Abstract
.Typhoid remains a major cause of morbidity and mortality in endemic countries. This review analyzed typhoid burden changes in Pakistan and its association with contextual factors. A retrospective cohort study on blood culture–positive typhoid and antibiotic resistance was conducted from three tertiary hospitals and contextual factor data obtained from primary household surveys. Salmonella Typhi/Paratyphi positivity rates were estimated and trend analysis was carried out using positive cases out of total number of blood cultures performed. Contextual factors’ associations were determined through bivariate correlation analysis, using STATA (SataCorp, College Station, TX). We report a total of 17,387 S. Typhi–positive and 8,286 S. Paratyphi A and B–positive specimens from 798,137 blood cultures performed. The results suggest an overall decline in typhoid incidence as S. Typhi positivity rates declined from 6.42% in 1992 to 1.32% in 2015 and S. Paratyphi (A and B) from 1.29% to 0.39%. Subgroup analysis suggests higher S. Typhi prevalence in adults older than 18 years, whereas S. Paratyphi is greater in children aged 5–18 years. The relative contribution of S. Paratyphi to overall confirmed cases increased from 16.8% in 1992 to 23% in 2015. The analysis suggests high burden of fluoroquinolone resistance and multidrug-resistant S. Typhi strains. Statistically significant associations of water, sanitation indicators, and literacy rates were observed with typhoid positivity. Despite some progress, typhoid remains endemic and a strong political will is required for targeted typhoid control strategies. A multipronged approach of improving water, sanitation and hygiene in combination with large-scale immunization in endemic settings of Pakistan could help reduce burden and prevent epidemics.
Highlights
Typhoid fever, known as enteric fever, is caused by Salmonella enterica serotype Typhi (Salmonella Typhi) and S. enterica serotype Paratyphi (Salmonella Paratyphi) A, B, and C.1 Typhoid is transmitted by the fecal–oral route and characterized by fever accompanied by chills, nausea, diffuse abdominal pain, rash, anorexia, and diarrhea or constipation[2] and on physical examination, hepatomegaly, splenomegaly, and relative bradycardia are common.[3]Typhoid remains a major global cause of morbidity and mortality, in low- and middle-income countries.[4]
A retrospective cohort study on blood culture–positive typhoid and antibiotic resistance was conducted from three tertiary hospitals and contextual factor data obtained from primary household surveys
A retrospective cohort study on blood culture–positive typhoid fever was conducted from data of three large tertiary care hospitals in Pakistan: The Aga Khan University (AKU) in Karachi, Armed Forces Institute of Pathology (AFIP) in Rawalpindi, and Shaukat Khanum Memorial Cancer Hospital & Research Center (SKH) in Lahore
Summary
Known as enteric fever, is caused by Salmonella enterica serotype Typhi (Salmonella Typhi) and S. enterica serotype Paratyphi (Salmonella Paratyphi) A, B, and C.1 Typhoid is transmitted by the fecal–oral route and characterized by fever accompanied by chills, nausea, diffuse abdominal pain, rash, anorexia, and diarrhea or constipation[2] and on physical examination, hepatomegaly, splenomegaly, and relative bradycardia are common.[3]Typhoid remains a major global cause of morbidity and mortality, in low- and middle-income countries.[4]. According to the World Health Organization (WHO) report published in 2014, the global annual incidence of typhoid was approximately 21 million cases with approximately 222,000 annual typhoid-related deaths.[5] A systematic review on the global morbidity and mortality due to typhoid and paratyphoid fever estimated the incidence of typhoid fever as < 0.1/100,000 in Central and Eastern Europe and Central Asia and 724.6/100,000 in sub-Saharan Africa. A literature review of typhoid in developing countries since 1960 reported the frequency of intestinal perforation as a complication of typhoid to be about 3% with a mortality rate of 39.6%.8
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