Cases Of Typhoid Fever Research Articles

SEIR Model and Simulation for Typus Disease

The objectives of this research are to obtain a mathematical model for the spread of typhoid by including the factor of flies and food as variables in the model; analyze and simulation models that will provide predictions and status of typhoid. The data used are secondary data on the number of Typhus cases in Makassar City, analysis of the model is done using the lyapunov function method, while the simulation uses the MatLab model. The results of this study are the SEIR model for typhoid spread, then the simulation results of the model using secondary data on the number of typhoid cases in the city of Makassar provide the number of typhus sufferers and the status of typhoid in Makassar city that is disease free or endemic. Prediction of the number of typhoid cases which can be a reference in the early steps of typhoid cases in Makassar.

Continued Outbreak of Ceftriaxone-Resistant Salmonella enterica Serotype Typhi across Pakistan and Assessment of Knowledge and Practices among Healthcare Workers.

Pakistan is experiencing the first known outbreak of extensively drug-resistant (XDR) Salmonella enterica serotype Typhi (resistant to third-generation cephalosporins). The outbreak originated in Hyderabad in 2016 and spread throughout the Sindh Province. Whereas focus has remained on Sindh, the burden of XDR typhoid in Punjab, the most populous province, and the rest of the country is understudied. Using laboratory data from Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore (Punjab Province) and its network of more than 100 collection centers across the country, we determined the frequency of blood culture-confirmed XDR typhoid cases from 2017 to 2019. We observed an increase in XDR typhoid cases in Punjab, with the percent of ceftriaxone resistance among Salmonella Typhi cases increasing from no cases in 2017, to 30% in 2018, and to 50% in 2019, with children bearing the largest burden. We also observed spread of XDR typhoid to the two other provinces in Pakistan. To assess prevailing knowledge and practices on XDR typhoid, we surveyed 321 frontline healthcare workers. Survey results suggested that inappropriate diagnostic tests and antibiotic practices may lead to underdiagnosis of XDR typhoid cases, and potentially drive resistance development and spread. Of those surveyed, only 43.6% had heard of XDR typhoid. Currently, serological tests are more routinely used over blood culture tests even though blood culture is imperative for a definitive diagnosis of typhoid fever. We recommend stronger liaisons between healthcare providers and diagnostic laboratories, and increased promotion of typhoid vaccination among healthcare workers and the general population.

A skeleton in the closet: The implications of COVID-19 on XDR strain of typhoid in Pakistan

Extensively drug resistant typhoid fever is a major public health concern in Pakistan. During the COVID-19 pandemic, poor sanitation is leading typhoid cases to a surge and obsolete diagnostic methods are paving the way towards ir-rational pharmacotherapy. In particular, the overuse of azithromycin for the treatment of COVID-19 might impair one of the few remaining regimens against XDR. Facing COVID-19 and XDR at the same time can lead to a catastrophy, unless the government, the stakeholders and healthcare workers take joint action to improve sanitation, educate the public, vaccinate vulnerable groups and establish good diagnostic and management practices.

Etiological survey and traceability analysis of five cases of typhoid fever during the same period in Yantai city

Objective: To analyze the etiological characteristics and molecular epidemiological correlation of five cases of typhoid fever during the same period in yantai city. Methods: Six S. Typhis strains were isolated from 5 typhoid patients and epidemiological samples in Yantai city in 2018. The onset time of the cases were from May 26, 2018 to July 24, 2018, distributed in Shuidao Town of Muping District, Dengzhou Street of Penglai District, Donglai Street of Longkou District, Wenhua Street of Muping District and Fulaishan Street of zhifu District. S. Typhis strains were analyzed by conventional bacterial isolation method and XbaⅠ/BlnⅠ double-enzyme digestion pulse-field gel electrophoresis (PFGE). Meanwhile, ViaB virulence gene detection and 27 common antibiotics sensitivity tests were conducted to study the etiology of S. Typhis. Results: Six strains of S. Typhi were isolated from 5 patients and the domestic egg of one patient, which were divided into 4 PFGE patterns by PFGE-XbaⅠ and PFGE-BlnⅠ and among which 3 strains had the same PFGE patterns.One multi-drug resistant strain (foreign patient), one single-drug resistant strain (patient with a history of provincial retention), and one completely sensitive strain were detected. The three strains of the same PFGE pattern exhibit the same drug-sensitive phenotype which were intermediate against aminoglycosides and quinolones and susceptibility against the other antibiotics.All of the strains carried the ViaB virulence factor except the strain from the foreign patient. Conclusion: Local S. Typhi is susceptibility or intermediate against antibiotics commonly used in clinic.Sporadic cases of typhoid fever and typhoid imported infections still need attention.

