JOURNAL OF CLINICAL MICROBIOLOGY, May 2004, p. 1885–1889 Vol. 42, No.

5
0095-1137/04/$08.00⫹0 DOI: 10.1128/JCM.42.5.1885–1889.2004
Copyright © 2004, American Society for Microbiology. All Rights Reserved.

Evaluation of Rapid Diagnostic Tests for Typhoid Fever

Sonja J. Olsen,1 Jim Pruckler,1 William Bibb,1 Nguyen Thi My Thanh,2 Tran My Trinh,2
Nguyen Thi Minh,3 Sumathi Sivapalasingam,1 Amita Gupta,1 Phan Thu Phuong,4
Nguyen Tran Chinh,5 Nguyen Vinh Chau,5 Phung Dac Cam,4
and Eric D. Mintz1*
Foodborne and Diarrheal Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia,1 and
Pasteur Institute2 and Hospital for Tropical Diseases,5 Ho Chi Minh City, Cai Lay Medical Center,
Cai Lay,3 and National Institute of Hygiene and Epidemiology, Hanoi,4 Vietnam
Received 10 September 2003/Returned for modification 7 January 2004/Accepted 12 January 2004

Laboratory diagnosis of typhoid fever requires isolation and identification of Salmonella enterica serotype

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Typhi. In many areas where this disease is endemic, laboratory capability is limited. Recent advances in
molecular immunology have led to the identification of sensitive and specific markers for typhoid fever and
technology to manufacture practical and inexpensive kits for their rapid detection. We evaluated three
commercial kits for serologic diagnosis of typhoid fever. Patients presenting with > 4 days of fever were
enrolled at two hospitals in Southern Vietnam. Cases were patients with serotype Typhi isolated from blood
samples, and controls were patients with other laboratory-confirmed illnesses. Serotype Typhi isolates were
confirmed and tested for antimicrobial susceptibility at the Pasteur Institute in Ho Chi Minh City. The Widal
test was run at the hospitals and the Pasteur Institute. Sera were shipped frozen to the Centers for Disease
Control and Prevention and tested by using Multi-Test Dip-S-Ticks, TyphiDot, and TUBEX to detect immu-
noglobulin G (IgG), IgG and IgM, and IgM, respectively. Package insert protocol instructions were followed.
We enrolled 59 patients and 21 controls. The sensitivity and specificity findings were as follows: 89 and 53%
for Multi-Test Dip-S-Ticks, 79 and 89% for TyphiDot, 78 and 89% for TUBEX, and 64 and 76% for Widal
testing in hospitals and 61% and 100% for Widal testing at the Pasteur Institute. For all assays, the sensitivity
was highest in the second week of illness. The Widal test was insensitive and displayed interoperator vari-
ability. Two rapid kits, TyphiDot and TUBEX, demonstrated promising results.

