First day update - 9th International Conference on Typhoid and Invasive NTS disease - Bali, Indonesia

The first day of the 9^th International Conference on Typhpoid and Invasive NTS disease was very interactive. This conference has provided us with a tremendous learning opportunity the amount of work that has been put into understanding Typhoid fever and invasive non typhoid salmonesis.

The day stated with Florian’s (from IVI) talk that provided us the update that include challenges on TSAP project in Sub Saharan Countries. This was followed by Kashimira Date’s talk which also updated on Surveillance of Enteric Fever in Asia (SEFA) project (including in Nepal). I had chance to meet those involved in this project. CDC / GTA along with GON.

Namrata Prasad and  Aaron Jenkins talked on Fiji Typhoid fever study which included case control (CC) study in Fiji, 2014 and another study whose objective was to carve out determinants of typhoid fever in Fiji (multidisciplinary study). The interesting part was the assay work on Soil samples (from houses of cases) and also there was mention of localized behavior / household environments

Questions

• Urban vs. Rural  (what is the key criteria that differentiate U vs. R)
•  Geospatial analysis – water supply along with sanitation
•  Soil sample - how long do the organism last in the soil? (7 to 10 days??)
• Hand washing – behavior vs. education vs. introduction of bias??
• Reported vs. observed hand washing practices
• Does those sites selected (Africa / Asia) really represents the true picture?
•  Larger geographic sites – could be a greater effort
• Rapid assessment: cases – from all hospitals / age wise breakdown (? physician’s opinion/survey of sanitation led by governments/spotty / patchy distribution of typhoid fever in Africa (this is what they observed despite good lab facilities)
• Rapid assessment tool (RAT) - real challenges??
• Paratyphi
• 20 % of total Africa population
• Drug resistance – Ciprofloxacin
• Vaccine acceptability??

The second session started with a presentation from University of Jakarta on clinical and demographic characteristics of TF in Indonesia. The below are some of the key messages:

• 64 % TF in 3 – 19 yrs (Indonesia)
• 3.1 to 10.4% - mortality in hospitalized patients
• 2^nd important infectious diseases
• Less than 20 liter per day – cut off point

The second and third talks were on mathematical modeling. The first was more focused on the potential consequence of the H58 haplotype of Salmonella Typhii. The following are key messages:

• Patan Hospital study – KTM Nepal compared to Malawi study
•  Emergence of H58 haplotype
• Why is typhoid incidence increasing in Malawi?
• Bowles CC et al (in prep) – Patan hospital study
• Infectiousness/ R₀
• usually 4  weeks shedding of bacteria
• Transmission rate
• Better diagnostics needed
• Chronic carrier in the community   
• ? natural immunity and its role
•  Influx of susceptible migrant male workers form low incidence rural regions in the country

o   Increasing pop density

o   Cross immunity

The third study was from LSTM / University of Liverpool on modeling in relation to malaria / hiv / malnutrition. While the fourth talk was on Evaluation of a rapid real time molecular assay (S. typhi, paratyphi and S. spp.) from Foundation Merieux, France. The final talk was by Dr. Quadri on Typhoid in Bangladesh: from infection to protection. Some of the key points were on immune response in children (Ty21a) oral route and also about IgA / ALS

Questions:

• Widal tests
• Blood c/s

This was also a panel discussion to discuss challenges and approaches in measuring typhoid fever disease burden. The following points were key point discussed:

•  Research vs. public health mode – what is more important?
• Generalibility  of what so far we have scientific data
• Rapid Assessment approach – e.g. used for Pneumo vaccine introduction ( may be based on serology)
•  It seems – typhoid organism does not survive much in environment!!
• Shousun Szu – vaccination is important for protection
• Government’s role and opinion is important
• Importance of severity study is more study as government policy makers interests in mortality data
• Policy and global / local investment – data / data / data that represent across geography and age group
• Partnership across various groups / researchers
• HiB rat
• WHO: visibility of the disease – evidence / measures / advocacy

The discussion was followed by symposium on water, Sanitation and hygiene (WASH) interventions for enteric fever control. The key points that were discussed as follows:

