LOOKING BACK WHILE MOVING FORWARD WITH ENTERIC FEVER SURVEILLANCE IN PAKISTAN. Dr. Farah Naz Qamar Assistant Professor, Pediatric Infectious disease, Aga Khan University, Pakistan 2 Outline • Overview • SEAP sites • Health care utilization survey • Defining catchment area • SEAP II results • Trends of AMR for typhoid • Summary 4/11/2017 4/11/2017 3 Overview of SEAP in Pakistan Phase 1 • Retrospective review of data • AKUH –2012-2014 • KGH –2014 Phase II • Prospective study • October 2016- September 2018 • AKUH, KGH, NICH, AKUH Lab Network 4/11/2017 5 SEAP II Pakistan Sites Aga Khan University National Institute of Hospital Child Health: • Inpatient • Surgical cases only – Medical – Surgical • AKUH Lab Network • Outpatient Blood Culture confirmed cases Kharadar General Hospital • Inpatient • Outpatient 4/11/2017 6 Phase II -Sites AKUH KGH NICH Aga Khan University Laboratory Network 4/11/2017 7 Enrollments SAPORT 4/11/2017 8 Health care utilization survey: Catchment Areas Aga Khan University Hospital (AKUH) • Culture proven cases (approx. 60% ) • Three towns • Gulshan-e-Iqbal, • Jamshed, and • Gulberg Kharadar General Hospital (KGH) • Febrile cases (approx. 60% ) • Three towns • Lyari town • Kharadar union council from Sadar town • Machar Colony and Baba Bhitt union council from Kemari Town 4/11/2017 9 AKUH Catchment Area 4/11/2017 10 KGH Catchment Area 4/11/2017 11 AKUH Catchment Area 4/11/2017 12 Health care utilization survey 4/11/2017 13 HCUS S# Town Total Clusters Total Households Number of Households from where Households Approached data collection refused for for Interview completed interview 1 Gulberg 14 Residential = 08 174 130 44 Non Residential = 04 2 Gulshan E Iqbal 80 Residential = 37 574 491 83 Non Residential = 43 3 Jamshed 28 Residential = 24 565 496 69 Non Residential = 04 4 Lyari 80 Residential = 53 1072 1005 67 Non Residential = 27 5 Kemari 40 Residential = 32 264 260 4 Non Residential = 08 Total 240 Residential = 154 2649 2382 267 Non Residential = 86 4/11/2017 14 RESULTS 4/11/2017 15 Enrollment Progress (October 17, 2016 – March 18, 2017) 4/11/2017 16 Cases of Ileal Perforation Site of Case # Enrollment Age Gender Outcome 1 NICH 12 years Female Recovered 2 NICH 5 years Female Recovered 3 NICH 7 years Female Died 4 NICH 7 years Male Recovered 5 NICH 5 years Male Recovered 6 NICH 12 years Male Recovered 7 NICH 7 years Male Recovered 8 NICH 12 months Male Recovered 9 NICH 8 years Male Recovered 10 NICH 4 years Female Recovered 11 AKU 15 years Male Recovered 4/11/2017 17 Comparison of Demographic Data 4/11/2017 18 Cases amongst children 0-5 Years 4/11/2017 19 Seasonality of Typhoid in Pakistan 90 84 r e Typhi Paratyphi 80 v 76 76 77 e 80 74 f 72 72 c i r 67 66 e 70 t 62 60 61 n 59 e 56 60 53 55 55 n 52 52 50 52 51 e 48 v 47 s 45 45 o 50 44 44 43 44 r e 41 41 s p 38 38 a 37 36 e c 35 r 40 32 32 31 33 33 u 30 30 t 28 29 29 28 l 25 25 27 26 u 30 24 23 24 23 24 24 c 22 20 f 19 18 19 17 18 o 16 20 14 r 13 e 9 9 10 b 10 m u N 0 l l l t t t r r r r c r c r c v v v y y y g g g n b p n b p n b p n n n u u u c c c a a a e e e a a a p p p o o o u u u a a a e e e e e e u u u J J J J J J J J J O O O F S F S F S A A A D D D A A A N N N M M M M M M 2012 2013 2014 4/11/2017 20 Trends of MDR Cases 2012-2017 4/11/2017 21 Trends of Ciprofloxacin Resistance Cases 2012-2017 4/11/2017 22 Summary • Typhoid fever is endemic in the region • High rates of MDR and fluoroquinolone resistance • Narrow therapeutic options • High rates of intestinal perforations • 80% of the cases are S. Typhi , even a monovalent vaccine will have an impact on disease control in Pakistan 4/11/2017 23 4/11/2017 24 Acknowledgements • Sabin Vaccine Institute • Pakistan SEAP Team • Tahir Yousufzai • Bill and Melinda Gates • Dr Sadia Shakoor Foundation • Dr Bushra Jamil • Dr Saqib Qazi • Dr Nasir Saddal • Scientific Advisory Process for Optimal Research on • Attaullah Baig Typhoid (SAPORT) • Dr Kahlid Pervaiz.