1 Chapter Two: Literature Review on the Prevalence of Widal Test

Among 5–20-Year-Olds Attending Muslim Specialist Hospital

1.1 Introduction
Typhoid (enteric) fever remains a significant cause of febrile illness in low- and
middle-income countries, particularly where safe water, sanitation and hygiene (WASH)
services are inadequate. In many Nigerian health facilities, diagnosis often relies heavily on
non-specific clinical features and simple serological tests—especially the Widal
agglutination test—because confirmatory microbiological methods such as blood culture
and molecular assays may be unavailable, slow or unaffordable. Evidence from Nigeria and
other endemic settings shows that single-sample Widal testing can markedly overestimate
typhoid burden, contribute to misdiagnosis and promote inappropriate antibiotic use,
thereby fuelling antimicrobial resistance (AMR).
This chapter provides an overview of the disease and diagnostic context that underpins the
present study. It reviews:
• the concept of typhoid fever and its global and Nigerian burden;
• the Widal test—its principles, interpretation, strengths and weaknesses;
• empirical studies reporting Widal positivity and culture-confirmed typhoid, with
emphasis on children and adolescents;
• factors that influence Widal results and their interpretation;
• a conceptual framework that links Widal use to diagnostic decisions and
public-health implications; and
• the evidence gaps that justify a facility-level study among 5–20-year-olds attending
Muslim Specialist Hospital.

1.2 Concept of typhoid fever

1.2.1 Etiology
Typhoid fever is caused primarily by Salmonella enterica serovar Typhi (S. Typhi), while
paratyphoid fever results mainly from S. Paratyphi A, B or C. These organisms are adapted
to humans; S. Typhi is particularly human-restricted, which shapes transmission dynamics
and makes prevention through WASH improvements and vaccination especially relevant.

1.2.2 Transmission and epidemiology

The classical route of transmission is faeco-oral ingestion of water or food contaminated by
S. Typhi. According to the World Health Organization, typhoid risk is highest in populations
lacking safe water and adequate sanitation, and children are among the groups at greatest
risk in endemic settings. Transmission is sustained by:
 • Shedding of bacteria by infected people—S. Typhi can be excreted in stool or
urine;
• Contamination of water sources and food chains—poorly protected wells or
street-food vendors can perpetuate outbreaks; and
• Asymptomatic or chronic carriers—individuals with persistent gall-bladder
colonisation may shed bacteria for months or years, particularly when surveillance
and diagnostics are weak.

1.2.3 Clinical features and complications

Typhoid fever typically presents as a systemic febrile illness with non-specific symptoms
that overlap with malaria and other febrile diseases common in Nigeria. Clinical
manifestations reported in Nigerian and African studies include fever, headache, abdominal
discomfort, constipation or diarrhoea, malaise and anorexia, with hepatosplenomegaly and
relative bradycardia in some cases. Complications include intestinal haemorrhage or
perforation, and in severe cases neuropsychiatric manifestations (“typhoid psychosis”) and
sepsis. For example, a paediatric study at the University of Maiduguri Teaching Hospital
reported intestinal perforation in 11.4 % of admitted children, underscoring the
importance of prompt and accurate diagnosis.

1.2.4 Global and regional burden

The World Health Organization estimated that in 2019 there were about 9 million typhoid
cases and approximately 110 000 deaths worldwide. Accurate burden measurement,
however, is complicated by diagnostic limitations and incomplete surveillance. In Nigeria
and many African settings, blood-culture capacity is limited and reliance on serology can
inflate case counts. In a prospective Nigerian study at University of Nigeria Teaching
Hospital (UNTH), only 14.1 % of febrile patients suspected to have typhoid had
culture-confirmed S. Typhi or S. Paratyphi, highlighting the diagnostic gap when serology
alone is used. Nigeria’s Integrated Disease Surveillance and Response (IDSR) system
emphasises laboratory confirmation to guide public-health action, reflecting the
recognition that clinical suspicion alone is insufficient for outbreak control and disease
monitoring.

1.3 Widal test and alternative diagnostic options

1.3.1 Principle and immunologic basis
The Widal test is a serological agglutination assay that detects antibodies in patient serum
directed against Salmonella antigens—classically O (somatic,
lipopolysaccharide-related) and H (flagellar) antigens. Agglutination occurs when
antibodies in serum bind to antigen suspensions and form visible clumps. Nigerian
laboratories commonly define “significant” titres as ≥1:80 for O antibodies and/or ≥1:160
for H antibodies, although cut-offs vary by kit and local practice.