Typhoid fever, caused by Salmonella enterica serotype Typhi, serum of patients with typhoid fever agglutinated typhoid ba-
is a major cause of morbidity and mortality worldwide, causing cilli (20). Unfortunately, neither the Widal test, which remains
an estimated 16.6 million new infections and 600,000 deaths in widespread use in the developing world, nor any of the
each year (14). In Vietnam, typhoid fever is highly endemic, serodiagnostic tests that have since been developed has proven
with the southern provinces most heavily affected. In a study sufficiently sensitive, specific, and practical to be of value in
conducted in Dong Thap Province in 1995 and 1996, the inci- areas where this disease is endemic (9). Recent advances in
dence of confirmed serotype Typhi infection was 198 per molecular immunology have led to the identification of poten-
100,000 for all ages (11). tially more sensitive and specific markers in the blood and
Isolation of serotype Typhi from blood, urine, or stool is the urine of patients with typhoid fever and have enabled the
most reliable means of confirming an infection. However, this manufacture of practical and inexpensive kits for their detec-
requires laboratory equipment and technical training that are tion. Here we report the results of an evaluation of three com-
beyond the means of most primary health care facilities in the mercial serodiagnostic assays for diagnosis of acute serotype
developing world. Most serotype Typhi infections are diag- Typhi infection with specimens collected in southern Vietnam.
nosed purely on clinical grounds and treated presumptively. As
a result, the diagnosis may be delayed or missed while other
MATERIALS AND METHODS
febrile illnesses are considered, and patients without typhoid
fever may receive unnecessary and inappropriate antimicrobial Specimen collection. Specimens were collected from patients at two hospitals
in Southern Vietnam: Cai Lay District Hospital (180 beds) in Tien Giang Prov-
therapy. Emerging drug resistance among circulating serotype
ince and the Hospital for Tropical Diseases (Cho Quan Hospital) (500 beds) in
Typhi strains in Vietnam (6, 15) and elsewhere (16) has com- Ho Chi Minh City. Patients ⱖ 3 years old who presented with ⱖ 4 days of fever
plicated the treatment of typhoid fever and heightened the between October 2000 and April 2002 were eligible for enrollment. Patients who
need for rapid accurate diagnosis and the appropriate and met the criteria were asked to give informed consent and answer a brief ques-
selective use of antimicrobial agents to which the organism has tionnaire about clinical signs and symptoms, antimicrobial treatment, and history
of typhoid fever and vaccination. Participants gave 5 ml of blood (3 ml from
thus far remained susceptible. children 3 to 5 years old) upon routine venipuncture for blood culture. Only patients
Serodiagnosis of typhoid fever has been attempted since the with a laboratory-confirmed etiology of their fever were included in the analysis.
late 19th century when Widal and Sicard showed that the Blood samples were centrifuged, and the serum was divided into aliquots and
stored at ⫺20°C. In order to minimize the degradation of the antibodies in the
serum, the specimens were frozen immediately and remained frozen until the
* Corresponding author. Mailing address: Foodborne and Diarrheal time of testing. At routine intervals, personnel from the Pasteur Institute re-
Disease Branch, Centers for Disease Control and Prevention, 1600 trieved the isolates and serum specimens from the hospitals; serum was stored at
Clifton Rd., MS A-38, Atlanta, GA 30333. Phone: (404) 639-2206. Fax: ⫺70°C. All isolates were confirmed at the Pasteur Institute, and serum was
(404) 639-2205. E-mail: edm1@[Link]. reevaluated by using the Widal test. Serum specimens from all patients with a

1885
1886 OLSEN ET AL. J. CLIN. MICROBIOL.

TABLE 1. Characteristics of patients enrolled in study by hospital and laboratory-confirmed diagnosis

Cai Lay Hospital Hospital for Tropical Diseases Total
Parameter
Typhoid fever Other Typhoid fever Other Typhoid fever Other

Total no. of patients 24 10 35 10 59 20

Median age in yr (range) 13 (2–72) 15 (4–70) 20 (3–67) 36 (14–91) 18 (2–72) 26 (4–91)
No. (%) of female patients 6 (25) 6 (60) 17 (49) 5 (50) 23 (39) 11 (55)
Median days (range) between fever onset and enrollment 9 (4–19) 6 (4–15) 11 (5–55) 12 (5–129) 11 (4–55) 9 (4–129)
Median (range) duration of hospitalization 10 (2–20) 5 (2–9) 10 (2–41) 7 (4–18) 10 (2–41) 6 (2–18)
No. of patients (%) treated before presenting to the 24/24 (100) 10/10 (100) 31/32 (97) 9/9 (100) 55/56 (98) 19/19 (100)
hospital/total no.
No. of patients (%) reportedly taking antibiotics at presentation/ 4/5 (80) 2/4 (50) 6/10 (60) 4/6 (67) 10/15 (67) 6/10 (60)
total no. of patients who reported medicine type

laboratory-confirmed illness were batched and shipped on ice every few months the outer membrane protein of serotype Typhi. For specimens that are indeter-

