“Typhoid: Lessons from India and Pakistan UCLA Department of International Development Studies” by Hannah Spero
Although typhoid fever was first described in 1829, by Dr. P. Ch. A. Louis, there is a surprisingly modest amount of knowledge about the disease today.1 Typhoid has remained a major public health concern since Dr. Louis identified its distinguishing lesions, with the British Medical Journal publishing articles about the disease dating back to 1897, in which it discussed an outbreak amongst “natives of India.”2 The first vaccine was produced in 1896, and there were discussions in 1897 of producing an improved vaccine.3 More practical vaccines were available by 1928, with the first trials being administered in 1937.4 However, those breakthroughs were nearly a century ago, and little progress has been made since. Efforts to combat the disease have been plagued with controversy concerning the accuracy of screening tests, the efficacy and toxicity of vaccines, and the continued failure to implement solutions to the typhoid crisis that continues today. In order to create an effectual international typhoid treatment and prevention program, we must examine and learn from the widespread, multi-drug resistant typhoid crises in India and Pakistan, and we must recognize that solutions can be developed only within the context of the afflicted society, not simply in the realm of isolated medical research.
It was not until 1884 that a German researcher successfully isolated the bacterium that causes typhoid fever, Salmonella typhi.5 Because this bacterium is of the Salmonella genus, many think of it as food poisoning, but the infection has sources other than food and is a much more serious illness than the typical case of food poisoning.6 It does, however, enter the body in the same way as food poisoning: through consumption of food or water contaminated with the bacterium.7 Once a person ingests the bacteria, the human body becomes a reservoir for the reproduction of the bacteria, and excretes it in his or her fecal matter.8 These characteristics of the disease explain why the level of hygiene is so closely tied to the proliferation of typhoid, and why typhoid is endemic to the developing world. In the developed world, there is infrastructure to ensure proper sewage disposal and to support hygiene efforts and ensure that anyone carrying the disease does not spread it to others via food, water, or personal contact.9 Even in 1921, the American Journal of Nursing understood the importance of hygiene when handling typhoid fever patients, publishing a thorough article about the precautions health care providers must take, many of which are still relevant today.10 These safety measures included the wearing of rubber gloves when handling anything in contact with a patient’s excretions and other bodily fluids, the sterilization of all medical instruments after each use, and the thorough washing of a patient’s plates and utensils after every meal, just to name a few.11 In part because of insufficient infrastructure and inadequate hygienic measures in developing countries, typhoid is endemic to these countries and spreads rapidly.
The course of the disease and its symptoms also contribute to difficulties in eradicating it. Once ingested, the bacterium infiltrates the walls of the gastrointestinal tract, where it reproduces in lymphoid tissue.12 Then, within one to three days, it makes its way into the person’s bloodstream.13Generally, the clinical expressions of typhoid manifest themselves about two weeks after infection, but the incubation period varies between seven and 22 days.14 After that period, the infected person begins to exhibit symptoms. Almost 75 percent of cases start with a headache, accompanied by a fever that increases over the first week of this symptomatic period.15 The fever peaks at around 104 degrees Fahrenheit in the second week, during which time a person also experiences vomiting, abdominal pain, loss of appetite, lesions, and diarrhea.16 Unfortunately, because these symptoms resemble those of many other illnesses common to regions where typhoid is endemic, including malaria, tuberculosis, infectious hepatitis, and other Salmonella bacterial infections, clinical diagnosis can be difficult.17
Difficulties in diagnosing the disease lead to misdiagnosis and improper antibiotic prescription, because a doctor might mistake typhoid for a different infection. Treating an infection with an antibiotic that is not effective in killing typhoid contributes to antibiotic resistant strains of typhoid and allows typhoid to reemerge and spread. Even when the disease is properly identified as typhoid, strains of Salmonella typhi vary on a regional basis. Each strain can be more effectively treated with antibiotics specific to the strain, and the misuse of antibiotics to treat one strain compromises the use of antibiotics to treat other strains.18 This is a problem not only on a local level, but on a global level, as the globalization of the world makes the spread of new strains of a disease worldwide ever more easy and likely.19 As a result, future treatment becomes more difficult not only for the region in which antibiotics are mis-prescribed, but also for areas where those antibiotics had previously been effective for their own specific regional strain. For example, from 1978-1985, fear arose regarding the efficacy of chloramphenicol as the drug of choice for treating typhoid patients in Britain.20 At the same time, chlorampheniol resistant strains of typhoid appeared in Mexico, India, Bangladesh, and Vietnam.21 Similarly, when the illness is actually something other than typhoid and requires different treatment, the over-prescription of antibiotics for typhoid will not treat the true illness, and creates the opportunity for the true illness to reemerge and spread in potentially multi-drug resistant forms. Therefore, difficulties in diagnosing typhoid fever jeopardize future treatment of the typhoid fever and other illnesses as well.
Another complication stemming from the nature of this infectious disease is the likelihood of reemergence due to carriers who do not exhibit symptoms. Although, ideally, treatment would entirely kill off the bacteria in a person, that is frequently not the case, especially in the developing world, where we see a problem of carriers: people who are a reservoir for the bacteria, but themselves do not produce symptoms.22 If someone no longer suffers symptoms of the illness, they unknowingly spread it to others, adding to the public health crisis. In the 1920s in the United States, there was an increase in the number of cases, but the new patients did not acquire the bacteria from abroad, but rather from carrier family members who had picked up the disease on their travels.23 This feature of typhoid fever makes it an elusive foe for public health workers, and highlights the need for greater hygiene in all communities.