A rare case of an imported typhoid fever caused by extensively drug-resistant salmonella typhi in the UAE

The emergence of extensively drug-resistant (XDR) strains of Salmonella enterica serovar Typhi-resistant to multiple first-line antibiotics started in the Sindh Province in Pakistan is a cause of concern in the management of typhoid fever. Recently, we experienced a case of XDR typhoid fever in a 4-year-old unvaccinated girl who contracted it during her visit to Pakistan in the summer of 2019, improved with meropenem and azithromycin. This is the first reported case of paediatric XDR typhoid diagnosed and treated in the UAE. Awareness of the on-going outbreak of XDR typhoid fever in Pakistan is very important for clinicians in the evaluation and management of febrile illnesses in a child with a history of travel to Pakistan.

A cross-sectional study of health-related issues in relation to housing environment in a rural area of Amritsar, Punjab

Background: The place where a person lives has a deep impact on his/her health status. The World Health Organization has highlighted the need to create healthy housing and neighborhood. Aims and Objectives: This study was conducted to explore the correlation between home environment and health as very few studies have been conducted in this field. Materials and Methods: The present cross-sectional study was conducted in the rural field practice of Government Medical College. As 10% of the houses were planned to be studied for the physical environment, so every 10th house was visited with a total of 117 houses for assessing the environmental factors and health problems in the households. Results: While open defecation was in practice in 19.6% of the houses, waste collection points nearby in 68.4% of the houses, and house flies around 82.1% of the houses, cases of diarrhea and typhoid were reported by 5.1% and 3.4% of the houses, respectively. The presence of mosquitoes in 82.1% of the houses and poor drainage system in 12.8% of the houses resulted in malaria and dengue in 5.9% and 1.7% of the houses, respectively. Occurrence of dog bite cases in 7.7% of the houses had been due to presence of stray dogs around 87.1% of the houses. Conclusion: Poor sanitary conditions near the house contribute to health issues such as diarrhea, typhoid fever, worm infestations, acute respiratory infections, and others.

Trends in pattern of communicable diseases during COVID-19 lockdown in Kerala.

Dear Editor, Kerala is witnessing an increase in instances of vector-borne diseases and water-borne infections in recent times. [1] The state witnessed Nipah virus outbreak during 2018 and 2019. [2] COVID-19 pandemic surfaced in Kerala on 30 January 2020 and the cases increased during the month of March. [3] We performed a retrospective analysis of communicable disease reported in Kerala with the data retrieved from the website archive of Integrated Disease Surveillance Programme and tuberculosis notification website. [45] The incidence of various communicable diseases were compared during the study period (month of March, April and May 2020 where cases of COVID-19 were reported and containment strategies were implemented) with similar months for last four years (2016 to 2019) as per availability of the data. There was a decrease in the incidence of chickenpox cases by 22.3%, 21.5% and 66.3%, respectively, during the month of March, April and May 2020 in comparison with similar months of 2019. Tuberculosis cases decreased by 19.4%, 35.77% and 19.41% during the study period in comparison with similar months in 2019 [Table 1]. The incidence of H1N1, hepatitis A and typhoid cases decreased during the study period in comparison with similar months of 2019. There was a trend of increase in incidence of ADD cases during the month of May, but during 2020 the percentage increase was lowest among the last 4 years. Malaria and Chikungunya cases reported low but the incidence of dengue cases was slightly more in study period in comparison with similar period in 2019 [Table 1].Table 1: Incidence of communicable diseases in Kerala during the month of March, April and May 2016-2020.The containment strategies against COVID-19 in Kerala prevent the interaction between the agent and host in a favourable environment which helps to contain communicable diseases [Figure 1]. Overcrowding which was prevented by lockdown measures, life style and behavioural changes like social distancing, respiratory hygiene/cough etiquette helped to decrease other respiratory infections like tuberculosis, chickenpox and H1N1 along with COVID-19.Figure 1: Epidemiological triad showing the factors prevented the interaction between agent, host and environmentLockdown measures confined individuals at home which removed the possibility of food and water intake from contaminated environment and routine hand washing practices curtailed the intestinal diseases like hepatitis A, typhoid and acute diarrheal diseases. It was also noticed a decrease in malaria and chikungunya cases which may be due to the environmental sanitation measures underwent during the pandemic [Table 1]. The response of health system to the pandemic, its containment strategies which was implemented through community participation and intersectorial coordination along with lifestyle and behavioral modification of people helped in control of other communicable diseases in the state. There may be some other reasons also for the decrease in the incidence of communicable diseases as people might have ignored slight manifestations of the disease because of the fear to go to hospitals. Health system is overwhelmed with COVID-19 cases which may result in less testing and under reporting of other communicable diseases. Control of infectious diseases is a difficult challenge for our public health systems; however, we believe that covid-19 response and strengthened containment strategies had an impact on the incidence of communicable diseases which need to be carried over. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgement The authors thank Dr. Binod Kumar Patro, Additional Professor, AIIMS, Bhubaneswar for his guidance and review of the article.

