ORIGINAL ARTICLE

JIACM 2004; 5(3): 244-6

A Comparative Study of Typhidot and Widal Test in Patients of Typhoid Fever

BL Sherwal**, RK Dhamija*, VS Randhawa**, M Jais**, A Kaintura***, M Kumar*** Abstract
Typhoid continues to be one of the leading causes of morbidity and mortality in our country. Conventional methods of diagnosis are gold standard blood culture and supportive widal test. We studied typhidot, a rapid serological test for diagnosis of typhoid fever and its usefulness for an early diagnosis, its sensitivity and specificity as compared to widal test. Methods : Typhidot test is an immunodot ELISA having an outer membrane protein specific for Salmonella typhi and separately identifies IgG and IgM antibodies. The study included 80 patients who presented with fever. Blood culture, widal test, and typhidot test were performed in all patients. Typhidot and widal tests were compared for sensitivity and specificity. Results : 56 patients out of 80 were clinically suspected to be cases of enteric fever (Gp-I), while 24 patients were non-typhoidal febrile illness (Gp-II). 38 patients (68%) of the Gp-I were positive for blood culture, 32 (57%) were widal positive, and 44(79%) were positive for typhidot test. Gp-II had all patients sterile on blood culture, 4 (17%) were widal positive, while 3 (12.5%) tested positive for typhidot. Amongst 38 culture positive cases in Gp-I, typhidot was positive in 35 patients, while widal was positive in 28 patients, giving sensitivity of 92% and specificity of 87.5% as compared to widal which had sensitivity of 74% and specificity of 83%. Conclusions : Typhidot test is an equally reliable, simple test that gives rapid diagnosis and can be helpful in early institution of therapy. Key Words : Typhidot, Widal test, Typhoid fever.

Introduction
Typhoid fever is a life threatening systemic infection occurring in lesser-developed areas of the world and continues to be a major public health problem. There are at least 16 million new cases of typhoid globally1. The annual incidence of typhoid fever has been reported as more than 13 million cases in Asia and causing more than six lakhs deaths worldwide annually2. India is the second most populous country of the world with majority inhabiting the rural areas with little access to modern diagnostic tools. Blood culture and widal test are routinely employed investigations for diagnosis of typhoid fever in all clinical settings. Widal test has been used in the diagnosis of typhoid illness for long time in this country but it remains a serological test with a moderate sensitivity and specificity. Therefore, a fast, reliable, and easy to perform serodiagnostic test with a higher sensitivity and specificity than widal test is required for rapid diagnosis and management of typhoid cases, thereby enabling clinicians to initiate an early therapy,

reducing morbidity and its complications. Typhidot is a rapid serological test for the diagnosis of typhoid fever. However, its usefulness in terms of specificity and sensitivity as compared to widal test has not been studied so far in our region. Few studies conducted in south India and other parts of Asia have reported encouraging results. In view of this, the present study was conducted to know its utility and effectiveness in terms of diagnostic yields as compared to widal test and to ascertain any difference of its specificity and sensitivity due to different strains of Salmonella typhi in this region.

Materials and Methods

Typhidot test is a dot ELISA kit that detects IgM and IgG antibodies against the outer membrane protein (OMP) of the Salmonella typhi. The typhidot test becomes positive within 2-3 days of infection and separately identifies IgM and IgG antibodies. The test is based on the presence of specific IgM and IgG antibodies to a specific 50KD OMP

*Professor of Medicine, **Professor of Microbiology, ***Resident in Medicine, Department of Medicine and Microbiology, Lady Hardinge Medical College andAssociated Hospitals, New Delhi.

antigen, which is impregnated on nitrocellulose strips. The reaction tray was divided into 2 columns marked as G and M. 250 ul of sample diluent was dispensed in each well and 2.5 ul of test /control was added and then incubated for 20 minutes. The strips were washed with washing buffer thrice, 250 ul of anti human IgG and IgM was dispensed then in each well and incubated for another 15 minutes. These were washed again, dispensed with 250 ul of colour development solution, and incubated for another 15 minutes and results were then interpreted. A positive IgM was interpreted clinically as acute typhoidal illness, while IgM and IgG positive were taken as acute typhoidal illness in middle stage of infection and IgG positive was interpreted as chronic carrier or previous infection or reinfection. The study included 80 patients of acute febrile illness who presented to our hospital. The patients were divided into 2 groups. Group I included 56 patients with clinical diagnosis of typhoid fever and group II comprised of 24 patients of suspected typhoid fever with alternative diagnosis. Routine investigations, complete blood counts, urine analysis and culture, X-ray chest, liver function tests, blood culture, widal test, and tyhidot test were done in all patients. Results of blood culture, widal, and typhidot test were compared in all patients for their sensitivity and specificity.

On comparative evaluation of widal test, typhidot, and blood culture, widal test had sensitivity of 57% and specificity of 83%, where as blood culture showed a sensitivity of 68% and specificity of 100% and typhidot test showed a sensitivity of 79 % and specificity of 87.5%. Amongst all the 38 patients in Group I, who were having positive blood culture, typhi dot test was positive in 35 patients, giving a sensitivity of 92%, a specificity of 87.5%, and a positive predictive value of 92% as compared to widal test which was positive in 28 patients with a sensitivity, specificity, positive predictive value of 74%, 83%, and 87.5% respectively.