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to the Centers for Disease Control and Prevention (CDC) in Atlanta, Ga., for minate (IgM negative and IgG positive), a confirmatory test, TyphiDot-M, is
further testing with the commercial assays. Patients with serotype Typhi isolated recommended by the manufacturer. Due to manufacturing problems with the
from blood were compared to patients with other laboratory-diagnosed patho- TyphiDot-M, only the TyphiDot was used in this evaluation. These first two tests,
gens by three commercial kits for rapid diagnosis of acute typhoid fever. the Multi-Test Dip-S-Ticks and the TyphiDot, are qualitative. The third test was
Laboratory analysis. (i) Blood culture. At Cai Lay Hospital, 5 ml of patient the TUBEX, a semiquantitative test that uses polystyrene particle agglutination
blood was added to blood culture medium (biphasic tryptic soy agar and brain to detect IgM antibodies to the O9 antigen. Specimens were run according to the
heart infusion broth with SPS [0.6 mg/ml]) supplied by the Pasteur Institute. The protocol listed on the packet inserts.
blood culture bottle was then incubated at 37°C for 24 h before being tilted so Ethical review. The study protocol was approved by the institutional review
that the liquid flowed over the solid medium. The broth was subcultured on boards of the CDC and the National Institute of Hygiene and Epidemiology,
blood agar after 1, 2, 3, and 7 days, and the solid medium was subcultured any Hanoi, Vietnam.
time there was a colony visible on the slant. Isolates were Gram stained and Statistical analysis. Analyses were performed by using SPSS version 11.0.1
identified by standard biochemical methods. Serotyping was performed by using (SPSS, Inc., Chicago, Ill.). Medians were compared by using the median test for
agglutination with Salmonella O, H, and Vi antisera. If there was no growth after nonparametric data that calculates a chi-square statistic. For each assay, we
10 days, the culture was considered negative. The Hospital for Tropical Diseases calculated the sensitivity, specificity, and positive and negative predictive values.
used the BACTEC system and surveyed the results after 5 days. If there was any Fleiss quadratic 95% confidence intervals were calculated by using Epi Info 6
growth, colonies were subcultured to blood agar and identified as described (CDC, Atlanta, Ga.). The patient age was calculated by using a mid-year birth
above. date and date of interview.
(ii) Confirmation and antimicrobial susceptibility testing of isolates at the
Pasteur Institute. The identification of suspect serotype Typhi isolates was con-
firmed at the Pasteur Institute by standard biochemical tests and Salmonella RESULTS
serotyping. Antimicrobial susceptibility testing was done by using the Kirby-
Bauer disk diffusion method. The following antimicrobial agents (zone size for We enrolled 59 serotype Typhi cases and 20 controls with
resistance) were used: ampicillin (ⱖ 17 mm), tetracycline (ⱖ 19 mm), chloram- other laboratory-confirmed febrile illnesses. The control diag-
phenicol (ⱖ 18 mm), ceftriaxone (ⱖ 21 mm), ciprofloxacin (ⱖ 21 mm), ofloxacin noses were as follows: 7 subjects with dengue fever, 4 subjects
(ⱖ 16 mm), norfloxacin (ⱖ 17 mm), nalidixic acid (ⱖ 19 mm), and gentamicin (ⱖ
with Escherichia coli cultured from blood, 1 subject with E. coli
15 mm).
(iii) Laboratory confirmation of other pathogens. Confirmation of other cultured from urine, 2 subjects with malaria (Plasmodium fal-
pathogens was done as follows: blood smear for malaria, acid-fast bacilli (AFB) ciparum), 2 subjects with tuberculosis, 2 subjects with Klebsiella
