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Typhoid fever in the developing world: a neglected disease?

5 Feb 2008

Source: TropIKA

Zulfiqar Ahmed Bhutta

Department of Paediatrics & Child Health The Aga Khan University Karachi, Pakistan

Although typhoid fever has been recognized as a major cause of morbidity for over a century, concerted efforts for its control have been largely restricted to the developed world. These measures have included provision of clean water, sanitation, and general improvements in public awareness and education. However, this evolutionary trajectory has taken time and enormous resources. While WHO recommended the use of vaccination for preventing typhoid fever in countries suffering from this infection in 1994 (1), the target populations and strategies for administration of these vaccines were unclear. As a result only a few countries were able to use these vaccines on a wide scale. Over the last decade new data has emerged on the importance of typhoid fever among children in south Asia, as well as the emergence of antimicrobial resistance to even newer agents such as fluoroquinolones and third generation cephalosporins. However, concerted action to address typhoid fever systematically within the research or development community is still sadly lacking.

Typhoid may be regarded as a neglected disease. There is considerable evidence to support this view.

• Despite its relative importance as a cause of serious morbidity and potential economic losses, typhoid does not appear as a major disorder in the global burden of disease estimates.

• Recent data from south Asia (2–4) have all provided evidence that typhoid fever may be largely a paediatric disease in this region. However, no national programmes addressing child health and survival in the region recognize typhoid fever prevention as a priority. Data on typhoid from Africa are sparse (5) and those from South America are rather dated (6)

• The emergence of resistance to newer antibiotics among isolates of typhoid is leading to a situation where, in some circumstances, the disease may well be untreatable without extremely expensive injectable or combination therapies

• Within global health bodies such as WHO it is unclear which departments have responsibilities regarding typhoid. It does receive attention from WHO's Vaccines and Biologicals group, but it is not regarded as a priority within the organization's Child and Adolescent Health and Development programme nor within the Tropical Diseases Research programme.

• The recent allocations for research and development in typhoid - outside of the DOMI programme of the International Vaccine Institute - are miniscule. To illustrate, the most commonly used serodiagnostic test for typhoid is over a century old (7) and there has been little concerted funding for research in this area.

Much needs to be done to end the neglect of typhoid. We need reliable epidemiological information on the burden and severity of the disease in populations at risk. At the same time, there needs to be consensus on case definitions and diagnostic criteria, the relationship of antimicrobial resistance to outcomes, and the appropriate mix of preventive strategies (carrier detection, water and sanitation interventions and targeted vaccination). These questions need to move up the research priority agenda of potential research funding bodies and policy makers.

References

1. Ivanoff B, Levine MM, Lambert PH, (1994) Vaccination against typhoid fever: present status. Bull World Health Organ 72: 957-971.
2. Sinha A, Sazawal S, Kumar R, Sood S, Reddaiah VP, Singh B, Rao M, Naficy A, Clemens JD, Bhan MK, (1999) Typhoid fever in children aged less than 5 years. Lancet 354: 734-737.
3. Siddiqui FJ, Rabbani F, Hasan R, Nizami SQ, Bhutta ZA, (2006) Typhoid fever in children: some epidemiological considerations from Karachi, Pakistan. Int J Infect Dis 10: 215-222.
4. Brooks WA, Hossain A, Goswami D, Nahar K, Alam K, Ahmed N, Naheed A, Nair GB, Luby S, Breiman RF, (2005) Bacteremic typhoid fever in children in an urban slum, Bangladesh. Emerg Infect Dis 11: 326-329.
5. Graham SM, (2002) Salmonellosis in children in developing and developed countries and populations. Curr Opin Infect Dis 15: 507-512.
6. Ferreccio C, Levine MM, Manterola A, Rodriguez G, Rivara I, Prenzel I, Black RE, Mancuso T, Bulas D, (1984) Benign bacteremia caused by Salmonella typhi and paratyphi in children younger than 2 years. J Pediatr 104: 899-901.
7. Muralidhar S, Srivastava L, Kaur J, (2006) Relevance of the Widal test today. J Commun Dis 38: 385-386.

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