Ileal Perforation and Enteric Fever: Implications for Burden of Disease Estimation

Defunctioning ileostomy for typhoid ileal perforations: Out of the frying pan into the fire?

Typhoid ileal perforation (TIP) is a common surgical emergency in low-middle income countries (LMICs). Its high surgical morbidity and mortality is due to its often late presentation or diagnosis, the patient's malnutrition, severe peritoneal contamination and unavailability of intensive care in most peripheral hospitals. This prompted the philosophy of minimizing the crisis by avoiding any repair or anastomosis, limiting the surgery in these physiologically compromised patients and performing only a temporary defunctioning ileostomy (DI) which could then be closed 10-12 weeks later.

Cost of Illness Due to Severe Enteric Fever in India

Background

Lack of robust data on economic burden due to enteric fever in India has made decision making on typhoid vaccination a challenge. Surveillance for Enteric Fever network was established to address gaps in typhoid disease and economic burden.

Methods

Patients hospitalized with blood culture-confirmed enteric fever and nontraumatic ileal perforation were identified at 14 hospitals. These sites represent urban referral hospitals (tier 3) and smaller hospitals in urban slums, remote rural, and tribal settings (tier 2). Cost of illness and productivity loss data from onset to 28 days after discharge from hospital were collected using a structured questionnaire. The direct and indirect costs of an illness episode were analyzed by type of setting.

Results

In total, 274 patients from tier 2 surveillance, 891 patients from tier 3 surveillance, and 110 ileal perforation patients provided the cost of illness data. The mean direct cost of severe enteric fever was US$119.1 (95% confidence interval [CI], US$85.8–152.4) in tier 2 and US$405.7 (95% CI, 366.9–444.4) in tier 3; 16.9% of patients in tier 3 experienced catastrophic expenditure.

Conclusions

The cost of treating enteric fever is considerable and likely to increase with emerging antimicrobial resistance. Equitable preventive strategies are urgently needed.