sputum smear for tuberculosis, blood or urine cultures for other bacterial patho- pneumoniae cultured from blood, and 2 subjects with S. en-
gens, or serum immunoglobulin M (IgM) detection by antibody-capture enzyme terica serotype Paratyphi A cultured from blood. Serum was
immunosorbent assay (MAC EIA) for dengue. AFB smears and blood and urine
cultures were done in the hospitals; sera were sent from Cai Lay Hospital to the
missing from one case and one control (serotype Paratyphi A).
Center for Preventive Medicine in Tien Giang province for dengue testing by The demographic characteristics of the serotype Typhi pa-
using a MAC EIA kit produced by the Pasteur Institute (validated by comparison tients and controls are listed in Table 1. In the Hospital for
to an Omega, UK, commercial kit). The Hospital for Tropical Diseases did not Tropical Diseases there was a slightly longer, but nonsignifi-
test or refer specimens for dengue serology.
cant, time between fever onset and enrollment compared to
(iv) Widal test. Widal testing was done by using the Sanofi qualitative agglu-
tination test kits (Bio-Rad) by two different methods. In both methods, serum Cai Lay Hospital (median number of days, 11 versus 8 [P ⫽
was serially diluted, starting at 1/10, in physiological saline and then further 0.07]). Twenty-five patients recalled taking antibiotics after
diluted 1/10 in suspensions containing serotype Typhi O and H antigens, sepa- fever onset (10 of 15 cases versus 6 of 10 controls), however, 74
rately. Cai Lay Hospital used the rapid centrifugation technique in which the of 75 (99%) reported taking any medicine in the same week.
tubes were centrifuged at 3,000 rpm for 5 min. The precipitate was resuspended
by tapping the bottom of the tube; if agglutination was visible, the results were
Most persons (54 of 79 [68%]) did not know if the medicine
considered positive. The Hospital for Tropical Diseases and the Pasteur Institute they took was an antibiotic or not. The dates of fever onset in
used the classical technique with incubation in which the tubes were incubated in patients with serotype Typhi ranged from January 2001 to
a 37°C water bath for 2 h for H suspensions and at room temperature overnight March 2002, peaking in April through October (Fig. 1). None
for O suspensions; if agglutination was visible, the results were considered positive.
of the participants reported vaccination for typhoid fever; one
(v) Rapid tests. Serum was evaluated by using the following three commer-
cially available rapid diagnostic kits: Multi-Test Dip-S-Ticks (PANBIO INDX, patient and two controls reported having a history of typhoid
Inc., Baltimore, Md.), TUBEX (IDL Biotech, Sollentuna, Sweden), and Typhi- fever.
Dot (Malaysian Biodiagnostic Research SDN BHD, Singapore, Malaysia). A comparison of the three assays in presented in Table 2. A
Briefly, the Multi-Test Dip-S-Ticks tests for five pathogens, including Salmonella refrigerator is needed for storage of all of the kits but very little
serotype Typhi. The test is in a dipstick format that detects anti-O, anti-H,
anti-Vi, IgM, or IgG antibodies in patient serum, plasma, or heparinized whole
additional equipment is needed. The Multi-Test Dip-S-Ticks
blood. We evaluated the IgG kit only. The TyphiDot is a DOT enzyme immu- method requires a water bath, and the TyphiDot requires a
noassay that detects either IgM or IgG antibodies against a specific antigen on calibrated pipette. At approximately $10 per test, the Multi-
VOL. 42, 2004 EVALUATION OF RAPID DIAGNOSTIC TESTS FOR TYPHOID FEVER 1887