Even if the problems with clinical diagnosis and reemergence are overcome, there still remain issues related to the available medical technology. These issues can be separated into three categories: vaccination, screening, and treatment. Although typhoid is not a new disease, its available vaccines are still questionable, both in terms of their efficacy and their toxicity. There are two main vaccines up for debate: the killed whole cell vaccine and the Ty21a live attenuatedoral vaccine.24 The former is made from a dead virus and is injected into the bloodstream, while the latter is a weakened live virus that is taken orally in the form of a capsule pill over several doses.25 The first typhoid vaccine, which was produced in 1896, was a primitive version of today’s killed whole cell vaccine.26 Field trials for this type of vaccine began in the 1950s and 1960s in Yugoslavia, Guyana, Poland, and the USSR.27 Reviews of Infectious Diseases reported that these trials yielded an overall efficacy of only 65 percent.28 It also cited field trials of the live vaccine in Nepal and South Africa as being 70 percent effective.29 Therefore, the first study favored the live oral vaccine. However, another study, published by the British Medical Journal, found an efficacy rate of 73 to 80 percent for the killed whole cell vaccine over three years, based on field studies in Yugoslavia, Guyana, Poland, the USSR, and Tonga30, and an average live vaccine efficacy of only about 50 percent, based on data gathered from trials in Egypt, Chile, Indonesia, Nepal, and South Africa.31 Therefore, this second study favored the use of the killed whole cell vaccine. An analysis of the two studies noted that the averages reported in each study were a compilation of many averages from regions all over the world, and that the vaccine efficacy varied greatly from country to country with both vaccines in both studies.32 The live vaccine was 96 percent effective after three years in the Egypt trials, and 45 percent effective in the Indonesian trials.33 The killed vaccine was 84 percent effective in Poland and 51 percent effective in Yugoslavia.34 Clearly there is a connection between the effectiveness of a vaccine and the context in which we implement it. Both vaccines provide some protection, but greater research must be done to confer better protection; in general, the efficacy of current licensed vaccines is less than desirable.
Besides efficacy, we must also consider the toxicity of vaccines. Although the killed whole cell vaccine had a high global average rate of efficacy, it also had a greater toxicity rate.35 About 16 percent of subjects reported feeling feverish from the vaccine, with 10 percent feeling ill enough to have to miss work or school.36 By comparison, the Ty21a live attenuated oral vaccine, with a lower averaged rate of efficacy, resulted in only two percent of subjects feeling feverish and almost no one feeling ill enough to miss work or school.37 From this consideration, the question then becomes whether to value the more effective vaccine with greater side effects or the slightly less effective vaccine with almost no side effects.
Finally, we must consider the practical mass implementation of each kind of vaccine in a public health setting. The killed vaccine injection requires more medical equipment than the live oral vaccine capsule, and more equipment requires more money and medical specialization to ensure the equipment is handled properly. On the other hand, the oral vaccine consists of three doses, which might be more difficult for people to remember to take, in contrast to a single injection of the dead vaccine. Both vaccines have implementation problems; if the flaws in these vaccines prevent them from stopping the spread of typhoid, we must look for better alternatives.
As with the methods of vaccination, there are issues with the accuracy and implementation of screening tests for typhoid fever. The three tests for typhoid examine stool, blood, and bone marrow samples. Stool tests require roughly a week to culture, which is a long time to wait in areas where typhoid is significant.38 Also, stool cultures require special lab facilities to ensure accurate screening and to prevent contamination while awaiting the results.39Another disadvantage is that a stool sample may be positive for typhoid up to four months after infection if a person goes untreated, increasing the likelihood of misdiagnosis and unneeded prescription of antibiotics.40 Stool samples probably have a more suitable application in the developed world as a test for additional confirmation of typhoid. Blood cultures are most widely used form of typhoid screening and they yield more rapid results than stool samples, but they are only 60 to 80 percent sensitive, meaning that they yield inaccurate results in roughly one out of four tests.41 Tests of blood cultures are also more likely to reveal a false positive if the person being tested has been vaccinated for typhoid, which creates questions around the test’s efficacy.42 However, blood cultures are more practical in public health applications due to their shorter wait time and easier sample collection requirements; collecting blood is easier than collecting stool. Bone marrow cultures take slightly longer than blood tests, but less time than stool cultures.43 That being said, bone marrow cultures are the most sensitive of the three tests, with an 80 to 95 percent positive result when typhoid is present; this is because of the higher concentration of the organism in bone marrow samples.44 Also, bone marrow test are more useful in identifying specific strains of typhoid compared to blood and stool cultures.45 However, like the stool cultures, bone marrow tests present difficulties in collecting samples when applied in a public health context. Besides these three tests, there are currently some promising efforts to produce more rapid, accurate serological testing methods, called Typhidot and Tubex, but these test are very new and require greater field testing to assess their efficacy and sensitivity.46
Overall, the screening methods present as many debates and information gaps as the vaccines in the case of typhoid fever. Given that typhoid was identified almost two centuries ago and that its first vaccine was produced more than a century ago, the lack of effective medical technology in this area is surprising. There is still so much to be researched in the field of typhoid. In general, future approaches to typhoid management must involve methods that are not only effective in ideal circumstances, but also have practical use in public health efforts. Bone marrow cultures are effective for obtaining positive results, but are not sensible for screening in developing countries, where the typhoid burden is immediate and there is a lack of training and facilities to handle those tests. Although blood cultures may be more rapid and require simpler sample collection methods, those advantages must be weighed against the technique’s efficacy. Is it worth the possible rate of misdiagnosis? These considerations demonstrate that we must strive for screening tests that reveal more specific and sensitive results in order to provide proper diagnosis and treatment, and that are in a form that can be practically implemented in a developing world setting.
