•How lab firms, pharmacies, hospitals make millions scamming unsuspecting patients •It’s mostly malaria; typhoid is rare in Nigeria–Medical experts
From Obinna Odogwu, Awka
Controversy is trailing the continued use of Widal test to ascertain whether a patient has typhoid fever or not in some Nigerian hospitals and other health facilities.
Typhoid fever, according to the World Health Organisation (WHO), is a life-threatening infection caused by the bacterium Salmonella Typhi.
It is usually spread through contaminated food or water; and once the bacteria are ingested, they multiply and spread into the bloodstream.
A report by the National Health Service of the United Kingdom adds that the bacterial infection can spread throughout the body, affecting many organs and that it can cause serious complications or even death if not treated promptly.
The risk of the multi-systemic illness which is also caused, to a lesser extent, by Salmonella enterica serotypes paratyphi A, B and C, is higher in populations that lack access to safe water and adequate sanitation.
Humans are the only reservoir for salmonella, and typhoid fever is highly contagious, reports say.
As of 2019, an estimated nine million people get sick from typhoid and 110,000 die from it every year, according to a report published by WHO on 30 March this year.
“Symptoms include prolonged fever, fatigue, headache, nausea, abdominal pain, and constipation or diarrhoea. Some patients may have a rash. Severe cases may lead to serious complications or even death,” WHO adds.
Although there had been an argument against the continued use of Widal tests to diagnose typhoid fever, in addition to some researches that support that position, Widal test is still very much in use in Nigeria majorly by private labs.
A research conducted by Osahon Enabulele and Simeon Nyemike Awunor which was published in the Nigerian Medical Journal 2016 concludes that “a single Widal agglutination test is not a valid diagnostic option for typhoid fever.”
A total of 271 blood samples from consecutive adults above 18 years with febrile illness attending the General Practice Clinic of the University of Benin Teaching Hospital were tested using the Widal agglutination test, blood culture, and malaria parasite test on each sample to establish the diagnosis of typhoid fever.
“Of the 271 blood samples, 124 (45.76 per cent) were positive following a Widal agglutination test, 60 (22.10 per cent) blood samples grew Salmonella organisms on blood culture while 55 (20.29 per cent) blood samples showed a co-infection of typhoid fever and malaria.
“A sensitivity of 35 per cent, specificity of 51 per cent, positive predictive value of 17 per cent, and a negative predictive value of 73 per cent were observed for Widal agglutination test as a diagnostic modality for typhoid fever infection”, the report partly reads.
In 2022, a set of Standard Treatment Guidelines was released for use in Nigeria. It was published by the Federal Ministry of Health, Abuja in collaboration with the World Health Organisation and Clinton Health Access Initiative.
Unfortunately, this all important health document doesn’t seem to be in the hands of those who are supposed to be making use of it in the country’s health facilities. It’s not also on the organisations’ websites.
Some doctors, pharmacists and other health practitioners who spoke to Saturday Sun said that they didn’t have the document but added that they knew about the ‘gold standard’ for the diagnosis and treatment of typhoid fever.
A Senior Registrar in the Department of Community Medicine, Faculty of Public Health, University College Hospital, Ibadan, Dr Kene Igwegbe, told Saturday Sun: “The right way to diagnose typhoid fever is by doing a microscopy culture and sensitivity, either using the blood, stool or urine.
“The result can be available within or after 48 hours. Widal test is not a specific test for diagnosing enteric fever.
“It was, formerly but research has proven that Widal test is not sensitive and specific. It can also be positive in other illnesses and medical conditions,” Igwegbe explained.
A report in the Journal of Clinical Microbiology published by the American Society for Microbiology (ASM) on 30 November, 2022 adds that blood and bone marrow cultures are considered the gold standard for the diagnosis of typhoid.
So why do many clinics and private laboratories still use Widal tests to diagnose typhoid fever?
Why do some doctors still accept and rely on results from such tests to treat their patients? Why do some pharmacists still use such results to dispense drugs?
Mr Afam Udeozo, a pharmacist at Chukwuemeka Odumegwu Ojukwu University Teaching Hospital (COOUTH), Awka said that it was part of the corruption in Nigeria’s health sector.
