The Coalition Against Typhoid: Mobilizing a Community for a Global Fight.

Typhoid became a low priority on the global public health agenda when it was largely eliminated from developed countries in the 1940s. However, communities in South Asia and sub-Saharan Africa continue to bear the brunt of the disease burden. One strategy to increase attention and coordinate action is the creation of a coalition to act as a steward for typhoid. The Coalition against Typhoid (CaT) was created in 2010 with the mission of preventing typhoid among vulnerable populations through research, education, and advocacy. CaT successfully raised the profile of typhoid through convening the community with a biennial international conference that has experienced growing participation, disseminating data and news through a website and newsletter with increasing readership, and advocating through social media and a blog reaching a diverse audience. In 2017, CaT joined forces with the Typhoid Vaccine Acceleration Consortium to "Take on Typhoid," combining advocacy and communications efforts to mobilize researchers, clinicians, and decision makers at the global, regional, and local levels to introduce the new typhoid conjugate vaccine. As a result, the knowledge base, political will, and momentum are increasingly in place to implement prevention and control interventions including the typhoid conjugate vaccine in the poor communities that have historically been left behind.

Enteric Fever in Cambodia: Community Perceptions and Practices Concerning Disease Transmission and Treatment.

Enteric fever is a systemic bacterial infection in humans that is endemic in Cambodia and for which antibiotic resistance is increasingly reported. To guide public health programs, this qualitative study sought to explore community perceptions on transmission and treatment. Participant observation was carried out in hospital settings, pharmacies, and at a community level in Phnom Penh. In-depth interviews 39 and one focus group discussion were carried out with blood culture-confirmed enteric fever patients and purposively selected key informants. Informants were theoretically sampled based on initial themes identified using abductive analysis. Nvivo 11 was used for thematic coding. An urgent need to address health literacy concerning the transmission of enteric fever was identified, as lay informants did not link the disease and its symptoms to bacterial contamination of foods and drinks but rather to foods considered "bad" following humoral illness interpretations. As a result, lay informants considered recurrence of enteric fever preventable with appropriate dietary restrictions and Khmer traditional medicines. This study also reveals pluralistic health-care-seeking behavior. For initial and mild symptoms, patients preferred home treatment or traditional healing practices; limited household finances delayed treatment seeking. When symptoms persisted, patients first visited drug outlets or private practitioners, where they received a mix of nonessential medicines and one or more antibiotics often without prescription or confirmation of diagnosis. Inappropriate use of antibiotics was common and was related to diagnostic uncertainty and limited finances, factors which should be addressed during future efforts to improve the uptake of appropriate diagnostics and treatment of enteric fever.

A Qualitative Study Investigating Experiences, Perceptions, and Healthcare System Performance in Relation to the Surveillance of Typhoid Fever in Madagascar.

BACKGROUND: The burden of typhoid fever (TF) in sub-Saharan Africa is largely unknown but is increasingly thought to be high, given that water and sanitary conditions remain unimproved in many countries. To address this gap in information, the Typhoid Fever Surveillance in Africa Program (TSAP) founded a surveillance system for TF in 10 African countries. This study was a component of the TSAP surveillance project in Madagascar. METHODS: The study entailed a qualitative assessment of patients' experiences and perceptions of services for febrile symptoms at the studies' rural and urban sentinel public health clinics. The study examined influences on the use of these facilities, alternative sources of care, and providers' descriptions of medical consultations and challenges in providing services. Data were collected through semistructured and open-ended individual interviews and a focus group with patients, caregivers, and medical personnel. RESULTS: Thirty-three patients and 12 healthcare providers participated in the data collection across the 2 healthcare facilities. The quality of services, cost, and travel distance were key factors that enabled access to and use of these clinics. Divergent healthcare-seeking patterns were related to variability in the care utilized, socioeconomic status, and potential distance from the facilities : These factors influenced delivery of care, patient access, and the health facilities' capacity to identify cases of febrile illness such as TF. CONCLUSIONS: This approach provided an in-depth investigation and understanding of healthcare-seeking behavior at the study facilities, and factors that facilitated or acted as barriers to their use. Our findings demonstrate the relevance of these public health clinics as sites for the surveillance of TF in their role as central healthcare sources for families and communities within these rural and urban areas of Madagascar.