A comparative evaluation of rapid card and widal slide agglutination tests for rapid diagnosis of typhoid fever

Background: Typhoid fever is a serious public health problem. It causes severe systemic infection in lesser developed areas of the world. Although blood culture is regarded as the gold standard for diagnosis, it is a time taking procedure. An early and accurate diagnosis is necessary for an effective treatment. Aims: The present study was done to comparatively evaluate rapid card and Widal slide agglutination tests for rapid diagnosis of typhoid cases. Settings and Design: The study design was a cross-sectional descriptive study done over a period of 6 months from January to June 2018. Materials and Methods: A total of 265 patients suspected of typhoid fever who gave their consent were included in the study whose blood samples were tested by both rapid card and Widal slide agglutination tests. Statistical Analysis Used: The collected data were analyzed using SPSS Data Editor Software version 20. Percentage of variables was calculated. Results: Of 265 patients, 97 patients were positive by the Widal slide test, whereas 113 patients were positive by the rapid card test, with 96.9% sensitivity and 88.7% specificity. Of 113 positives, 83 cases were positive for immunoglobulin M (IgM) only, whereas 30 cases were positive for both IgM and IgG. Conclusion: Rapid card test is a simple and easy to perform the diagnostic test for rapid detection of typhoid cases with an additional advantage of separate determination of IgM and IgG antibody, thereby aiding in identification of current infection and previous exposure so that appropriate and timely treatment could be given to the patients.

Antibiotic Sensitivity and Resistance Patterns of Salmonella Typhi in Rajshahi Medical College Hospital

Typhoid and paratyphoid fevers, collectively known as enteric fever, is caused by Salmonella enterica subspecies serovars Typhi and Paratyphi A, B and C. Despite this declining global trend, enteric fever is still considered to be a major public health hazard in Bangladesh and other developing countries due to poor sanitation, inadequate food safety measures and poor personal hygiene. In Bangladesh, the incidence of typhoid fever was reported to be 200 episodes per 100,000 person-years during 2003–2004. Multidrug-resistant (resistance to the first-line antimicrobials ampicillin, cotrimoxazole, and chloramphenicol) strains of S. Typhi and S. Paratyphi are on the rise globally and even cases of extensively drug-resistant (XDR) typhoid cases resistant to chloramphenicol, ampicillin, trimethoprim-sulfamethoxazole, third generation cephalosporins and fluoroquinolones are being reported from many corners of the world. This descriptive, observational study was carried out in Rajshahi Medical College Hospital Hospital, Rajshahi, Bangladesh from July 2017 to June 2019. Antibiotic sensitivity pattern of total 76 cases of enteric fever due to Salmonella Typhi were studied. Blood culture was carried out by BACT ALERT-3D, Automated blood culture analyzer from BioMeriuex SA, France Patented FAN Plus method. Based on the minimum inhibitory concentration (MIC), the organism was categorized as sensitive, intermediate, and resistant against the respective antibiotics as per Clinical and Laboratory Standards Institute (CLSI) criteria. We are reporting antibiotic sensitivity and resistant patterns of S. Typhi documented in Rajshahi Medical College Hospital, a large tertiary care hospital in Northern Bangladesh.
 TAJ 2020; 33(2): 10-14