Typhoid fever solutions should be considered in the context of the developing world because they are almost exclusively relevant to the developing world. Typhoid very rarely appears in the developed world, and when it does, the source is a person who has recently returned from a developing region where typhoid is endemic. Those few cases are treated in a vastly different setting than cases treated in places like India or Mexico. Developed countries have greater access to superior medical facilities and treatment.47 In addition, developed countries have built an infrastructure to support personal hygiene, clean food and water, and sanitation.48 Developing regions of the world often lack access to clean water, which makes clean food and personal hygiene difficult.49 Also, the lack of functional sewage drainage means frequent exposure to dangerous bacteria, like Salmonella tyhpi, from human and nonhuman sources.50 Unfortunately, sometimes there is no distinction between where people get their water and where they excrete their waste products. With no other alternative water source present, people are forced to choose whether to risk dying from typhoid or dying from dehydration. The proliferation of typhoid is inevitable in these conditions.
While more advanced vaccines and screening methods would help slow the spread of typhoid fever in these regions, the efforts will be useless unless we fix the entire system, including the poor living conditions of the developing world. Typhoid fever requires societal solutions, not only medical answers. Resources must also finance projects to create access to clean food and water as well as build in infrastructure for hygiene and sanitation in the developing world. These basic conditions are what have made the difference between almost no typhoid in the developed world and many strains of typhoid endemic to the developing world.51 These necessary systemic changes would support the efforts of future advancements in medical technology.
There is a great loss of life due to the proliferation of typhoid fever. The death toll of the illness makes it a human tragedy, made even more tragic by the fact that the disease is treatable and preventable. According to the United States Centers for Disease Control, there are 21.6 million cases of typhoid annually, with over 2 million fatalities.52 Unfortunately, those numbers will likely increase with the emergence of antibiotic resistant strains, making treatment options less effective and death more likely. Although most of the cases are in the developing world, typhoid fever and its growing resistance to antibiotics is of global concern. Citizens of the developed world are directly affected by the situation when they visit regions of the developing world where typhoid is endemic. Moreover, even when these travelers have received vaccinations in their developed countries, the current misuse of antibiotics to treat typhoid cases in developing areas is contributing to the evolution of strains against which current vaccinations will not protect and which are more difficult to treat even in the medical facilities of the developed world.53 This modern reality is important to keep in mind as we examine typhoid fever in India and Pakistan, which have the highest prevalence of the illness as well as the greatest number antibiotic resistant strains; we must learn from the ways in which the public health crisis unfolded there if we hope to slow proliferation in the future.
India and Pakistan provide a glimpse of the potential future for regions where typhoid is endemic if we do not change the way in which we manage the disease.54 The typhoid situations in India and Pakistan are dire, with 7.7 million of the 21.6 million global annual cases of typhoid occurring in South Asia.55 This makes the two countries excellent case studies as we look for practical solutions for the future. In considering the region’s predisposition for typhoid proliferation, we first examine their populations. Like most other developing countries, India and Pakistan are experiencing rapid population growth of already large populations, which would make resource management and maintenance difficult for even a better equipped country.56 Pakistan is growing at a rate between 2 and 3 percent, which means that its population of 173.6 million will double in the next 23 to 35 years.57 India’s population is even larger, and is quickly approaching 1.2 billion people.58
In addition, each country’s population has demographic features that make public health efforts more difficult. A problem specific to India is its varied population density. Although there is an average of about 300 people per square kilometer, this number is not representative of the polarization of the population densities throughout the country.59 At one end of the spectrum, the North East District, where Delhi is located, has more than 29,000 people per square kilometer.60 At the other end of the spectrum, the rural districts of Lahul and Spiti have only about two people per square kilometer.61 Each extreme presents it own problems when it comes to implementing public health solutions for typhoid. In the densely populated parts of India, which are among the densest in the world, the spread of disease is rapid and unavoidable.62 Furthermore, having so many people packed together makes it difficult to provide and maintain human services like sewage drainage systems and clean running water, both of which would help to slow the spread of typhoid. In rural areas, the problems associated with attempts to provide services to people stem from the fact that the people are spread so far apart across such a large area. The distance and isolation make it difficult to implement cost-effective programs for these people to access medical and other services. In Pakistan, 95 percent of the population lives in a rural setting. Further impeding the delivery services is the mountainous terrain of Pakistan is a mountainous country. The difficulties created by these features have been documented in a study of attempts to provide women’s education and family planning in the region to slow the infant mortality rate.63