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FIG. 1. Time of fever onset in patients with Salmonella Typhi by hospital.

Test Dip-S-Ticks is the most expensive, followed by TUBEX at to be women (50% versus 55%, P ⫽ 1.0); these differences are
approximately $4 per test and the TyphiDot at approximately not statistically significant. Nine of the ten controls were pos-
$1 per test. itive on the Multi-Test Dip-S-Ticks, and four of these had
The sensitivity, specificity, and predictive values are shown in dengue fever. One control with a false-positive result reported
Table 3. Although the sensitivity of the Multi-Test Dip-S-Ticks having a history of typhoid fever.
was quite high (89%), it had low specificity (50%). The Typhi- Antibiotic susceptibility. A total of 58 of the 59 serotype
Dot and the TUBEX both had high sensitivities (79 and 78%, Typhi isolates were available for testing. Of the 58 isolates
respectively) and specificities (89 and 94%, respectively). The tested, 14 (24%) were pansensitive. All of the remaining 44
Widal test was the least sensitive of the assays, and the results isolates were resistant to nalidixic acid; 33 were also resistant
varied by place performed (64% sensitive and 76% specific in to chloramphenicol and tetracycline, and 29 of these were also
the hospitals and 61% sensitive and 100% specific at the Pas- resistant to ampicillin. Only two isolates were also resistant to
teur Institute). cefotaxime, one of which was also resistant to norfloxacin.
We examined the sensitivity of the assays by week after fever Among the 57 cases with serologic results, there was no statis-
onset (Fig. 2). These were not tests performed on specimens tically significant difference in the typhoid assay results by
from the same patient at weeks 1, 2, and 3 but rather the sensitivity as defined by pansensitivity or resistance to at least
merged results of single samples collected at a single time one antimicrobial agent.
point from each patient. The sensitivity of all tests was highest
for serum specimens obtained during the second week of ill- DISCUSSION
ness. The numbers were too small to do a meaningful evalua-
tion of the specificity of the assays by the week after fever onset We evaluated three commercial rapid diagnostic kits for
(data not shown). serotype Typhi with sera collected from patients with acute
There were no discernible differences between the 10 con- febrile illness of ⱖ 4 days’ duration at two hospitals in Viet-
trols with a false-positive result on one of the three commercial nam. Overall, the TyphiDot and TUBEX, both of which detect
assays and the 9 other controls, although the numbers were IgM antibodies, demonstrated the most promising results.
small. The controls with a false-positive result were slightly However, the performance of the TyphiDot assay may not
younger (mean age, 31 versus 37 years [P ⫽ 0.6]) and less likely have been optimized since we were unable to run our 15

TABLE 2. Characteristics of assays

Characteristic Multi-Test Dip-S-Ticks TyphiDot TUBEX Widal
a
Approximate cost (U.S. dollars)/specimen 10 2.14 4.00 0.50
No. of tests/kit 50 56 30 55
Antibody IgM and IgG IgM or IgG IgM IgM and IgG
Antigen O, H, and Vi OMPb O9 O, H, and Vi
Amt of serum needed (␮l) 10 2.5 35–40 ⫾ (one drop) 300 ⫾ (two dilutions)
Reaction time (min) 90 60 3 5c
Temp for storage (°C) 2–8 2–8 2–8 2–8
a
Personal communication (Prue Griffin, PANBIO INDX, Inc.; Kok-hai Ong, Malaysian Bio-Diagnostic Research Sdn. Bhd.; Helena Goike, IDL Biotech). TyphiDot
price includes running each sample twice; once for IgM and once for IgG (an additional $2.93 should be added for each TyphiDot-M run on IgM-negative, IgG-positive
specimens). All costs assume samples are batched to maximize kit use; use of the kits for single use increases the price per specimen. Costs do not include shipping.
b
OMP, outer membrane protein.
c
As determined by the rapid centrifugation technique (the classical technique is 2 h to overnight).
1888 OLSEN ET AL. J. CLIN. MICROBIOL.