AN IMPORTED CASE OF TYPHOID FEVER IN CHUVASHIA

Typhoid fever and paratyphoids are still a widespread topical problem, especially in connection with the possibility of imported cases from regions that are epidemically disadvantaged by the disease. The current relevance of typhoid fever problem in the Russian Federation is determined by its persistent sporadic morbidity. Reduced control over the sanitary and hygienic state of the environment, deterioration of the quality of water treatment in water supply and sewerage systems, and a number of other reasons can still result in an increase in the number of patients with typhoid-paratyphoid diseases. At the same time, a mild and subtle course of typhoid fever is a common cause of late disease diagnosis and late start of the patient's treatment. Methods of modern diagnosis and treatment of typhoid-paratyphoid disease are considered. The article describes a case of typhoid fever that was diagnosed in the Chuvash Republic in 2017 after a long period of epidemiological welfare. The aim of the study is to analyze an imported case of typhoid fever and characterize the current course of the disease in the period of sporadic morbidity. A retrospective analysis of the patient's history of typhoid fever was performed. The diagnosis was made on the basis of clinical, epidemiological and laboratory data. To confirm the diagnosis of typhoid fever, bacteriological methods to study blood, urine and feces were used. The study of this female patient's medical history showed that there were no typical symptoms characteristic of typhoid fever: subcutaneous fat was moderately expressed, on palpation submandibular lymph nodes were painless, mobile, of soft-elastic consistency up to 0.6 cm. Nasal breathing was not disturbed, breathing was vesicular, the RR was 16 movements per 1 min., heart tones were muted, rhythmic, the heart rate was 100 beats / min, BP – 120/75 mm Hg, temperature – 39°C. The tongue was dry, coated with a grayish-brown plaque with tooth marks on the edges. The pharynx was moderately hyperemic. The stomach was soft, painless, the liver and the spleen were not enlarged, Padalka’s symptom was negative. The patient reported fecal excretion with a tendency to constipation. There was no CVA tenderness on both sides. Thus, it is difficult to make a diagnosis of typhoid fever with sporadic morbidity. Modern clinical presentation of typhoid fever in moderate severity differs from the classic one. The patient had an atypical course of typhoid fever. Typhoid status was absent. The cutaneous coverings were normal, there was no rash. There was no congestive splenomegaly or Padalka's symptoms. No complications or relapses developed. The diagnosis was made only when the pathogen was seeded from the blood (hemoculture) and basing on clear epidemiological data.

Salmonella enterica serovar Typhi H58 clone has been endemic in Zimbabwe from 2012 to 2019.

Typhoid fever, caused by S. enterica ser. Typhi, continues to be a substantial health burden in developing countries. Little is known of the genotypic diversity of S. enterica ser. Typhi in Zimbabwe, but this is key for understanding the emergence and spread of this pathogen and devising interventions for its control. To report the molecular epidemiology of S. enterica ser. Typhi outbreak strains circulating from 2012 to 2019 in Zimbabwe, using comparative genomics. A review of typhoid cases records from 2012 to 2019 in Zimbabwe was performed. The phylogenetic relationship of outbreak isolates from 2012 to 2019 and emergence of antibiotic resistance was investigated by whole-genome sequence analysis. A total 22 479 suspected typhoid cases, 760 confirmed cases were reported from 2012 to 2019 and 29 isolates were sequenced. The majority of the sequenced isolates were predicted to confer resistance to aminoglycosides, β-lactams, phenicols, sulphonamides, tetracycline and fluoroquinolones (including qnrS detection). The qnrS1 gene was associated with an IncN (subtype PST3) plasmid in 79% of the isolates. Whole-genome SNP analysis, SNP-based haplotyping and resistance determinant analysis showed that 93% of the isolates belonged to a single clade represented by multidrug-resistant H58 lineage I (4.3.1.1), with a maximum pair-wise distance of 22 SNPs. This study has provided detailed genotypic characterization of the outbreak strain, identified as S. Typhi 4.3.1.1 (H58). The strain has reduced susceptibility to ciprofloxacin due to qnrS carried by an IncN (subtype PST3) plasmid resulting from ongoing evolution to full resistance.

