Background Extensively drug resistant typhoid fever (XDR-TF) has been responsible for an ongoing outbreak in Pakistan, which began in November 2016. Objective This study aimed to determine the risk factors associated with XDR-TF. Methods This age- and sex-matched case-control study was conducted during May-October 2018 in Karachi. All patients with XDR-TF were identified from the laboratory-based surveillance system data. Cases included patients aged <15 years living in Karachi with culture-positive Salmonella enterica serovar Typhi with resistance to chloramphenicol, ampicillin, trimethoprim/sulfamethoxazole, fluoroquinolones, and third-generation cephalosporins. Age- and sex-matched controls included children free from the symptoms of TF, aged under 15 years, and residing in Karachi. All controls were recruited from among those who attended outpatient clinics. Results A total of 75 cases and 75 controls were included in this study. On univariate analysis, the odds of having XDR-TF were 13-fold higher among participants who used piped municipal water than among those who did not (odds ratio [OR] 12.6, 95% CI 4.1-38.6). The use of bore water was significantly associated with XDR-TF (OR 5.1, 95% CI 1.4-19.0). Cases were more likely to report eating French fries with sauce (OR 13.5, 95% CI 3.9-47.0) and poppadum (OR 3.4, 95% CI 1.7-6.7) from street vendors than controls. Boiling water at home was negatively associated with XDR-TF (OR 0.3, 95% CI 0.2-0.7). On multivariate analysis, 2 factors were independently associated with XDR-TF. Using piped municipal water (OR 10.3, 95% CI 3.4-30.4) and eating French fries with sauce from street vendors (OR 8.8, 95% CI 2.1-36.2) were significantly associated with an increased odds of XDR-TF. Conclusions Community water supply and street food eating habits were implicated in the spread of the superbug S typhi outbreak, which continues to grow in Karachi. Therefore, it is recommended to improve the community water supply to meet recommended standards and to develop a policy to improve the safety of street food. In addition, health authorities are required to conduct mass vaccination for TF among high-risk groups.
BACKGROUND Extensively Drug-Resistant Typhoid Fever (XDR-TF) was responsible for a continuing outbreak in Pakistan that began in November 2016. OBJECTIVE This study aimed to determine the risk factors associated with XDR-TF. METHODS Age and sex-matched case-control study (75 cases and 75 Controls) was conducted during May-October 2018 in Karachi. All patients with XDR-TF were identified from the lab-based surveillance system data. Cases were defined as patients aged < 15 years living in Karachi with culture positive Salmonella enterica serovar who are resistant to chloramphenicol, ampicillin, trimethoprim-sulfamethoxazole, fluoroquinolones and third generation cephalosporins. Age and sex-matched controls were defined as children free from symptoms of typhoid fever, under 15 years, and resident of Karachi. All controls were recruited from those attending outpatient clinics. RESULTS A total of 75 cases and 75 controls were included in this study. In the univariate analysis, the odds of having XDR-TF in participants who used piped municipal water were 13 times higher as compared to those who did not (OR=12.6, 95% CI: 4.1 – 38.6). Use of bore water was significantly associated with XDR-TF (OR=5.1, 95% CI: 1.4-19.0). Cases were more likely to report eating French fries with sauce (OR=13.5, 95% CI: 3.9 –47.0) and poppadum (OR=3.4, 95% CI: 1.7 – 6.7) from street vendors. Boiling water at home was negatively associated with with XDR-TF (OR=0.3, 95% CI: 0.2 – 0.7). In the multivariate analysis, two factors were independently associated with XDR-TF. Using piped municipal water (OR=10.3, 95% CI: 3.4 – 30.4) and eating French fries with sauce from street vendors (OR=8.8, 95% CI: 2.1 – 36.2) were significantly associated with increased odds of XDR-TF. CONCLUSIONS Community water supply and street vendor eating habits were implicated in the spread of the superbug S typhi outbreak that continues to grow in Karachi. Therefore, it is recommended to improve community water supply to meet recommended standards and develop a policy to improve safety of street food. In addition, health department should conduct mass vaccination in high-risk group against typhoid fever.
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