Formative investigation of acceptability of typhoid vaccine during a typhoid fever outbreak in Neno District, Malawi.

Typhoid fever affects an estimated 22 million people annually and causes 216,000 deaths worldwide. We conducted an investigation in August and September 2010 to examine the acceptability of typhoid vaccine in Neno District, Malawi where a typhoid outbreak was ongoing. We used qualitative methods, including freelisting exercises, key informant and in-depth interviews, and group discussions. Respondents associated illness with exposure to "bad wind," and transmission was believed to be airborne. Typhoid was considered extremely dangerous because of its rapid spread, the debilitating conditions it produced, the number of related fatalities, and the perception that it was highly contagious. Respondents were skeptical about the effectiveness of water, sanitation, and hygiene (WaSH) interventions. The perceived severity of typhoid and fear of exposure, uncertainty about the effectiveness of WaSH measures, and widespread belief in the efficacy of vaccines in preventing disease resulted in an overwhelming interest in receiving typhoid vaccine during an outbreak.

Pretravel health preparation among US residents traveling to India to VFRs: importance of ethnicity in defining VFRs.

BACKGROUND: International travelers visiting friends and relatives (VFRs) in lower income countries experience high rates of travel-related infections. We examined demographic characteristics and pretravel preparation practices among US residents traveling to India to determine factors that may contribute to higher infection rates and that would allow for improved prevention strategies. METHODS: A cross-sectional study was conducted among US residents traveling to India in departure areas for flights to India at three US international airports during August 2005. Eligible travelers were US residents going to India who were English speaking and >or=18 years. Self-administered questionnaires were used to assess knowledge of and compliance with pretravel health recommendations. RESULTS: Of 1,574 eligible travelers, 1,302 (83%) participated; 60% were male and the median age was 37. Eighty-five percent were of South Asian/Indian ethnicity and 76% reported VFR as the primary reason for travel. More than 90% of VFRs had at least a college education and only 6% cited financial barriers as reasons for not obtaining travel health services. VFRs were less likely than non-VFR travelers to seek pretravel health advice, to be protected against hepatitis A or typhoid fever, and less likely to be taking appropriate antimalarial chemoprophylaxis. However, when stratified by ethnicity, travelers of South Asian ethnicity were less likely than other travelers to adhere to pretravel health recommendations, regardless of VFR status. CONCLUSIONS: Similar to previous studies, VFR status was associated with pretravel health practices that leave travelers at risk for important infectious diseases. This association differed by ethnicity, which may also be an important marker of nonadherence to pretravel health recommendations. These findings have important implications for identifying at-risk travelers and properly targeting prevention messages.

Health care preferences for children with typhoid fever in two slum communities in Karachi, Pakistan.

This study examined health care preferences and influences in response to initial and persistent symptoms of typhoid fever among children in two slum communities in Karachi, Pakistan. Typhoid fever in this area is endemic and has a high rate of multi-drug resistantce. The study involved a household survey of 502 respondents. Private practitioners, including qualified medical specialists, were the preferred providers for initial symptoms, with government and private hospitals preferred for continuing symptoms. A number of cases continued to select initial health care choices regardless of the severity of symptoms. The findings point to factors of cost, access to care, previous use of a provider and perceived quality of care as key influences regarding health care choices. These findings suggest that cases of typhoid fever in these communities are at risk for not receiving appropriate diagnoses and treatment for children who are at risk for severe cases of multi-drug resistant disease. Suggestions are made for improving the care of children with typhoid in this context.

Trial participation and vaccine desirability for Vi polysaccharide typhoid fever vaccine in Hue City, Viet Nam.

