Prevalence, probability, and outcomes of typhoidal/non-typhoidal Salmonella and malaria co-infection among febrile patients: a systematic review and meta-analysis
Authors: Wilairatana Polrat , Mala Wanida , Klangbud Wiyada Kwanhian , Kotepui Kwuntida Uthaisar , Rattaprasert Pongruj , Kotepui Manas 
Published: November 2021

The geographical overlaps of malaria parasites andSalmonellaspp. can lead to co-infection of these two pathogens, especially in the tropics where malaria is endemic. Moreover, few literatures suggested that malaria infection was associated withSalmonellabacteremia. Therefore, this study quantified pooled prevalence of typhoidal/non-typhoidalSalmonella(NTS) and probability of typhoidal/NTS and malaria co-infection among febrile patients. The systematic review protocol was registered at PROSPERO (CRD42021252322). Studies on co-infection of typhoidal/NTS and malaria were searched in PubMed, Scopus, and Web of Science. The risk of bias of the included studies was assessed using the checklist for analytical cross-sectional studies developed by the Joanna Briggs Institute. Meta-analyses on the following criteria were performed: (1) pooled prevalence of typhoidal/NTS and malaria co-infection among febrile patients, (2) pooled prevalence of typhoidal/NTS among malaria patients, (3) pooled prevalence of malaria infections among patients withSalmonellaspp. infection, and (4) probability of typhoidal/NTS and malaria co-infection among febrile patients. Additionally, the case fatality rate and mean difference of malarial parasitemia between typhoidal/NTS and malaria co-infection andPlasmodiummonoinfection were also determined. The subgroup analyses of typhoidal/NTS, regions (Africa and Asia), countries, time (publication year), characteristics of participants, and diagnostic tests for identifyingSalmonellaspp. were also conducted. A sensitivity test was performed to determine the robustness of the study outcomes. Publication bias among the included studies was evaluated using the funnel plot and Egger’s test. All analyses were performed using Stata version 15 (StataCorp LLC, Texas, USA) with a p-value < 0.05 indicating statistical significance. Eighty-one studies that met the eligibility criteria were included in the analyses. Of the 73,775 study participants, 4523 had typhoidal/NTS and malaria co-infections. The pooled prevalence rates of typhoidal/NTS and malaria co-infection among febrile patients were 14% (95% confidence interval [CI], 9–19%; I2, 99.4%; 2971/17,720 cases) and 1% (95% CI 1–1%; I2, 89.9%; 252/29,081 cases) using the Widal test and culture methods for identifyingSalmonellaspp., respectively. The pooled prevalence rates of typhoidal/NTS infection among patients with malaria were 31% (95% CI 23–39%; I2, 99.5%; 3202/19,208 cases) and 3% (95% CI 2–3%; I2, 86.8%; 407/40,426 cases) using the Widal test and culture methods for identifyingSalmonellaspp., respectively. The pooled prevalence rates of malaria infection among patients with typhoidal/NTS were 17% (95% CI 6–29%; I2, 33.3%; 13/75 cases) and 43% (95% CI 32–53%; I2, 89.1%; 287/736 cases), respectively. Malaria infection was associated with typhoidal/NTS in children aged < 15 years (p < 0.0001; odds ratio, 0.36; 95% CI 0.23–0.58; I2, 73.9%; 3188/43,212 cases). The case fatality rate in patients with malaria and NTS co-infections was 16% (95% CI 9–24%; I2, 89.1%; 18/103 cases). From the view of the present study, the inappropriate use of the Widal test forSalmonellaspp. diagnosis can overestimate the prevalence of typhoidal/NTS and malaria co-infections.Malaria infection associated with typhoidal/NTS in children and the high case fatality rates among few patients with co-infections were highlighted. Future prospective longitudinal studies using the appropriate and confirmatory dsiagnosis forSalmonellaspp. infections are highly recommended to ensure the real prevalence of co-infection and highlight the outcome of co-infection for providing adequate treatment in febrile patients who live in areas where malaria is endemic, such as tropical Africa and India.