A letter in The Lancet Infectious Diseases: Extensively drug-resistant typhoid fever in Pakistan.
We read the Article by Farah Qamar and colleagues about the outbreak of ceftriaxone-resistant Salmonella enterica serotype Typhi in Hyderabad, Pakistan, with great interest. S Typhi was observed as being twice as prevalent in the Qasimabad subdistrict of Hyderabad City (attack rate 15 per 1000 residents) as in the Latifabad subdistrict (seven per 1000 residents), two areas that differ socioeconomically. In most cases, children younger than 15 years were affected. The main reason for the outbreak was the mixing of drinking water and sewage in two subdistricts.
Up to 21 million people contract typhoid each year, often by consuming food or water contaminated by faeces, of whom up to 161 000 die. 3·6 cases of typhoid per 100 000 persons-years are estimated to occur in south Asia, which includes Pakistan. Among the 16 countries in Asia where typhoid is prevalent, inhabitants of the Punjab and Sindh provinces of Pakistan were at the highest risk of developing typhoid.
Extensively drug-resistant typhoid fever is spreading in Pakistan, raising fears of antibiotic failure at global level. Experts believe that Pakistan's abysmal sewage and water systems coupled with low vaccination rates and overpopulated city dwellings are the root causes of the spread of extensively drug-resistant typhoid. In a 10-month period between 2016 and 2017, health authorities in Pakistan detected more than 800 cases of extensively drug-resistant typhoid in the city of Hyderabad alone.
A new typhoid conjugate vaccine, Typbar-TCV, recently pre-qualified by the WHO, has been used by the public health officials in the province of Sindh to vaccinate 250 000 children in Hyderabad. However, the local population is reluctant to use vaccination as rumours are circulating that vaccination is a foreign plot to poison Pakistan's children, and vaccinators face refusals almost every day.
Extensively drug-resistant typhoid has the potential to spread globally by replacing less resistant strains where they are endemic. One remaining oral antibiotic, azithromycin, is still active against extensively drug-resistant typhoid; however, further genetic mutation could make typhoid untreatable in some areas.
The provincial government of Sindh, Pakistan, which deals with the water and sanitation issues has started revamping the water filtration plant of Jamshoro, Hyderabad, after the judicial commission appointed by the Supreme Court of Pakistan ordered an inquiry into mixing of sewage water into natural waterways. The provincial government has also sanctioned 399·74 million Pakistani rupees for restoration of the water distribution network and 414·13 million Pakistani rupees for revival of the sewage system in Hyderabad.
These initiatives can also curb the practices of using hand-operated water pumps in the vicinity of affected areas, which was one of the reasons cited in the paper, causing mixing of sewage and drinking water. Another initiative that should be started by the government is the education of local people, particularly children, about hygiene practices and use of boiling water in cooking food and drinking through pictorial pamphlets and school education programmes. Another major step that should be made by the newly established Sindh Food authority is the inspection of the local restaurants and eateries for unhygienic practices.
The spread of extensively drug-resistant typhoid should be an alarming sign that the world is slowly moving towards a pre-antibiotic era because of widespread overuse of antibiotics. This has become a serious concern in developing nations such as Pakistan, where antimicrobial surveillance is poor and in urgent need of strengthening.
Both governmental and non-governmental organisations in Pakistan need to actively promote vaccination campaigns and healthy hygiene habits and discourage irrational use of antibiotics to prevent the mortality and morbidity associated with increasing antibiotic resistance in pathogens.