OBJECTIVES: To identify demand for Vi typhoid fever vaccine for school-age children; obstacles and enabling factors for vaccine delivery; and socio-behavioural factors associated with trial participation and possible predictors of future vaccine acceptance, in Hue City, Viet Nam. METHODS: Pre- and post-trial surveys of randomly selected households with children aged 6-17 years. Simple multinomial logistic analyses for ratios of relative risks (RRR) and significance on trial participation by demographics and variables related to typhoid fever, vaccination, and pre-trial experiences with information and consents. Multiple logistic regressions to assess differences in participation based on child's characteristics. RESULTS: As many as 62.6% of households let all school age children participate, 10.2% let some participate, and 26.8% let none of their children participate in the trial. Factors associated with all children participating included past use of healthcare facilities (RRR, 0.45; 95% CI, 0.24-0.83), knowledge of vaccines (RRR, 0.17; 95% CI, 0.03-0.86), and perceived causes of typhoid fever (RRR, 0.90; 95% CI, 0.81-0.99). Factors associated with some children participating included utilization of healthcare facilities (RRR, 0.08; 95% CI, 0.01-0.66) and perceived severity of typhoid fever (RRR, 0.64; 95% CI 0.46-0.88). Participation was associated with satisfaction regarding pre-vaccination information and consent procedures. Children and adolescents were active decision-makers. Only 14 of 461 (2.2%) respondents would not use the Vi vaccine in the future for their child(ren). CONCLUSIONS: Inter-related factors contribute to participation in a clinical vaccine trial, which may differ from desire to participate in a public health campaign. Educational campaigns need to be targeted to children and adolescents, and consideration for assent procedures for minors. Obtaining informed consent may affect trial participation within a social and political system unaccustomed to these procedures.

Adults' perceived prevalence of enteric fever predicts laboratory-validated incidence of typhoid fever in children.

This study was undertaken to develop a model to predict the incidence of typhoid in children based on adults' perception of prevalence of enteric fever in the wider community. Typhoid cases among children, aged 5-15 years, from epidemic regions in five Asian countries were confirmed with a positive Salmonella Typhi culture of the blood sample. Estimates of the prevalence of enteric fever were obtained from random samples of adults in the same study sites. Regression models were used for establishing the prediction equation. The percentages of enteric fever reported by adults and cases of typhoid incidence per 100,000, detected through blood culture were 4.7 and 24.18 for Viet Nam, 3.8 and 29.20 for China, 26.3 and 180.33 for Indonesia, 66.0 and 454.15 for India, and 52.7 and 407.18 for Pakistan respectively. An established prediction equation was: incidence of typhoid (1/100,000= -2.6946 + 7.2296 x reported prevalence of enteric fever (%) (F=31.7, p<0.01; R2=0.992). Using adults' perception of prevalence of disease as the basis for estimating its incidence in children provides a cost-effective behavioural epidemiologic method to facilitate prevention and control of the disease.

Differences in perception of dysentery and enteric fever and willingness to receive vaccines among rural residents in China.

BACKGROUND: Enteric diseases including dysentery and enteric fever remain significant public health problems in China. While vaccines offer great potential in controlling these diseases, greater understanding of factors influencing acceptance of vaccines is needed to create effective enteric disease control programs in rural China. DESIGN: Cross-sectional quantitative study with randomly sampled households from two sites in China, one experiencing high rates of shigellosis (Zengding) and the other of typhoid/paratyphoid (Lingchuan). METHODS: Sociobehavioral survey data were collected through face-to-face interviews from 501 respondents (56% female) in Zhengding regarding dysentery and 624 in Lingchuan (51% female) regarding enteric fever. Vaccine acceptability was measured by expressed need for vaccination and willingness to pay. Comparative and associative analyses were conducted to assess disease perception, vaccination service satisfaction, likelihood of improvements in water and sanitation, and vaccine acceptability. RESULTS: Nearly all respondents in Lingchuan considered enteric fever to be prevalent in the community, while only one half of the respondents in Zhengding considered dysentery to be problematic (p < 0.01). Nevertheless, more respondents in Zhengding were fearful that a household member would acquire dysentery than were Lingchuan respondents worried that a household member would acquire enteric fever (p < 0.01). Perceived vulnerability of specific subgroups (odds ratios ranging from 1.6 to 8.1), knowing someone who died of the disease (odds ratio reached infinity) and satisfaction with past vaccination services (odds ratios reached infinity) were consistently associated with perceived need for vaccines of target populations of all age groups while the association between perception of sanitary improvement and vaccine need was limited. Perceived need for a vaccine was associated with willingness to pay for the vaccine. CONCLUSIONS: Perceptions of enhanced vulnerability of specific subgroups to a disease and satisfactory experiences with vaccination services may increase the perceived need for a vaccine, leading to increased willingness to pay for vaccine. Vaccines are not perceived as important for the elderly.

Mild acute inflammatory stimulation induces transient negative mood.

