Cardiac Involvement in Travelers with Enteric Fever

Enteric Fever with Intussusception, Myocardial Dysfunction, Encephalopathy, and Hemophagocytic Lymphohistiocytosis in an Indian Child

Enteric fever is an endemic disease in developing and low-middle income countries due to poor sanitation and hygiene. The majority of cases have mild symptoms and resolve with oral or intravenous antibiotics. However, multisystemic involvement due to enteric fever requiring intensive care is not uncommon and is associated with high mortality and morbidity. We report a 5-year-old boy from Mohali, Punjab, India with enteric fever who had fulminant course with several complications including transient intussusception, myocardial dysfunction, encephalopathy, and secondary hemophagocytic lymphohistiocytosis. He was treated with ceftriaxone, vasoactive drugs, mechanical ventilation, dexamethasone, and intravenous immunoglobulin and had favorable outcome despite life-threatening complications.

Global burden, trends and inequalities for typhoid and paratyphoid fever among children younger than 15 years over the past 30 years

BACKGROUND

Typhoid and paratyphoid fever, collectively known as enteric fever, are systemic infections caused by Salmonella enterica and are highly prevalent in children. We aimed to describe the global burden, trends and inequalities of enteric fever among children under 15 years from 1990 to 2019 based on data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019).

METHODS

In this secondary analysis of GBD 2019, we extracted data for incident cases, deaths and disability-adjusted life-years (DALYs) as measures of enteric fever burden. We estimated the average annual percentage changes (AAPCs) in enteric fever incidence, mortality and DALYs rate to quantify trends over time. Cross-country inequalities in enteric fever incidence were measured using the slope index of inequality and concentration index.

RESULTS

In 2019, the global cases of typhoid and paratyphoid were 4 833 282 and 1 793 172, respectively, both lower than those in 1990. On secondary analysis, paratyphoid incidence decreased at a faster rate than typhoid from 1990 to 2009, whereas the incidence of paratyphoid (AAPC = -3.78, 95% CI: -4.07, -3.49) declined slower than that of typhoid (AAPC = -4.32, 95% CI: -4.50, -4.13) from 2010 to 2019 (P < 0.05) at the global level. The incidence burden of enteric fever increased in Australasia (AAPC = 1.28, 95% CI: 0.77, 1.78) and Western Europe (AAPC = 0.77, 95% CI: 0.44, 1.11). Death and DALYs burden in low socio-demographic index (SDI) region showed a stable trend. A significant reduction in SDI-related inequality occurred, with the concentration index falling from -0.31 in 1990 to -0.22 in 2019.

CONCLUSIONS

The global disease burden of enteric fever and the magnitude of inequalities across countries have declined since 1990, but low SDI countries remain a region of concern. Travellers from Oceania and Western Europe to endemic regions should be particularly aware of the risk of enteric fever.

Travel vaccines-priorities determined by incidence and impact

BACKGROUND

Infectious disease epidemiology is continuously shifting. While travel has been disrupted by the COVID-19 pandemic and travel-related epidemiological research experienced a pause, further shifts in vaccine-preventable diseases (VPDs) relevant for travellers have occurred.

METHODS

We conducted a literature search on the epidemiology of travel-related VPD and synthesized data for each disease with a focus on symptomatic cases and on the impact of the respective infection among travellers, considering the hospitalization rate, disease sequela and case fatality rate. We present new data and revised best estimates on the burden of VPD relevant for decisions on priorities in travel vaccines.

RESULTS

COVID-19 has emerged to be a top travel-related risk and influenza remains high in the ranking with an estimated incidence at 1% per month of travel. Dengue is another commonly encountered infection among international travellers with estimated monthly incidence of 0.5-0.8% among non-immune exposed travellers; the hospitalized proportion was 10 and 22%, respectively, according to two recent publications. With recent yellow fever outbreaks particularly in Brazil, its estimated monthly incidence has risen to >0.1%. Meanwhile, improvements in hygiene and sanitation have led to some decrease in foodborne illnesses; however, hepatitis A monthly incidence remains substantial in most developing regions (0.001-0.01%) and typhoid remains particularly high in South Asia (>0.01%). Mpox, a newly emerged disease that demonstrated worldwide spread through mass gathering and travel, cannot be quantified regarding its travel-related risk.

CONCLUSION

The data summarized may provide a tool for travel health professionals to prioritize preventive strategies for their clients against VPD. Updated assessments on incidence and impact are ever more important since new vaccines with travel indications (e.g. dengue) have been licensed or are undergoing regulatory review.

Typhoid and paratyphoid fever: a clinical seminar

Rationale for review: Enteric fever (EF) caused by Salmonella enterica subspecies enterica serovar Typhi (Salmonella Typhi) and S. Paratyphi (Salmonella Paratyphi) remains an important cause of infectious morbidity and mortality in many low-income countries and, therefore, still poses a major infectious risk for travellers to endemic countries. Main findings: Although the global burden of EF has decreased over the past two decades, prevalence of EF remains high in Asia and Africa, with the highest prevalence reported from the Indian subcontinent. These statistics are mirrored by data on travel-related EF. Widespread and increasing antimicrobial resistance has narrowed treatment options for travel-related EF. Ceftriaxone- and azithromycin-based therapies are commonly used, even with the emergence of extremely drug-resistant typhoid in Pakistan. Preventive measures among locals and travellers include provision of safe food and water and vaccination. Food and water precautions offer limited protection, and the efficacy of Salmonella Typhi vaccines is only moderate signifying the need for travellers to be extra cautious. Recommendations: Improvement in the diagnosis of typhoid with high degree of clinical suspicion, better diagnostic assays, early and accurate detection of resistance, therapy with appropriate drugs, improvements in hygiene and sanitation with provision of safe drinking water in endemic areas and vaccination among travellers as well as in the endemic population are keys to controlling typhoid. While typhoid vaccines are recommended for travellers to high-risk areas, moderate efficacy and inability to protect against Salmonella Paratyphi are limitations to bear in mind. Improved Salmonella Typhi vaccines and vaccines against Salmonella Paratyphi A are required.