NURS 4115 – Week 3 Assignment – Epidemiology in Public and Global Health
As a society, we have come a long way in dealing with communicable or infectious diseases, such as the eradication of Polio, but in the case of other communicable diseases, we have not had the same success. The article by Chatham-Stephens et al. (2019) describes a 2018 outbreak of extensively drug-resistant salmonella typhi (XDR) in Pakistan; between November 2016 to September 2017, there were 339 cases of XDR, and in recent reports, this number went as high as 5,372 cases. This outbreak has also been reported in the United States with 29 cases of Salmonella Typhi (S. Typhi) and 5 cases of XDR reported of patients with recent travel history to Pakistan. This article describes a very serious issue with this disease which is a deterioration of treatment options. Initially, Salmonella Typhi became multi-drug resistant to the initial antibiotic regimen, which was chloramphenicol, ampicillin, and trimethoprim-sulfamethoxazole, which opened the door to the use of fluoroquinolones, but its increased ineffectiveness gave rise to the use of 3rd generation of cephalosporins (ceftriaxone) the preferred method to treat S. Typhi (Chatham-Stephens al et., 2019). Now the root of this recent outbreak is due to S. Typhi not reacting to this preferred line of treatment. This article describes that the antibiotics appropriate to treat XDR are the use of azithromycin for simple cases and carbapenems for serious or complex cases of S. Typhi or travellers who have recently been in Pakistan.
Salmonella Typhi is strictly a human disease that has a systemic effect in a person with symptoms ranging from fever, headache, abdominal pain, diarrhoea and slow heart rate (Qamar al., 2018). These authors state that according to the World Health Organization (WHO) globally, there is an estimated 21 million cases, with 222,000 deaths each year attributed to S. Typhi, with Asia being responsible for 90% of its morbidity and mortality cases. The causative agents are contaminated food or water. In the outbreak described by Qamar al. (2018) most of the 486 cases were centralized near sewerage lines where drinking water was getting infected.
Who is susceptible to Salmonella Typhi? According to Ahmedullah al et. (2018), people at high risk are immigrants or travellers to high-incidence areas of this disease. Another group at risk for S. Typhi is young people. Qamar al. (2018) pointed out that 92% of the 486 cases in their study were 15 years of age or younger, and over half of the cases, or 61%, involved males. All these cases were only susceptible to azithromycin and carbapenems. Young people being the main target was also shown in other studies done in West Bengal, India, from a different outbreak of this disease. As Qamar al et. (2018) points out, children are vulnerable to water and food-related illnesses outbreaks due to their immunity deficiency response and the difference in dosage-strength of antibiotics needed to fight these diseases as opposed to adults. The reason cannot be just poor immunity response places people at risk.
NURS 4115 – Week 3 Assignment – Epidemiology in Public and Global Health
Specific areas in which people in developing countries live, and their environment must play a crucial role. In Ted (2014), Dr Rishi Manchanda, an “upstream” who has focused on the many challenges of patients’ living conditions in southcentral Los Angeles, states that scientific knowledge shows a tremendous correlation between a person’s health and environmental conditions such as where a person lives and works which also is responsible for 60% of deaths that could have been avoided. He says that environmental conditions are twice more important as a person’s genetics. So, what is it in the environment of developing countries that allows such diseases as S. Typhi to flourish? De Alwis et al. (2018) describe how the constant increase of S. Typhi cases in Fiji could be explained in part by the Cyclone season, which extends from November to April and brings flooding by bringing water from rivers and cheeks.
Flooding gets intensified by Fiji’s people living in a low-level coastal environment which causes the overflow of septic tanks, consequently polluting drinkable water and the habitat. Not surprisingly, after cyclone Winston in April 2016, Fiji experienced an outbreak of S. Typhi in areas that are prone to this type of outbreak due to its environmental conditions. After identifying causal agents, susceptible people, and environmental factors, what can be done about it from a public health nurse’s perspective to deal with such an outbreak?
