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Dr. Huma Arshad
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Dr. Huma Arshad

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  • 1. Vaccine preventable waterborne diseases—Typhoid fever and Hepatitis A
    Professor Huma Arshad Cheema
    Pediatric Gastroenterologist Hepatologist
    Chairperson PPA GI group
  • 2. Transmission of Hepatitis A and typhoid
    Faeco-oral transmission
    Ever increasing burden due to declining standards of hygiene
    Diseases of both rich and poor due to contaminated food handling and poor hand washing
  • 3. Ah the blessing of clean drinking water
  • 4. Where do we stand?
    >1 billion people worldwide don’t have access to safe drinking water
    Labeled as “the Silent Global Emergency” by WHO & UNICEF in their report of Aug 26, 2004
    Estimated that over two third of Pakistanis do not have access to clean drinking water
  • 5. Some facts
    Ranking 135th on the United Nation’s Human Development Index, Pakistan has a population of approximately 148 million, ranking 7th in the world, of whom half are children.
    Infant Mortality stands at 90 per 1,000 live births, and maternal Mortality at 340 per 100,000 live births (median estimates).
    In terms of health status, Pakistan faces a double burden: a rapidly increasing incidence of non-communicable diseases (NCDs) and injuries, superimposed on endemic communicable diseases (CDs).
  • 6. Priorities
  • 7. Forces we are up against
  • 8. The heavy price of conflict
  • 9. Price of natural and man made disasters
    Natural disasters, conflict, economic crisis and political turmoil have increased the vulnerability of thousands of children. In 2008 and 2009, conflict displaced some 1.6 million children
    Ongoing conflict in the north-west has displaced some 2 million people since 2008, with most displaced since April 2009. About a tenth of those displaced live in camps for internally displaced people. 
  • 10. Under-5 mortality rate (probability of dying by age 5 per 1000 live births)  
  • 11. 11
    What has been the impact of vaccines on public health?
    The 2 things man has done to improve health the most:
    Clean Water
    Vaccines
    The impact of vaccines has been tremendous since they were first used in the 1700s.
  • 12. 12
    Smallpox
  • 13. 13
    Smallpox Vaccine
    Last case: 1979
  • 14. 14
    Polio
    Last US case: 1979
  • 15. 15
    Measles
  • 16. 16
    Tetanus
  • 17. And now this
  • 18. Where are child death occurring?
    Eastern Mediterranean 14%
    Europe 2%
    Americas 4%
    Southeast Asia 30%
    Western Pacific 10%
    Africa 39%
    Developing countries: 99%
    Africa and Asia: 69%
  • 19. Public Health Priorities
  • 20. Hepatitis A
  • 21. Difference between life and death
  • 22. Some less understood facts about Hepatitis A
    Among different parts of the world there is a notable difference in the predominant manifestation of hepatitis A.
    The clinical presentation of childhood hepatitis A is more severe with poverty and poor sanitation 
    In less developed regions, HAV is the main etiological agent for pediatric acute liver failure. Many affectedchildren are in the preschool age bracket.
     
     
  • 23. In Turkey, HAV was the most common identifiable cause of pediatric fulminant hepatic failure, accounting 26% of cases
    In India, where the prevalence of HAV infection varies by geography and socio-economic class HAV infection was identified in 40–53% of cases of pediatric acute liver failure among cohorts from New Delhi, West Bengal and southern India
  • 24.
  • 25. At Children's Hospital lahore
    60 % of cases of fulminant hepatic failure were due to Hepatitis A with a mortality of 35%
    Morbidity from other complications underestimated
    - prolonged cholestatic syndrome
    - Hemolytic anemia both viral induced and G6PD deficiency induced
    - precipitation of autoimmune liver disease
    - Bone marrow aplasia
  • 26. Combined infections
    Co infection with Hepatitis A and S typhi seen increasingly at Children's
    Co infection of Hepatitis A and E also seen producing more severe illness and prolonged cholestasis
  • 27. Prevention is the Key
    Time to understand that the assumption that Hepatitis A is a harmless disease and vaccination is a luxury is false
    When the difference is between death and a thousand rupees the choice is obvious
  • 28. Similarities between the epidemiology of Hep A and Polio virus suggesting
    widespread vaccination of susceptible populations can substantially lower disease incidence
    Eliminate virus transmission
    Ultimately eradicate HAV
  • 29. Immunoprophylaxis
    Inactivated Hep A vaccine
    15 years of marketing experience
    Highly immunogenic
    Provides lasting protection in healthy individuals
    Generates protective levels of antibodies in patients with chronic liver disease or impaired immunity
  • 30. Vaccine
    Timing of booster dose not critical to effectiveness but in routine now booster is recommended
    Effective in curbing outbreaks of hepatitis A
    After completion of primary dosage antibodies last longer than 10 years and immune memory may last even longer
  • 31. Post exposure
    Effective postexposure due to rapid seroconversion and long incubation period
    Multiple studies show that contacts given vaccine within 14 days have equal or better protection than immunoglobulins
    Very young children < 1 yrs may still need immunoglobulins
  • 32.
  • 33. Where are the people dying from typhoid fever
  • 34. Typhoid Global Burden
    Burden probably underestimated
    Many hospitals lack facilities for blood cultures
    Up to 90% of patients are treated as outpatients
    Sporadic disease in developed countries - mainly in returning travelers
  • 35. Epidemiology of Typhoid Fever
    World wide
    Annual incidence of 12.5 M (WHO)
    Mortality rate: 600,000 deaths every year
    more than 90% of morbidity and mortality occurs in Asia.