FREQUENCY ASSESSMENT OF EMERGENCE OF EXTENSIVELY DRUG RESISTANT SALMONELLA TYPHI STRAINS IN QUETTA, BALOCHISTAN

Objectives: To determine frequency of multidrug resistant (MDR) and extensive drug resistant (XDR) strains of Salmonella typhi (S. typhi) and Salmonella paratyphi (S. paratyphi) in Quetta, Balochistan of Pakistan
 Study Design: Descriptive Cross-Sectional
 Place and Duration: Department of Microbiology, CMH Quetta, Pakistan. from March 2019 to March 2020
 Materials and Methods: A total of 2760 (n) suspected cases of typhoid fever, irrespective of age and gender, reporting at the hospital in this duration and underwent blood culture. Isolates were cultured and identified using standard microbiological procedures. Antimicrobial sensitivity against typhoidal Salmonellae was determined using Kirby-Bauer disc diffusion method as per the guidelines of Clinical and Laboratory Standards Institute (2018) and all the XDR isolates were confirmed by Vitek 2 system. 
 Results: A total of 173 (6.3%) cultures showed positive results. with mean age of 18.9 ± 11.1 years, out of which 136 (78.6%) were male and 37 (21.1%) were female patients. Antibiotic susceptibility results showed that 166 (96%) of isolates were S. typhi. MDR strains were observed in 104(60.1%) and XDR strains were observed in 81 (46.8%) cases.
 Conclusion: A significant proportion of S. typhi isolates from confirmed cases of enteric fever demonstrated MDR (60.1%) and XDR (46.8%) strains in Quetta, Balochistan. We recommend empiric therapy with azithromycin in patients with uncomplicated and therapy with carbapenem for complicated cases of enteric fever acquired in Karachi or Quetta. Large scale population-based studies are recommended to get better information about antibiotic susceptibility pattern of S. typhi and S. paratyphi in other areas.

Vi-Vaccinations Induce Heterogeneous Plasma Cell Responses That Associate With Protection From Typhoid Fever.

Vi-polysaccharide conjugate vaccines are efficacious against cases of typhoid fever; however, an absolute correlate of protection is not established. In this study, we investigated the leukocyte response to a Vi-tetanus toxoid conjugate vaccine (Vi-TT) in comparison with a plain polysaccharide vaccine (Vi-PS) in healthy adults subsequently challenged with Salmonella Typhi. Immunological responses and their association with challenge outcome was assessed by mass cytometry and Vi-ELISpot assay. Immunization induced significant expansion of plasma cells in both vaccines with modest T follicular helper cell responses detectable after Vi-TT only. The Vi-specific IgG and IgM B cell response was considerably greater in magnitude in Vi-TT recipients. Intriguingly, a significant increase in a subset of IgA+ plasma cells expressing mucosal migratory markers α4β7 and CCR10 was observed in both vaccine groups, suggesting a gut-tropic, mucosal response is induced by Vi-vaccination. The total plasma cell response was significantly associated with protection against typhoid fever in Vi-TT vaccinees but not Vi-PS. IgA+ plasma cells were not significantly associated with protection for either vaccine, although a trend is seen for Vi-PS. Conversely, the IgA- fraction of the plasma cell response was only associated with protection in Vi-TT. In summary, these data indicate that a phenotypically heterogeneous response including both gut-homing and systemic antibody secreting cells may be critical for protection induced by Vi-TT vaccination.

Utilization of Blood Culture in South Asia for the Diagnosis and Treatment of Febrile Illness.

