Outbreak Investigation of Extensive Drug Resistant Typhoid Fever - Hyderabad, Pakistan 2017

  • Anti-microbial resistance
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Background:
Since 2016, Pakistan is experiencing the world’s largest outbreak of extensive drug resistant typhoid fever (XDR-TF). On 9th January 2017, Directorate General Health Services, Sindh received a report of 14 confirmed cases of XDR-TF from Hyderabad District. FELTP fellows were deputed to investigate the outbreak and implement control measures.

Methods:
A case was defined as, clinically diagnosed typhoid fever with culture confirmed Salmonella entericasero type-typhi; demonstrating resistance to first line drugs, fluoroquinalones and third generation cephalosporins, in a resident of District-Hyderabad between 10th November 2016 to 31st December 2017. Active case finding was carried out in the affected areas. A case control study was conducted. Controls were culture positive typhoid fever patients showing sensitivity to first line drugs from the same areas. Environmental assessment was done and water samples sent to Aga Khan University Hospital Lab for microbiological analysis.

Results:
Of total 1,378 suspected cases (465 by active case finding), 629 (46%) were confirmed XDR-TF, however 438 (69%) consented and were enrolled. Median age was four years (range 1-55 years) and 60% were males. Overall attack-rate was 2 per 10,000 population and the most affected age-group was 2-4 years (AR=11/10,000). Of the 438 cases 32% consumed water from community filter plants (aOR:3.6; 95%CI=2.4-5.4), 41% reported presence of open sewage lines around their house (aOR:3.0; 95%CI=2.2-4.3) and 39% reported dilapidated water lines in their neighborhood (aOR:2.9; 95%CI=2.1-4.1). Environmental assessment revealed pipelines with unauthorized punctures and leaks with illegal vacuum suction. Of the 55 water samples 12 were positive for Salmonella typhi DNA strands on PCR testing.

Conclusion:
Consumption of contaminated water was the most probable cause of the outbreak. Sewage contamination of drinking water contributed to the spread. Chlorination with repair of the filtration plants and supply lines was proposed. A typhoid-vaccination-campaign was started from August-2017.

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