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Incidence of Typhoid and Paratyphoid Fever in Bangladesh, Nepal, and Pakistan: Results of the Surveillance for Enteric Fever in Asia Project

31 Pages Posted: 14 Jun 2021

See all articles by Denise Garrett

Denise Garrett

Sabin Vaccine Institute

Ashley Longley

Government of the United States of America - Centers for Disease Control and Prevention (CDC)

Kristen Aiemjoy

Stanford University - Division of Infectious Diseases and Geographic Medicine

Farah Naz Qamar

Aga Khan University - Department of Paediatrics & Child Health

Samir K. Saha

International Center for Diarrhoeal Disease Research, Bangladesh (ICDDR,B)

Mohammad Tahir Yousafzai

Aga Khan University - Department of Paediatrics & Child Health

Caitlin Hemlock

University of California, Berkeley - Division of Epidemiology and Biostatistics; Sabin Vaccine Institute

Alexander Yu

Stanford University - Division of Infectious Diseases and Geographic Medicine

krista Vaidya

Kathmandu University - Dhulikhel Hospital

Dipesh Tamrakar

Kathmandu University - Dhulikhel Hospital

Shampa Saha

Child Health Research Foundation

Isaac Bogoch

University of Toronto, Toronto, Canada - Department of Medicine

Caryn Bern

University of California, San Francisco (UCSF) - Department of Epidemiology and Biostatistics

Kashmira Date

Government of the United States of America - Global Immunization Division

Senjuti Saha

Child Health Research Foundation

Mohammad Shahidul Islam

Aga Khan University - Department of Paediatrics & Child Health

Ishtiaque Sayeed

Child Health Research Foundation

Sadia Shakoor

Aga Khan University - Department of Pathology and Laboratory Medicine

Irum Dehraj

Aga Khan University - Department of Paediatrics & Child Health

Junaid Mehmood

Aga Khan University - Centre of Excellence in Women and Child Health

Mohammad Sajib

Child Health Research Foundation

Maksuda Islam

Child Health Research Foundation

Rozina Thobani

Aga Khan University

Aneeta Hotwani

Aga Khan University - Infectious Disease Research Laboratory

Najeeb Ur Rehman

Aga Khan University - Department of Paediatrics & Child Health

Seema Irfan

Aga Khan University

Shiva Naga

Kathmandu University - Dhulikhel Hospital

Ashraf Memon

Kharadar General Hospital - Clinical Laboratory

Sailesh Pradhan

Kathmandu Medical College - Teaching Hospital

Khalid Iqbal

Kharadar General Hospital - Clinical Laboratory

Rajeev Shrestha

Kathmandu University - Dhulikhel Hospital

Hafizur Rahman

Child Health Research Foundation

Md Mahmudul Hasan

Child Health Research Foundation

Saqib Qazi

Aga Khan University - Department of Surgery

Abdul M. Kazi

Aga Khan University - Department of Paediatrics & Child Health

Nasir Saddal

National Institute of Child Health

Jamal R. Syed

National Institute of Child Health

Mohammed Hunzai

Aga Khan University

Florian Marks

International Vaccine Institute

Jessica Seidman

Sabin Vaccine Institute

Alice S. Carter

Sabin Vaccine Institute - Applied Epidemiology

Jason R. Andrews

Stanford University - Division of Infectious Diseases and Geographic Medicine

Stephen Luby

Stanford University - Division of Infectious Diseases and Geographic Medicine

More...

Abstract

Background: Precise enteric fever disease burden data are needed to inform prevention and control measures, including the use of newly available typhoid vaccines. To inform these strategies, the Surveillance for Enteric Fever in Asia Project (SEAP) conducted prospective, facility-based surveillance for Salmonella Typhi and S . Paratyphi A from 2016-2019.

Methods: To generate population-based incidence estimates of enteric fever, we conducted prospective clinical surveillance at five hospitals in pre-determined catchment areas in Dhaka, Bangladesh, Kathmandu and Kavrepalanchok, Nepal, and Karachi, Pakistan. We employed a hybrid surveillance model, pairing facility-based blood culture surveillance with community surveys of healthcare utilization. Blood cultures were performed for enrolled patients.

We calculated overall and age-specific typhoid and paratyphoid incidence estimates for each study site. Adjusted estimates accounted for the sensitivity of blood culture, the proportion of eligible individuals who consented and provided blood, the probability of care-seeking at a study facility, and the influence of wealth and education on care-seeking.

