title: Typhoid Fever in South Africa in an Endemic HIV Setting.
abstract: BACKGROUND
  Typhoid fever remains an important disease in Africa, associated with outbreaks and the emerging multidrug resistant Salmonella enterica serotype Typhi (Salmonella Typhi) haplotype, H58. This study describes the incidence of, and factors associated with mortality due to, typhoid fever in South Africa, where HIV prevalence is high.
  
  
  RESULTS
  Nationwide active laboratory-based surveillance for culture-confirmed typhoid fever was undertaken from 2003-2013. At selected institutions, additional clinical data from patients were collected including age, sex, HIV status, disease severity and outcome. HIV prevalence among typhoid fever patients was compared to national HIV seroprevalence estimates. The national reference laboratory tested Salmonella Typhi isolates for antimicrobial susceptibility and haplotype. Unadjusted and adjusted logistic regression analyses were conducted determining factors associated with typhoid fever mortality. We identified 855 typhoid fever cases: annual incidence ranged from 0.11 to 0.39 per 100,000 population. Additional clinical data were available for 369 (46.8%) cases presenting to the selected sites. Among typhoid fever patients with known HIV status, 19.3% (29/150) were HIV-infected. In adult females, HIV prevalence in typhoid fever patients was 43.2% (19/44) versus 15.7% national HIV seroprevalence (P < .001); in adult males, 16.3% (7/43) versus 12.3% national HIV seroprevalence (P = .2). H58 represented 11.9% (22/185) of Salmonella Typhi isolates tested. Increased mortality was associated with HIV infection (AOR 10.7; 95% CI 2.3-50.3) and disease severity (AOR 9.8; 95% CI 1.6-60.0) on multivariate analysis.
  
  
  CONCLUSIONS
  Typhoid fever incidence in South Africa was largely unchanged from 2003-2013. Typhoid fever mortality was associated disease severity. HIV infection may be a contributing factor. Interventions mandate improved health care access, including to HIV management programmes as well as patient education. Further studies are necessary to clarify relationships between HIV infection and typhoid fever in adults.
authors: Centre for Enteric Diseases, National Institute for Communicable Diseases, Johannesburg, South Africa.|Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors: Karen H
authors: KH
authors: Keddy
authors: Centre for Enteric Diseases, National Institute for Communicable Diseases, Johannesburg, South Africa.
authors: Arvinda
authors: A
authors: Sooka
authors: Centre for Enteric Diseases, National Institute for Communicable Diseases, Johannesburg, South Africa.|Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors: Anthony M
authors: AM
authors: Smith
authors: International Emerging Infections Programme, South Africa Global Disease Detection Centre, Centers for Disease Control and Prevention, Pretoria, South Africa.
authors: Alfred
authors: A
authors: Musekiwa
authors: Centre for Enteric Diseases, National Institute for Communicable Diseases, Johannesburg, South Africa.
authors: Nomsa P
authors: NP
authors: Tau
authors: Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.|Bill and Melinda Gates Foundation, Seattle, WA, United States of America.
authors: Keith P
authors: KP
authors: Klugman
authors: Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States of America.
authors: Frederick J
authors: FJ
authors: Angulo
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D019353:Endemic Diseases; D005260:Female; D015658:HIV Infections / Q000453:epidemiology*; D006801:Humans; D015994:Incidence; D007223:Infant; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D013019:South Africa / Q000453:epidemiology; D014435:Typhoid Fever / Q000453:epidemiology* / Q000401:mortality; D055815:Young Adult