among the females. On the perception of the
possible causes of malaria and typhoid fever, 24 respondents reported excessive fried oil as the
cause while 17 respondents stated excessive intake of alcohol. On the perception of the sign and
symptoms associated with malaria and typhoid fever, 77 respondents stated loss of appetite, 67
respondents stated fatigue and 70 respondents stated headache. On the practices available for
protection against malaria and typhoid fever, 54 respondents reported routine treatments with
drugs, 21 respondents stated good sanitary measures while 33 respondents reported access to safe
food and water. There is need for massive health education campaign to educate the residents of
Obuda-Aba to correct the wrong perception they have about malaria and typhoid fever for
effective treatment and control of the diseases.

-- Sebuah studi tentang prevalensi, pengetahuan, sikap dan praktik manajemen

malaria dan koinfeksi demam tifoid dilakukan di antara penduduk Obuda-Aba,
Abia State, Nigeria, antara Juli dan September 2014. Teknik venepuncture
digunakan untuk pengumpulan darah. sampel. Sejumlah 245 orang yang terdiri
dari 120 pria dan 125 wanita diperiksa. Bidang film darah tebal dan tipis
yang diwarnai digunakan untuk mendeteksi parasit malaria dalam sampel. Demam
tifus didiagnosis dari masing-masing sampel darah menggunakan alat tes Widal.
Dari 245 orang sampel, 95 (38,78%) positif malaria, 105 (42,86%) positif
demam tifoid, 45 (37,50%) koinfeksi malaria dan demam tifoid di antara laki-
laki dan 55 pasien (44,00%). ) koinfeksi malaria dan demam tifoid di antara
betina. Koinfeksi malaria dan demam tifoid tertinggi pada kelompok usia 61-75
tahun, 4 (100%) di antara laki-laki dan tertinggi pada kelompok usia 16-30
tahun, 15 (83,33%) di antara perempuan. Pada persepsi kemungkinan penyebab
malaria dan demam tifoid, 24 responden melaporkan minyak goreng berlebihan
sebagai penyebabnya sementara 17 responden menyatakan asupan alkohol
berlebihan. Pada persepsi tanda dan gejala yang berhubungan dengan malaria
dan demam tifoid, 77 responden menyatakan kehilangan nafsu makan, 67
responden menyatakan kelelahan dan 70 responden menyatakan sakit kepala. Pada
praktik yang tersedia untuk perlindungan terhadap malaria dan demam tifoid,
54 responden melaporkan perawatan rutin dengan obat-obatan, 21 responden
menyatakan langkah-langkah sanitasi yang baik sementara 33 responden
melaporkan akses ke makanan dan air yang aman. Ada kebutuhan untuk kampanye
pendidikan kesehatan besar-besaran untuk mendidik warga Obuda-Aba untuk
memperbaiki persepsi yang salah mereka tentang malaria dan demam tifoid untuk
pengobatan yang efektif dan pengendalian penyakit.
Keywords: malaria, typhoid fever, co-infection, knowledge, attitude, practices

Received June 22, 2015; Revised July 02, 2015; Accepted July 06, 2015

Copyright © 2015 Science and Education Publishing. All Rights Reserved.

Cite this article:

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 Okore Oghale O’woma, Ubiaru Prince. Chigozirim., Nwaogwugwu Uzoamaka Gloria. Prevalence
of Malaria and Typhoid Fever Co-Infection: Knowledge, Attitude and Management Practices
among Residents of Obuda-Aba, Abia State, Nigeria. American Journal of Public Health Research.
Vol. 3, No. 4, 2015, pp 162-166. http://pubs.sciepub.com/ajphr/3/4/6

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1. Introduction

Malaria and typhoid fever remain the diseases of major public health importance and cause of
morbidity and mortality in tropical Africa [7, 26]. Both diseases are common in many countries of
the world where the prevailing environmental conditions of warm humid climate, poor sanitary
habits, poverty and ignorance exist. These two diseases have been associated with poverty and
underdevelopment [7].

Malaria is transmitted by the bites of infected female Anopheles mosquitoes from one person to
another. It is one of the most severe public health problems worldwide and leading causes of
diseases and death in many developing countries, where young children and pregnant women are
the groups most affected [29]. Globally, an estimated half of the world population (3.4 billion
persons) lives in areas at risk of malaria infection. Six countries in sub-Saharan Africa (Nigeria,
Democratic Republic of the Congo, Tanzania, Uganda, Mozambique, and Cote d’Ivoire) account
for an estimated 103 million malaria cases and 47% of the global total each year. Nigeria and the
Democratic Republic of the Congo, together account for 40% of the estimated total global