Findings: Of the 33,136 blood cultures performed on enrolled patients, 8,705 (26%) were positive for typhoidal Salmonella . Adjusted incidence of S . Typhi, expressed per 100,000 person-years, was 1,110 (95% CI: 949-1,305) in Dhaka. In Nepal, the adjusted typhoid incidence rates were 330 (95% CI: 232-476) in Kathmandu and 271 (95% CI:205-365) in Kavrepalanchok. In Pakistan, the adjusted incidence rates per hospital site were 195 (95% CI:163-236) and 126 (95% CI:106-151). Although lower than the rates of typhoid, the adjusted incidence rates of paratyphoid were 150 ( 95% CI: 127-177) in Bangladesh, 49 (95% CI: 38-65) and 82 (95% CI: 57-116) in the Nepal sites, and 25 (95% CI: 21-31) and 1 (95% CI: 1-1) in the Pakistan sites. Adjusted incidence of hospitalization was high across sites, and overall 32% of case patients were hospitalized.

Interpretation: Across diverse communities in three South Asian countries, adjusted incidence exceeded the threshold for “high burden” of enteric fever (100 per 100,000 person-years). Incidence was highest among children, although age patterns differed across sites. The substantial disease burden identified highlights the need for control measures, including improvements to water and sanitation infrastructure and the implementation of typhoid vaccines.

Funding: This work was supported by a grant from the Bill and Melinda Gates Foundation (grant
number INV-008335).

Declaration of Interest: None to declare.

Ethical Approval: We obtained written informed consent from all eligible participants and the parents/guardians of participants aged <18 years prior to collection of blood samples and completion of the questionnaire. We also obtained written assent from children aged 11–15 years in Bangladesh and children 15-17 years in Nepal and Pakistan. Institutional Review Boards in the United States (Centers for Disease Control and Prevention; Stanford University Institutional Review Board), Bangladesh (Bangladesh Institute of Child Health Ethical Review Committee), Nepal (Nepal Health Research Council and Institutional Review Committee; DH, KUH and KMC) and Pakistan (AKU Ethic Review Committee and Pakistan National Bioethics Committee) approved the study forms and protocols.

Keywords: Enteric fever; surveillance; typhoid; paratyphoid; incidence

Suggested Citation

Garrett, Denise and Longley, Ashley and Aiemjoy, Kristen and Qamar, Farah Naz and Saha, Samir K. and Yousafzai, Mohammad Tahir and Hemlock, Caitlin and Hemlock, Caitlin and Yu, Alexander and Vaidya, krista and Tamrakar, Dipesh and Saha, Shampa and Bogoch, Isaac and Bern, Caryn and Date, Kashmira and Saha, Senjuti and Islam, Mohammad Shahidul and Sayeed, Ishtiaque and Shakoor, Sadia and Dehraj, Irum and Mehmood, Junaid and Sajib, Mohammad and Islam, Maksuda and Thobani, Rozina and Hotwani, Aneeta and Rehman, Najeeb Ur and Irfan, Seema and Naga, Shiva and Memon, Ashraf and Pradhan, Sailesh and Iqbal, Khalid and Shrestha, Rajeev and Rahman, Hafizur and Hasan, Md Mahmudul and Qazi, Saqib and Kazi, Abdul M. and Saddal, Nasir and Syed, Jamal R. and Hunzai, Mohammed and Marks, Florian and Seidman, Jessica and Carter, Alice S. and Andrews, Jason R. and Luby, Stephen, Incidence of Typhoid and Paratyphoid Fever in Bangladesh, Nepal, and Pakistan: Results of the Surveillance for Enteric Fever in Asia Project. Available at SSRN: https://ssrn.com/abstract=3866551 or http://dx.doi.org/10.2139/ssrn.3866551

Denise Garrett (Contact Author)

Sabin Vaccine Institute ( email )

2000 Pennsylvania Avenue, NW
Suite 7100
Washington, DC 20006
United States

Ashley Longley

Government of the United States of America - Centers for Disease Control and Prevention (CDC) ( email )

1600 Clifton Rd., NE
Atlanta, GA 30333
United States

Kristen Aiemjoy

Stanford University - Division of Infectious Diseases and Geographic Medicine ( email )

Stanford, CA
United States

Farah Naz Qamar

Aga Khan University - Department of Paediatrics & Child Health ( email )

Karachi
Pakistan

Samir K. Saha

International Center for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) ( email )