BackgroundBlood culture is the current standard for diagnosing bacteremic illnesses, yet it is not clear how physicians in many low- and middle-income countries utilize blood culture for diagnostic purposes and to inform treatment decisions.MethodsWe screened suspected enteric fever cases from 6 hospitals in Bangladesh, Nepal, and Pakistan, and enrolled patients if blood culture was prescribed by the treating physician. We used generalized additive regression models to analyze the probability of receiving blood culture by age, and linear regression models to analyze changes by month to the proportion of febrile cases prescribed a blood culture compared with the burden of febrile illness, stratified by hospital. We used logistic regression to analyze predictors for receiving antibiotics empirically. We descriptively reviewed changes in antibiotic therapy by susceptibility patterns and coverage, stratified by country.ResultsWe screened 30 809 outpatients resulting in 1819 enteric fever cases; 1935 additional cases were enrolled from other hospital locations. Younger outpatients were less likely to receive a blood culture. The association between the number of febrile outpatients and the proportion prescribed blood culture varied by hospital. Antibiotics prescribed empirically were associated with severity and provisional diagnoses, but 31% (1147/3754) of enteric fever cases were not covered by initial therapy; this was highest in Pakistan (50%) as many isolates were resistant to cephalosporins, which were commonly prescribed empirically.ConclusionsUnderstanding hospital-level communication between laboratories and physicians may improve patient care and timeliness of appropriate antibiotics, which is important considering the rise of antimicrobial resistance.

Typhoid and Paratyphoid Cost of Illness in Nepal: Patient and Health Facility Costs From the Surveillance for Enteric Fever in Asia Project II.

BackgroundEnteric fever is endemic in Nepal and its economic burden is unknown. The objective of this study was to estimate the cost of illness due to enteric fever (typhoid and paratyphoid) at selected sites in Nepal.MethodsWe implemented a study at 2 hospitals in Nepal to estimate the cost per case of enteric fever from the perspectives of patients, caregivers, and healthcare providers. We collected direct medical, nonmedical, and indirect costs per blood culture–confirmed case incurred by patients and their caregivers from illness onset until after enrollment and 6 weeks later. We estimated healthcare provider direct medical economic costs based on quantities and prices of resources used to diagnose and treat enteric fever, and procedure frequencies received at these facilities by enrolled patients. We collected costs in Nepalese rupees and converted them into 2018 US dollars.ResultsWe collected patient and caregiver cost of illness information for 395 patients, with a median cost of illness per case of $59.99 (IQR, $24.04–$151.23). Median direct medical and nonmedical costs per case represented ~3.5% of annual individual labor income. From the healthcare provider perspective, the average direct medical economic cost per case was $79.80 (range, $71.54 [hospital B], $93.43 [hospital A]).ConclusionsEnteric fever can impose a considerable economic burden on patients, caregivers, and health facilities in Nepal. These new estimates of enteric fever cost of illness can improve evaluation and modeling of the costs and benefits of enteric fever–prevention measures.

Stool shedding of Salmonella Typhi in children with blood culture-confirmed typhoid fever

Background: Shedding of Salmonella Typhi in stool following symptomatic or asymptomatic infections may play a substantial role in the transmission of typhoid fever. This study estimated the proportion of children shedding S. Typhi in stool during and after an episode of typhoid fever, as well as shedding among members of their household. Methods and materials: The study was nested within a paediatric cohort of the Surveillance for Enteric Fever in India (SEFI) study, Vellore, where 6000 children are under active surveillance for fever. As per the study protocol, children with fever for ≥3 days receive a blood culture and receive azithromycin therapy, if the culture grew S. Typhi. Children positive for S.Typhi were requested to provide stool samples (3 samples/week) over the next three weeks. Concurrently, three stool samples were also collected from each of the household contacts of these children, for screening S. Typhi. The STY0201 gene was detected using Real-time Polymerase Chain Reaction (RT-PCR). Clinical characteristics of children with blood culture-confirmed typhoid fever who shed S. Typhi and did not were compared. Results: Of 65 children with blood culture-confirmed typhoid fever between November 2018 to July 2019, 58(89.2%) children from 53 households consented to provide stool samples. Of these 58 children, 15(25.9%) shed S. Typhi, with a median time (IQR) of shedding at 17(11-24) days from the onset of fever and three of these 15, shed S. Typhi again at a median interval of 30 days from the onset of fever. History of hospitalization during the typhoid fever episode was associated with shedding S. Typhi [OR: 6.6(95% CI:1.5-29)]. Eight(15.1%) of the 53 households with a case of typhoid fever had at least one family member shedding S. Typhi, of whom five were asymptomatic and remaining three had a recent history of fever. Conclusion: One in four children shed S.Typhi during and after the typhoid fever and severity of illness was associated with shedding. About 15% of the households with a child with typhoid fever had a family member shedding S. Typhi concurrently. Thus, it is recommended to consider these parameters while studying disease transmission in endemic settings.