• WASH interventions for enteric fever control ( a ppt. by Standard University)
• Linking typhoid transmission to the water distribution with water system
•  main factors for transmission
•  live change and your risk
• specific haplotypes circulation and how
• GPS mapping
• “Water quality in KTM is poor
• Typhoid fever, cholera and hepatitis
• Municipality water supply
• Surveillance will be the way we will control infectious disease / sort our antimicrobial resistance (AMR) 
• Why is the H58 lineage so successful? 
• S. Typhi in the Pacific region are generally island specifics
• Is this an opportunity for an eradication program?
• Bring a solution in front of Politician’s nose and hammer it

Open talk on cholera, Dr. Sack's question and Nepal - Part 2 of 6 parts series

This year also, we are hearing  reports of cholera outbreaks in Sub Saharan countries like Malawi, Mozambique and so on. I have been following these outbreaks closely through promedmail updates, however the only limitation that I personally feel is that I do not know first hand information of its seriousness in the local community. I love to hear those who have been engaged in its control and prevention especially those closely involved in Malawi vaccination. Reason after all, "seeing is believing" and this is true !! In this light, once I read an experience of a Nepali young doctor - Mr. Partha Bhurtel, who volunteered and served to care people in remote villages of Jajarkot during the tragedy called Jajarkot as a result of cholera outbreak that took lives of many unfortunates. When I read his real field experience as an opinion piece. Oh, it was heart touching. Once I read it - I have begun to question what is my purpose as a health professional? Nonetheless, we have to be objective and do our best from our part what we can do. Sometime we can do nothing but just pray. That is what it would be reasonable. You can read opinion piece : Dissecting the cholera outbreak in western Nepal  I take this story as a real public health endeavor at personal level very passionate. 

While getting shocked with real public health crisis of Jajarkot, I had a chance to read a recent blog post by Dr. David Sack in STOP CHOLERA JHU website: He ask a very important question: "How to handle the mismatch between actual needs and the practical use of current tools for cholera surveillance, prevention, and control?" Dr. Sack is asking a very practical question, which is the same question I also have in my mind. This is important when we go back in our memory line of Haiti and Jajarkot outbreaks. Well I have to be honest, I do not have a concrete answer but let us exercise our mind by asking: What is the real issue here? 

This real issue can be summarized in one question after it is several questions in long procession," Have we been successful in addressing this deadly disease called cholera in Africa, Asia and some Pacific islands especially during disasters?" Well I am not the right person to answer this "loaded" and "heavy" question, instead I would like to put forward opinions so let me link this question in a way that would make sense to Earthquake in Nepal. We faced an sudden and unexpected natural calamity of such magnitude that we are struggling with it. We are so far being tested so far of what nature Nepali people are built with be it physical and of course - social and moral integrity at this time of such despair. Anyway, we are fortunate that we are coping and dealing with the situation as it comes. However, it is one bitter truth that our disaster preparedness should be robust and now onward we have to hard work on it. This means this preparation must spreads across all faculties. People have started to question the government's very core of functioning. This is high time we act quick and adapt to the situation. Sure, the political landscape has to change. You may also say, we are talking about cholera and what in the world, we are talking about socio - political "connotations". Well, my understanding is that for any public health program including vaccine and vaccination - it has to convince the political and bureaucratic establishment, since they are the key decision body. This means - coming back to Dr. Sack's question - have we done better in this area of advocacy with those government, who need these vaccine. My opinion therefore is that we need to work hard to address the gaps in advocating OCV vaccine and its vaccination in a coordinated fashion, especially WHO, UNICEF, GAVI and other stakeholders like IVI, JHU - DOVE, We have to therefore act in unison rather than in a fragmented way. Here we can discuss more but i will halt here at this time.

However, we all also realize that Nepalese government has to remain vigilant and put its public health structure in order so we do not repeat the same situation that happened in Haiti some years ago. This is the key activity that should be put in place first, therefore disease surveillance utilizing the current system in place is the most important task. Should there arise the need for vaccination any threat of cholera, then we should think of vaccinating high risk population especially children. Importantly, we need to work with WHO to prepare for STOCKPILE mobilization from now on. For now, i would leave this post here. I think I would be in a better position to answer this question in next post based on "real field" experience like a somebody who has the same passion as Dr. Sack.

2nd May 2015