OBJECTIVE: This study aims to assess the mood changes induced by mild acute inflammatory stimulation (typhoid vaccination). METHODS: Using a double blind study design, 26 healthy volunteers underwent baseline assessments of mood, financial strain and work stress and were randomised to injection of Salmonella typhi vaccine or placebo injection. Mood, symptoms and body temperature was assessed by a modified version of the Profile of Mood States at 1, 2, 3, 4, 6 and 8 h post injection. RESULTS: Typhoid vaccination induces no increases in physical symptoms or temperature. Mood improved over the day in the placebo but not in the vaccine condition. Negative changes in mood following injection were correlated with chronic stress (financial strain) in the vaccination condition (r=-.65, P<.025). CONCLUSION: A mild acute inflammatory stimulus induces transient negative mood, and responses were modulated by chronic stress. Implications for depressed mood in physical illness are discussed.

Fregoli syndrome: a rare persecutory delusion in a 17 year old sufferer of psychosis associated with typhoid fever at Jos University Teaching Hospital, Jos, Nigeria.

This paper describes a rare delusional disorder, the Fregoli syndrome, in a 17 year old girl who suffered from typhoid psychosis as seen at the Psychiatric Unit of the Jos University Teaching Hospital, Jos.

Typhoid spine: somatic versus psychosomatic diagnosis in Osler's time.

OBJECTIVE: To review the history of typhoidal spondylitis as a paradigm of conflicts between medical and psychiatric diagnoses. METHODS: Because William Osler was the principal advocate for a psychogenic cause of this disease, all of his relevant writings are reviewed together with pertinent psychiatric concepts of the late 19th century, as well as the relevant bacteriologic and clinical research. RESULTS: Bacteriologic research had advanced sufficiently by 1903 that "typhoid spine" could be proved an osteomyelitis. Nevertheless, the belief that at least some cases were manifestations of a traumatic neurosis analogous to "railway spine" persisted, the trauma having been the acute typhoid infection. The last vestiges of this concept were represented by Osler's article of 1919. CONCLUSIONS: Osler's 25 year struggle to understand typhoidal spondylitis is an example of the persistent tendency of physicians to attribute a psychologic cause to a syndrome, often pejoratively, because of the absence of a sufficient pathophysiologic explanation or reluctance to acknowledge a new concept.

[The functional status of the body and work capacity of convalescent patients after typhoid fever]. / Funktsional'noe sostoianie organizma i rabotosposobnost' rekonvalestsentov posle briuushnogo tifa.

Convalescents (168 patients) who went through typhoid and 48 sound men (control group) were examined in order to study their clinical and physiological indices, mental and performance capabilities. At the end of inpatient treatment the complete normalization of functional state was marked only in group 1 (convalescents after abortive typhoid). In 96% of patients who went through slight form of disease (group 2) and middle-severe form (group 3) different disorders of functional state of organism were marked. One week after medical rehabilitation the number of convalescents who needed the continuation of rehabilitation treatment has decreased 50% in the 2nd group, after 2 weeks--up to 35%, after 3 weeks there were no changes. In the 3rd group at the end of the 1st week functional disorders were marked in 85% of patients, after 2 weeks--in 35%, after 3 weeks--in 13.8%, after 4 weeks--in 2.5%.

[Typhoid fever with intestinal hemorrhage, drug-induced fever, DIC, ARDS and psychiatric disorder (a case report)].

A 40-year-old poor nutritional Japanese male was admitted to our hospital on June 5, 1989, with a 31-day history of fever. He had been working as a crew member of a ship in South East Asia. Salmonella typhi was isolated from his blood culture. In the course of the disease, intestinal hemorrhage, drug-induced fever and liver dysfunction, DIC, ARDS, and psychiatric disorder were identified. Intestinal hemorrhage occurred after the coagulation test became normal, so it was thought that the intestinal hemorrhage did not correlate with DIC. The patient was treated with CP, ABPC and supportive therapy. He became well, and ARDS and psychiatric disorder were disappeared. He was discharged on the 118th day of illness. Drug-induced fever was thought as one of the allergic reaction and the causative drug was not identified by LST. It was suspected that psychiatric disorder correlated with poor nutrition. Supportive therapy such as mandatory bed rest, intravenous hyperalimentation and low-volume blood transfusions, as well as an antimicrobial treatment were important for the inhibition of shock and/or intestinal perforation.