A significant burden on our healthcare system

Typhoid fever is one of the global life-threatening infections caused by the bacterium Salmonella Typhi. According to the WHO, an estimated 9 million people get sick from typhoid and 110,000 people die from it every year. Typhoid continues to be a public health problem in many developing areas of Africa, Eastern Mediterranean, South-East Asia and Western Pacific Regions.

The disease also remains a significant public health issue in our country, particularly due to the rise of extensively drug-resistant (XDR) strains of Salmonella Typhi. According to the WHO, Pakistan has one of the highest burdens of typhoid fever globally. It has been estimated to have the highest rate of typhoid among the South Asian countries with 493.5 per 100,000 cases in 2018. Since 2016, Sindh has been dented with severe typhoid outbreaks, with Karachi and Hyderabad being the most affected areas. From November 2016 to June 2021, there were over 15,000 cases of XDR typhoid reported in Karachi alone, and 5,741 cases in other districts of Sindh province. Reports from 2017 show that 63% of typhoid cases and 70% of typhoid deaths in Pakistan were among children younger than 15 years of age. This highly prevalent disease has been burdening our healthcare system.

A landmark development in the fight against typhoid in Pakistan is the introduction of the typhoid conjugate vaccine (TCV) into the routine immunisation programme. Pakistan became the first country to do so in 2019, with the goal of providing longer-term protection to children as young as six months old. The data from Pakistan shows that TCV has an efficacy of 95% against culture-confirmed Salmonella Typhi and 97% against XDR Salmonella Typhi strains. These high efficacy rates further highlight the vaccine’s effectiveness and could help reduce the over-reliance on antibiotics which led to the emergence of different strains of typhoid. Dr Farah Qamar, representing Agha Khan University, played an integral role in this, resulting in her being honoured with the esteemed Tamgah-e-Imtiaz.

Numerous socio-economic factors ranging from lack of hygiene and sanitation, poor access to safe drinking water, illiteracy, self-medication habits, vaccine hesitancy, poor living standards and inflation largely, directly or indirectly, also contribute to its spread and exacerbation.

The interplay of climate change, unchecked population growth, and ensuing urbanisation significantly increases the likelihood of typhoid fever. As, climate change alters temperature and precipitation patterns creating conditions favourable for the survival and proliferation of the bacteria. Uncontrolled population growth and the subsequent urbanisation strain existing water resources and sanitation infrastructure leading to inadequate waste management and sewage disposal systems. Extreme weather events such as floods and heavy rainfall further contaminates water supplies. The vaccine hesitancy majorly due to illiteracy, cultural and religious stigmas surrounding vaccination is also one of the facilitators in the spread and exacerbation of the disease. A significant portion of the population resorts to self-medication, leading to an excessive use of antibiotics. This practice greatly elevates the risk of antibiotic resistance and the emergence of new, multidrug-resistant strains of typhoid.

The Pakistani government, along with international partners, has implemented various measures to combat typhoid crisis. On May 13^th, the Sindh government kicked off a comprehensive 13-day Typhoid Conjugate Vaccination (TCV) campaign to curb the alarming rise of typhoid cases in Karachi and Hyderabad. It aims to administer the vaccine to 8.94 million children aged nine months to 15 years in 8 districts.

But such campaigns can only fetch greater fruits if vaccination coverage be increased, and vaccine hesitancy be addressed. Firm steps must be taken to curb the rampant overuse of antibiotics in the country. Translational and comprehensive interventions focused on improving sanitation and hygiene, access to clean water and food safety, population control and public health education should be made. All the relevant stakeholders must be taken onboard for typhoid management.

Published in The Express Tribune, May 22^nd, 2024.

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