Social and Economic Burden Associated With Typhoid Fever in Kathmandu and Surrounding Areas: A Qualitative Study.

Typhoid fever is a significant contributor to infectious disease mortality and morbidity in low- and middle-income countries, particularly in South Asia. With increasing antimicrobial resistance, commonly used treatments are less effective and risks increase for complications and hospitalizations. During an episode of typhoid fever, households experience multiple social and economic costs that are often undocumented. In the current study, qualitative interview data from Kathmandu and surrounding areas provide important insights into the challenges that affect those who contract typhoid fever and their caregivers, families, and communities, as well as insight into prevention and treatment options for health providers and outreach workers. When considering typhoid fever cases confirmed by blood culture, our data reveal delays in healthcare access, financial and time costs burden on households, and the need to increase health literacy. These data also illustrate the impact of limited laboratory diagnostic equipment and tools on healthcare providers' abilities to distinguish typhoid fever from other febrile conditions and treatment challenges associated with antimicrobial resistance. In light of these findings, there is an urgent need to identify and implement effective preventive measures including vaccination policies and programs focused on at-risk populations and endemic regions such as Nepal.

A Qualitative Study Investigating Experiences, Perceptions, and Healthcare System Performance in Relation to the Surveillance of Typhoid Fever in Madagascar.

BACKGROUND: The burden of typhoid fever (TF) in sub-Saharan Africa is largely unknown but is increasingly thought to be high, given that water and sanitary conditions remain unimproved in many countries. To address this gap in information, the Typhoid Fever Surveillance in Africa Program (TSAP) founded a surveillance system for TF in 10 African countries. This study was a component of the TSAP surveillance project in Madagascar. METHODS: The study entailed a qualitative assessment of patients' experiences and perceptions of services for febrile symptoms at the studies' rural and urban sentinel public health clinics. The study examined influences on the use of these facilities, alternative sources of care, and providers' descriptions of medical consultations and challenges in providing services. Data were collected through semistructured and open-ended individual interviews and a focus group with patients, caregivers, and medical personnel. RESULTS: Thirty-three patients and 12 healthcare providers participated in the data collection across the 2 healthcare facilities. The quality of services, cost, and travel distance were key factors that enabled access to and use of these clinics. Divergent healthcare-seeking patterns were related to variability in the care utilized, socioeconomic status, and potential distance from the facilities : These factors influenced delivery of care, patient access, and the health facilities' capacity to identify cases of febrile illness such as TF. CONCLUSIONS: This approach provided an in-depth investigation and understanding of healthcare-seeking behavior at the study facilities, and factors that facilitated or acted as barriers to their use. Our findings demonstrate the relevance of these public health clinics as sites for the surveillance of TF in their role as central healthcare sources for families and communities within these rural and urban areas of Madagascar.

Typhoid vaccine introduction: An evidence-based pilot implementation project in Nepal and Pakistan.

The World Health Organization (WHO) in 2008 recommended the use of currently licensed typhoid vaccines using a high risk or targeted approach. The epidemiology of disease and the vaccine characteristics make school-based vaccination most feasible in reducing typhoid disease burden in many settings. To assess feasibility of school-based typhoid vaccination, two districts in Kathmandu, Nepal and two towns in Karachi, Pakistan were selected for pilot program. Vaccination campaigns were conducted through the departments of health and in partnerships with not-for-profit organizations. In total 257,015 doses of Vi polysaccharide vaccine were given to students in grades 1-10 of participating schools. The vaccination coverage ranged from 39 percent (38,389/99,503) in Gulshan town in Karachi, to 81 percent (62,615/77,341) in Bhaktapur in Kathmandu valley. No serious adverse event was reported post vaccination. The coverage increased for vaccination of the second district in Pakistan as well as in Nepal. There was an initial concern of vaccine safety. However, as the campaign progressed, parents were more comfortable with vaccinating their children in schools. Supported and conducted by departments of health in Pakistan and Nepal, a school-based typhoid vaccination was found to be safe and feasible.

Uptake during an oral cholera vaccine pilot demonstration program, Odisha, India.

Approximately 30% of reported global cholera cases occur in India. In 2011, a household survey was conducted 4 months after an oral cholera vaccine pilot demonstration project in Odisha India to assess factors associated with vaccine up-take and exposure to a communication and social mobilization campaign. Nine villages were purposefully selected based on socio-demographics and demonstration participation rates. Households were stratified by level of participation and randomly selected. Bivariate and ordered logistic regression analyses were conducted. 517/600 (86%) selected households were surveyed. At the household level, participant compared to non-participant households were more likely to use the local primary health centers for general healthcare (P < 0.001). Similarly, at the village level, higher participation was associated with use of the primary health centers (P < 0.001) and private clinics (p = 0.032). Also at the village level, lower participation was associated with greater perceived availability of effective treatment for cholera (p = 0.013) and higher participation was associated with respondents reporting spouse as the sole decision-maker for household participation in the study. In terms of pre-vaccination communication, at the household level verbal communication was reported to be more useful than written communication. However written communication was perceived to be more useful by respondents in low-participating villages compared to average-participating villages (p = 0.007) These data on participation in an oral cholera vaccine demonstration program are important in light of the World Health Organization's (WHO) recommendations for pre-emptive use of cholera vaccine among vulnerable populations in endemic settings. Continued research is needed to further delineate barriers to vaccine up-take within and across targeted communities in low- and middle-income countries.