The circumstances that have made India and Pakistan prime for the spread of typhoid fever do not end with their sheer population size or respective distributions of those populations over the region, urban and rural. Another demographic characteristic shared by India and Pakistan, which makes them ideal for the spread of an infectious disease, is the age structure of their populations.64 Their recent rapid population growth has led a large proportion of their populations being comprised of youth.65 As of 2007, one third of the billion-person population of India was under the age of 15.66 That fact is even more startling when we consider that only 6 percent of the population is over the age of 65; these numbers reflect the country’s huge population growth and the struggles it faces in developing.67 The imbalance is even more extreme in Pakistan, where 43 percent of the population is under the age of fifteen, and only 4 percent is over the age of 65.68 This demographic shift in both countries toward a greater number of young people does not bode well for efforts to curb typhoid proliferation in the region. Younger people are more susceptible to Salmonella typhi for several reasons. First, their bodies are not fully developed, which makes them more susceptible to disease. Second, because they are younger, they have less built-up natural immunity to local strains of typhoid compared to the older generations who have lived in the region longer. In an epidemiological study of typhoid in Karachi, Pakistan in 1998, the median age of afflicted patients was 5.8 years, with 71 percent of total subjects being under the age of 10.69 This supports the frequent assertion by scholars that in Pakistan the highest rates of typhoid incidence occur in children of pre-school and school ages.70 Similar statistics have been published in studies of India.71 One study that specifically looked at the demographics of Calcutta residents affect by multi-drug resistant forms of Salmonella typhi reported the mean age of the subjects to be six years.72
For the young people of India and Pakistan, age is not the only factor that commonly makes their bodies less developed, and therefore more susceptible to typhoid fever. The living conditions of the developing world make it difficult to grow a strong body to fight against infection. The study from Calcutta classified 60 percent of the children as being malnourished or severely malnourished.73 Also, a majority of the patients also could obtain water only from contaminated public water sources. These realities of the lives of the young people in this region reinforce the need for societal changes to hygiene infrastructure and access to medical services, clean water, and adequate food to support medical efforts in this crisis.
The inadequate supplies of clean food, clean water, and health services in the developing world are further stressed by regional movement and instability; India and Pakistan are no exception. These issues of movement and instability in relation to the spread of typhoid fever and drug resistance fall into three main categories: natural disasters, conflict, and scarce resources. Developing nations like India and Pakistan are especially vulnerable to natural disasters because of their population size, their population density, their limited access to human services, and the absence of effective infrastructure to mount and execute large-scale relief efforts. When natural disasters strike, these countries typically suffer a large number of human casualties, and also a “large amount of damage to property and other infrastructure, and severe crop loss.” 74 In India and Pakistan, the most frequent natural disasters are cyclones, floods and earthquakes, which are a product of location and lack of infrastructure.75 Additionally, volcanic eruptions, fires, droughts and landslides stress the region.76 The lack of development in the area makes all of these things more devastating than if they had unfolded in a more developed area. Not only are there casualties as a direct result of a given natural disaster, but there are more casualties in the aftermath due to the magnification of the hardships associated with living in a region of poverty. This consequence further increases the ability for a disease to spread, as it becomes even harder to maintain hygiene, obtain clean food and water, and access appropriate medical services.
The book, International Perspectives on Natural Disasters: Occurrence, Mitigation, and Consequences, highlights the occurrence and severity of natural disaster in India, and offers a clear picture of the frequency of those disasters in creating additional hardship.77 In 2001 alone, India suffered high severity floods and droughts, medium severity cyclones and earthquakes, and low severity landslides.78 In 2004, a 9.0 magnitude earthquake, with an epicenter in Indonesia, was felt in both India and Pakistan, and caused a tsunami toward the Indian coast.79 The Indian government estimated the death toll from the tsunami at 11,000 people, with 380,000 people displaced.80 In Pakistan in 2010, flooding of the Indus basin following a powerful monsoon killed 2,000 people and displaced about three million people.81 The conditions that develop in the wake of the displacement of large numbers of people following natural disasters are ideal for the spread of disease.82 First, displaced peoples are uprooted from wherever they were and become more mobile in an effort to find safety; this means that many people are coming into contact with new people, and potentially coming into contact with other strains of typhoid for which they have no natural immunity. Then, when refugee camps form, people are packed closer together with even more unsanitary conditions. Therefore, in addition to the society changes discussed above, such as programs for better hygiene, food, and access to water, solutions to curb the spread of typhoid fever must include improved disaster relief programs to prevent natural disasters from contributing to the proliferation of typhoid.
The same connections between natural disasters and the spread of typhoid fever can be seen in the relationship between the infectious disease and conflict. Following the model of the natural disaster scenario, armed struggle creates warzones where it becomes more difficult to satisfy basic needs.83 In the developing world, conflict magnifies the already existing destitute conditions. Conflict causes people to flee, which, like the displacement of people by natural disasters, leads to contact with new people and new strains of diseases like typhoid.84 The immediate surrounding conditions deteriorate, and the probability of contact with disease increases. Therefore, conflict-resolution is important to any public health solutions where there are war zones.