Burden of Ileal Perforations Among Surgical Patients Admitted in Tertiary Care Hospitals of Three Asian countries: Surveillance of Enteric Fever in Asia Project (SEAP), September 2016–September 2019

BackgroundTyphoid fever is caused by Salmonella enterica subspecies enterica serovar Typhi (S. Typhi) and can lead to systemic illness and complications. We aimed to characterize typhoid-related ileal perforation in the context of the population-based Surveillance of Enteric Fever in Asia Project (SEAP) in Bangladesh, Nepal and Pakistan.MethodsBetween September 2016 and September 2019, all cases of nontraumatic ileal perforation with a clinical diagnosis of typhoid were enrolled from 4 tertiary care hospitals in Karachi, 2 pediatric hospitals in Bangladesh, and 2 hospitals in Nepal. Sociodemographic data were collected from patients or their caregivers, and clinical and outcome data were retrieved from medical records. Tissue samples were collected for histopathology and blood cultures where available.ResultsOf the 249 enrolled cases, 2 from Bangladesh, 5 from Nepal and 242 from Pakistan. In Pakistan, most of the cases were in the 0–15 (117/242; 48%) and 16–30 (89/242; 37%) age groups. In all countries, males were most affected: Pakistan 74.9% (180/242), Nepal 80% (4/5), and Bangladesh 100% (2/2). Blood culture was done on 76 cases; 8 (11%) were positive for S. Typhi, and all were extensively drug resistant (XDR) S. Typhi. Tissue cultures was done on 86 patients; 3 (3%) were positive for S. Typhi, and all were XDR S. Typhi, out of 86 samples tested for histopathology 4 (5%) revealed ileal perforation with necrosis. Culture or histopathology confirmed total 15 (11%) enteric fever cases with ileal perforation are similar to the clinically diagnosed cases. There were 16/242 (7%) deaths from Pakistan. Cases of ileal perforation who survived were more likely to have sought care before visiting the sentinel hospital (P = .009), visited any hospital for treatment (P = .013) compared to those who survived.ConclusionsAlthough surveillance differed substantially by country, one reason for the higher number of ileal perforation cases in Pakistan could be the circulation of XDR strain of S. Typhi in Karachi.

Illness Severity and Outcomes Among Enteric Fever Cases From Bangladesh, Nepal, and Pakistan: Data From the Surveillance for Enteric Fever in Asia Project, 2016-2019.

BackgroundEnteric fever can lead to prolonged hospital stays, clinical complications, and death. The Surveillance for Enteric Fever in Asia Project (SEAP), a prospective surveillance study, characterized the burden of enteric fever, including illness severity, in selected settings in Bangladesh, Nepal, and Pakistan. We assessed disease severity, including hospitalization, clinical complications, and death among SEAP participants.MethodsWe analyzed clinical and laboratory data from blood culture–confirmed enteric fever cases enrolled in SEAP hospitals and associated network laboratories from September 2016 to September 2019. We used hospitalization and duration of hospital stay as proxies for severity. We conducted a follow-up interview 6 weeks after enrollment to ascertain final outcomes.ResultsOf the 8705 blood culture-confirmed enteric fever cases enrolled, we identified 6 deaths (case-fatality ratio, .07%; 95% CI, .01–.13%), 2 from Nepal, 4 from Pakistan, and none from Bangladesh. Overall, 1.7% (90/5205) of patients recruited from SEAP hospitals experienced a clinical complication (Bangladesh, 0.6% [18/3032]; Nepal, 2.3% [12/531]; Pakistan, 3.7% [60/1642]). The most identified complications were hepatitis (n = 36), septic shock (n = 22), and pulmonary complications/pneumonia (n = 13). Across countries, 32% (2804/8669) of patients with hospitalization data available were hospitalized (Bangladesh, 27% [1295/4868]; Nepal, 29% [455/1595]; Pakistan, 48% [1054/2206]), with a median hospital stay of 5 days (IQR, 3–7).ConclusionsWhile defined clinical complications and deaths were uncommon at the SEAP sites, the high proportion of hospitalizations and prolonged hospital stays highlight illness severity and the need for enteric fever control measures, including the use of typhoid conjugate vaccines.

