Niger retrospective cohort of presumed typhoid perforations finds 11.2% mortality

A multicentre retrospective cohort study of patients undergoing surgery for acute peritonitis in Niger found 2,931 presumed typhoid ileal perforations among 4,271 operated cases treated at two referral hospitals from January 2014 through December 2019. The perforations accounted for 68.6% of the surgical caseload, while 328 of the 2,931 patients died during hospitalization, producing an overall in-hospital case-fatality rate of 11.2%. The findings describe a large burden of presumed typhoid-related intestinal perforation among surgically treated patients; they do not estimate the prevalence of typhoid fever in Niger’s general population.

The cohort was composed predominantly of children and adolescents and people from socioeconomically disadvantaged circumstances. Mean patient age was 14.4 ± 11.2 years, and 72.1% of cases involved people aged 1–15. The male-to-female ratio was 1.8.

Rural residents accounted for 67.4% of the cohort, and 71.3% of patients were classified as indigent. The mean interval between symptom onset and hospital admission was 114.8 ± 62.2 hours. These figures characterize the patients who reached surgical care at the two hospitals; the retrospective design did not determine population-wide incidence or outcomes among people who did not receive surgery.

Cases were identified using epidemiological, clinical and intraoperative criteria for presumed typhoid ileal perforation rather than through a design that represented all cases of typhoid fever. The investigators noted that restricted access to bacteriological investigations in Niger contributes to under-recognition of the disease burden. Diverting ileostomy was the most frequently performed operation, recorded in 61.3% of cases.

Because the study was observational and described treatment among patients already presenting with acute peritonitis, its surgical findings do not establish that any particular operation improved survival. Multivariable logistic regression identified two patient characteristics independently associated with in-hospital mortality. Rural origin was associated with 1.47 times the adjusted odds of death compared with non-rural origin (95% confidence interval 1.13–1.86; p = 0.021), while indigent status was associated with 1.66 times the adjusted odds of death (95% confidence interval 1.21–2.07; p = 0.002).

These were statistical associations within the retrospective surgical cohort and do not demonstrate that rural residence or economic disadvantage directly caused the deaths. The authors described presumed typhoid ileal perforation as a substantial surgical burden in Niger, especially among children and socioeconomically disadvantaged populations. They identified strengthened early diagnosis, expanded vaccination coverage—including the recent introduction of the typhoid conjugate vaccine into Niger’s Expanded Programme on Immunisation—and better access to emergency surgical care as public-health priorities.

The study was published in BMC Infectious Diseases on 3 September 2026 in an early-access version subject to subsequent editorial changes. Its principal contribution is to quantify the frequency of severe surgical presentations and the associated in-hospital mortality at two referral centres over a six-year period, while highlighting the mortality associations observed in rural and indigent patients.

Subject of Research: Epidemiology and in-hospital mortality of presumed typhoid ileal perforation in two Nigerian referral hospitals

Article Title: When surgery unmasks the typhoid fever epidemic in Niger: a multicentre retrospective cohort study of 2,931 ileal perforations (2014–2019)

Article References: Bara, A.-A. A., Magagi, M. I. A., Mahaman, M. L., Maman, B. A., Fils, S. A., Bagnou, H., Adakal, O., Adamou, H., & Doutchi, M. (2026). When surgery unmasks the typhoid fever epidemic in Niger: a multicentre retrospective cohort study of 2,931 ileal perforations (2014–2019). BMC Infectious Diseases. https://doi.org/10.1186/s12879-026-14369-1

Image Credits: AI Generated

DOI: 10.1186/s12879-026-14369-1

Keywords: typhoid fever, ileal perforation, Niger, retrospective cohort, in-hospital mortality, rural origin, economic disadvantage, emergency surgery, child health, typhoid vaccination, surgery, unmasks