In South Asia, India and Pakistan constitute the same conflict, which makes the public health implications even greater. Since the end of British colonization in the region in 1947, Pakistan and India have disputed reign over the territory of Kashmir, previously called Jammu and Kashmir.85 The conflict has been described as much a conflict for territory as “a clash of identities, imagination, and history.”86 Pakistanis are entrenched in their belief that not only do they have the right to the land despite the 1947 partition, but also that the Indian possession of the land represents India’s refusal to recognize the reality of Pakistan; there are also clashes of religion in all of these issues between Indian Hindus and Pakistani Muslims.87 This is reflected in the Indian viewpoint on the conflict. Indians say that Pakistan is a “state defined and driven by its obsession with religion,” and that the conflict stems from the reality that Pakistan “is unwilling to accept the fact of a secular India.”88
Through this conflict, India and Pakistan, two of the countries that suffer from the highest incidence of typhoid and have the greatest number of multi-drug resistant strains of typhoid are further destroying the public health situations of each nation. Due to the conflict, living conditions in Kashmir further deteriorate and people are constantly forced to move, coming into contact with each country’s strains of typhoid. The public health consequences of the conflict over Kashmir demonstrate how essential conflict-resolution is to supporting typhoid control efforts. By resolving conflict, we help to prevent the greater spread of all strains of the disease, and also put more focus on providing adequate basic human services to the afflicted region.
While governments in the region spend scarce resources on the conflict in Kashmir, they have made only minimal efforts to control typhoid, consisting of a few small-scale vaccination programs.89 To implement effective solutions to the epidemic levels of typhoid fever in the developing world, the governments in the region must devote resources to the effort, establish systems to monitor the sources, proliferation and evolution of the disease, and regulate conduct that contributes to the spread of the disease. The absence of a typhoid surveillance system leaves the nations without the information they need to prevent the spread of typhoid or its growing drug resistance.90 The governments of India and Pakistan must establish systems to and the occurrence of have also aided in the proliferation of typhoid fever through the absence of a typhoid surveillance system and gaps in government regulations that could control typhoid. Also, there are simple regulatory measures that both governments could take to hinder disease spread. In the United States, there are employment restrictions on typhoid carriers. For example, typhoid carriers cannot be employed in the food industry, especially involving food preparation.91 If India and Pakistan adopted similar regulations, they would eliminate many of the cases of typhoid contracted in the workplace and from commercially prepared foods.
In addition to inadequate infrastructure and government regulation to aid the control of typhoid in the region, there also exist major gaps in the countries’ medical systems. According to the World Health Organization, there are 8.1 doctors and 5.6 nurses/midwives for every 10,000 people in Pakistan, which has a population of 173.6 million.92 India, with a population of nearly 1.2 billion, has six doctors and 13 nurses/midwives for every 10,000 people.93 Even ignoring the overwhelming health crises of the two countries, these numbers reflect a debilitating shortage of medical personnel; there simply are not enough medical workers to come close to operating satisfactory medical systems in India and Pakistan. The shortage creates several problems. First, because of the high rates of typhoid and other disease, it is impossible for doctors to see everyone who is sick.94 Second, this shortage puts pressure on doctors to come up with quick diagnoses and treatments; misdiagnosis is not unlikely, especially in the case of typhoid where many other common diseases present the same clinical symptoms. Third, because of the large number of patients, doctors cannot personalize treatment options; instead, doctors resort to “one size fits all” treatments for diseases of major public health concern, which results in less effective and more problematic treatment. Because strains of typhoid vary regionally, prescribing the same antibiotic treatment for all patients is not a sustainable way to treat the disease. This practice is a major contributor to antibiotic-resistant typhoid in India and Pakistan. When doctors choose not to tailor prescriptions to attack the regional strain of typhoid present in the patient, and instead prescribe a more general antibiotic, they slowly contribute to the antibiotic resistance of the regional strain. This development forces doctors to look for other treatment options once the strain is multi-drug resistant and the former general antibiotic treatment is rendered useless. With more medical personnel and a shift to regional-specific antibiotic treatments for typhoid fever, these countries would slow the growing number of antibiotic resistant strains, and would reduce the number of people who contract typhoid by reducing the incidence of typhoid reemergence.
In order to make those changes in the medical systems of India and Pakistan, we must understand the current mentality of the systems, both on the side of the patients and the medical professionals. Even if doctors began to treat typhoid with more regionally specialized prescriptions, the change is useless if patients do not understand how important it is for them to take their antibiotics properly. Unfortunately, that fact is not limited to the developing world. Many people in the developed world and the developing world misuse their antibiotic prescriptions.95 When a patient does not take antibiotics at the proper intervals, the antibiotics are not effective. Instead of being killed, the virus survives, adapts, and becomes resistant to the antibiotic in the future.96 Similarly, because people often begin to feel healthy after a few days of their antibiotic regimen, they stop taking their antibiotics, allowing the virus to survive and become stronger. When the virus reemerges, the same antibiotic treatment will not be as effective.97 Patients are focused on feeling better faster, and they do not think of their treatment as something that needs to be sustainable on a society level. An education campaign is necessary to teach people about the importance of proper antibiotic use in order to make a long-term typhoid treatment effort successful.