Udeozo alleged that some laboratory scientists connive with some doctors and pharmacists to conduct tests for unsuspecting patients who, most times, do not have typhoid fever.
“A lot of things are unregulated in Nigeria but we have the laws. So you see all sorts of criminal activities going on. Sometimes you will see a community pharmacist working in conjunction with a private lab. I am a pharmacist but this is the truth.
“Like when I was a young community pharmacist in Nigeria, you’ll just be sitting down in your office and some private lab staff will come with their forms and tell you, if you get a certain number of patients to come and do so, so and so tests, just tick it and write your name under and if those patients come to our lab for the tests, we will give you a certain percentage of the money. I always rejected it.
“Sometimes, somebody will come in with something you can diagnose. Most of the time how clinicians diagnose illness is through a physical examination and the clinical history.
“If it is fever, when did the fever start? Has it happened to you before? Does anything make it worse? And so on. Not by lab tests. What they do is that they send you wrongly to go and do this test.
“Then, in some labs too, they also prescribe (drugs). So, even if they are not working in conjunction with the patent medicine store or community pharmacy, they are also prescribing,” he stated.
Udeozo, who’s the unit head, Drug Information and Pharmacovigilance at COOUTH and a member of WHO medication safety network, alleged that some doctors demand for the diagnosis of typhoid fever which they knew their patients didn’t have because they wanted money.
“I did what we call a medication review for a woman recently. She had so many drugs. I said ‘where did you get this one from?’ She said she got it from a physician from a teaching hospital.
“That is, she went there and they prescribed and dispensed it. I said ‘where did you get that one from?’ She said she went to the lab; they did some tests, prescribed drugs for her. So, they just do it to make money. Simple!
“A lot of us are not confident to charge people the professional fees. A lot of private physicians are not comfortable charging somebody a professional fee.
“A physician is supposed to charge you even if it is N5,000 or N10,000. He is supposed to charge you. But in Nigeria, sometimes they will call such a person a thief. So, they want you to buy drugs.
“To have a reason for you to buy drugs, they will just cook up a test. There is nowhere to the best of my knowledge the Widal’s test is used singly to diagnose typhoid fever. It is a complete fraud. It’s a farce”, Udeozo declared.
The pharmacist, who lamented that many laboratories across the country were still using Widal test to diagnose typhoid fever, said that the option was still popular because it’s easy to use.
“I give you another example. If you really want to use the Widal test, you then take the person’s blood and do the test today. About two weeks later, 10 to 14 days later, you will do it again.
“And then you check whether the titre values are times four. This is the protocol of the Widal’s test. They have the C, the H and the O antigens. So, you will check. Sometimes you will see all those numbers: 1:80, 1:320; that kind of thing.
“So, you do it today and it has 1:80, 1:320. It is reactive. You keep it. A physician won’t treat it. No! He would tell you to come back in two weeks.
“Then, when you come back in two weeks time and do the Widal’s test, if there is a high chance that you have typhoid fever, it will then be reading 1:320, 1:1280, then you might have a typhoid fever.
“Let me tell you a true life story about my maternal uncle. He went into a private hospital for what they call check up.
“One of the things that the physician suggested that he should do was to check whether he had typhoid fever even though he had no symptoms of typhoid fever.
“He didn’t have a fever, he didn’t have any pain. In fact, there was nothing wrong with him. He just felt that he would need a check up. He was getting old and wanted to check himself.
“So, he did a Widal test and the titre values were off the chart – one is to 1000 and something. So, the physician shouted, saying that his condition was very serious and then prescribed the drug we call chloramphenicol which is an ancient drug that is almost never used now.
“It has horrible side effects including bone marrow suppression. He could give something else if the person, indeed, has typhoid fever.
“I told my uncle not to drink it; that he didn’t have typhoid fever; that the drug has bad side effects but he insisted.
“And after taking it for two or three days, he was taking four capsules four times a day, I remember. They gave him 250ml because they didn’t have 500ml and he was taking four each day.
“Eventually, he started having all sorts of reactions. So, he carried the drugs and flushed them down the toilet. And nothing still happened to him because it was when he started taking the drug that he started becoming sick.
“When he wasn’t taking the drugs he was okay. So, he stopped taking the drugs and recovered.