-- Malaria dan demam tifoid tetap menjadi penyakit yang sangat penting bagi
kesehatan masyarakat dan penyebab morbiditas dan mortalitas di Afrika tropis
[7, 26]. Kedua penyakit ini umum di banyak negara di dunia di mana kondisi
lingkungan iklim lembab yang hangat, kebiasaan sanitasi yang buruk,
kemiskinan dan ketidaktahuan ada. Kedua penyakit ini dikaitkan dengan
kemiskinan dan keterbelakangan [7].
Malaria ditularkan oleh gigitan nyamuk Anopheles betina yang terinfeksi dari
satu orang ke orang lain. Ini adalah salah satu masalah kesehatan masyarakat
yang paling parah di seluruh dunia dan penyebab utama penyakit dan kematian
di banyak negara berkembang, di mana anak-anak muda dan wanita hamil adalah
kelompok yang paling terpengaruh [29]. Secara global, diperkirakan setengah
dari populasi dunia (3,4 miliar orang) tinggal di daerah yang berisiko
terinfeksi malaria. Enam negara di sub-Sahara Afrika (Nigeria, Republik
Demokratik Kongo, Tanzania, Uganda, Mozambik, dan Cote d'Ivoire) menyumbang
sekitar 103 juta kasus malaria dan 47% dari total global setiap tahun.
Nigeria dan Republik Demokratik Kongo, bersama-sama mencapai 40% dari total
global yang diperkirakan

[12]
.

Malaria is holoendemic in Nigeria [25]. Ninety percentage (90%) of Nigeria’s population are at
risk of malaria and it contributes also to an estimated 11% of maternal mortality [29]. There are an
estimated 100 million malaria cases with over 300, 000 deaths per year in Nigeria, about 100,
000 more than the deaths from HIV/AIDS [29]. It accounts for 60% of outpatient visits, 30% of
hospitalizations among children under 5 years of age, and 11% maternal mortality [24].

Typhoid fever, also known as typhoid, is a symptomatic bacterial infection due to Salmonella
typhi [27]. It is largely a disease of developing nations due to their poor sanitation and poor
hygiene [27]. It is spread by eating food or drinking water contaminated with faeces of an infected
person [28]. Transmission by flies such as Musca domestica has also been reported [6]. The most
prominent feature of the infection is fever [15]. Globally, typhoid fever is an important cause of
morbidity and mortality in many regions of the world with an estimated 12-33 million cases
leading to 216,000 – 600,000 deaths annually [21]. Co-infection of malaria and typhoid fever
causes extra hardship to the health and economy of the victims.

Malaria holoendemik di Nigeria [25]. Sembilan puluh persen (90%) dari

penduduk Nigeria beresiko malaria dan itu juga menyumbang sekitar 11%
kematian ibu [29]. Ada sekitar 100 juta kasus malaria dengan lebih dari
300.000 kematian per tahun di Nigeria, sekitar 100, 000 lebih banyak daripada
kematian akibat HIV / AIDS [29]. Ini menyumbang 60% dari kunjungan rawat
jalan, 30% dari rawat inap di kalangan anak-anak di bawah 5 tahun, dan 11%
kematian ibu [24].
Demam tifoid, juga dikenal sebagai tifoid, adalah infeksi bakteri simptomatik
karena Salmonella typhi [27]. Penyakit ini sebagian besar merupakan penyakit
negara berkembang karena sanitasi yang buruk dan kebersihan yang buruk [27].
Ini menyebar dengan makan makanan atau air minum yang terkontaminasi dengan
kotoran dari orang yang terinfeksi [28]. Transmisi oleh lalat seperti Musca
domestica juga telah dilaporkan [6]. Ciri yang paling menonjol dari infeksi
adalah demam [15]. Secara global, demam tifoid adalah penyebab morbiditas dan
mortalitas yang penting di banyak wilayah di dunia dengan perkiraan 12-33
juta kasus yang menyebabkan 216.000 - 600.000 kematian setiap tahun [21].
Koinfeksi malaria dan demam tifoid menyebabkan kesulitan ekstra bagi
kesehatan dan ekonomi para korban
Like malaria, there is a popular belief that typhoid fever is endemic and quite prevalent in
Nigeria [17, 18]. Patients, who fail to respond to the first line of malaria treatment usually suspect
typhoid fever [18]. Malaria and typhoid fever usually present similar symptoms particularly at the
beginning of typhoid fever [16, 22]. Owing to the fact that it is sometimes very difficult to
differentiate clinically the presentation of typhoid fever from that of malaria without laboratory
support [23], many clinicians usually request that both tests be performed on individuals
presenting with fever of typhoid/malarial signs and symptoms. Co-infection with malaria and
typhoid is believed to be common and therefore the simultaneous treatment of both infections is
quite rampant [14, 16].

This study therefore sought to investigate the occurrence of Typhoid fever and Malaria co-
infection among residents of Obuda-Aba, Abia State and to highlight people’s knowledge,
attitude and management practices utilized in treatment of Malaria and Typhoid fevers in the
study area. The specific objectives were to determine:

1. Malaria infection through examination of stained blood films under the microscope.

2. Typhoid infections using widal agglutination kit.

3. Co-infections of malaria and typhoid through careful examination of the results and
calculations.

-- Oleh karena itu, penelitian ini berusaha untuk menyelidiki terjadinya

demam tifoid dan koinfeksi malaria di antara penduduk Obuda-Aba, Abia, dan
untuk menyoroti pengetahuan, sikap, dan praktik manajemen masyarakat yang
digunakan dalam pengobatan Malaria dan Demam tifoid di wilayah penelitian.
Tujuan spesifiknya adalah untuk menentukan:
1. Infeksi Malaria melalui pemeriksaan film darah bernoda di bawah mikroskop.
2. Tifoid infeksi menggunakan aglutinasi kit widal.
3. Co-infeksi malaria dan tifoid melalui pemeriksaan yang teliti terhadap
hasil dan perhitungan.