TABLE 3. Senstivity, specificity, positive predictive value, negative predictive value, and 95% confidence intervals
of rapid diagnostic assays for typhoid fever
No. of samples/total no. of samples, % (95% confidence interval)
Assaya
Sensitivity Specificity Positive predictive value Negative predictive value

Multi-Test Dip-S-Ticks for Serotype Typhi 51/57, 89 (78–96) 9/18, 50 (27–73) 51/60, 85 (73–93) 9/15, 60 (33–83)
TyphiDot 46/58, 79 (66–88) 17/19, 89 (66–98) 46/48, 96 (85–99) 17/29, 59 (39–76)
TUBEX 43/55, 78 (65–88) 17/18, 94 (71–100) 43/44, 98 (87–100) 17/29, 59 (39–76)
Widal testing in the hospitalb 30/47, 64 (49–77) 13/17, 76 (50–92) 30/34, 88 (72–96) 13/30, 43 (26–62)
Widal testing at the Pasteur Institute 33/54, 61 (47–74) 19/19, 100 (79–100) 33/33, 100 (87–100) 19/40, 48 (32–64)
a
Widal, TO or TH agglutinin ⱖ100.
b
At any time during hospitalization.

indeterminate specimens (seven cases and eight controls) on H agglutinins usually appear around day 8 and days 10 to 12,

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the TyphiDot-M assay for confirmation. The Multi-Test Dip- respectively.
S-Ticks, which only detects IgG antibodies, had poor specific- The Multi-Test Dip-S-Ticks was the most costly assay, pre-
ity. The Multi-Test Dip-S-Ticks to detect IgM was not evaluat- sumably because the dipstick measures antibodies to five
ed. The Widal test had low sensitivity and was highly operator different pathogens. Although all three assays were relatively
dependent. Since the other three assays were performed at easy to use, the TUBEX was the simplest. A limitation of the
only one laboratory, we could not assess their operator vari- TUBEX test, which uses a colorimetric reaction, is the poten-
ability. tial for difficulty in interpreting the results of hemolyzed sam-
The hospitals participating in this evaluation were quite dif- ples. Another concern is that the TUBEX may produce a false
ferent and had the potential to enroll patients at different positive in persons with recent S. enterica serotype Enteritidis
stages of illness. Cai Lay is a small, rural hospital with minimal infection and result in inappropriate antibiotic treatment (13).
laboratory capability, whereas the Hospital for Tropical Dis- Ideally, the Widal test should be run on both acute- and
eases is a large, urban referral hospital with good laboratory convalescent-phase sera to detect an increase in the agglutina-
capability. Despite this, there were few differences in the pa- tion titer. However, to inform treatment decisions before con-
tients enrolled. Patients at the Hospital for Tropical Diseases valescent samples can be obtained, it is common for a single
were slightly older, more likely to be women, and were seen a acute-phase serum sample to be run. The results from a single
median of 2 days later in their illness. sample are difficult to interpret because high background rates
In our evaluation, the sensitivity of the TyphiDot was high of circulating antibodies to serotype Typhi or other Salmonella
beginning in the first week of illness onset. Presumably, this is serotypes may produce a false-positive result. In Vietnam, an
because the TyphiDot relies more heavily on IgM results that area of high endemicity, a single Widal test can lead to many
occur earlier in the course of the illness, whereas IgG rises false-positive and false-negative results (17). Operator variabil-
later; however, we did not see this effect with the TUBEX, ity also contributes to unreliable results, as evidenced in the
which also detects IgM antibodies. In the Widal test, the O and present study.

FIG. 2. Sensitivity by week after fever onset.

