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

XDR Typhoid

Chloramphenicol, ampicillin, trimethoprim
Cefixime is recommended by the International Academy of the Philippines (IAP) for uncomplicated typhoid fever. Ceftriaxone is recommended for complicated typhoid fever.
Fluoroquinolones
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.