One strategy that a public health nurse can do is to educate healthcare providers and people at risk, such as travellers and stay updated on how to deal with the latest outbreaks of S. Typhi. As in the case of travellers, provide education on the need for pre-travelling vaccinations and, while at places like Pakistan, to follow strict food and water safe use such as drinking bottled water only and proper hand hygiene (Chatham-Stephens al et., 2019). According to this same article, travellers must look for medical care with the first signs of illness so cultures can be collected and antibiotics can be initiated in a timely manner to improve issues of morbidity and mortality. Make sure that providers treat returning travellers with appropriate lines of antibiotics, such as azithromycin and carbapenems, to ensure proper treatment and avoid the spread of the disease until susceptibility tests come back. As a health care provider, send patients with positive typhoid fever to the local health department so they can inform the Centers for Disease Control and Prevention and send the isolates to National Antimicrobial Resistance Monitoring System (NARMS) to test them for antimicrobial susceptibility.
NURS 4115 – Week 3 Assignment – Epidemiology in Public and Global Health
Locally, in these high-risk areas, a public health nurse can educate people on how to follow appropriate sanitation practices. A public health nurse could take the lead as an “upstream” and, as Dr Rishi Manchanda states in his video, bring up resources in different areas such as public health, politicians or whoever is interested in helping alleviate the problem (Ted, 2014). These resources would help with such issues as water sanitation, flooding issues, fixing sewage pipes, and possibly starting a free vaccine campaign since getting vaccinated against this disease is the best approach to preventing S. Typhi (Qamar al et., 2018). Also, locals would benefit from education on the improper use of antibiotics which leads to such issues as resistance to antibiotics. In places such as Southeast Asia, people do not need a prescription to obtain antibiotics; therefore, in Pakistan, through a systematic review, it was revealed that 9% of antibiotic usage was done without a prescription (Qamar al et., 2018). These same authors explain that the wrong use of antibiotics causes a reduction in normal flora found in the stomach which, consequently, provides the perfect environment for S. Typhi to thrive.
Outbreaks such as the one that originated in Pakistan spread all the way to the United States and could be contained by education and being aware of all potential consequences, such as becoming antibiotic resistant. The awareness and willingness of countries and their healthcare workers to get involved in containing this disease is the best tool to mitigate its devastation. Being aware of who and where people are at the most risk and what to do about it from the public nurse perspective is a must. Salmonella Typhi is a disease that arises from devastation and poverty. It needs everyone collaborating and being knowledgeable, from the U.S. traveller to the impoverished women in a remote area in Fiji. If Salmonella Typhi is left untreated, it will become an uncontrolled monster, and nothing will be able to stop it.
References
Abdullah, H., Khan, F. Y., Maslamani, M. A., Soub, H. A., Chacko, K., Khattab, M. A., … Deshmukh, A. (2018). Epidemiological and Clinical Features of Salmonella Typhi Infection Among Adult Patients in Qatar: A Hospital-based Study. Oman Medical Journal, 33(6), 468–472. https://doi-org.ezp.waldenulibrary.org/10.5001/omj.2018.87
Chatham-Stephens, K., Medalla, F., Hughes, M., Appiah, G. D., Aubert, R. D., Caidi, H., … Friedman, C. R. (2019). The Emergence of Extensively Drug-Resistant Salmonella Typhi Infections Among Travelers to or from Pakistan – United States, 2016-2018. MMWR: Morbidity & Mortality Weekly Report, 68(1), 11–13. https://doi- org.ezp.waldenulibrary.org/10.15585/mmwr.mm6801a3
de Alwis, R., Watson, C., Nikolay, B., Lowry, J. H., Vu Thieu, N. T., Van, T. T., … Ngoc, D. T. T. (2018). Role of Environmental Factors in Shaping Spatial Distribution of Salmonella enterica Serovar Typhi, Fiji. Emerging Infectious Diseases, 24(2), 284–293. https://doi- org.ezp.waldenulibrary.org/10.3201/eid2402.170704
Qamar, F. N., Yousafzai, M. T., Khalid, M., Kazi, A. M., Lohana, H., Karim, S., … Hasan, R. (2018). An outbreak investigation of ceftriaxone-resistant Salmonella enterica serotype Typhi and its risk factors among the general population in Hyderabad, Pakistan: a matched case-control study. Lancet Infectious Diseases, 18(12), 1368–1376. https://doi- org.ezp.waldenulibrary.org/10.1016/S1473-3099(18)30483-3
Stanhope, M. & Lancaster, J., 2016. Public health nursing: Population-centered health care in the community (9th ed.) St. Louis, MO: Elsevier TED. (2014). What makes us get sick? Look upstream. Retrieved from https://www.ted.com/talks/rishi_manchanda_what_makes_us_get_sick_look_upstream
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