Hospitalization of Pediatric Enteric Fever Cases, Dhaka, Bangladesh, 2017-2019: Incidence and Risk Factors.

BackgroundEnteric fever causes substantial morbidity and mortality in low- and middle-income countries. Here, we analyzed Surveillance for Enteric Fever in Asia Project (SEAP) data to estimate the burden of enteric fever hospitalization among children aged <15 years and identify risk factors for hospitalization in Bangladesh.MethodsSEAP used hospital surveillance paired with a community-based health-care utilization assessment. In SEAP hospital surveillance, blood was obtained for culture from children aged <15 years with ≥3 days of fever. In the hospital catchment area, a health-care utilization survey (HCUS) was conducted to estimate the proportion of febrile children hospitalized at the study hospitals. We analyzed hospital surveillance and HCUS data to estimate the health care–adjusted incidence of enteric fever hospitalization, and conducted univariable and multivariable logistic regressions.ResultsFrom July 2017 through June 2019, 2243 laboratory-confirmed enteric fever cases were detected in 2 study hospitals; 673 (30%) were hospitalized. The health care–adjusted incidence of enteric fever hospitalization among children <15 years old was 303/100 000 children/year (95% confidence interval [CI], 293–313). Salmonella Typhi contributed most to the enteric fever hospitalization incidence (277/100 000 children/year; 95% CI, 267–287). The incidence was highest among children aged 2 to <5 years (552/100 000 children/year; 95% CI, 522–583), followed by those aged <2 years (316/100 000 children/year; 95% CI, 288–344). Factors independently associated with enteric fever hospitalization included fever duration, diarrhea, vomiting, abdominal pain, and leukocytopenia.ConclusionsWe estimated a high burden of hospitalization due to enteric fever among children aged <5 years in Bangladesh. The introduction of a typhoid conjugate vaccine would protect children from typhoid and avert typhoid hospitalizations.

Knowledge attitude and practices of doctors on drug resistant Typhoid and extreme drug resistance Typhoid in Karachi Pakistan

Background: Since November 2016, Pakistan has been facing an outbreak of XDR typhoid fever. 7529 Multiple Drug Resistant (MDR) typhoid fever cases were reported from Hyderabad and Karachi and the fever is showing resistance to third generation cephalosporin. Study aims to assess knowledge, attitude and practices of medical doctors on diagnosis and management of typhoid, XDR and MDR typhoid in the tertiary care hospitals of Karachi, Pakistan. Methods and materials: Mix method approach was use to conduct the knowledge attitude and practice survey. For quantitative part 321 doctors interviewed in four tertiary care hospitals between April to June 2019. All medical doctors provided consent and involved in prescribing the medication to doctors were included. In the qualitative part 12 IDIs and 4 focus group were conducted using a semi structured guide- to know doctor's perspective on patients compliance related to antibiotic prescription, DR salmonella and XDR salmonella, routine practices, influencing the decision about prescribing, acceptability and appropriateness of potential interventions. Quantitative data analysis was done on SPSS version 25 and results were presented on ratios and percentages. Qualitative data was analyzed manually based on thematic analysis. Results: Knowledge specific to XDR 85% respondent that infection is common in the country, 65% agreed that they have lack of knowledge on AMR to suspect cases. Antibiotics are overly prescribed by doctors (62%), its available over the counter (58%) and (57%) patient compliance to the treatment option were the most reported reasons to AMR in the survey. Azithromycin is the only drug of choice in both DR and XDR 58% and 48% respectively, very few (3.8%) recommending Carbapenes in XDR and no drug combination is using to treat XDR in all four hospital. In the in-depth discussion majority doctors stated that use of third-generation cephalosporin (in basic fever/flue condition), greatly limiting treatment options and Similar environments and approaches to treatment of typhoid fever, may be the reason of widespread typhoid fever. Conclusion: Considering XDR typhoid is increasing and warranted sense of urgency in the country, there is need to endorse National/Provincial Hospital based AMR prevention guidelines for doctors to reduce the burden of treatable diseases.