Abstract
.A very high incidence of typhoid was described in studies conducted in urban locations on the Indian subcontinent at the end of the twentieth century. Despite their availability, licensed immunogenic conjugate typhoid vaccines have not been introduced in the national immunization program, in part, because of a lack of understanding of where and for whom prevention is most necessary. Uncertainty regarding the burden of disease is based on the lack of reliable, recent estimates of culture-confirmed typhoid and an observed trend of low isolations of Salmonella Typhi and fewer complications at large referral hospitals in India. In this article, we examine the trends of S. Typhi isolation at three large tertiary care centers across India over 15 years and describe trends of recognized risk factors for typhoid from published literature. There appears to be a decline in the isolation of S. Typhi in blood cultures, which is more apparent in the past 5 years. These trends are temporally related to economic improvement, female literacy, and the use of antibiotics such as cephalosporins and azithromycin. The analysis of trends of culture-confirmed typhoid may not accurately capture the typhoid incidence trends if antibiotic use confounds the burden of disease presenting to larger facilities. Emerging antimicrobial resistance may result in a resurgence of disease if the underlying incidence and transmission of typhoid are not adequately addressed through public health approaches.
Highlights
IntroductionThe Diseases of the Most Impoverished projects between 2000 and 2006 helped quantify the disease burden of typhoid and paratyphoid across different settings in Asia
Typhoid is believed to be endemic in Asia, an estimation of the magnitude of burden has been confounded by the lack of access to laboratories in settings that are most likely to have a high disease burden and the poor diagnostic accuracy of available tests
We reviewed blood culture records at the Christian Medical College (CMC), Vellore; All India Institute of Medical Sciences (AIIMS), New Delhi; and B Y L Nair (BYLN) Hospital, Mumbai, between 2000 and 2014
Summary
The Diseases of the Most Impoverished projects between 2000 and 2006 helped quantify the disease burden of typhoid and paratyphoid across different settings in Asia. These population-based studies in the urban slums of India, Pakistan, and Indonesia found the incidence of blood culture– confirmed typhoid to be between 180 and 494 cases per 100,000 children aged 5–15 years.[4] Younger children between 2 and 4 years were noted to be at higher risk with incidence rates between 149 and 573 cases per 100,000 children.[4,5] A prospective cohort study in the early 1990s in the slums of Delhi revealed an incidence of culture-confirmed typhoid of 980 cases per 100,000 population per year with a much higher incidence of 2,730 cases per 100,000 child years in children younger than 5 years.[6,7] Similar findings of high disease burden in younger children was noted in a study from an urban slum in Bangladesh in 2001 where the incidence was 1,870 cases per 100,000 pre-school children per year.[8] These studies indicated that despite heterogeneity in estimates from different settings, India had a significant burden of typhoid especially among its young children
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