2. Materials and Methods

2.1. Study Area

The study was carried out in Obuda-Aba Autonomous Community, Aba South Local
Government Area of Abia State, Southeastern Nigeria from July to September 2014. The
geographical coordinates for Obuda-Aba Autonomous Community are 5°07’N 7°22’E/ 5.117°N
7.367°E. It lies at an elevation of 205m (673ft) above sea level and has a rain forest belt with dry
and wet seasons typical of the West African sub-region. The town has many bore holes as source
of drinking water with many commercial fish ponds and agricultural farms. The majority of
dwellers are traders and farmers; few are public servants and students.

2.2. Study Population

Advocacy visits to the traditional ruler of the community, H.R.H Eze (Rt.Hon.) C.B.C.
Ajuzieogu, village heads and members of the community with an introductory letter from the
Head of Department of Zoology and Environmental Biology, which helped in obtaining both
permission to carry out the research and cooperation of the people. Participants were mobilized
through town criers and announcements in the churches and market places. Informed consent of
each adult participant was obtained before blood sample collection. Consent for screening of the
children was obtained from their parents and teachers. A total of 245 subjects; (120 males and
125 females) blood samples were collected from subjects and questionnaires were administered
to the subjects to obtain socio-demographic information, knowledge, attitude, and practices about
malaria and typhoid fever.

2.3. Sample collection

The method of sample collection employed was venepuncture technique recommended by [11].

2.4. Laboratory Analysis

The collected blood samples were analyzed within 30 minutes to an hour of collection.
Microscopic examination of stained thick and thin blood films for malaria diagnosis were
prepared according to the technique outlined by [8] and described by [11]. A drop of each blood
sample was placed in the center of a grease-free clean glass slide. Thereafter, the reverse side of
the slide was cleaned with cotton wool and kept for air-drying and staining with field’s stain. The
slide was held with the dried thick film side facing downward and dipped in field’s stain A
(eosin) for 5 seconds. It was washed off gently in clean water and then dipped in field’s stain B
(methyl azure) for 5seconds and washed again in clean water. The back of the slide was cleaned
with cotton wool and kept in the draining rack to air-dry. For thin film; A small drop of blood
was placed on the centre of a grease free microscopic slide. The drop of blood was then spread
with a glass spreader held at an angle of 300 to obtain a thin film with a smooth tail end. This was
allowed to air dry in a horizontal position and then fixed with absolute methanol for two minutes.
A Giemsa stain diluted with buffer for 30 minutes staining was applied on the thin film and
allowed to air dry for 30 minutes. The stain was applied on the thin film and allowed to air dry
for 30 minutes. The stain was then washed off using distilled water and also air dried. The
stained thick and thin films were viewed using oil immersion at 100X magnification to observe
for Plasmodium parasites. Presence of ring forms of Plasmodium and Trophozoites of
Plasmodium indicate positive results. A blood smear was considered negative if no parasite is
seen after 10 minutes of search or examination under 100 high power fields of microscope.

Typhoid fever infections were diagnosed using the participant’s blood serum and Widal test kits.
The Widal kit contained reactants with attenuated typhoid antigen which reacted specifically
with the body’s antibody.

2.5. Identification

Positive specimens were identified on the basis of microscope for malaria parasite. Using
standard methods recommended by [6], a trained laboratory technician at Prince medical
Laboratory Aba clinic interpreted the malaria blood slides. For typhoid fever, an agglutination
reaction in any of the reagents was an indication that Salmonellae were present. The degree of
agglutination was recorded in titres as follows:

Prevalence of malaria parasite and typhoid fever were calculated as the proportion of sampled
persons with a positive result divided by the number of persons who provided blood samples.

2.6. Data Analysis

The data generated from this study were presented using descriptive statistics. The results were
analyzed in percentages.

3. Results

A total of 245 persons were examined for malaria and typhoid fever in Obuda-Aba, Abia State.
Out of the number 95(38.78%) had malaria parasite and 105(42.86%) had typhoid fever (Table
1). The participants were aged between 1 and 75 years. More participants were in the age group
of 1-15 years and the least were in the age group of 61-75years.

-- Sebanyak 245 orang diperiksa untuk malaria dan demam tifoid di Obuda-Aba,
Abia State. Dari jumlah 95 (38,78%) memiliki parasit malaria dan 105 (42,86%)
mengalami demam tifoid (Tabel 1). Para peserta berusia antara 1 dan 75 tahun.
Lebih banyak peserta berada di kelompok usia 1-15 tahun dan paling sedikit
berada di kelompok usia 61-75 tahun

Table 1. Overall prevalence of malaria and typhoid fever among residents of Obuda-Aba.

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The prevalence of malaria among the genders is shown in (Table 2). Of the 245 individuals
examined, 41(34.17%) of the males were positive of malaria and 54(43.20%) of the females
were positive of malaria. Among the age groups, 1-15 years had the highest malaria prevalence
rate of 38(50.67%) while 61-75 years had the least malaria prevalence rate of 3(25.00%) (Table
3).