1.3.2 Procedure
In routine Nigerian practice, the Widal test may be performed as either of the following:
 • Rapid slide agglutination—a screening test in which a drop of serum is mixed with
antigen on a slide and observed for clumping within minutes; and/or
• Tube agglutination with serial dilutions—a semi-quantitative test in which
serum is diluted twofold and the highest dilution giving visible agglutination (the
titre) is reported.

1.3.3 Interpretation
Interpretation is the most controversial aspect of Widal testing:
• Best-practice serology requires demonstrating a four-fold rise in antibody titre
between paired sera collected 7–14 days apart to support recent infection.
• Common practice in endemic settings relies on a single “significant” titre because
follow-up samples are often not obtained. This approach is unreliable in endemic
areas where baseline antibodies are common due to prior exposure or
cross-reacting infections.

1.3.4 Diagnostic accuracy and limitations

Evidence shows that Widal performance is highly variable and context-dependent. Studies
from Benin City, Enugu and Dar es Salaam report sensitivity ranging from about 35 % to
49 %, poor positive predictive value (PPV) (e.g., 17 % PPV in Benin City) and high
apparent positivity relative to culture-confirmed prevalence. Cross-reactivity with malaria
and other infections is a major limitation: for example, at UNTH Enugu malaria
parasitaemia was strongly associated with false-positive Widal results. Baseline titres vary
geographically, single tests cannot distinguish past from current infection, and the test’s
poor PPV means that many positive results do not correspond to true typhoid fever.

1.3.5 Alternative diagnostics

Because of the limitations of the Widal test, more specific options are recommended where
feasible:
• Blood culture—detects viable bacteria and enables organism identification with
antibiotic susceptibility testing. Sensitivity (~59 % on average) improves with
larger blood volumes but is reduced by prior antimicrobial use.
• Bone-marrow culture—more sensitive than blood culture but impractical for
routine use due to invasiveness and resource requirements.
• Rapid serological tests (e.g., Typhidot, TUBEX)—detect specific IgM/IgG
antibodies and have average sensitivity around 78 % and specificity around 77 %.
They are faster than culture but cost more than Widal and still have imperfect
performance.
• Molecular tests (PCR/qPCR)—detect bacterial DNA in blood or other specimens.
They offer high analytic specificity but require specialised equipment, skilled
personnel and a reliable power supply, and therefore are not widely available in
many Nigerian hospitals.
1.3.6 Table 1 – Comparison of major diagnostic tests for typhoid fever
Typical Key Main
What it turnaroun performan advantage Main
Test Specimen detects d ce insights s limitations
Widal Serum Antibodies Minutes to Highly Cheap, Cross-reac
agglutinat against O same day variable rapid and tivity
ion and H results; widely (notably
antigens poor PPV available with
in many malaria);
African cannot
settings— distinguis
e.g., PPV h past
≈17 % in versus
Benin City; current
high infection;
apparent baseline
positivity titres
relative to vary; a
culture in single test
Tanzania is often
unreliable
Blood Blood Viable ~2–5 days Meta-anal Identifies Requires
culture Salmonella yses the laboratory
bacteria report organism infrastruct
sensitivity and allows ure;
~59 % antibiotic sensitivity
overall; susceptibil reduced
increases ity testing by prior
with blood antimicro
volume; bial
lower exposure
after prior and low
antibiotics blood
volume;
slower
turnaroun
d
Rapid Serum IgM/IgG Minutes to Cochrane Faster More
serologic antibodies hours review than expensive
al tests to specific suggests culture than
(e.g., antigens average and Widal;
Typhidot sensitivity potentially performan
/TUBEX) ~78 % better ce varies;
and than Widal requires
specificity in some supply
 Typical Key Main
What it turnaroun performan advantage Main
Test Specimen detects d ce insights s limitations
~77 %; settings chain and
varies by quality
kit and assurance
study
setting
PCR/ Blood or Bacterial Hours if Field High Requires
qPCR other DNA equipment usefulness analytic specialise
specimens available depends specificity; d
on can detect equipment
protocols; pathogen , technical
a Lagos DNA even expertise
study when and stable
showed culture power
that fails supply;
molecular not widely
confirmati available
on in many
revealed Nigerian
non-typho hospitals
idal
pathogens
among
febrile
patients
labelled as
“typhoid”

