Healthcare Utilization Patterns for Acute Febrile Illness in Bangladesh, Nepal, and Pakistan: Results from the Surveillance for Enteric Fever in Asia Project

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Enteric fever remains a public health concern in communities lacking sanitation infrastructure to separate sewage from drinking water. To bridge the gap until large-scale civil-engineering projects are implemented in high-burden countries, typhoid conjugate vaccine presents a promising disease-prevention technology. A new typhoid conjugate vaccine was prequalified by the World Health Organization in 2017 and is beginning to be introduced in countries around the world. To help inform vaccine introduction, the Surveillance for Enteric Fever in Asia Project (SEAP) conducts prospective enteric fever surveillance in Bangladesh, Nepal, and Pakistan. This supplement presents findings from Phase II of the study (2016–2019) on burden of disease, clinical presentation, the growing spread of drug-resistant strains, and policy and economic ramifications. These findings are delivered to support policymakers in their deliberations on strategies to introduce typhoid conjugate vaccine as a preventive tool against enteric fever.

Section: Results From 3 Years Of Hybrid Surveillance For Enteric Fevementioning

confidence: 99%

Introducing Typhoid Conjugate Vaccine in South Asia: Lessons From the Surveillance for Enteric Fever in Asia Project

Carter

Luby

Garrett

2020

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“…The proportion of households not home and thus unavailable to survey was 5.6% (1562 of 28 085), slightly higher in Kathmandu (5.8% [1090 of 18 694]) than in Kavrepalanchok (5.0% [472 of 9391]; P < .05 [ χ 2 test]). Healthcare utilization and other results from the survey are reported separately in this supplement [ 6 ].…”

Section: Resultsmentioning

confidence: 99%

“…Details of the overall SEAP methods, including the healthcare utilization survey, are described elsewhere in this supplement [ 6 ]. In brief, to adjust facility-based enteric fever rates for care-seeking behavior, a healthcare utilization survey was administered to households in each facility catchment area.…”

Section: Methodsmentioning

confidence: 99%

“…Once grids were created, we divided the population residing in each catchment area (2011 Nepal Demographic and Health Survey [ 7 ]) by the total number of clusters representing those areas to estimate the average number of households expected per cluster [ 10 ]. We used this number to calculate the number of clusters needed to reach sample size for each study facility catchment area, adjusted for expected intracluster correlation and resultant design effects [ 6 ]. We then took a simple random sample (nonweighted), using the sample function in R software, version 3.5.1.…”

Section: Methodsmentioning

confidence: 99%

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A Cluster-based, Spatial-sampling Method for Assessing Household Healthcare Utilization Patterns in Resource-limited Settings

Shakya

Adhikari

et al. 2020

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Background Implementation of population-based surveys is resource intensive and logistically demanding, especially in areas with rapidly changing demographics and incomplete or no enumeration of the underlying population and their residences. To remove the need for pre-enumeration and to simplify field logistics for the population healthcare utilization survey used for the Surveillance for Enteric Fever in Asia Project in Nepal, we incorporated a geographic information system–based geosurvey and field mapping system into a single-stage cluster sampling approach. Methods A survey was administered to ascertain healthcare-seeking behavior in individuals with recent suspected enteric fever. Catchment areas were based on residential addresses of enteric fever patients using study facilities; clusters were randomly selected from digitally created grids using available satellite images and all households within clusters were offered enrollment. A tablet-compatible geosurvey and mapping system that allowed for data-syncing and use in areas without cellular data was created using the ArcGIS suite of software. Results Between January 2017 and November 2018, we surveyed 25 521 households in Nepal (16 769 in urban Kathmandu and 8752 in periurban Kavrepalanchok), representing 84 202 individuals. Overall, the survey participation rate was 90.9%, with geographic heterogeneity in participation rates within each catchment area. Areas with higher average household wealth had lower participation rates. Conclusion A geographic information system–based geosurvey and field mapping system allowed creation of a virtual household map at the same time as survey administration, enabling a single-stage cluster sampling method to assess healthcare utilization in Nepal for the Surveillance for Enteric Fever in Asia Project . This system removed the need for pre-enumeration of households in sampling areas, simplified logistics and could be replicated in future community surveys.

“…We conducted a household-based healthcare utilization survey in both catchment areas [ 15 , 16 ]. In brief, we used grid-based random sampling to select geographic clusters, from which all households were approached.…”

Section: Methodsmentioning

confidence: 99%

Spatial Heterogeneity of Enteric Fever in 2 Diverse Communities in Nepal

Tamrakar

Vaidya

et al. 2020

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Background Typhoid fever is endemic in the urban Kathmandu Valley of Nepal; however, there have been no population-based studies of typhoid outside of this community in the past 3 decades. Whether typhoid immunization should be prioritized in periurban and rural communities has been unclear. Methods We performed population-based surveillance for enteric fever in 1 urban catchment (Kathmandu) and 1 periurban and rural catchment (Kavrepalanchok) as part of the Surveillance for Enteric Fever in Asia Project (SEAP). We recruited individuals presenting to outpatient and emergency departments at 2 study hospitals with suspected enteric fever and performed blood cultures. Additionally, we conducted a household survey in each catchment area to characterize care seeking for febrile illness. We evaluated spatial heterogeneity in febrile illness, care seeking, and enteric fever incidence. Results Between September 2016 and September 2019, we enrolled 5736 participants with suspected enteric fever at 2 study hospitals. Among these, 304 (5.3%) were culture positive for Salmonella Typhi (249 [81.9%]) or Paratyphi A (55 [18.1%]). Adjusted typhoid incidence in Kathmandu was 484 per 100 000 person-years and in Kavrepalanchok was 615 per 100 000 person-years. While all geographic areas for which estimates could be made had incidence >200 per 100 000 person-years, we observed spatial heterogeneity with up to 10-fold variation in incidence between communities. Conclusions In urban, periurban, and rural communities in and around Kathmandu, we measured a high but heterogenous incidence of typhoid. These findings provide some support for the introduction of conjugate vaccines in Nepal, including outside urban areas, alongside other measures to prevent enteric fever.