25 years after Vi typhoid vaccine efficacy study, typhoid affects significant number of population in Nepal.

Salmonella Typhi, first isolated in 1884, results in infection of the intestines and can end in death and disability. Due to serious adverse events post vaccination, whole cell killed vaccines have been replaced with new generation vaccines. The efficacy of Vi polysaccharide (ViPS) vaccine, a new generation, single-dose intramuscular typhoid vaccine was assessed in Nepal in 1987. However, despite the availability of ViPS vaccine for more than 25 years, Nepal has one of the highest incidence of typhoid fever. Therefore we collected information from hospitals in the Kathmandu Valley from over the past five years. There were 9901 enteric fever cases between January 2008 and July 2012. 1,881 of these were confirmed typhoid cases from five hospitals in the Kathmandu district. Approximately 70% of the cases involved children under 15 years old. 1281 cases were confirmed as S. Paratyphi. Vaccines should be prioritized for control of typhoid in conjunction with improved water and sanitation conditions in Nepal and in endemic countries of Asia and Africa.

Desirability for a typhoid fever vaccine among rural residents, Pemba Island, Tanzania.

BACKGROUND: Surveillance data indicate that Salmonella enterica serotype Typhi (S. Typhi) is a significant cause of morbidity and mortality in Africa. With limited anticipated short-term improvements in sanitation and water infrastructure, targeted vaccination campaigns may be an important prevention tool for typhoid fever. METHODS: A cross-sectional survey was conducted with 435 randomly selected households in four rural villages on Pemba Island, Tanzania. A dichotomous 'readiness to pay' variable was created to assess vaccine desirability. Data analyses included univariate and bivariate descriptive statistics and binary logistic regression. Bivariate outcomes (ANOVA, t-tests, and chi-square) and odds ratios with 95% confidence intervals are reported. RESULTS: A total of 66% respondents stated that they would pay for a typhoid fever vaccine in the future. Readiness to pay was not significantly associated with household expenditures. Readiness to pay was associated with use of local Primary Health Care Units (PHCUs) compared to use of cottage or district hospitals (OR 1.8 [95% CI, 1.2-2.7]: p=.007) and with knowledge of someone being sick from typhoid fever (OR 2.2 [95% CI, 1.0-4.5]: p=.039). Respondents perceiving prevention measures as more effective (OR 1.0 [95% CI, 1.0-1.2]: p=.009) were also more likely ready to pay. Preferred methods of communication of information about a typhoid fever vaccine included broadcasting via microphone ('miking'), radio, and door-to-door visits. CONCLUSIONS: With rapid increase in numbers of licensed and promising vaccines, policy makers and health administrators are faced with decisions regarding allocation of scarce health resources for competing interventions. Community residents need to be informed about diseases which may not be readily recognized, diagnosed, and treated. Perceived vulnerability to the disease may increase likelihood of vaccine desirability. A better local understanding of typhoid fever is needed for general prevention measures, increasing treatment access, and future vaccination campaigns.

Formative research and development of an evidence-based communication strategy: the introduction of Vi typhoid fever vaccine among school-aged children in Karachi, Pakistan.

The authors conducted formative research (a) to identify stakeholders' concerns related to typhoid fever and the need for disease information and (b) to develop a communication strategy to inform stakeholders and address their concerns and motivate for support of a school-based vaccination program in Pakistan. Data were collected during interactive and semi-structured focus group discussions and interviews, followed by a qualitative analysis and multidisciplinary consultative process to identify an effective social mobilization strategy comprised of relevant media channels and messages. The authors conducted 14 focus group discussions with the parents of school-aged children and their teachers, and 13 individual interviews with school, religious, and political leaders. Parents thought that typhoid fever was a dangerous disease, but were unsure of their children's risk. They were interested in vaccination and were comfortable with a school-based vaccination if conducted under the supervision of trained and qualified staff. Teachers and leaders needed information on typhoid fever, the vaccine, procedures, and sponsors of the vaccination program. Meetings were considered the best form of information dissemination, followed by printed materials and mass media. This study shows how qualitative research findings can be translated into an effective social mobilization and communication approach. The findings of the research indicated the importance of increasing awareness of typhoid fever and the benefits of vaccination against the disease. Identification and dissemination of relevant, community-based disease and vaccination information will increase demand and use of vaccination.

Utilization and accessibility of healthcare on Pemba Island, Tanzania: implications for health outcomes and disease surveillance for typhoid fever.

