April 5, 2012 | The Atlantic
Controlling the Typhoid Epidemic Plaguing Sub-Saharan Africa
By Chris Nelson, director of the Coalition against Typhoid (CaT)
The Coalition against Typhoid was established to combat this neglected disease and advocate for the millions currently suffering from it.
Since early November 2011, there has been a surge of typhoid fever outbreaks in central and southern Africa, affecting children and adults alike. Unfortunately, it takes a series of outbreaks such as these in Zambia, Zimbabwe, and the Democratic Republic of Congo (DRC), to draw attention to this often-overlooked disease in a region plagued by many needs and few resources.
Typhoid outbreaks usually occur when common water and food sources become contaminated with infected human waste. Symptoms include high fever, flu-like symptoms, abdominal pain, constipation or diarrhea, and even death. According to the World Health Organization (WHO) approximately 21.6 million cases of typhoid occur each year, resulting in at least 200,000 deaths, mostly among school- and preschool-aged children.
The recent cases of typhoid fever reported in Zambia and Zimbabwe can be directly attributed to problems with water and sanitation. In Kikwit, DRC, typhoid is already highly endemic. However, contamination of a local water source caused cases to spike into the thousands, resulting in life threatening intestinal complications and death.
Apart from the illness, severe complications, and death that accompanies these typhoid outbreaks, disruptions of local water supplies interrupt the daily activities of entire communities and cities. Despite this large burden, typhoid has remained on the back burner of the global public health agenda, allowing the cycle of endemic disease and episodic outbreaks to continue, particularly in Africa.
To combat this neglected disease, the Coalition against Typhoid (CaT) was established to advocate for the millions of people suffering from typhoid fever who cannot speak for themselves. CaT supports research into next-generation typhoid vaccines and improved diagnostics and advocates for the use of effective vaccines that are already available and recommended by the WHO. Our members are also working with local governments to identify sustainable funding mechanisms for typhoid prevention and control programs, and to improve typhoid surveillance, especially in parts of sub-Saharan Africa where the typhoid burden is not well-documented.
Public awareness about typhoid and the areas where it is endemic is essential for effective disease control and prevention. To that end, researchers from CDC-Kenya have documented rates of endemic typhoid fever in urban Nairobi that, surprisingly, are comparable to those reported from urban slums in Asia, where the burden of typhoid was thought to be highest. Together with the recent outbreaks, these results from Kenya add to growing evidence of typhoid across Africa, from Ghana and Nigeria in the west to Ethiopia, Uganda, Malawi, Mozambique, and South Africa in the east and south.
Recent surveillance activities have also found that multi-drug-resistant (MDR) typhoid strains are widespread in Africa, in some areas exceeding 75 percent of all cases. Historically, typhoid has been treatable with antibiotics, but as MDR typhoid becomes more prevalent and widespread, new and more expensive antibiotics are required for treatment in order to prevent serious complications and increased risk of death.
Public health experts agree that a comprehensive approach is needed to effectively control typhoid. This includes providing safe water to the community; improving access to basic sanitation facilities; promoting proper hygiene, including hand washing and the safe preparation and consumption of food and drink; and typhoid vaccination. Improved surveillance and diagnostic tools are also needed to identify at-risk populations and prevent delays in treatment.
To date, typhoid control efforts have focused on Asia. Emerging evidence of high disease burden across sub-Saharan Africa will serve as the basis for developing a comprehensive and integrated typhoid prevention and control strategy for the region.
While recent improvements in typhoid surveillance are a step in the right direction, much more work is needed to increase general awareness and turn the tide against typhoid in Africa and in other parts of the world. This falls on the international global health community, including CaT and national governments, to develop and implement integrated typhoid control strategies and protect these vulnerable communities from typhoid fever and other diseases of poverty.
With Ciro de Quadros, executive vice president of the Sabin Vaccine Institute