    Incidence in developing countries
    100-1000 per 100,000 per year
    Population-based studies indicate that, contrary to previous views, the age-specific incidence of typhoid may be highest in children <5 yr of age, with comparatively higher rates of complications and hospitalization
  • 36. Typhoid in Pakistan
    As per a paper presented at the WHO 6th International Conference on Typhoid Fever and Other Salmonellas in 2004
    Typhoid is the 4th most common cause of death in Pakistan 9
    Source:
    9. Richens J. Typhoid fever, Surgery in Africa – Monthly Review; 2006 (World
    Health Organization. 6th International Conference on Typhoid Fever and
    other Salmonellas. 2006. Geneva, WHO.)
  • 37. Others
    (18.2%)
    S. typhi (42.8%)
    Strep. spp.
    (8.3%%)
    Staph. epidermis (10.8%)
    S. paratyphi (8.3%)
    E.coli (2.7%)
    Study Results of AKUH Karachi 11
    Hospital-based and other studies have indicated that typhoid fever is a serious problem among children in Pakistan:
    S. typhi found to be most common cause on bacterium among children dying with diarrhea at AKUMC.
    Spectrum of Paediatric blood culture isolates from AKUMC
    emergency services
  • 38. Causative Agent
    Salmonella typhi
    Flagellar antigen
    Capsular polysaccharideantigen (Vi)
    Somatic antigen
  • 39.
  • 40. Some Important practical clinical information
    Humans are the only natural reservoir of styphi
    Clinical presentation varies from mild disease to severe with high grade fever ,abdominal discomfort and complications
    Presentation more severe in infants and older patients
    Infants may have diarrhea and abdominal distension along with fever as the main symptom
  • 41. Some Important practical clinical information
    Classic stepladder rise of fever is now rare
    Severe rigors unusual
    Hepatomegaly more frequent than splenomegaly
    Mild Hepatitis with altered liver enzymes very common but frank hepatitis with jaundice rare
    Bronchitis a frequent accompaniment
  • 42. Deadly complications
    Intestinal Bleed
    Intestinal perforation
    Osteomyelitis
  • 43. 200 years old specimens of intestine from Hunterian museum of RCSE
  • 44. Typhoid Perforation and typhoid osteomyelitis
  • 45. Diagnosis
    First week --- and no previous antibiotic given the best yield is from a blood culture
    After 4 days the Typhidot test also becomes positive
    Widal test has notoriously high percentage of false positive and negative---rising titres over the days more diagnostic
  • 46. Treatment and the implications of Antibiotic ResistanceTHE SUPER BUGS
    Study of typhoid fever from 5 asian countries gives dismal news on antimicrobial resistance
    Nearly 60% of the isolates were resistant to chloramphenicol, ampicillin, TMP-SMX and nalidixic acid.
    In contrast, all isolates from sites in China and Indonesia were susceptible to all antimicrobial agents
  • 47. THE SUPER BUGS
    Multidrug resistance (resistance to chloramphenicol, ampicillin and TMP-SMX) was observed in 65% isolates from the site in Pakistan
    Nalidixic acid resistance was found in 59% isolates from the site in Pakistan,
  • 48. Disease Burden StudyAntibiotic resistance patterns
    No resistance against these antibiotics were found from China and Indonesia sites
  • 49.
  • 50. Treatment of enteric fever
    Choosing the right empirical therapy is problematic and controversial
    Increasing incidence of multiresistance to chloramphenicol Ampicillin and TMP- SMX in 49-83% of salmonella typhi is being reported from India
    Resistant strains are usually susceptible to third generation cephalosporins
    Quinolones are not to be used as first line
  • 51. WHO POSITION PAPER-2008
    In view of the continued high burden of typhoid fever and increasing antibiotic resistance, and given the safety, efficacy, feasibility and affordability of licensed vaccines , countries should consider the programmatic use of typhoid vaccines for controlling endemic disease.
  • 52. WHO POSITION PAPER-2008
    All typhoid fever vaccination programmes should be implemented in the context of other efforts to control the disease, including
    Health education, water quality
    Sanitation improvements,
    Training of health professionals in diagnosis and treatment.
  • 53. Current issues
    Very high incidence of this infectious and deadly disease in Pakistan
    Endemic all year round and incidence on the rise
    Multi drug resistant salmonella becoming a big health issue
    Significant cost of treatment and hospitalization.
  • 54. Typhoid dragon can be slain by prevention
  • 55. Prevention is the key
  • 56. Public Health Measures
    Supply of clean, safe drinking water
    Effective and sanitary disposal of human feces and urine
    Careful attention to cleanliness and hygiene during food preparation
    Provision of adequate hand washing facilities wherever food is handled
    Education in personal hygiene procedures and public health measures
    Enforced regulations governing manufacture of food and drink
  • 57. Vaccination ….
    Is the most effective and most reliable
    way of preventing typhoid fever.
  • 58. The Vi polysaccharide vaccine
    First licensed in the United States in 1994.
    Elicits a T-cell independent IgG response that is not boosted by additional doses.
    The target value for each single human dose is about 25μg of the antigen.
    The Vi vaccine does not elicit adequate immune responses in children aged <2 years.
  • 59. Schedule
    Only 1 dose is required, and the vaccine confers protection 7 days after injection.
    To maintain protection, revaccination is recommended every 3 years
    Can be co administered with other childhood vaccines
  • 60. Prevention is the need of the day
  • 61.
  • 62. Vision of equal opportunities
  • 63. Summary
    Ever increasing burden of infectious water borne diseases is a cause for alarm at all level
    Need to create public awareness about prevention through clean water , hand washing, better hygienic practices and vaccination
    Professional body of doctors needs to push the government to clamp down on food vendors and public eating places for enforcing standards of hygiene
  • 64. With availability of typhoid and hepatitis A vaccines at affordable prices there is no excuse for not vaccinating
    Culture of vaccination as a business should be discouraged in order to enroll and benefit more and more people
  • 65. Thank You!