1.4 Prevalence studies on Widal positivity and typhoid burden

Prevalence in typhoid literature is reported in two ways: (1) Widal positivity prevalence
among febrile or suspected typhoid patients, and (2) culture-confirmed prevalence
among those suspected. Because this study focuses on the “prevalence of the Widal test
among 5–20 years,” emphasis is placed on Widal positivity rates from studies including
children and adolescents. The contrast between serological and culture-confirmed
prevalence underscores the risk of misdiagnosis when Widal is relied upon.

1.4.1 Nigerian evidence (including children and adolescents)

• Use and yield of Widal among febrile children (Nigeria, 1992) – In a
retrospective review of 973 febrile children (1 113 Widal tests), 29 % of tests
were positive (>1:64 titre), 8 % were borderline (1:64) and 63.4 % were negative.
The authors concluded that Widal was frequently requested but rarely used to guide
treatment and recommended clearer criteria for its use in febrile children.
 • Hospitalised children with suspected typhoid (UMTH Maiduguri, admissions
2010) – Among 35 children admitted with clinical typhoid diagnosis, 57.1 % had
significant Widal titres whereas 22.9 % had positive blood cultures. The study
population ranged from 6 months to 15 years, with the 5–9-year group most
represented. This illustrates that Widal positivity in paediatric admissions may far
exceed culture confirmation.

• Febrile suspects in a referral hospital (UNTH Enugu, 2013–2016) – Among 810

febrile “typhoid suspects”, only 114 (14.1 %) had culture-confirmed typhoid or
paratyphoid, and malaria parasitaemia strongly increased false-positive Widal
results. Widal sensitivity was 49.1 % and specificity 90.7 %, and poor diagnostic
performance contributed to antibiotic overuse and resistance.

• Outpatients including adolescents (Kano State, 2022) – In a cross-sectional

study of 200 outpatients at two hospitals, 44.5 % had positive Widal tests overall.
In the 11–20-year subgroup, 35.7 % were Widal positive (10 of 28). The study
emphasised that Widal cannot differentiate past from active infection and may
misclassify adolescents.

• Hospitalised febrile patients (Lagos, samples April–August 2021) – Among 125

hospitalised febrile patients, Widal positivity at a 1:160 cut-off was 28.8 %
(O antigen) and 32.8 % (H antigen). Malaria parasitaemia prevalence was high
(65.5 %), supporting the observation that febrile illness differentials are complex
and that Widal serology may reflect diverse infectious exposures rather than
confirmed S. Typhi infection.

1.4.2 Regional evidence outside Nigeria (Africa/West Africa)

• Ghana (Ga West Municipality, 2017) – In a study of 157 febrile patients aged 2–
37 years (median 6 years), Widal detected O/H antigens in 14.6 %, while blood
culture confirmed Salmonella in only 6.4 %. The study notes overestimation by
Widal and low malaria–typhoid co-infection when confirmed by culture.

• Tanzania (Dar es Salaam, 2018) – Among 158 suspected patients aged 5–

82 years, Widal positivity was 81 % whereas blood-culture-confirmed typhoid
prevalence was only 10.1 %, illustrating extreme overestimation when Widal is
used alone.

