Drug-resistant typhoid on the rise in rural Bangladesh

The emergence of antibiotic-resistant typhoid strains and the lack of early diagnostic tools have become major stumbling blocks in the fight against typhoid in Bangladesh.

This was amongst several key findings presented at a seminar jointly organised by icddr,b and the Bangladesh Paediatric Association at icddr,b’s Sasakawa Auditorium on Monday 14 November.

Younger victims on the rise

Several important experts in the field of typhoid research presented their findings and recommendations in a series of presentations. Bangabandhu Sheikh Mujib Medical University Professor ASM Bazlul Karim pointed out that although typhoid fever has traditionally affected young people and adults, recent epidemiology shows that school children and even infants are increasingly afflicted with typhoid, especially in rural areas.

An old enemy resurfaces

Not only is there a change in the pattern of typhoid infections, there is also an increase in the total number of typhoid patients in Bangladesh and throughout the world due to a range of reasons from poor hygiene to a general lack of awareness of the disease. This increase is worrying experts who previously thought that they were winning the battle against typhoid.

In his presentation, icddr,b’s Medical Director Dr. Mark Pietroni cited the World Health Organization’s estimates that put the annual number of typhoid patients at around 21 million and the annual number of deaths at around 600,000. Dr. Pietroni shared the results of surveillance at icddr,b’s Dhaka Hospital, where from February 2008 to October 2011, around 916 patients were detected with typhoid strains, a significant increase from pre-2008 numbers. He also mentioned that while there are safe and effective vaccines for adults, there are none for infants, and the high costs of such vaccines prove to be a major barrier to their acceptance and use in Bangladesh.

Drug resistance an increasing worry

Dr. Doli Goswami, an assistant scientist in icddr,b’s Centre for Communicable Diseases, shared data from the ongoing urban typhoid surveillance being carried out in Kamalapur, a southern suburb of Dhaka that has traditionally been prone to typhoid. According to Dr. Goswami, 51% of those detected were resistant to three drugs (b-lactams, chloramphenicol, cotrimoxazole) and 49% to four drugs (b-lactams, chloramphenicol, cotrimoxazole and nalidixic acid). Such increased resistance is problematic in treating typhoid with traditional antibiotics.

“Currently, we are doing more studies on exactly why these strands are showing increased resistance, but I would say indiscriminate use of antibiotics is definitely a valid reason to explain why we are seeing more typhoid cases every year,” explained Dr Goswami.

A silver lining?

Before proper treatment, appropriate diagnosis is essential, which is not always possible in rural areas where the quality of health services and awareness of typhoid are low.

But the picture is not entirely bleak. Dr. Firdausi Qadri, director of icddr,b’s Centre for Vaccine Sciences,  presented data on a new technique using ‘antibodies in lymphocyte supernatant’ (ALS) for diagnosis of typhoid fever. Such techniques significantly reduce the time taken to detect typhoid in a patient, while at the same time may also reduce diagnosis costs for patients and health centres.

However, Dr Qadri pointed out that new techniques such as ALS need more time to be tested, and while such research is underway, it was important to treat the underlying causes that have led to a surge in typhoid rates.

“Typhoid is prevalent more in the rural areas of Bangladesh than the urban areas. Poor public health services could be the reason for this. Another important reason might be increasing drug resistance of typhoid due to improper and irregular treatment, which needs special care and attention,” explained Dr Qadri.

The seminar closed with a description of major obstacles in preventing typhoid fever and ways in which typhoid awareness could be raised in both the medical profession and amongst the rural population, including the use of grassroots theatre activism, as well as more research on how to decrease the cost of vaccines and diagnostic tools.

For more information, please contact Dr Firdausi Qadri