VOL. 42, 2004 EVALUATION OF RAPID DIAGNOSTIC TESTS FOR TYPHOID FEVER 1889

Each of these three commercial kits has been previously REFERENCES

evaluated but, to our knowledge, this is the first time they have 1. Barrett, T. J., J. D. Snyder, P. A. Blake, and J. C. Feeley. 1982. Enzyme-
all been included together in the same evaluation. In a recent linked immunosorbent assay for detection of Salmonella typhi Vi antigen in
urine from typhoid patients. J. Clin. Microbiol. 15:235–237.
evaluation of the Multi-Test Dip-S-Ticks in Singapore, the
2. Bhutta, Z. A., and N. Mansurali. 1999. Rapid serologic diagnosis of pediatric
sensitivity varied greatly depending upon the case definition typhoid fever in an endemic area: a prospective comparative evaluation of
(5). Among clinical and blood culture-positive cases it was two dot-enzyme immunoassays and the Widal test. Am. J. Trop. Med. Hyg.
51%, and among blood culture-positive patients only it was 61:654–657.
3. Fadeel, M. A., J. A. Crump, F. J. Mahoney, I. A. Nakhla, A. M. Mansour, B.
78%. The specificity among control patients who had a clinical Reyad, D. E. Melegi, Y. Sultan, E. D. Mintz, and W. F. Bibb. 2004. Rapid
diagnosis of typhoid but were culture negative, had other lab- diagnosis of typhoid fever by enzyme-linked immunosorbent assay detection
oratory diagnoses, or had pyrexia of unknown origin was 81%. of Salmonella serotype Typhi antigens in urine. Am. J. Trop. Med. Hyg.
70:323–328.
The TyphiDot was evaluated in Pakistan and Singapore by 4. Gilman, R. H., M. Terminel, M. M. Levine, P. Hernandez-Mendoza, and
using a variety of case definitions (2, 5). The sensitivity ranged R. B. Hornick. 1975. Relative efficacy of blood, urine, rectal swab, bone-
from 59 to 93% for the TyphiDot and 73 to 84% with the marrow, and rose-spot cultures for recovery of Salmonella typhi in typhoid
fever. Lancet i:1211–1213.
addition of the TyphiDot-M. Specificity was consistently higher
5. Gopalakrishnan, V., W. Y. Sekhar, E. H. Soo, and S. Devi. 2002. Typhoid

