XDR Typhoid - Blog Post by Hasan Jamal
XDR Typhoid – Blog Post by Hasan Jamal
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Extensively Drug-Resistant Typhoid Fever in Pakistan
In recent
months there have been growing discussions and concern about Extensively
Drug-Resistant Typhoid (XDR) among the medical professionals and the general
public. Typhoid fever is not a new term for any of us, but few understand the
dreaded outcome if safety measures are not taken and in the event of someone
suffering from this infection is not treated seriously. Let us first try to
understand the disease.
What is Typhoid Fever or Enteric Fever?
It is a
serious disease caused by the bacterium Salmonella Typhi that is spread
by contaminated food and water. Symptoms of Typhoid Fever which is also known
as Enteric Fever often include high fever, weakness, stomach pain, nausea,
headache, cough, and loss of appetite. Some patients may have diarrhea or
constipation. In rare cases, typhoid fever can be fatal. Symptoms appear roughly
ten days after the bacteria enter the human system. This bug enters through
mouth and contaminated water is mostly the main source.
Treatment
with antibiotics is essential. Timely diagnosis and treatment help in curing
the disease which usually takes 20 – 25 days. For diagnosis commonly blood,
urine, stool tests and chest X-Rays are carried out but specific blood test to
diagnose typhoid is Widal. Currently, Typhidot has also become popular
alternative to Widal.
Vaccination
helps to protect from getting Typhoid Fever.
What is XDR?
Initially the
word “Super Bug” came to light in Britain. The reason why common bacteria
convert into super bugs is due to drug resistance. Indiscriminate use of
antibiotics, self-medication or under dosing of antibiotics results into
resistance and that’s how the drug becomes ineffective in typhoid, leading to
the development of XDR.
Typhoid affects
all age groups, but children and elderly people are more vulnerable to get
infected due to weak immune system and low body resistance. The delay in
diagnosis can lead to serious complications like perforation of intestines,
pneumonia, diarrhea and dehydration. This can also cause serious liver and
brain damage.
Unfortunately,
in our country the non- availability of clean drinking water is a ubiquitous
problem and there is no tangible solution in sight. The availability of clean
drinking water alone, besides typhoid, can greatly reduce many other serious
health issues like hepatitis A & E and gastroenteritis, which are life
threatening conditions especially for children and elderly patients.
Typhoid
vaccine is available for all age groups and everyone must get vaccinated to
prevent it. In case of getting infected, an aggressive treatment under the
supervision of a qualified doctor is imperative. Good news is that we still
have few antibiotics which are effective in XDR Typhoid.
In order to
prevent the worsening of problem, there is a great need for careful
recommendation of antibiotics by the doctors, public education/ awareness
programs to be designed and run on media and on different forums to prevent
self-medication, awareness about the importance of hand washing and to root out
the menace of quackery.
The Current Situation
Pakistan
Health Authorities have reported an ongoing outbreak of extensively drug
resistant (XDR) typhoid fever that began in the Hyderabad district of Sindh
province in November 2016. An increasing trend of typhoid fever cases caused by
antimicrobial resistant (AMR) strains of Salmonella enterica serovar
Typhi (or S. Typhi) poses a notable public health concern. In May 2018,
the case definitions for non-resistant, multi-drug resistant (MDR) and XDR
typhoid fever were formally agreed by the Regional Disease Surveillance and
Response Unit (RDSRU) in Karachi, following a review by an expert group of
epidemiologists, clinicians and microbiologists from Pakistan. All typhoid
fever cases reported from 2016 to 2018 were reviewed and classified according
to these case definitions (see Table 1).
Table 1
Classification of Typhoid Fever Cases by Drug Resistance Status, Pakistan, 2018
1. Chloramphenicol, ampicillin, trimethoprim
2. Cefixime is recommended by the International Academy of the
Philippines (IAP) for uncomplicated typhoid fever. Ceftriaxone is
recommended for complicated typhoid fever.
3. Fluoroquinolones
4. First and second-line drugs and third generation cephalosporin
Public health authorities in
Pakistan are identifying possible typhoid fever cases, starting typhoid
vaccination campaigns in the most affected districts, and spreading educational
messages about proper hand washing and safe food and water practices.
Key Points
- There is an ongoing outbreak of extensively
drug-resistant (XDR) typhoid fever in Pakistan that does not respond to
most antibiotics.
- During 2018, cases have been reported in the
United Kingdom and in the United States among travelers returning from
Pakistan.
- All travelers to Pakistan are at risk of getting
XDR typhoid fever. Those who are visiting friends or relatives are at
higher risk than are tourists and business travelers.
- Travelers to South Asia, including Pakistan,
should take precautions to protect themselves from typhoid fever,
including getting a typhoid fever vaccination.
- In Pakistan there are two types of vaccines
available for active immunization against Typhoid fever – Injectable
(Polysaccharide Typhoid Vaccine) and Oral (Ty 21a).
- Travelers to these areas should also take extra
care to follow safe food and water guidelines.
WHO Recommendations
- This outbreak highlights the importance of public
health measures to prevent the spread of resistant and non-resistant
pathogens. While the emerging resistance in S. Typhi complicates
treatment, typhoid fever remains common in places with poor sanitation and
a lack of safe drinking water. Access to safe water and adequate
sanitation, hygiene among food handlers, and typhoid vaccination are the
main and most important recommendations.
- WHO recommends typhoid vaccination in response to
confirmed outbreaks of typhoid fever, and travelers to typhoid-endemic
areas should consider vaccination. Further, where the TCV is licensed, WHO
recommends TCV as the preferred typhoid vaccine. Typhoid vaccination
should be implemented in combination with other efforts to control the
disease.
- In view of the observed capacity for S.
Typhi to quickly acquire new resistance mechanisms, WHO recommends
strengthening surveillance of typhoid fever, including surveillance of AMR
to monitor known resistance, detect new and emerging resistance, and
mitigate its spread. WHO also recommends that surveillance data is shared
locally and internationally in a timely manner.
- Currently, azithromycin is the only remaining
reliable and affordable first-line oral therapeutic option to manage
patients with XDR typhoid in low-resource settings. Patients with
suspected typhoid fever should be tested microbiologically to detect S.
Typhi and define antimicrobial susceptibility wherever possible to inform
patient management and contribute to the surveillance efforts.
Verification and advanced testing (including molecular methods) of S.
Typhi strains with unusual resistance should be performed by designated
expert laboratories that provide confirmatory testing, where such capacity
exists within countries. In countries where no laboratory capacity
currently exists, regional collaboration may be an option, whereby a
neighboring country’s reference laboratory or a WHO Collaborating Center
can fulfill this role.
Preventive Measures
As it is
said “Care is better than Cure” certain preventive measures have to be adopted
by the families:
· Maintain clean and hygienic living environment at
home.
· Ensure clean drinking water specifically at home and
office.
· Wash hands properly after using washroom and before
going for meals.
· Ensure high standards of sanitation over-all at home
and offices.
· Utensils and kitchen have to be kept very clean.
· Keep the edibles properly covered.
· Before eating fruit or initiating cooking, the culinary
items should be thoroughly washed with hot water.
· Even paper currency is sources of contamination and
infested with germs, therefore, wash hands after handling currency.
· Be extra careful while eating out in open or
restaurants.
· Summer season is about to set in, extra care needs to
be taken in eating, drinking etc.
· To the best possible extent ice from the market should
be avoided.
· Get vaccinated under the care of a qualified doctor.
· In case of disease immediately consult doctor for
proper diagnosis and treatment
References:
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