Incidence of invasive salmonella disease in sub-Saharan Africa: a multicentre population-based surveillance study

Florian Marks, Vera von Kalckreuth, Peter Aaby, Yaw Adu-Sarkodie, Muna Ahmed El Tayeb, Mohammad Ali, Abraham Aseffa, Stephen Baker, Holly M. Biggs, Morten Bjerregaard-Andersen, Robert F. Breiman, James I. Campbell, Leonard Cosmas, John A. Crump, Ligia Maria Cruz Espinoza, Jessica Fung Deerin, Denise Myriam Dekker, Barry S. Fields, Nagla Gasmelseed, Julian T. HertzNguyen Van Minh Hoang, Justin Im, Anna Jaeger, Hyon Jin Jeon, Leon Parfait Kabore, Karen H. Keddy, Frank Konings, Ralf Krumkamp, Benedikt Ley, Sandra Valborg Løfberg, Jürgen May, Christian G. Meyer, Eric D. Mintz, Joel M. Montgomery, Aissatou Ahmet Niang, Chelsea Nichols, Beatrice Olack, Gi Deok Pak, Ursula Panzner, Jin Kyung Park, Se Eun Park, Henintsoa Rabezanahary, Raphaël Rakotozandrindrainy, Tiana Mirana Raminosoa, Tsiriniaina Jean Luco Razafindrabe, Emmanuel Sampo, Heidi Schütt-Gerowitt, Amy Gassama Sow, Nimako Sarpong, Hye Jin Seo, Arvinda Sooka, Abdramane Bassiahi Soura, Adama Tall, Mekonnen Teferi, Kamala Thriemer, Michelle R. Warren, Biruk Yeshitela, John D Clemens, Thomas F. Wierzba

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    Abstract

    Background: Available incidence data for invasive salmonella disease in sub-Saharan Africa are scarce. Standardised, multicountry data are required to better understand the nature and burden of disease in Africa. We aimed to measure the adjusted incidence estimates of typhoid fever and invasive non-typhoidal salmonella (iNTS) disease in sub-Saharan Africa, and the antimicrobial susceptibility profiles of the causative agents. 

    Methods: We established a systematic, standardised surveillance of blood culture-based febrile illness in 13 African sentinel sites with previous reports of typhoid fever: Burkina Faso (two sites), Ethiopia, Ghana, Guinea-Bissau, Kenya, Madagascar (two sites), Senegal, South Africa, Sudan, and Tanzania (two sites). We used census data and health-care records to define study catchment areas and populations. Eligible participants were either inpatients or outpatients who resided within the catchment area and presented with tympanic (≥38·0°C) or axillary temperature (≥37·5°C). Inpatients with a reported history of fever for 72 h or longer were excluded. We also implemented a health-care utilisation survey in a sample of households randomly selected from each study area to investigate health-seeking behaviour in cases of self-reported fever lasting less than 3 days. Typhoid fever and iNTS disease incidences were corrected for health-care-seeking behaviour and recruitment. 

    Findings: Between March 1, 2010, and Jan 31, 2014, 135 Salmonella enterica serotype Typhi (S Typhi) and 94 iNTS isolates were cultured from the blood of 13 431 febrile patients. Salmonella spp accounted for 33% or more of all bacterial pathogens at nine sites. The adjusted incidence rate (AIR) of S Typhi per 100 000 person-years of observation ranged from 0 (95% CI 0–0) in Sudan to 383 (274–535) at one site in Burkina Faso; the AIR of iNTS ranged from 0 in Sudan, Ethiopia, Madagascar (Isotry site), and South Africa to 237 (178–316) at the second site in Burkina Faso. The AIR of iNTS and typhoid fever in individuals younger than 15 years old was typically higher than in those aged 15 years or older. Multidrug-resistant S Typhi was isolated in Ghana, Kenya, and Tanzania (both sites combined), and multidrug-resistant iNTS was isolated in Burkina Faso (both sites combined), Ghana, Kenya, and Guinea-Bissau. 

    Interpretation: Typhoid fever and iNTS disease are major causes of invasive bacterial febrile illness in the sampled locations, most commonly affecting children in both low and high population density settings. The development of iNTS vaccines and the introduction of S Typhi conjugate vaccines should be considered for high-incidence settings, such as those identified in this study. Funding Bill & Melinda Gates Foundation.

    Original languageEnglish
    Pages (from-to)e310-e323
    Number of pages14
    JournalThe Lancet Global Health
    Volume5
    Issue number3
    DOIs
    Publication statusPublished - 1 Mar 2017

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    Marks, F., von Kalckreuth, V., Aaby, P., Adu-Sarkodie, Y., El Tayeb, M. A., Ali, M., Aseffa, A., Baker, S., Biggs, H. M., Bjerregaard-Andersen, M., Breiman, R. F., Campbell, J. I., Cosmas, L., Crump, J. A., Espinoza, L. M. C., Deerin, J. F., Dekker, D. M., Fields, B. S., Gasmelseed, N., ... Wierzba, T. F. (2017). Incidence of invasive salmonella disease in sub-Saharan Africa: a multicentre population-based surveillance study. The Lancet Global Health, 5(3), e310-e323. https://doi.org/10.1016/S2214-109X(17)30022-0