1.4.3 Table 2 – Summary of reviewed prevalence studies

Location & Sample & age
Study (year) design range Key findings Notes
Bondi et al. (1 Nigeria; 973 febrile 29 % Widal Highlights
992) retrospective children; positive frequent
review tests = 1 113; (> 1:64); 8 % ordering of
age not borderline; Widal but
specified 63.4 % negative limited impact
on clinical
decision-makin
 Location & Sample & age
Study (year) design range Key findings Notes
g; calls for clear
testing criteria
Rabasa et al. ( University of 35 children 57.1 % had Shows Widal
2013) Maiduguri (6 months–15 y significant positivity
Teaching ears) Widal titres; exceeding
Hospital, 22.9 % culture culture
Nigeria; positive confirmation;
prospective complication
study of 2010 rate (intestinal
admissions perforation)
underscores
diagnostic
stakes
Enabulele & A University of 271 adults 45.76 % Widal Demonstrates
wunor (2016) Benin Teaching (>18 years) positive; poor PPV and
Hospital, 22.10 % culture association of
Nigeria; positive; PPV malaria
cross-sectional ≈17 % parasitaemia
with Widal
positivity
Ohanu et al. (2 UNTH Enugu, 810 suspects 14.1 % culture Highlights
019) Nigeria; (plus 288 confirmed; diagnostic
prospective controls); Widal confusion
case–control includes sensitivity between
(2013–2016) children 49.1 % and malaria and
< 18 years specificity typhoid and
90.7 %; malaria implications for
parasitaemia antimicrobial
strongly resistance
associated with
false positives
Osue et al. (20 Kano State, 200 Overall Widal Provides
22) Nigeria; outpatients; positivity age-bracket
cross-sectional includes < 10 44.5 %; 11– breakdown
and 11–20-year 20-year relevant to the
groups subgroup present study;
35.7 % emphasises
(10 of 28) inability of
Widal to
distinguish past
versus current
infection
 Location & Sample & age
Study (year) design range Key findings Notes
Igiri et al. (201 Ahmadu Bello 216 33.3 % Widal Reports zero
8) University participants (all positive; 0 % typhoid by
Teaching ages) culture positive culture despite
Hospital, Zaria, high Widal
Nigeria; positivity,
cross-sectional suggesting
(Jul–Nov 2016) misclassificatio
n or poor
laboratory yield
Fakorede et al. Lagos, Nigeria; 125 Widal positivity Illustrates the
(2024) hospital-based hospitalised 28.8 % (O) and complexity of
(samples Apr– febrile patients; 32.8 % (H) at febrile illness
Aug 2021) age unspecified 1:160; high and importance
malaria of molecular
parasitaemia confirmation
(65.5 %); qPCR
detected
non-typhoidal
Salmonella
Rufai et al. (20 Ga West 157 febrile 14.6 % Widal Shows Widal
23) Municipality, patients (2– positive; 6.4 % overestimation
Ghana; 37 years; culture relative to
cross-sectional median 6) confirmed culture; low
(Feb–May 2017 malaria–
) typhoid
co-infection
Mawazo et al. ( Dar es Salaam, 158 suspected 81 % Widal Illustrates
2019) Tanzania; patients (5– positive; 10.1 % extreme
cross-sectional 82 years) culture overestimation
(Jun–Sep 2018) confirmed by Widal and
concludes it is
not reliable as a
standalone test

1.5 Factors affecting Widal results and their interpretation

1.5.1 Prior antibiotic exposure and timing of illness
Antibiotic use before presentation may suppress bacterial growth, reducing culture
positivity, yet antibody titres may still persist or rise depending on timing. In many
settings, patients start antibiotics prior to hospital care. Reduced culture yield drives
clinicians to rely on Widal results, but these may reflect past exposure or cross-reactivity
rather than acute infection.
1.5.2 Endemicity and baseline titres
In endemic areas, background antibody titres can be elevated even among healthy
individuals. Without local baseline-titre studies, choosing a single “significant titre”
threshold is arbitrary. Some Nigerian work from Borno and Plateau States suggested that
an O-titre ≥160 may be appropriate in those settings, reinforcing the idea that diagnostic
cut-offs are location-specific rather than universal.

1.5.3 Malaria and other co-infections

Malaria is a major confounder in Nigeria and West Africa. Studies from Enugu and Benin
City show that malaria parasitaemia is strongly associated with positive Widal results,
leading to large numbers of false positives. Ghanaian data similarly report Widal
overestimation relative to culture in febrile populations where malaria is common. Other
bacterial pathogens—including Klebsiella, Staphylococcus, Streptococcus and Proteus
species—can also co-exist in febrile patients and complicate interpretation, as noted in a
Lagos evaluation where several pathogens were detected among patients with positive
Widal or immunochromatographic tests.

1.5.4 Laboratory factors: kits, methods and cut-offs

Differences in antigen preparations, manufacturer cut-offs and whether slide or tube
agglutination is used can markedly affect apparent prevalence. This explains why Widal
positivity ranges from about 14.6 % in Ghana to 81 % in Tanzania. Local laboratories
should validate kit performance and establish context-appropriate cut-offs.