Part of educating the public in these areas where typhoid is endemic requires changing the mentality developed by many of the medical professionals during their training and practice. At medical schools in Pakistan, doctors are educated to provide basic clinical care rather than comprehensive evaluations.98 To make matters worse, much of their educational material is similar to that taught in the developed world; Pakistani medical students read about typhoid fever in the context of the developed world, where the infection is rare.99 Physicians receive a generic education that is unrelated to the circumstance that they will be practicing medicine in the developing world amid a major public health crisis.100 Another consequence of the focus on training doctors to provide basic, generic care is that medical research is not a for medical professionals in India or Pakistan.101 In addition, many doctors and medical researchers in these countries see research as an “unaffordable luxury.”102 This attitude may be traced back to the shortage of doctors. Because doctors are in such high demand, both nations are looking only for doctors with a medical license to provide basic treatment. Compared to the developed world, there is far less incentive to fund and produce medical research. Dr. Zuberi of Pakistan puts it best when he explains, “Research is not a prerequisite for appointment or promotion and there is not academic or financial rewards. You really have to be crazy to do research in this country, for it is something that is looked down upon and considered a waste of time which should be spent seeing more patients and making more money.”103 This mentality must be changed if we hope to effectively combat not only typhoid fever, but also any public health crisis in the future. The support of the medical community is vital to efforts to implement typhoid control programs. One of the most effective things we can do is educate doctors in the context of the setting where they will be working, and also teach them about the importance of developing sustainable treatment methods. The frequency of multi-drug resistant typhoid strains can be reduced, but any successful programs will require a collaborative, integrated partnership with the medical community that focuses on tailoring and improving treatment in the particular region.
The numerous factors that have made India and Pakistan prime locations for the spread of typhoid fever and the development of drug resistance strains yield many lessons that must be applied globally to public health efforts against this infectious disease. The task may seem daunting in light of the situations in these two countries, but typhoid may be controlled if we focus our efforts on curbing the spread of typhoid, and doing so in a way that preserves the integrity of its methods; in other words, it must be a long-term sustainable solution, not a quick fix. Moreover, the solutions must be practical in the sense that they can be easily implemented in a developing world context; any solution will useless if it is not user-friendly for the developing world.
There are lessons we can learn from the cases of India and Pakistan. More research must be conducted in the areas of vaccines and screenings. We can and must develop more effective, less toxic vaccines, preferably in more practical forms that do not require excessive equipment or multiple doses. Also, by committing resources to finding more specific and accurate screening tests for typhoid, we may develop means to better identify cases in general, and also treat infections with greater specificity based on local strains, as opposed to the same treatment for all strains. As noted, treatment methods can also be made more effective if the public understands the importance of proper antibiotic use and if doctors adjust their attitudes to consider more sustainable ways to treat typhoid and to avoid contributing to new drug resistant strains of typhoid.
All of these solutions are on a micro-level, in that they look to address typhoid in the context of the patient/doctor relationship. However, the global typhoid crisis requires more comprehensive effort geared towards the societal factors that have aided in the proliferation of today’s typhoid crisis. Solutions must include development efforts to increase all of the following: clean food, clean water, hygiene infrastructure, functional sewage drainage systems, government disease surveillance, medical professionals, medical support staff, and adequate disease research laboratory facilities. This list is not exhaustive, as it must include all reforms and initiatives that improve living conditions and thereby make people stronger and better able to fight off typhoid and other diseases, that provide access to facilities for proper treatment in the case that they do contract typhoid fever, and eradicate the conditions that allow typhoid to thrive and spread. There is great potential for defeating this disease and ending this crisis, especially as people begin to realize that public health concerns are relevant globally, not just to the developing world. Notwithstanding the global relevance of typhoid, however, the treatment and prevention systems we create must address the disease in the setting in which our programs must be implemented: the developing world with its many barriers to success in this fight.
Endnotes
1 Robert Edelman, and Myron M. Levine, “Summary of an International Workshop on Typhoid Fever,” Reviews of Infectious Disease, 8, no. 3 (1928): 329-349.
2 C.B. Maitland, “Typhoid Fever Amongst the Natives of India,” BMJ: British Medical Journal, 2, no. 1921 (1789): 1214-5.
3 Robert Edelman, and Myron M. Levine, “Summary of an International Workshop on Typhoid Fever.”
4 W.B. Wherry, T.J. LeBlanc, L. Foshay, and R. Thomas, “The Treatment of Typhoid Fever with
Detoxicated Vaccine,”Journal of Infectious Diseases, 43, no. 3 (1928): 189-193; S. Watson Smith, Richard Taylor,and J.V. Pincus, “Immunization Against Typhoid,” BMJ: British Medical Journal, 2, no. 4013 (1937): 1139-1140.
5 Robert Edelman, and Myron M. Levine, “Summary of an International Workshop on Typhoid Fever.”
6 Richard B. Hornick, “Selective Primary Health Care: Strategies for Control of Disease in the Developing World, Typhoid Fever,” Reviews of Infectious Disease, 7, no. 4 (1985): 536-546.
7 Zulfiqar Bhutta, “Current Concepts in the Diagnosis and Treatment of Typhoid Fever,”
BMJ: British Medical Journal, 333, no. 7558 (2006): 78-82.
8 Encyclopedia Britannica Inc., “Typhoid Fever.” Accessed March 5, 2012.
9 C. Bell, and Alec Kyriakides, Salmonella: A Practical Approach to the Organism and Its Control in Foods, (Oxford: Blackwell Science, 2002).
10 Harriet L.P. Friend, “Typhoid Precautions,” American Journal of Nursing, 11, no. 9 (1911): 712-3.
11 Ibid.
12 Encyclopedia Britannica Inc., “Typhoid Fever.”
13 Ibid.
14 S.P. Luby, M.K. Faizan, S.P. Fisher-Hoch, A. Syed, E.D. Mintz, Z.A. Bhutta, and J.B. McCormick,
“Risk Factors for Typhoid Fever in an Endemic Setting: Karachi, Pakistan,” Epidemiology and Infection, 120, no. 2 (1998): 129-138; John Rice Miner, “The Incubation Period of Typhoid Fever,” Journal of Infectious Diseases, 31,no. 3 (1922): 296-301.