Table 2. Frequency and distribution of malaria parasite and typhoid fever between genders of
Obuda-Aba.

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Table 3. Age Incidence of malaria parasite and typhoid fever among residents of Obuda-Aba.

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The prevalence of typhoid fever among the genders is shown in (Table 2). Of the 245
participants examined, 57(47.50%) of the males were positive for typhoid fever and 48(38.40%)
of the females were positive for typhoid fever. Among the age groups, 46-60 years had the
highest typhoid prevalence rate of 29(48.33%) while 61-75 years had the least typhoid
prevalence rate of 4(33.33%).

Out of the 245 participants examined for co-infection of malaria and typhoid fever (Table 4),
45(37.50%) of the males were co-infected while 55(44.00%) of the females were co-infected
with malaria and typhoid fever. The age group of 61-75 years of the males had the highest co-
infection 4(100%), and the age group of 46-60 years of the males had the least co-infection
7(31.82%) while the age group of 16-30 years of the females had the highest co-infection of
15(83.33%) and the age group of 46-60 years of the females had the least co-infection
7(18.42%).
Table 4. Rate of co-infection with malaria parasite and typhoid fever among the resident of
Obuda- Aba.

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On the perception of the possible causes of malaria and typhoid co-infection fever (Table 5).
67(33.50%) reported mosquito bite as the cause of malaria and typhoid fever, 57(28.50%) stated
that intake of contaminated food and water as the cause. On the knowledge of the signs and
symptoms associated with malaria and typhoid fever (Table 6). 72(15.62%) reported that loss of
appetite is the symptom associated with malaria while 28(6.32%) reported the same as the
symptom of typhoid fever.

On the practices available for protection against malaria and typhoid co-infection fever,
54(27.00%) reported the use of routine treatments with drugs while 21(10.50%) reported good
sanitary measures.
4. Discussion

Malaria and typhoid fever co-infection is a major public health problem in Obuda-Aba Abia
state, Nigeria. The respondents indicated that malaria is the major illness for them and their
family members. The prevalence rate of malaria in the study area is high. For the males, the
number of malaria positive cases was 41(34.17%), while the number of positive cases recorded
for the females was 54(43.20%). This is in agreement with [5, 20] who reported the prevalence
rates of 76% for males and 62% for females in Azia and Umudioka communities in Anambra
state respectively.

Out of the 245 persons, 57(47.50%) males tested positive for typhoid fever, 48(38.40%) females
tested positive for typhoid. This is in contrast with the work of [19] who reported 2(18.18%)
among the males and 9(81.82%) among the females in Ekwulumili Community Anambra State,
Southeastern Nigeria. Among the age groups, those within the age group of 46-60 years had the
highest prevalence of typhoid fever 29(48.33%) while those in 61-75 had the least 4(33.33%).
This is in contrast with the report of [19]. The higher prevalence among the age group of 46-60
years could be as a result of the individuals always in the market where they buy food from food
vendors and drink any available water. Exposure to polluted drinking water, close proximity to
human waste and refuse dumps, low standards of food preparation, and ignorance contribute to
occurrence, prevalence and transmission of typhoid [10].

-- Malaria dan koinfeksi demam tifoid adalah masalah kesehatan masyarakat

utama di negara bagian Obuda-Aba Abia, Nigeria. Para responden menunjukkan
bahwa malaria adalah penyakit utama bagi mereka dan anggota keluarga mereka.
Tingkat prevalensi malaria di daerah penelitian tinggi. Untuk laki-laki,
jumlah kasus malaria positif adalah 41 (34,17%), sedangkan jumlah kasus
positif yang tercatat untuk perempuan adalah 54 (43,20%). Hal ini sesuai
dengan [5, 20] yang melaporkan tingkat prevalensi 76% untuk laki-laki dan 62%
untuk perempuan di komunitas Azia dan Umudioka di negara bagian Anambra.
Dari 245 orang, 57 (47,50%) laki-laki diuji positif untuk demam tifoid, 48
(38,40%) perempuan dinyatakan positif tifus. Hal ini berbeda dengan karya
[19] yang melaporkan 2 (18,18%) di antara laki-laki dan 9 (81,82%) di antara
perempuan di Komunitas Ekwulumili Negara Anambra, Nigeria Tenggara. Di antara
kelompok usia, mereka yang berada dalam kelompok usia 46-60 tahun memiliki
prevalensi tertinggi demam tifoid 29 (48,33%) sedangkan mereka yang berusia
61-75 memiliki paling sedikit 4 (33,33%). Ini berbeda dengan laporan [19].
Prevalensi yang lebih tinggi di antara kelompok usia 46-60 tahun bisa sebagai
akibat dari orang-orang selalu di pasar di mana mereka membeli makanan dari
penjual makanan dan minum air yang tersedia. Paparan terhadap air minum yang
tercemar, dekat dengan kotoran manusia dan pembuangan sampah, standar
persiapan makanan yang rendah, dan ketidaktahuan berkontribusi pada
terjadinya, prevalensi dan transmisi tifus

The co-infection of malaria and typhoid fever reported in the study area is very high,
100(40.82%) among whom were 55(44.00%) females and 45(37.50%) males when compare with
report of [3] who reported overall co-infection rate of 10(5.0%), 2(20.0%) males and 8(80.0%)
females in Ekwulumili. The higher co-infection rate amongst females agrees with the work of [3]
who observed that most female farmers and traders spend their time in the farms and markets
where they may have no other sources of drinking water and hence have to purchase sachet
water. On the age group, 61-75 years had the highest co-infection rate 4(100%) in males and
15(83.33%) in females. This is in contrast with the work of [19], who had the age group of 1-10
years as the highest co-infection rate, 1(11%) and 51-60 years as the least, 1(2.78%).