1.6 Conceptual framework linking Widal use to diagnosis and public-health

implications
In endemic febrile illness settings such as Nigeria, diagnostic reasoning and stewardship
can be conceptualised as a sequence of steps that link patient presentation to treatment
and surveillance outcomes:
1. Population context: High background exposure to Salmonella and high malaria
prevalence; limited access to definitive diagnostics.
2. Clinical presentation: Non-specific febrile symptoms prompt suspicion of typhoid
and other infections.
3. Diagnostic choice: Widal is requested because it is inexpensive and available,
whereas culture or PCR may be unavailable or delayed.
4. Test results and interpretation: A single Widal titre is often interpreted as
definitive, despite its inability to distinguish current from past infection or
cross-reactivity.
5. Treatment decision: Patients with positive Widal results frequently receive
antibiotics for typhoid; if the result is a false positive, unnecessary antibiotic use
contributes to AMR and cost.
 6. Public-health outcome: Overestimation of typhoid burden distorts facility
statistics, surveillance data and resource allocation; under-use of confirmatory
testing hinders outbreak detection and response.

1.6.1 Figure 1 – Widal testing pathway

The flowchart below illustrates the pathway from presentation of a febrile patient to
interpretation of Widal results and clinical decision-making. It highlights points at which
misinterpretation may occur and where alternative diagnostics or clinical judgement are
required.

Flowchart showing the Widal testing pathway from patient presentation through testing and
interpretation to clinical decisions

1.7 Summary of the literature and identified gaps

1.7.1 Key points from the reviewed literature
• Typhoid fever remains a significant global health problem, with approximately
9 million cases and 110 000 deaths annually; children in low-resource settings are
disproportionately affected.
• The Widal test is widely used in Nigeria because it is inexpensive and rapid;
however, its performance is highly variable. In Benin City, Widal positivity
(45.76 %) greatly exceeded culture-confirmed typhoid and had a PPV of only 17 %.
 In Enugu, malaria parasitaemia strongly increased false-positive Widal results,
emphasising diagnostic confusion between malaria and typhoid.
• Among children and adolescents, studies report high Widal positivity (e.g., 57.1 % in
admitted children at UMTH Maiduguri and 29 % in febrile children reviewed in
1992), but culture confirmation is much lower, indicating probable overestimation
and misclassification when Widal is relied upon.
• Evidence from West Africa (e.g., Ghana) similarly shows Widal positivity exceeding
culture-confirmed infection in a young febrile population (median age 6 years). In
Tanzania, Widal positivity reached 81 % whereas culture-confirmed prevalence was
10.1 %.

1.7.2 Gaps that justify the present study

Despite abundant evidence that Widal performance varies across settings, local
facility-level data remain essential for informed clinical practice. Key gaps include:
1. Lack of hospital-specific prevalence data for the 5–20-year age group. Many
studies report combined age groups or adult-focused samples. Age-stratified data
are needed to understand Widal positivity among adolescents and older children.
2. Uncertainty about local cut-off titres and baseline titres. Diagnostic thresholds
vary geographically; without site-specific baseline studies, interpretation of a single
Widal titre remains uncertain.
3. Co-infection context (especially malaria). Multiple studies show that malaria
strongly influences Widal positivity. Establishing the pattern among 5–20-year-olds
in the study hospital is important because this group frequently presents with
malaria-like febrile illness in Nigeria.
4. Implications for antibiotic use and AMR. Over-reliance on Widal leads to
inappropriate antibiotic use and contributes to multidrug resistance. Facility-level
data can support better diagnostic stewardship and rational prescribing.
5. Surveillance and reporting quality. Nigeria’s IDSR framework emphasises
laboratory confirmation for priority conditions. Local evidence on Widal positivity
and culture confirmation can inform quality improvement in diagnostic pathways
and surveillance.

1.7.3 Concluding statement

The literature shows that, while Widal testing is ubiquitous and sometimes highly positive
in endemic settings, its interpretation is compromised by background immunity, variable
cut-offs and cross-reactivity—particularly with malaria. There is a clear need for a
hospital-based, age-focused study among 5–20-year-olds attending Muslim Specialist
Hospital to quantify Widal positivity, explore its relationship with culture confirmation
and co-infection and provide a credible local baseline for improving diagnosis, rational
treatment and public-health action.
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