Dr. Huma Arshad


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Dr. Huma Arshad

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