15 R.L. Huckstep, Typhoid Fever and Other Salmonella Infections, (Edinburgh: Livingstone, 1962).
16 Ibid.
17 Zulfiqar Bhutta, “Current Concepts in the Diagnosis and Treatment of Typhoid Fever.”
18 B. Rowe, E.J. Threlfall, and L.R. Ward, “Does Chloramphenicol Remain the Drug of Choice for Typhoid?,” Epidemiology and Infection, 98, no. 3 (1987): 379-383.
19 Ibid.
20 Ibid.
21 Ibid.
22 Stanley H. Osborn, and Edith A. Beckler, “Once a Typhoid Carrier, Always a Typhoid Carrier,” Journal of Infectious Diseases, 27, no. 2 (1920): 145-150.
23 Ibid.
24 Myron M. Levine, Catterine Ferreccio, Robert E. Black, Carol O. Tacket, and Rene Germanier, “Progress in Vaccines Against Typhoid Fever,” Reviews of Infectious Disease , 11, no. 3 (1989): S552-S567.
25 Pietro Mastroeni, and Duncan Maskell, Salmonella Infections: Clinical, Immunological, and Molecular Aspects, (Cambridge, UK: Cambridge UP, 2006).
26 Robert Edelman, and Myron M. Levine, “Summary of an International Workshop on Typhoid Fever.”
27 Myron M. Levine, Catterine Ferreccio, Robert E. Black, Carol O. Tacket, and Rene Germanier, “Progress in Vaccines Against Typhoid Fever.”
28 Ibid.
29 Ibid.
30 Eric Engles, Matthew Falagas, Joseph Lau, and Michael Bennish, “Typhoid Fever Vaccines: A Meta-Analysis of Studies on Efficacy and Toxicity,” BMJ: British Medical Journal , 316, no. 7125 (1998): 110-6.
31 Ibid.
32 Pietro Mastroeni, and Duncan Maskell, Salmonella Infections: Clinical, Immunological, and Molecular Aspects.
33 Ibid.
34 Eric Engles, Matthew Falagas, Joseph Lau, and Michael Bennish, “Typhoid Fever Vaccines: A Meta-Analysis of Studies on Efficacy and Toxicity”; Pietro Mastroeni, and Duncan Maskell, Salmonella Infections:Clinical, Immunological, and Molecular Aspects.
35 Eric Engles, Matthew Falagas, Joseph Lau, and Michael Bennish, “Typhoid Fever Vaccines: A Meta-Analysis of Studies on Efficacy and Toxicity.”
36 Ibid.
37 Ibid.
38 Richard B. Hornick, “Selective Primary Health Care: Strategies for Control of Disease in the DevelopingWorld, Typhoid Fever.”
39 Ibid.
40 Ibid.
41 Zulfiqar Bhutta, “Current Concepts in the Diagnosis and Treatment of Typhoid Fever”; Pietro Mastroeni, and Duncan Maskell, Salmonella Infections: Clinical, Immunological, and Molecular Aspects.
42 Pietro Mastroeni, and Duncan Maskell, Salmonella Infections: Clinical, Immunological, and Molecular Aspects.
43 Ibid.
44 Ibid.
45 Zulfiqar Bhutta, “Current Concepts in the Diagnosis and Treatment of Typhoid Fever.”
46 Ibid.
47 S.P. Luby, M.K. Faizan, S.P. Fisher-Hoch, A. Syed, E.D. Mintz, Z.A. Bhutta, and J.B. McCormick,
“Risk Factors for Typhoid Fever in an Endemic Setting: Karachi, Pakistan.”
48 Ibid.
49 Pietro Mastroeni, and Duncan Maskell, Salmonella Infections: Clinical, Immunological, and Molecular
Aspects.
50 Ibid.
51 Zulfiqar A. Bhutta, Shehla H Naqvi, Raza A. Razzaq, and Badr J. Farooqui, “Multi-Drug ResistantTyphoid in Children: Presentation and Clinical Features,”Reviews of Infectious Disease, 13, no. 5 (1991): 832-6.
52 Zulfiqar Bhutta, “Current Concepts in the Diagnosis and Treatment of Typhoid Fever.”
53 Zulfiqar A. Bhutta, Shehla H Naqvi, Raza A. Razzaq, and Badr J. Farooqui, “Multi-Drug Resistant
Typhoid in Children: Presentation and Clinical Features,”
54 Stella R. Quah, Crisis Preparedness: Asia and the Global Governance of Epidemics, (Stanford, CA:Walter H. Shorenstein Asia-Pacific Research Center, 2007).
55 R.L. Rasaily, P. Dutta, M.R. Saha, U. Mitra, M.T.J. Lahiri, and S.C. Pal, “Multi-Drug Resistant Typhoid Fever in Hospitalized Children: Clinical, Bacteriological, and Epidemiological Profiles,” European Journal of Epidemiology. 10, no. 1 (1994): 41-6,
56 Google Public Data Explorer, “World Development Indicators and Global Development Finance.” Last modified February 16, 2012. Accessed March 7, 2012. http://www.google.com/publicdata/explore?ds=d5bncppjof8f9_.
