The government has decided to contact the Global Alliance for Vaccines and Immunisation (Gavi) to incorporate a vaccine for typhoid in routine immunization.

“It takes some time to convince Gavi to include new vaccines in the immunisation programme so it has therefore been decided to arrange for about 10 million vaccines which will be administered to children of up to 10 years of age, free of cost. The vaccines will be administered to children in the urban areas as they are more vulnerable to typhoid due to weak immune systems,” Ministry of National Health Services Director General Dr Asad Hafeez told Dawn.

A leading American national public health institute had recently issued an advisory to travelers regarding the outbreak of an extensively drug-resistant (XDR) typhoid fever in Pakistan which does not respond to most antibiotics.

The advisory has caused panic in national and international health circles as Pakistan is already exporting the polio virus and it is now being blamed for exporting an antimicrobial resistance (AMR) typhoid bacteria.

The advisory issued by the US’ Centre for Disease Control and Prevention says there is an outbreak of XDR typhoid fever in Pakistan that does not respond to most antibiotics. Cases have been reported in the UK and the US among travellers from Pakistan during this year.

Bacteria have internal intelligence and with excessive use of antibiotics, can change themselves according to the medicine and create resistance against it. In the past, bacteria could be killed with low potency medicines, but now high potency medicines are required for the same virus which is due to AMR.

Dr Hafeez said that on July 11, a very important meeting of the 25-member Steering Committee on AMR was held in which it was unanimously decided that legislation should be done to address the issue.

“The Drug Regulatory Authority of Pakistan (Drap) will be involved and awareness will be raised among those in the health circles and the masses. In the European countries, people are reluctant to give their children antibiotics and in Pakistan, people do not think doctors are competent if they do not prescribe antibiotics,” he said.

During the meeting, it was also decided to devise a surveillance system to look into the kinds of research being done, he said.

“Currently, most of the research on AMR is being done in animals and poultry. Antibiotics are included in the feed for chickens due to which AMR bacteria get into the environment and also affect people who eat chicken. There is need for legislation in this regard,” he added.

Dr Hafeez said a task force has been established for typhoid which will analyse data and ensure children who are at higher risk are protected from the disease.

“Now, there are just a few [antibiotics] which work on typhoid. Therefore, we are trying to raise awareness among doctors that they should prescribe those,” he added.

Former head of the Pakistan Institute of Medical Sciences Prof Dr Javed Akram told Dawn that according to the law, antibiotics cannot be sold without prescription, but Pakistan is still one of the few countries with widespread use of antibiotics.

“People buy antibiotics on their own and some request salesmen at medical stores to suggest an antibiotic for their children after only telling them of symptoms. Salesmen at medical stores are not pharmacists and so 70pc of antibiotics are misused,” Dr Akram said.

He added that due to the misuse and abuse of antibiotics, medicines have stopped being affective as bacteria have developed resistance.

He said doctors also prescribe medicines for typhoid to patients who come with just a fever and that typhoid medicines should not be prescribed without first conducting a blood culture test.

“A number of doctors frequently use quinolones, a group of antibiotics which are becoming the reason for bacteria to become antibiotic resistant and also stop the growth of bones in children. These medicines do not work on typhoid. Viral infections are also increasing due to the misuse of antibiotics,” he said.

The government should formulate a guideline for typhoid and awareness should be raised among people, he suggested.

“I suggest the government should ban the use of quinolones for at least two years across the country because that is how we can eradicate the antibiotic resistant bacteria,” Dr Akram said.

National Institute of Health Executive Director Prof Dr Aamer Ikram told Dawn that there is an outbreak of typhoid every summer in some areas of the country and that the transportation of AMR bacteria to the US has caused panic among many in the world.

“Antibiotics are unnecessarily prescribed by doctors. Things have become difficult to manage after the devolution, but we have still being making efforts to ensure antibiotics are not used unnecessarily,” he said.

Dr Ikram said people should take care of hygiene and avoid eating at substandard places. Poor appetite, abdominal pain, headaches, high fever often of up to 104 F, lethargy, intestinal bleeding or perforation and diarrhea or constipation are some of the symptoms of typhoid, he said.

According to some estimates, 700,000 people die every year across the world due to infections by drug-resistant pathogens and if the situation remains unchecked, these deaths will increase to 10 million by 2050.

Published in Dawn, July 15th, 2018