Discussion
Typhoid fever is a systemic illness with a significant morbidity and mortality in developing countries. Poor sanitation, overcrowding, low standard of living, lack of medical facilities, and indiscriminate use of antibiotics lead to endemicity of typhoid fever and multi-resistant strains of Salmonella typhi in developing countries3,4. Blood culture has remained the gold standard test in diagnosis of typhoid fever, but its utility in early diagnosis is limited in early phase of illness thereby making the isolation of the organism difficult. Widal test has been used for over a century in developing countries for diagnosing typhoid fever but it has a low sensitivity, specificity and positive predictive value, which changes with the geographical areas. Sharing of O and H antigens by other Salmonella serotypes and other members of Enterobacteriaceae makes the role of widal test even more controversial in diagnosing typhoid fever5. However, modified widal test particularly when used alongwith conventional widal test has a greater sensitivity6. Typhidot is a new, inexpensive, and reliable serodiagnostic test recently available commercially and studied in many endemic areas with reports of higher sensitivity and specificity. We studied typhidot test for its usefulness in patients of typhoid fever presenting to our hospital and observed that it has a sensitivity of 92% and specificity of 87.5%, which was higher than that of widal test and comparable to the studies done elsewhere in India and outside.

Observations
Blood culture was positive in 38 out of 56 patients (group I), whereas all the 24 patients in group II were sterile on blood culture. 32 patients of group I were positive for widal test, whereas 44 out of 56 were positive for typhidot test (table I). A total of 4 patients (17 %) in group II were widal positive, while only 3 (12 .5 %) tested positive for typhidot (table I). Table I : Comparison of Blood culture, Widal Test, and Typhidot Test.
Test Number Positive in Clinical and Culture ProvenTyphoidCases n = 56 (sensitivity) Gp 1 38 (68%) 32 (57%) 44 (79%) Non-Typhoid Cases n = 24 (sensitivity) GpII 0 4 (17%) 3 (12.5%)

Blood culture Widal test Typhidot

Journal, Indian Academy of Clinical Medicine

Vol. 5, No. 3

July-September, 2004

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A similar study carried out in the southern part of India reported typhidot of having a sensitivity of 100% and a specificity of 80% and was recommended for its utility in conjunction with widal test for an early diagnosis of typhoid fever7. In another study group of typhoid patients in Pakistan, typhidot test had a comparable sensitivity of 94% and specificity of 77%, while widal test had a sensitivity and specificity of 63% and 83% only8. The effectiveness of typhidot test in early diagnosis of typhoid fever patients was also studied in two different studies in Malaysia. Its sensitivity and specificity was reported as 90.3% and 91.9% respectively in the first study, and was significantly higher, while the second study, also showed a sensitivity and specificity of 98% and 76.6% respectively9, 10 . Both the Malaysian studies showed it to be a better test in contrast to widal test for rapid diagnosis as well as for its simplicity of ease in use. Results of all the studies done to evaluate typhidot test in developing countries have consistently shown similar and comparable results (table III). Table II : Comparison of Widal test and Typhidot tests In Culture Proven Cases and Non-Typhoid Cases.
Test Number Positive in Culture Proven TyphoidCases n = 38 (sensitivity) 28 (74%) 33 (92%) Non-Typhoid Cases n = 24 (sensitivity) 4 (17%) 3 (12.5%)

test and can be useful in early institution of therapy. However, a larger prospective study would be required to fully evaluate the usefulness of this test in countries endemic to typhoid fever.

References
1. Ivanoff B. Typhoid fever, global situation and WHO recommendations. Southeast Asian J Trop Med Public Health.1995; 26: supp 2; 1-6. Ivanoff B, Levine MM, Lambert PH. Vaccination against typhoid fever, present status. Bull WHO, 1994; 72 (6). 957-71. Brown JC, Shanahan PM, Jesudason MV et al. Mutations responsible for reduced susceptibility to 4-quinilones in clinical isolates of multi-resistant Salmonella typhi in India. J Antimicrobol Chemother 1996; 37: 891-900. Therlfall, Ward LR, Skinner JA, Smith HR, Lacy S. Ciprofloxacin resistant Salmonella typhi and treatment failure. Lancet 1999; 353: 1590-1. Parry CM, Hien TT, Dougan G et al. Typhoid fever. N Eng J Med 2002; 347: 1770-82. Pai AP, Koppikar GV, Deshpande S. Role of modified widal test in the diagnosis of enteric fever. JAPI 2003; 51: 9-11. Jesudasson M, Esther E, Mathai E. Typhidot test to detect IgG and IgM antibodies in typhoid fever 2002. Indian J Med Res 2002; 116: 70-2. Butta ZA, Mansurali N. Rapid serological diagnosis of pediatric typhoid fever in an endemic area: a prospective comparative evaluation of two dot enzyme immunoassays and the widal test. Am J Trop Med Hyg 1999; 61: 645-7. Choo KE, Davis T M, Ismail A et al. Rapid and reliable serological diagnosis of enteric fever, comparative sensitivity and specificity of typhi dot and typhi dot M in febrile Malaysian children. Acta Trop 1999; 72: 175-83.

2. 3.

4.

5. 6. 7.

8.

Widal Test Typhidot Test

9.

Table III : Comparative Evaluation of Typhidot test in Different Studies

Author Name/Year K. E Choo 1991 K. E Choo 1994 Butta et al 1999 Jesudasson et al 2002 Gopalakrishan et al 2002 Present Study Total Patients 109 149 97 150 144 80 Sensitivity (%) 95 90 94 100 98 92 Specificity (%) 75 91 89 80 76.6 87.5

10. Gopalakrishan V, Sekhar WY , Soo EH et al. Typhoid fever in Kuala Lumpur and a comparative evaluation of two commercially available diagnostic kits for detection of antibodies to S. typhi 2002. Singapore Med J. 2002; 43 (10): 495.

Conclusion
Typhidot test is a highly sensitive and specific test in diagnosing typhoid fever. It is a rapid, easy to perform, more reliable test for typhoid fever as compared to widal

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Journal, Indian Academy of Clinical Medicine

Vol. 5, No. 3

July-September, 2004