The finding of this study indicated that people of this community were still ignorant of the
causes, symptoms and the treatment of malaria and typhoid fever. This is shown in this study in
which 57(28.50%) attributed the cause of malaria to intake of contaminated food and water and
24(12.00%) reported excessive fried oil as the cause. This is similar to the report of [2, 9, 24] but in
contrast with [1, 13]. 67(33.50%) of the respondents stated that they got the infection through the
bite of mosquitoes. This finding agrees with similar report from [4].

-- Koinfeksi malaria dan demam tifoid yang dilaporkan di daerah penelitian

sangat tinggi, 100 (40,82%) di antaranya adalah 55 (44,00%) perempuan dan 45
(37,50%) laki-laki ketika dibandingkan dengan laporan [3] yang melaporkan
secara keseluruhan tingkat ko-infeksi 10 (5,0%), 2 (20,0%) laki-laki dan 8
(80,0%) perempuan di Ekwulumili. Tingkat koinfeksi yang lebih tinggi di
antara perempuan setuju dengan pekerjaan [3] yang mengamati bahwa sebagian
besar petani perempuan dan pedagang menghabiskan waktu mereka di peternakan
dan pasar di mana mereka mungkin tidak memiliki sumber air minum lain dan
karenanya harus membeli air sachet. Pada kelompok usia, 61-75 tahun memiliki
tingkat koinfeksi tertinggi 4 (100%) pada laki-laki dan 15 (83,33%) pada
perempuan. Hal ini berbeda dengan karya [19], yang memiliki kelompok usia 1-
10 tahun sebagai tingkat koinfeksi tertinggi, 1 (11%) dan 51-60 tahun sebagai
yang paling sedikit, 1 (2,78%).
Temuan penelitian ini menunjukkan bahwa orang-orang dari komunitas ini masih
belum mengetahui penyebab, gejala dan pengobatan malaria dan demam tifoid.
Hal ini ditunjukkan dalam penelitian ini di mana 57 (28,50%) disebabkan
penyebab malaria untuk asupan makanan dan air yang terkontaminasi dan 24
(12,00%) melaporkan minyak goreng yang berlebihan sebagai penyebabnya. Ini
mirip dengan laporan [2, 9, 24] tetapi berbeda dengan [1, 13]. 67 (33,50%)
dari responden menyatakan bahwa mereka mendapat infeksi melalui gigitan
nyamuk. Temuan ini setuju dengan laporan serupa dari

On the perception of the signs and symptoms, 77(15.62%) and 28(6.32%) respondents reported
loss of appetite as the symptoms of malaria and typhoid fever respectively. This is lower when
compare with the report of [9, 24].

On the practices for prevention and control, 54(27.00%) reported routine treatments with drugs,
33(16.50%) reported access to safe food and water. The ignorance of the people might be
responsible for the high prevalence of the disease in the study area, and probably this could be
attributed to lack of health education programme as majority of the residents of Obuda-Aba are
mainly traders and farmers.

5. Conclusion

The study revealed that malaria prevalence rate among the residents of Obuda-Aba is high. The
rate of malaria and typhoid co-infection was equally high. These observations can be attributed
to the wrong perceptions about the causes of malaria and typhoid fever. The findings pose a great
challenge to the public health in Obuda-Aba. It is therefore recommended that the local health
authorities intensify efforts at sensitizing the populace of Obuda-Aba on the causes of the
diseases and possible preventives measures.

-- Studi ini mengungkapkan bahwa tingkat prevalensi malaria di antara

penduduk Obuda-Aba tinggi. Tingkat malaria dan koinfeksi tifoid juga sama
tinggi. Pengamatan ini dapat dikaitkan dengan persepsi yang salah tentang
penyebab malaria dan demam tifoid. Temuan ini menimbulkan tantangan besar
bagi kesehatan masyarakat di Obuda-Aba. Oleh karena itu direkomendasikan
bahwa otoritas kesehatan setempat mengintensifkan upaya untuk meningkatkan
kepekaan penduduk Obuda-Aba tentang penyebab penyakit dan kemungkinan
langkah-langkah pencegahan

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4. Prevalence of malaria and typhoid coinfection among patients in some hospitals in Samaru, Zaria

