KARACHI: While the highly resistant typhoid fever is spreading fast across Sindh, there is no public sector facility in the interior areas to carry out a blood culture, a laboratory test considered the gold standard for typhoid diagnosis.

Also, regrettably, the government so far hasn’t showed any urgency to fix issues pertaining to the supply of contaminated water and mixing of sewage with water in the lines, the main cause of the disease outbreaks in Hyderabad and Karachi, affecting thousands of people.

These public health issues were discussed in detail at a seminar titled ‘XDR-Typhoid, updates and management’ organised by the Pakistan Medical Association (PMA) at the PMA House on Monday.

Giving a presentation on the subject, Dr Farah Naz Qamar, an associate professor at the department of paediatrics and child health, Aga Khan University Hospital (AKUH), described the typhoid fever as a systematic illness (caused by Salmonella Typhi usually through ingestion of contaminated food and water) endemic to many developing countries, including Pakistan.

“Ninety per cent of typhoid-related mortalities and morbidities occur in Asia. In Pakistan, the incidence of typhoid is 573.2 and 412.9 per 100,000 persons for children aged two to four years and children five to 15 years, respectively,” she said, while sharing some data on typhoid prevalence.

‘No child should die of a preventable disease in this day and age’

She also traced the history of antibiotics’ efficacy from 1950 till 2010 and the emergence of antimicrobial resistance in Salmonella Typhi (S. Typhi).

“S. Typhi is a human restricted pathogen and is transmitted from human to human by the faecal oral route. In 2016, the first case of extremely drug resistant (XDR) S. Typhi was identified in Hyderabad.

“Within a week two more cases were identified in the same hospital and then we saw several cases,” she said, adding that the particular pathogen derived its name from the fact that it was resistant against five drugs.

Outbreak in Hyderabad

Sharing details about the XDR typhoid outbreak in Hyderabad, she said it was concentrated in Qasimabad and Latifabad, where more than 2,000 cases were identified, most of which were children.

According to her, a multipronged strategy in collaboration with different stakeholders, including the government, was developed and implanted in affected areas to address the Hyderabad outbreak.

Its components, she said, included education, community awareness, collaboration with local physicians, emphasis on diagnostics and antimicrobial resistance, mass vaccination and testing of water samples from patients’ households and public sources.

The majority of water samples, she said, had coliforms (a broad class of bacteria found in environment including faeces. Their presence in drinking water may indicate a possible presence of harmful, disease-causing organisms). In reply to a question, she said the AKUH data showed four and eight deaths caused by XDR typhoid in Hyderabad and Karachi, respectively. The data also reported over 5,000 cases in Karachi from 2016 to 2018.

She concluded her presentation with a picture of a child who died of XDR typhoid in Hyderabad last year, saying that no child should die of a preventable disease in this day and age.

Sharing her perspective on the disease in the light of scientific evidence, Dr Seema Irfan of the AKUH’s department of pathology and microbiology, said that typhoid had remained a major public health issue in the developing world where 12 million to 20m cases were reported worldwide every year.

This situation, according to her, existed owing to lack of facilities for sanitation and clean drinking water as well as lack of diagnostic facilities and inappropriate use of antibiotics.

Blood culture

Dr Seema Irfan highlighted why it’s important that doctors should opt for a blood culture if they suspect typhoid fever and what were the limitations of the test. If the blood culture was done within one week, the test would be 90pc effective, she said.

Talking about typhoid fever’s clinical presentation, Prof Shehla Baqi, head of the infectious diseases department at the Shaheed Mohtarma Benazir Bhutto Trauma Centre, said it varied from a mild illness with low-grade fever, malaise and dry cough to a severe clinical picture with abdominal discomfort, altered mental status and multiple complications “Any patient presenting fever with no clear focus of infection in an endemic setting for more than three days should be suspected to have typhoid fever,” she said, adding that blood culture was the gold standard for typhoid diagnosis.

During the question-answer session, it was pointed out that almost half of the typhoid cases now being reported at some hospitals were of XDR typhoid. Cases were also being reported from other parts of Sindh, including Mirpurkhas and Badin.

Children, it was stated, were increasingly falling victim to the disease apparently because of consumption of contaminated food being sold in and outside school premises.

“People should consume boiled water and avoid eating out. Washing hands with soap before eating is also effective in disease prevention,” said Dr Qaiser Sajjad, representing the PMA, adding that healthcare providers should exercise caution before prescribing antibiotics.

Published in Dawn, March 12th, 2019