review · Environmental Health Insights
A systematic review and meta-analysis of twenty-four studies across fourteen low- and middle-income countries assessed Salmonella outbreaks recorded between 2016 and 2026. Salmonella Typhi accounted for 70.8 percent of documented outbreaks. Waterborne transmission was the most common route overall at 37.5 percent, and was particularly dominant in Africa where it accounted for 83.3 percent of outbreaks, whereas foodborne and faecal-oral routes were more frequent in Asia. Laboratory confirmation was achieved in only 28.02 percent of pooled cases, falling to 6.1 percent in Africa. The pooled case fatality rate was 7.0 percent, with fever, abdominal pain, and headache representing the most frequent symptoms. Furthermore, pooled antimicrobial resistance reached 59.3 percent across outbreaks, with resistance peaking at 94.2 percent for trimethoprim-sulfamethoxazole and 61.3 percent for ciprofloxacin, highlighting widespread resistance to commonly used first-line antibiotics.
Salmonella outbreaks in developing regions present severe health risks due to high fatality rates and extensive resistance to primary antibiotics. Because waterborne routes drive most African outbreaks and diagnostic confirmation remains remarkably low, public health systems face substantial challenges. Understanding these regional patterns is vital for updating clinical treatment protocols and focusing investments on water sanitation and diagnostic surveillance.
The findings point to clear requirements for affordable, point-of-care diagnostic tools to raise confirmation rates above current low levels, as well as water-sanitation technologies for vulnerable communities. Public health agencies, municipal water managers, and clinical laboratories are primary users. As this work is a secondary review of historical outbreak data rather than a product validation, development of specific surveillance tools or treatment alternatives remains at an early concept stage.
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Background Salmonella outbreaks persist as a public health burden in low- and middle-income countries (LMICs), yet comprehensive synthesis of their epidemiology over the past decade remains limited. Methods Following PRISMA 2020 guidelines, we searched PubMed, Scopus, Web of Science, and Google Scholar for laboratory-confirmed Salmonella outbreaks in LMICs (1 January 2016–1 January 2026). Random-effects meta-analysis estimated pooled prevalence rates, with statistical heterogeneity quantified using I 2 statistic. Given extreme heterogeneity across most outcomes (I 2 > 90%), we present individual study ranges alongside pooled estimates. Results Twenty-four studies from 14 LMICs met inclusion criteria. Salmonella Typhi was the predominant pathogen (70.8% of outbreaks). Waterborne transmission was most frequent (37.5%), predominating in Africa (83.3%), whereas foodborne and fecal-oral routes were common in Asia. Pooled laboratory confirmation rate was 28.02% (95% CI: 12.2–52.1; observed range: 1.5–100%), varying by region: Southeast Asia 54.2% (95% CI: 4.3–96.9), Western Pacific 27.6% (95% CI: 8.0–56.9), and Africa 6.1% (95% CI: 5.3–6.9). The pooled case fatality rate was 7.0% (95% CI: 3.4–13.7; range: 3.6–10.0%). Fever (93.0%), abdominal pain (53.6%), and headache (52.0%) were most common symptoms. Pooled antimicrobial resistance reached 59.3% (95% CI: 26.6–85.4%), highest for trimethoprim–sulfamethoxazole (94.2%) and ciprofloxacin (61.3%). Extreme heterogeneity and wide confidence intervals were observed across some pooled estimates and should be interpreted with caution. Conclusions Salmonella outbreaks in LMICs are characterized by high S. Typhi prevalence and predominant waterborne transmission. Elevated mortality and widespread first-line antibiotic resistance show the need for improved WASH infrastructure, enhanced real-time outbreak surveillance, and revised empiric treatment protocols.
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DOI: 10.1177/11786302261487799
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