Christian E Mbah, Blessing Agu

Department of Biological Sciences, Ahmadu Bello University, Zaria, Nigeria

Background: A large number of staff and students live off-campus (cannot be accommodated
on campus) because of limited space. Most of them live in houses where there are no clean, safe
drinking water and poor or no drainage system. The investigation was carried out by screening
blood samples of patients who attended the Ahmadu Bello University Clinic (Sickbay) and
Jama'a hospital in Samaru, Zaria to determine the occurrence of malaria and typhoid parasites in
the area. Materials and Methods: Blood samples were collected with new disposable syringes
from 264 patients during the period of study of 3 months. Blood films were stained with Giemsa
stain, air- dried, treated with immersion oil, and examined under high-power objective of the
microscope. Malaria parasites were identified based on their ring forms. The Widal test was used
to detect the presence of Salmonella antibodies in the patient's serum. Result: Majority of the
people screened 143 (84.1%) adults were not infected while 27 (15.9%) had malaria parasites in
their blood stream. Only 20 (21.3%) of the children screened were positive for malaria parasites.
Two Plasmodium parasites, Plasmodium falciparum and P. vivax were detected in the blood
samples. Plasmodium falciparum was found to be significantly higher than P. vivax. More adults
from age 19 and older had typhoid pathogens (57.0%) in their blood samples than children who
were 18 years and younger (21.2%). A small but significant proportion (15.2%) of those
screened were co-infected with malaria and typhoid. Conclusion: Malaria and typhoid are
diseases of poverty that are still endemic in developing countries. It requires the combined effort
of the government at all levels, the scientific community and co-operation of every member of
the society to conquer these re-emerging diseases.

Keywords: Coinfection, malaria, typhoid, Zaria

ntroduction

The first historical evidence of malaria parasites was found in mosquitoes preserved in amber
from the Palaeogene period about 30 million years ago. [1] Human malaria is believed to have
originated from Africa and coevolved with its hosts, mosquitoes and non-primates. [2] Human
beings probably first became infected by mosquitoes which fed on gorillas and transmitted
Plasmodium falciparum with their bites. [3] Plasmodium vivax may have been transmitted from
chimpanzees and gorillas. [4] Plasmodium knowlesi has its origin in Asian macaque monkeys
while Plasmodium malariae is highly specific to humans with some evidence of asymptomatic
infection among wild chimpanzees. [5]

Malaria parasites are transmitted by the bites of an infected female Anopheles mosquito. The
African continent is the most severely affected by malaria. For this reason, April 25 th of every
year has been declared African Malaria Day and the Roll Back Malaria (RBM) campaign has
Africa as its main focus. [6]

The Anopheles gambiae species A of the An. gambiae complex is widespread in nearly all
African countries south of the Sahara and it is probably the world's most efficient malaria vector.
[7]
It consists of morphologically similar species separated by banding patterns of their polytene
chromosomes and certain aspects of their biology and behavior. They include: An. arabiensis,
An. quadriannulatus, An. melas, An. merus, An. funestus, An. nilli, An. mucheti, An. hargreavesi,
and An. Hanocki. [8]

Typhoid is a common worldwide bacterial disease, transmitted by the ingestion of food or water
contaminated with the feces of an infected person, which contains the bacterium Salmonella
typhi enteric serovar. The pathogen is a Gram-negative short bacillus that is motile due to its
peritrichous flagella. [9]

There are about 33 million cases of typhoid annually resulting in 216,000 deaths in endemic
areas. The World Health Organization (WHO) identifies typhoid as a serious public health
problem with high incidence on children and young adults. [9] Typhoid fever also has a very high
social and economic impact because of the hospitalization of patients with acute disease and the
complications and loss of income during the duration of the clinical illness. [10]

In April 2000, the government of Nigeria hosted the African Summit on RBM in Abuja,
demonstrating political commitment at higher levels. In African countries, there has been an
increase in NGO (non-governmental organization), private sector, and non-health sector
involvement (e.g., collaboration with Ministries of Education, Communication, Finance,
Agriculture, Environment) and non-traditional partners have become involved, e.g., UNESCO in
Sudan. Joint actions on malaria between neighboring countries have also taken shape, e.g., the
health for peace initiative in West Africa. [11]

The Global Malaria Action Plan (GLAP) with guidelines of its implementation was laid down in
1993-2000. The basic technical elements of the strategy is to provide early diagnosis and prompt
treatment, plan and implement selective and sustainable preventive measures including vector
control, to detect an early stage or epidemic, to strengthen local capacities. [12]

Typhoid is spread by the fecal-oral route and closely associated with poor hygiene; lack of clean,
safe drinking water; and poor sanitation. The disease is exclusively transmitted through food and
water contaminated by the urine and feces of patients and carriers. Polluted water is the most
common source of typhoid transmission. In addition, shellfish taken from sewage contaminated
beds, unwashed vegetables fertilized with night-soil and eaten raw, contaminated milk and milk
products have been shown to be a ready source of infection. [9]
Taxonomy within the genus Salmonella has been receiving attention. Recent classification based
on DNA sequencing has left only two species, S. enteric and S. bongori, further subdivided into
subspecies and serovars. Salmonella enterica serovar Typhi continues to be referred to as S.
typhi.