“Some months later, he was in town and he came for another medical check up and they did the Widal’s test again and got an identical result which is 1:1000 plus.
“It was only then that the physician decided to ask him questions. And what was the pertinent question? ‘Have you ever received a vaccination for typhoid fever?’ My uncle answered yes. He used to travel a lot.
“There was a time he went to South America and it was compulsory that you receive it before you could enter.
“So, my uncle was one of the persons in the world to get typhoid fever even if you inject the bacteria into him, it will protect him; almost certainly. And they were treating him. That’s how useless the test is”, Udeozo stated.
Speaking further, the pharmacist said that there were only a few cases of typhoid fever in Nigeria.
“I have only seen one study done. They checked everyone that had a fever. Only one that I know of and that their fever was caused by salmonella typhi, if I remember correctly, it was 2%. “And I have practiced for over 30 years. I have met only one case. I know a nurse that is older than me that has practised for longer. He also has seen only one case of typhoid fever in Nigeria.
“So, it is not something that you will run into. It is hard to see it. It is rare. What people have most of the time is malaria. So, the test is really a very poor test,” Udeozo concluded.
But the allegation that some doctors connive with lab scientists to conduct Widal test on patients who didn’t have typhoid just to collect money from them did not go down well with Dr Austin Ikwudimma who works at Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AE-FUTHA) in Ebonyi State.
Ikwudimma, former Chairman of the Nigeria Medical Association (NMA) in that state, said that it was actually some pharmacists that engage in such sharp practices as alleged.
“It is not true. Majority of the people doing that are the pharmacists and lab scientists because these things have quick reagents. There are strips for it. So, most of these pharmacists have these strips behind their counter.
“When you come, they will conduct tests and give you drugs. Everybody is now a doctor. A very few private hospitals will do that.
“What they will do is that they will tell you that they have done some tests for you and charge you. They won’t go and start puncturing you but a pharmacist will bring that strip, puncture you and collect money. Everybody is now a doctor.
“When you hear about doctors now, it is no longer specific to a medical doctor. That allegation is meant for them (the pharmacists) and patent medicine dealers. I don’t want to call a pharmacist a patent medicine vendor.
“A patent medicine vendor is what you call a ‘chemist’. Where they breed quacks are some of these private hospitals that train auxiliary nurses. When they finish, they will go and open ‘chemist’ shops. Some also go to learn as apprentices”, Ikwudimma stated.
The former NMA boss, however, made it clear that Widal test was no longer in use in most of the teaching hospitals in Nigeria.
“The test is now being abandoned because if you do once and the titre is high, it does not necessarily mean that it is enteric fever infection.
“Typhoid present with a non-remittent, persistent high fever; high fever that is hitting above 38, 40 persistently; then you will now start to suspect it.
“If you see the person, the person will be ill-looking with that temperature. It is at that point that you will say, we might be dealing with typhoid fever.
“But most of the time our people are dealing with resistant malaria and they are now calling it typhoid fever. We have so many substandard drugs in this country.
“So, we are dealing with resistant malaria instead of typhoid. People mistake resistant malaria for typhoid fever. And when they take drugs for enteric fever and they feel better, they say it is typhoid. It is not typhoid fever,” Ikwudimma explained.
Some private lab operators in Awka, Anambra State capital who didn’t want their identities disclosed told Saturday Sun that they still make use of Widal test to check for typhoid fever but added that they combine it with blood and stool tests.
Former President-General of Umuzu community in Ogbaru Local Government Area of the state, Mr Chukwudum Ndedigwe, told Saturday Sun that he once had a test for typhoid fever in a private hospital which turned out positive.
He explained further: “One day, I went to my doctor in a private hospital for medical attention. I wasn’t feeling very well. So, after discussing with him, he said that I needed to run some tests for malaria and typhoid fever.
“That test was carried out in his hospital. There was a lab there. When the results came out, it showed that I had typhoid and malaria. And I was treated in his hospital too. I bought the drugs there as well,” he narrated.
Ndedigwe said that there was a need for proper funding of Nigeria’s health sector by the government, as well as proper monitoring of how health policies were implemented across the country.
“The issue of regulation matters a lot because if there is proper regulation and monitoring, everybody will be playing according to the rules for the good of the society. There is a need for consistent monitoring by the government,” the former PG said.