Downloaded from [Link] on March 6, 2019 by guest

when TyphiDot-M was used; 89% compared to 77% or lower fever in Kuala Lumpur and a comparative evaluation of two commercial
with only the Typhi-Dot. An evaluation of the TyphiDot in diagnostic kits for detection of antibodies to Salmonella typhi. Singapore
India was 100% sensitive and 80% specific compared to a Med. J. 43:354–358.
6. Hoa, N. T., T. S. Diep, J. Wain, C. M. Parry, T. T. Hien, M. D. Smith, A. L.
blood culture “gold standard” (8). In an early evaluation, the Walsh, and N. J. White. 1998. Community-acquired septicaemia in southern
TUBEX demonstrated 100% sensitivity and specificity (10). Viet Nam: the importance of multidrug-resistant Salmonella typhi. Trans. R.
However, this was before the kit was commercially available. In Soc. Trop. Med. Hyg. 92:503–508.
7. House, D., J. Wain, V. A. Ho, T. S. Diep, N. T. Chinh, P. V. Bay, H. Vinh, M.
Vietnam, it was 87% sensitive among blood culture positive
Duc, C. M. Parry, G. Dougan, N. J. White, T. T. Hien, and J. J. Farrar. 2001.
patients and 76% sensitive among hospitalized patients with Serology of typhoid fever in an area of endemicity and its relevance to
fever (7). diagnosis. J. Clin. Microbiol. 39:1002–1007.
One limitation in the previous and current evaluations is 8. Jesudason, M., E. Esther, and E. Mathai. 2002. Typhidot test to detect IgG
and IgM antibodies in typhoid fever. Indian J. Med. Res. 116:70–72.
that blood culture-confirmed cases were used as the gold stan- 9. Levine, M. M., and W. A. Orenstein. 1999. Typhoid fever vaccines, p. 781–
dard. Since blood culture is less sensitive than bone marrow 814. In S. A. Plotkin (ed.), Vaccines, 3rd ed. W. B. Saunders Co., Philadel-
culture for diagnosing typhoid fever (4), the results should be phia, Pa.
interpreted with caution. It is possible that the rapid diagnostic 10. Lim, P. L., F. C. Tam, Y. M. Cheong, and M. Jegathesan. 1998. One-step
2-minute test to detect typhoid-specific antibodies based on particle separa-
tests are more sensitive than blood culture. If so, a result that tion in tubes. J. Clin. Microbiol. 36:2271–2278.
appears to be a false-positive test compared to a blood culture 11. Lin, F. Y., A. H. Vo, V. B. Phan, T. T. Nguyen, D. Bryla, C. T. Tran, B. K. Ha,
may in fact be a true positive. This hypothesis requires further D. T. Dang, and J. B. Robbins. 2000. The epidemiology of typhoid fever in
the Dong Thap Province, Mekong Delta region of Vietnam. Am. J. Trop.
evaluation. Alternatively, a false-positive may be the result of Med. Hyg. 62:644–648.
past infection with serotype Typhi or another nontyphoidal 12. Nguyen, N. Q., P. Tapchaisri, M. Chongsa-nguan, V. V. Cao, T. T. Doan, Y.
Salmonella serotype that shares common antigens. Sakolvaree, P. Srimanote, and W. Chaicumpa. 1997. Diagnosis of enteric
fever caused by Salmonella spp. in Vietnam by a monoclonal antibody-based
Researchers continue to search for the ideal rapid test to dot blot ELISA. Asian Pac. J. Allergy Immunol. 15:205–212.
diagnose acute typhoid fever. Several urine assays have been 13. Oracz, G., W. Feleszko, D. Golicka, J. Maksymiuk, A. Klonowska, and H.
developed (1, 3, 12, 18), although none has proved optimal. In Szajewska. 2003. Rapid diagnosis of acute Salmonella gastrointestinal infec-
the field, there is a definite advantage to collecting urine in- tion. Clin. Infect. Dis. 36:112–115.
14. Pang, T., M. M. Levine, B. Ivanoff, J. Wain, and B. B. Finlay. 1998. Typhoid
stead of blood; urine collection is simple, less invasive than fever–important issues still remain. Trends in Microbiology 6:131–133.
venipuncture, and requires less training and equipment. In 15. Parry, C., J. Wain, N. T. Chinh, H. Vinh, and J. J. Farrar. 1998. Quinolone-
addition, some antigens may be excreted in higher concentra- resistant Salmonella typhi in Vietnam. Lancet 351:1289.
16. Parry, C. M., T. T. Hien, G. Dougan, N. J. White, and J. J. Farrar. 2002.
tion in the urine. With the recent sequencing of the entire
Typhoid fever. N. Engl. J. Med. 347:1770–1782.
serotype Typhi genome, it may now be possible to identify 17. Parry, C. M., N. T. Hoa, T. S. Diep, J. Wain, N. T. Chinh, H. Vinh, T. T.
other antigens, such as fimbrial antigens, that may produce an Hien, N. J. White, and J. J. Farrar. 1999. Value of a single-tube Widal
antibody response specific to serotype Typhi (19). More so- test in diagnosis of typhoid fever in Vietnam. J. Clin. Microbiol. 37:2882–
2886.
phisticated molecular techniques for diagnosis, such as PCR, 18. Rockhill, R. C., L. W. Rumans, M. Lesmana, and D. T. Dennis. 1980.
are also being explored. However, their use in developing Detection of Salmonella typhi D, Vi, and d antigens, by slide coaggluti-
countries will most likely be limited. nation, in urine from patients with typhoid fever. J. Clin. Microbiol.
11:213–216.
ACKNOWLEDGMENTS 19. Wain, J., D. House, J. Parkhill, C. Parry, and G. Dougan. 2002. Unlocking
the genome of the human typhoid bacillus. Lancet Infect. Dis. 2:163–170.
We thank Tran Thi My Trinh and Bui Thu Hien of the Pasteur 20. Widal, F. 1896. Serodiagnostique de la fievre typhoide. Semaine Med. 16:
Institute in Ho Chi Minh for their assistance with laboratory testing. 259.