The study was carried out in Ahmadu Bello University, Main Campus, Zaria and Samaru Village
located opposite the Main Campus. The University Campus is well-planned with layouts of
academic areas, student hostels and staff quarters; the contrary is the case in Samaru Village
where houses were built indiscriminately with utter disregard to town planning regulations and
most areas are without access roads and basic amenities, such as clean and safe drinking water
and observance of environmental sanitation.

The university cannot provide accommodation for all of its students and staff. The majority of
the students, staff and their families live off campus in Samaru Village. Among the patients (staff
and students) who attend the university clinic, their major complaints are usually connected with
typhoid fever and malaria. This is what prompted this investigation to unravel the probable
causes of these problems and proffer lasting solutions.

Materials and methods

Blood samples were collected with new disposable syringe from 264 patients who attended
Ahmadu Bello University Health Center and Jama'a Hospital during the period of study of 3
months.

Blood films were made by using the end of a pipette to apply a large drop of blood on the slide to
produce a thick smear. An area of about 15 mm × 15 mm was covered by the film. The blood
films were air-dried and the slide placed on a horizontal position. [13]

Giemsa stain, buffered water or saline of pH 7.1-7.2 was used for staining. Giemsa stain was
diluted with 10% solution for 10 min staining. The slides were placed face downwards on a slide
rack. Immersion oil was added by the edge and it spread to cover an area of about that is
equivalent to the diameter of the film. Blood films were examined under ×40 and ×100
objectives and malaria parasites recorded. The parasites were identified based on their ring
forms.

Widal test

The Widal test is a serological technique used to detect the presence of Salmonella antibodies in
the patient's serum. [13] Serum was obtained from 5 ml of the patient's venous blood. [14] One drop
of positive control was placed on a reaction circle of a glass slide. A 50 μl of physiological saline
was placed on the next reaction circle of the glass slide. One drop of the patient's serum was
placed to be tested on each of the reaction circles. A drop of the appropriate Widal antigen
suspension was added to the reaction circles containing positive control and physiological saline.
One drop of appropriate widal antigen suspension was also added to the reaction circles
containing the patient's serum. The content of each circle is uniformly mixed over the entire
circle with separate mixing sticks. The slides were gently rocked back and forth, and observed
for agglutination for one minute. Agglutination is a positive test result which indicates the
presence of the corresponding antibody in the patient's serum. [14]

Result

A total of 264 blood samples was collected from Sickbay and Jama'a Hospital in Samaru, Zaria
and analyzed. Four parameters were used to compare the occurrence of malaria and typhoid: age,
sex, Plasmodium species, and Salmonella typhi type.

The majority of the people screened, 143 (84.1%) adults, were not infected while 27 (15.9%) had
malaria parasites in their bloodstream. Twenty (21.3%) children screened were positive for
malaria parasites [Table 1]. There was no significant association between infection status and
age.

Females had slightly higher prevalence of S. typhi (45.3%) than males (42.2%) [Table 5]. Association
between S. typhi infection and sex did not differ significantly. The prevalence of Salmonella typhi
infection was slightly higher (48.5%) with H antigen than the infections for O antigen (38.6%) [Table 6].
The association with Salmonella typhi H antigen was not significant. It was discovered that out of the
264 blood samples screened, 47 (17.8%) patients were infected with malaria parasites, 115 (43.7%)
patients with typhoid, while 40 (15.2%) were infected with malaria and typhoid at the same time.
Parasites of malaria and typhoid were not detected from the remaining 62 patients representing 23.5%
of all those screened

Discussion

The vast majority of estimated cases (80%) and deaths (91%) caused by malaria occur in sub-
Saharan Africa and most of them are in children under five years of age. Patients suffering from
malaria represent about 60% of clinic visits annually. [15]

One out of every 6 adults screened were predisposed to malaria infection compared to one out
every 5 children screened. This is probably because children require repeated infections before
they could develop resistance, while adults must have developed resistance before reaching their
present age. The majority of malaria cases occur in children and pregnant women who are also
known to be vulnerable. Children who suffer first and second bouts of malaria are believed not to
have developed appropriate immunity against the parasite. This is probably responsible for more
malaria cases observed in children. [15]

Both male and female patients were equally predisposed to malaria infection because any part of
the body that is exposed to mosquito bite is an avenue for parasite innoculation and transmission
irrespective of gender.
The major malaria parasite incriminated in this study was Plasmodium falciparum. It is the main
species found in hotter parts of the world including tropical Africa, part of South America,
Bangladesh, Nepal, India, the Middle East, and the eastern Mediterranean. This pathogen has
wider distribution in tropical and sub-tropical regions of the world including Nigeria.
Plasmodium vivax develops in mosquitoes at lower temperatures. Although it is found in tropical
countries P. vivax is the main pathogen in South America occurring as far as south of northern
Argentina, Mexico, and the Middle East. It is possible that the pool of P. vivax in tropical
countries of the world is maintained by a stream of travellers who import them from temperate
regions where they are endemic. [5],[12]

Several people opt for self-medication when they suspect that they are suffering from malaria.
Some use herbs and concoctions, which they believe cure malaria. However, the high cost of
drugs and medical treatment also limits its accessibility. Malaria is strongly associated with
poverty. [15]

The drug of choice endorsed by the WHO for children and adults is Coartem, artemether 20
mg/lumefantrine 120 mg. It is an antimalarial agent manufactured by Novartis Pharmaceutics
Corporation, Suffern, New York, USA. Another recommended drug similar to Coartem is
Gvitherplus, artemether 80 mg/lumefantrine 480 mg. It is used for treatment of malaria including
multidrug resistant strains of P. falciparum. It is manufactured by Bliss Pharma Ltd.
Maharashtra, India with NAFDAC No. A4-6730. Artemisnin derivatives like artemether are the
fastest-acting schizonticides, which clears the parasites rapidly.

