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Life sciences · Review
Environmental Health Insights · September 1, 2026
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This systematic review synthesizes epidemiology of 24 laboratory-confirmed Salmonella outbreaks across LMICs from 2016–2026, identifying S. Typhi dominance (70.8%), waterborne transmission predominance (37.5%), case fatality of 7.0%, and high antimicrobial resistance (59.3%). Extreme heterogeneity (I² > 90%) across most outcomes substantially limits confidence in pooled estimates and requires cautious interpretation by regional variation.
Systematic review and meta-analysis. Laboratory-confirmed Salmonella outbreaks in low- and middle-income countries. n = 24. 14 low- and middle-income countries (specific countries not enumerated in abstract; regions include Africa, Southeast Asia, Western Pacific).
Salmonella Typhi was predominant pathogen in 70.8% of outbreaks Waterborne transmission most frequent at 37.5% overall, predominating in Africa at 83.3% Pooled laboratory confirmation rate 28.02% (95% CI: 12.2–52.1; range: 1.5–100%)
Source does not report separate pooled estimates by transmission route or by outcome type (e.g., mortality stratified by age or treatment)
Clinicians and public health officials in LMICs should recognize high mortality (7.0%) and prevalence of first-line antibiotic resistance (59.3%) in Salmonella infections, particularly S. Typhi, and consider region-specific transmission routes (waterborne in Africa, foodborne/fecal-oral in Asia) when tailoring empiric treatment and outbreak control strategies. However, extreme heterogeneity in outcomes necessitates interpretation within local epidemiological context rather than reliance on pooled estimates alone.
Systematic review and meta-analysis of 24 laboratory-confirmed outbreak studies across 14 LMICs following PRISMA 2020 guidelines, synthesizing transmission dynamics, clinical outcomes, and resistance patterns with pooled effect estimates and confidence intervals, though extreme heterogeneity limits some inferences.
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Clinicians and public health officials in LMICs should recognize high mortality (7.0%) and prevalence of first-line antibiotic resistance (59.3%) in Salmonella infections, particularly S. Typhi, and consider region-specific transmission routes (waterborne in Africa, foodborne/fecal-oral in Asia) when tailoring empiric treatment and outbreak control strategies. However, extreme heterogeneity in outcomes necessitates interpretation within local epidemiological context rather than reliance on pooled estimates alone.
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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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