57 Stella R. Quah, Crisis Preparedness: Asia and the Global Governance of Epidemics; Google Public Data Explorer, “World Development Indicators and Global Development Finance.
58 Google Public Data Explorer, “World Development Indicators and Global Development Finance.”
59 Census of India, Office of the Registrar General & Census Commissioner, “Census of India – India at a Glance: Population Density.” Accessed March 7, 2012. http://censusindia.gov.in/Census_Data_2001/India_at_glance/density.aspx.
60 Ibid.
61 Ibid.
62 Richard B. Hornick, “Selective Primary Health Care: Strategies for Control of Disease in the Developing World, Typhoid Fever.”
63 John Stoeckel, “Infant Mortality Trends in Rural East Pakistan,” Demography, 7, no. 2 (1970): 235-240.
64 Zulfiqar Bhutta, “Current Concepts in the Diagnosis and Treatment of Typhoid Fever.”
65 The World Factbook, “India.” Last modified March 1, 2012. Accessed March 7, 2012. https://www.cia.gov/library/publications/the-world-factbook/geos/in.html; Population Association of Pakistan,
“Population Association of Pakistan – Statistics.” Accessed March 7, 2012. http://www.pap.org.pk/statistics/population.htm.
66 Stella R. Quah,Crisis Preparedness: Asia and the Global Governance of Epidemics.
67 The World Factbook, “India.”
68 Population Association of Pakistan, “Population Association of Pakistan – Statistics”; The World
Factbook, “Pakistan.” Last modified February 27, 2012. Accessed March 7, 2012.
https://www.cia.gov/library/publications/the-world-factbook/geos/pk.html.
69 S.P. Luby, M.K. Faizan, S.P. Fisher-Hoch, A. Syed, E.D. Mintz, Z.A. Bhutta, and J.B. McCormick,
“Risk Factors for Typhoid Fever in an Endemic Setting: Karachi, Pakistan.”
70 P.M.A Shanahan, K.A. Karamat, C.J. Thomson, and S.G.B Amyes, “Characterization of Multi-Drug Resistant Salmonella Typhi Isolated from Pakistan,”Epidemiology and Infection, 124, no. 1 (2000): 9-16.
71 R.L. Rasaily, P. Dutta, M.R. Saha, U. Mitra, M.T.J. Lahiri, and S.C. Pal, “Multi-Drug Resistant Typhoid
Fever in Hospitalized Children: Clinical, Bacteriological, and Epidemiological Profiles.”
72 Ibid.
73 Ibid.
74 Joseph P. Stoltman, John Lidstone, and Lisa M. Dechano, International Perspectives on Natural Disasters, (Dordrecht: Kluwer Academic, 2004).
75 Ibid.
76 Ibid.
77 Ibid.
78 Ibid.
79 Cramer, Brandon. Academic Program Pages at Evergreen, “Tsunami – India.” Accessed March 7, 2012. http://academic.evergreen.edu/g/grossmaz/cramerbd/.
80 Ibid.
81 Kiss, Tamas S. “Pakistan Floods Displace 3 Million.” The Budapest Report, August 4, 2010.
http://www.budapestreport.com/2010/08/04/pakistan-floods-displace-3-million/ (accessed March 7, 2012).
82 Cramer, Brandon, “Tsunami – India.”
83 Kaiser Family Foundation, “Study Examines Relationship Between Conflict, Rise In NTDs In Middle East, North Africa.” Last modified March 2, 2012. Accessed March 7, 2012. http://globalhealth.kff.org/Daily-Reports/2012/March/02/GH-030212-Conflict-NTDs-Middle-East.aspx?p=1.
84 Cramer, Brandon, “Tsunami – India.”
85 P.R. Chari, Pervaiz I. Cheema, and Stephen P. Cohen, Perceptions, Politics and Security in South Asia: The Compound Crisis of 1990, (New York: RoutledgeCurzon, 2003).
86 Ibid.
87 S.G. Kashikar, Dialogue with Pakistan, (New Delhi: India First Foundation, 2004).
88 P.R. Chari, Pervaiz I. Cheema, and Stephen P. Cohen, Perceptions, Politics and Security in South Asia: The Compound Crisis of 1990.
89 John Stoeckel, “Infant Mortality Trends in Rural East Pakistan.”
90 S. Akbar Zaidi, “Health Research in Pakistan,” Economic and Political Weekly, 30, no. 6 (1995): 307-8.
91 S.P. Luby, M.K. Faizan, S.P. Fisher-Hoch, A. Syed, E.D. Mintz, Z.A. Bhutta, and J.B. McCormick,
“Risk Factors for Typhoid Fever in an Endemic Setting: Karachi, Pakistan.”
92 World Health Organization: Global Health Observatory, “Pakistan: Health Profile.” Accessed May 18,
- http://www.who.int/gho/countries/pak.pdf.
93 World Health Organization: Global Health Observatory, “India: Health Profile.” Accessed March 7,
- http://www.who.int/gho/countries/ind.pdf.
94 S. Akbar Zaidi, “Health Research in Pakistan.”
95 Ibid.
96 Pietro Mastroeni, and Duncan Maskell, Salmonella Infections: Clinical, Immunological, and Molecular Aspects.
97 Ibid.
98 S. Akbar Zaidi, “Health Research in Pakistan.”
99 Ibid.
100 Ibid.
101 Ibid.
102 Ibid.
103 Ibid.
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