Prevention of malaria can be accomplished by use of insecticide treated bednets, administration

of prophylactic drugs through a licensed medical practitioner, and mosquito eradication. The
plan to produce vaccines that will destroy all stages of the parasite and possible mutations is still
a thing of the future. Research towards replacement of current population of mosquitoes with
genetically engineered population has produced the first Plasmodium resistant species announced
by a team of researchers at Case Western Reserve University in Ohio in 2002. [15] A researcher
from Liverpool, School of Tropical Medicine Gareth Lyceth, told BBC that "it is another step on
the journey towards malaria control through genetically-modified mosquito release." [15] In
addition, the Biology and Control of Vectors (BCV) group has sponsored groundbreaking
research into the genetic manipulation of Anopheles gambiae. There is ongoing global genomics
research effort to create a transgenic mosquito. This will open up the prospect of modifying
mosquitoes so that they become unable to transmit malaria parasites. [16]

Some symptoms of malaria such as fever, headache, and shivering are similar to that of typhoid.
More adults were infected with Salmonella typhi than children probably because of occupational
hazards such as eating food or raw vegetables in the farms without proper washing, eating, and
drinking satchet water of questionable hygienic quality especially on a journey could expose
them to infection. Children who contract typhoid may still be learning about hygiene, or even
lack basic amenities such as clean, safe drinking water.

Typhoid infection did not exhibit preference for either of the sexes, likely because patients who
were screened live and work in the same environment and obtained their food and water
basically from the same source.

Although typhoid fever has practically disappeared from industrialized countries [17],[18] it
remains a serious public health problem in several Asian, African and South American regions of
the world.

The rediscovery of Oral Rehydration Therapy (ORT) provided a simple way to prevent many of
the deaths of diarrheal diseases including typhoid. Where resistance is uncommon, the treatment
of choice is a fluoroquinolone such as ciprofloxacin, otherwise, a third generation cephalosporin
such as ceftriaxone or cefataxime is preferred. Cefixime is a suitable oral alternative.

Typhoid in most cases is not fatal. Antibiotics such as ampicillin, chloroamphenicol,

trimethoprin - sulfamethoxazole, amoxicillin, and ciprofloxacin have been commonly used to
treat typhoid in developed countries. [9]

The fact that more individuals were infected with typhoid than malaria indicates a poor level of
personal and general hygiene among the patients screened within the communities where they
reside.

A small but significant proportion (15.2%) of those screened were coinfected with malaria and
typhoid. Where such people embark on self-treatment without proper laboratory tests and
Doctor's prescription, malaria is usually treated while typhoid is masked. The danger is that they
are healthy carriers like Mary Mallon, known as "Typhoid Mary," who was the first known case
of a healthy carrier in the United States. [19] She was incriminated in the contamination of at least
120, including five dead. [19] By the time it would be realized that there was coinfection the
victims' intestines would have been perforated leading to complications and avoidable deaths.

When untreated, typhoid fever persists for 3-4 weeks and death occurs in some 10 to 30% of
such cases. [9]

Two vaccines have been licensed for use for the prevention of typhoid: The live, oral Ty21 a
vaccine marketed as Vivotif Berna and the injectable typhoid polysaccharide vaccine sold as
Typhim Vi by Sanofi Pasteur and Typherix by GlaxoSmithKline. They are protective and are
recommended for travelers to areas where typhoid is endemic.

The introduction of typhoid vaccines in routine vaccination programs will greatly reduce the
disease burden and cost of illness to governments and individuals. Only China and Vietnam have
incorporated typhoid vaccination into their immunization programs. [15],[16],[17]

Conclusion

Malaria and typhoid have been vanquished from developed countries, but they remain a life-
threatening health problem in Africa and other developing third-world nations. Only combined
effort by individuals, governments, and NGOs through the provision of basic social amenities
can turn the tide in favor of millions who are effected. Malaria and typhoid infections cut across
all strata of the society, irrespective of sex and age. Control strategies should be tailored to cater
for all segments of the community including unborn babies who in some cases are unwilling
victims.

Recommendations

Distribution of insecticide treated nets should cover every hamlet, free of charge, under the RBM
Program. Applied research into drugs for the treatment of resistant malaria and typhoid
pathogens should be intensified while all hands must be on deck to teach children the rudiments
of personal hygiene and everyone should imbibe the good habit of washing hands before and
after eating with clean water.

http://www.bioanthrojournal.org/article.asp?issn=2315-
7992;year=2014;volume=2;issue=2;spage=43;epage=48;aulast=Mbah

5.