Evaluation of the Diagnosis of Typhoid Fever Using the Widal Test and the Anti Salmonella typhi IgM Test

Typhoid fever is a systemic infectious disease caused by Salmonella enteric serotype typhi. Laboratory tests are essential because the clinical symptoms of typhoid fever are not specific. The definitive diagnosis of typhoid fever make by culture isolation of Salmonella typhi, but this test is expensive and takes a long time. Other supporting tests that can do quickly are the Widal and Salmonella typhi IgM tests. This study aimed to determine the suitability between the results of the Widal test and the results of the anti-Salmonella typhi IgM test. This type of research is an observational analytic study determining the sample based on the accidental sampling technique. The number of samples taken was 42 samples. The results showed that the Widal Test in typhoid patients was 76% positive and 24% negative. Based on the antiSalmonella typhi IgM test results in typhoid patients, 38% were positive, and 62% were negative. The study concluded a fragile agreement between the Widal test results and the results of the anti-Salmonella typhi IgM test. It recommended that the Widal test carried out for the initial examination and a quick community survey. The Tubex test highly recommends for diagnosis.


INTRODUCTION
Infectious diseases are one of the leading causes of health problems in developing countries, including Indonesia. Infectious diseases caused by tuberculosis (Rifa'i, A, 2019) and Salmonella a significant obstacle in Indonesia, in addition to the problem of environmental contamination bacteria such as Staphylococcus aureus (Mustika Sari, P, 2019) and Bacillus (Fahani, A., 2019).
An infectious disease caused by Samonella typhi is called typhoid fever, which occurs due to ingesting food or drinks contaminated with salmonella germs. Suspected typhoid fever cases in Indonesia show an increasing trend from year to year, with an average morbidity rate of 500/100,000 and a mortality rate between 0.6-5% (Depkes RI, 2006). Typhoid fever is still an obstacle in Indonesia, even though this country is rich in medicinal plants that are antibacterial against Salmonella typhi, such as rosella (Sutiany, A., 2019).
The Widal test can do salmonella detection by determining the agglutinin titer found in the patient's serum against the O and H antigens of Salmonella typhi or Salmonella paratyphi antigens. The Widal test can be either false-negative or falsepositive (Depkes RI., 2006).
Salmonella test using DNA-probe and PCR techniques has a high diagnostic value, which has not been widely used for daily practical purposes because it is quite expensive and requires sophisticated equipment. Another sensitive test has developed for early detection of acute Salmonella typhi infection, namely the anti-Salmonella typhi IgM test. Anti Salmonella typhi IgM test performed to detect antibodies to lipopolysaccharide 09 antigen, which is highly specific for the bacterial antigen. Marleni M. (2014) conducted a study on the accuracy of the TP Tubex test in diagnosing typhoid fever, which showed a sensitivity value of 63% and 69%, an estimated cost of 43, and a negative predictive value of 83%. Ilham I. (2017) examined IgM anti-Samonella typhi by examining Tubex TP and obtained 65.8% positive results and 34.2% negative results. Dwi Novitasari's research (2015) in 35 inpatients in the internal medicine department and the children's department of Dr. M. Djamil Padang, Indonesia. Shows the results of the suitability of the Widal test with Tubex TF, the kappa value = 0.337 (p = 0.0046, so there is a lack of compatibility between the Widal test and Tubex TF. Research by Rao, V. (2018) A total of 794 patient serum samples in India tested using the Salmonella-IgM (Typhi-dot M) rapid test, the Widal test, and blood culture. Demonstrates the Rapid Salmonella-IgM (Typhi-dot M) test is significantly more sensitive and specific than the Widal test in diagnosing enteric fever.
The suitability of the results of the examination between these two tests carried out in other areas. Still, it is necessary to know the usefulness of typhoid patients' outcomes at the Community Health Center in Indonesia's Banjarbaru area using the Widal test reagent brand and the anti-Salmonella typhi IgM test, which commonly used at the Community Health Center. This study's purpose was the compatibility between the results of the Widal test and the results of the anti-Salmonella typhi IgM test in typhoid patients in the Banjarbaru area.

MATERIALS AND METHOD
This research is an observational analytic study with a cross-sectional approach that aims to determine whether there is a match between the Widal test results and the Anti Salmonella typhi IgM test results and approved by the Health Research Ethics Committee. Banjarmasin Health Polytechnic (HREC-PKB) Number: 258/KEPK-PKB/ 2018, the population used in this study were all patients at Sungai Ulin Banjarbaru Community Health Center and Cempaka Banjarbaru inpatient Community Health Center. Determination of the sample based on the accidental sampling technique. The criteria for receiving the sample/inclusion were patients who had a fever, headache, weakness, abdominal pain, vomiting, indigestion, dry skin, chapped lips, typhoid tongue.
The instrument used in this study was a typhoid fever clinical symptom test. Salmonella typhi test using the Widal slide method (Lorne Laboratories) using Salmonella typhi O and H suspense antigen, Salmonella paratyphi A-O, and A-H, and anti-Salmonella typhi IgM test: Tubex® TF (Biotech).
Research implementation, including clinical history studies and observation by doctors to obtain a clinical picture of typhoid fever. It is said to be positive (+) if there is a clinical picture of typhoid fever and negative (-) if there is no clinical picture of typhoid fever.
Data collected and edits to make to check completeness, continuity, and uniformity of data validation data. Data entered into a computer program, data analysis obtained in the form of primary data, namely the Widal test results with the results of the Anti Salmonella typhi IgM test in typhoid patients tested with the Kappa Agreement.   IgM test (table 7) obtained a significance value of 0.177 (>0.05), which means that the compatibility between the Widal test and the Tubex test is not significant. The correlation value is 0.153, which means that the Widal test and Tubex test show very weak suitability (0.000-0.199 = very weak). The Widal Test of 42 samples found that 32 samples (76%) were positive, and ten samples (24%) were negative. The Widal test conducted in this study is a single test. According to Khanna, A., 2015, and not  The working principle of this test is the bond between magnetic particles covered by the O9 antigen and IgM antibody. If there is a bond between the O9 antigen and the patient's serum IgM, when the addition of blue latex-coated indicator particles coated with anti-Salmonella typhi LPS antibody, there is no binding with the O9 antigen. As a result, when Tubex place on a buffer magnet, the coated antigen magnetic particles bound to the patient's IgM serum will settle to the bottom. However, the antibody-coated indicator particles did not pay. What is noticeable is that there is no blue discoloration in the Tubex test. This test result shows a positive effect (the patient indicates to have typhoid fever). However, suppose the patient's serum does not contain Salmonella typhi IgM. In that case, there will be an antigen-coated magnetic particle bond with antibody-coated indicator particles so that they place on a magnetic holder; they remain so that a blue to red discoloration occurs on the Tubex test. This test result is negative (the patient does not indicate to have typhoid fever). A quantitative assessment compares the colors formed in the Tubex test with the colors on the Tubex color scale from 0 (red) to 10 (blue). A positive value on the Tubex test supported by clinical signs and symptoms indicates diagnosing typhoid fever (Frankie C H Tam, 2008).

RESULTS AND DISCUSSION
From the Kappa analysis, the results of the Widal test with the results of the Anti Salmonella typhi IgM test in typhoid patients (table 7) obtained a significance value of 0.177 (> 0.05), which means that the suitability of the Widal test with the Tubex test is not significant. The correlation value is 0.153, which means that the Widal test and the Tubex test showed very weak suitability (0.000-0.191 = very weak). This result is by Dwi Novitasari's research (2015), which states that there is weak compatibility between the Widal test and the Tubex test. This weak suitability is because the Widal