68 Shahid Tajuddin Ahmed Sharani
Mohakhali (GPO Box 128, Dhaka 1000)
Dhaka, DC Dhaka 1212 Dhaka
Bangladesh

Mohammad Tahir Yousafzai

Aga Khan University - Department of Paediatrics & Child Health ( email )

Karachi
Pakistan

Caitlin Hemlock

Sabin Vaccine Institute

2000 Pennsylvania Avenue, NW
Suite 7100
Washington, DC 20006
United States

University of California, Berkeley - Division of Epidemiology and Biostatistics ( email )

United States

Alexander Yu

Stanford University - Division of Infectious Diseases and Geographic Medicine ( email )

Stanford, CA
United States

Krista Vaidya

Kathmandu University - Dhulikhel Hospital ( email )

Nepal

Dipesh Tamrakar

Kathmandu University - Dhulikhel Hospital ( email )

Nepal

Shampa Saha

Child Health Research Foundation ( email )

Dhaka
Bangladesh

Isaac Bogoch

University of Toronto, Toronto, Canada - Department of Medicine ( email )

Toronto
Canada

Caryn Bern

University of California, San Francisco (UCSF) - Department of Epidemiology and Biostatistics

Third Avenue and Parnassus
San Francisco, CA 94143
United States

Kashmira Date

Government of the United States of America - Global Immunization Division ( email )

Atlanta, GA
United States

Senjuti Saha

Child Health Research Foundation ( email )

Dhaka
Bangladesh

Mohammad Shahidul Islam

Aga Khan University - Department of Paediatrics & Child Health ( email )

Karachi
Pakistan

Ishtiaque Sayeed

Child Health Research Foundation ( email )

Dhaka
Bangladesh

Sadia Shakoor

Aga Khan University - Department of Pathology and Laboratory Medicine ( email )

Karachi
Pakistan

Irum Dehraj

Aga Khan University - Department of Paediatrics & Child Health ( email )

Karachi
Pakistan

Junaid Mehmood

Aga Khan University - Centre of Excellence in Women and Child Health ( email )

Pakistan

Mohammad Sajib

Child Health Research Foundation ( email )

Dhaka
Bangladesh

Maksuda Islam

Child Health Research Foundation ( email )

Rozina Thobani

Aga Khan University

Stadium Road, P.O. Box 3500
Nairobi, 74800
Kenya

Aneeta Hotwani

Aga Khan University - Infectious Disease Research Laboratory ( email )

Stadium Road, P.O. Box 3500
Nairobi, 74800
Kenya

Najeeb Ur Rehman

Aga Khan University - Department of Paediatrics & Child Health ( email )

Karachi
Pakistan

Seema Irfan

Aga Khan University

Stadium Road, P.O. Box 3500
Nairobi, 74800
Kenya

Shiva Naga

Kathmandu University - Dhulikhel Hospital ( email )

Nepal

Ashraf Memon

Kharadar General Hospital - Clinical Laboratory ( email )

Karachi
Pakistan

Sailesh Pradhan

Kathmandu Medical College - Teaching Hospital ( email )

PO Box 21266
Sinamangal
Kathmandu
Nepal

Khalid Iqbal

Kharadar General Hospital - Clinical Laboratory

Karachi
Pakistan

Rajeev Shrestha

Kathmandu University - Dhulikhel Hospital

Nepal

Hafizur Rahman

Child Health Research Foundation

Dhaka
Bangladesh

Md Mahmudul Hasan

Child Health Research Foundation

Dhaka
Bangladesh

Saqib Qazi

Aga Khan University - Department of Surgery ( email )

Stadium Road, P.O. Box 3500
Nairobi, 74800
Kenya

Abdul M. Kazi

Aga Khan University - Department of Paediatrics & Child Health

Karachi
Pakistan

Nasir Saddal

National Institute of Child Health ( email )

Karachi
Pakistan

Jamal R. Syed

National Institute of Child Health

Karachi
Pakistan

Mohammed Hunzai

Aga Khan University

Stadium Road, P.O. Box 3500
Nairobi, 74800
Kenya

Florian Marks

International Vaccine Institute

Seoul
Korea, Republic of (South Korea)

Jessica Seidman

Sabin Vaccine Institute

Alice S. Carter

Sabin Vaccine Institute - Applied Epidemiology

Washington, DC
United States

Jason R. Andrews

Stanford University - Division of Infectious Diseases and Geographic Medicine

Stanford, CA
United States

Stephen Luby

Stanford University - Division of Infectious Diseases and Geographic Medicine ( email )

United States