Salmonella enterica serotype Typhi (S. Typhi) was estimated to cause over 200,000 deaths and more than 21 million illnesses worldwide, including over 400,000 illnesses in Africa. The current study was conducted in four villages on Pemba Island, Zanzibar, in 2010. We present data on policy makers', health administrators', and village residents' and leaders' perceptions of typhoid fever, and hypothetical and actual health care use among village residents for typhoid fever. Qualitative data provided descriptions of home-based treatment practices and use of western pharmaceuticals, and actual healthcare use for culture-confirmed typhoid fever. Survey data indicate health facility use was associated with gender, education, residency, and perceptions of severity for symptoms associated with typhoid fever. Data have implications for education of policy makers and health administrators, design and implementation of surveillance studies, and community-based interventions to prevent disease outbreaks, decrease risks of complications, and provide information about disease recognition, diagnosis, and treatment.

Vaccine desirability during an effectiveness trial of the typhoid fever polysaccharide Vi vaccine in Kolkata India.

BACKGROUND: High rates of typhoid fever and the emergence of multi-drug resistant strains create a need for prevention efforts including vaccines. Socio-behavioral research can provide important data for participation in future trials and public health vaccination campaigns. DESIGN: A 3b phase clinical trial in Kolkata India including pre- and post-vaccination socio-behavioral surveys. RESULTS: 47.9% of respondents were male. Ward 29 respondents included 32.4% Hindu and Ward 30 respondents were 99.0% Hindu. Lower rates of participation were found among Muslim respondents and those with post high school education. Lack of information and negative information affected participation. Joint decision-making within households increased participation rates. METHODS: seven hundred households were randomly selected 503 respondents (71.85%) completed both the pre- and post-closed-ended surveys. Data analysis included descriptive statistics, Pearson's chi-square tests, independent t-tests, and stepwise logistic regression analysis. Four open-ended questions were included in the survey. These qualitative data were coded and reviewed for common themes and patterns. CONCLUSIONS: Individuals' decisions to participate or not participate in a vaccine trial entail a balance between individual beliefs, household dynamics and socio-political influences. Efforts prior to vaccination trials need to develop strategies which address potential underlying mediators for belief systems as well as structural factors which may reinforce individuals' beliefs and perceptions about vaccination trials.

Health care preferences for children with typhoid fever in two slum communities in Karachi, Pakistan.

This study examined health care preferences and influences in response to initial and persistent symptoms of typhoid fever among children in two slum communities in Karachi, Pakistan. Typhoid fever in this area is endemic and has a high rate of multi-drug resistantce. The study involved a household survey of 502 respondents. Private practitioners, including qualified medical specialists, were the preferred providers for initial symptoms, with government and private hospitals preferred for continuing symptoms. A number of cases continued to select initial health care choices regardless of the severity of symptoms. The findings point to factors of cost, access to care, previous use of a provider and perceived quality of care as key influences regarding health care choices. These findings suggest that cases of typhoid fever in these communities are at risk for not receiving appropriate diagnoses and treatment for children who are at risk for severe cases of multi-drug resistant disease. Suggestions are made for improving the care of children with typhoid in this context.

Differences in perception of dysentery and enteric fever and willingness to receive vaccines among rural residents in China.

BACKGROUND: Enteric diseases including dysentery and enteric fever remain significant public health problems in China. While vaccines offer great potential in controlling these diseases, greater understanding of factors influencing acceptance of vaccines is needed to create effective enteric disease control programs in rural China. DESIGN: Cross-sectional quantitative study with randomly sampled households from two sites in China, one experiencing high rates of shigellosis (Zengding) and the other of typhoid/paratyphoid (Lingchuan). METHODS: Sociobehavioral survey data were collected through face-to-face interviews from 501 respondents (56% female) in Zhengding regarding dysentery and 624 in Lingchuan (51% female) regarding enteric fever. Vaccine acceptability was measured by expressed need for vaccination and willingness to pay. Comparative and associative analyses were conducted to assess disease perception, vaccination service satisfaction, likelihood of improvements in water and sanitation, and vaccine acceptability. RESULTS: Nearly all respondents in Lingchuan considered enteric fever to be prevalent in the community, while only one half of the respondents in Zhengding considered dysentery to be problematic (p < 0.01). Nevertheless, more respondents in Zhengding were fearful that a household member would acquire dysentery than were Lingchuan respondents worried that a household member would acquire enteric fever (p < 0.01). Perceived vulnerability of specific subgroups (odds ratios ranging from 1.6 to 8.1), knowing someone who died of the disease (odds ratio reached infinity) and satisfaction with past vaccination services (odds ratios reached infinity) were consistently associated with perceived need for vaccines of target populations of all age groups while the association between perception of sanitary improvement and vaccine need was limited. Perceived need for a vaccine was associated with willingness to pay for the vaccine. CONCLUSIONS: Perceptions of enhanced vulnerability of specific subgroups to a disease and satisfactory experiences with vaccination services may increase the perceived need for a vaccine, leading to increased willingness to pay for vaccine. Vaccines are not perceived as important for the elderly.

The health belief model and factors relating to potential use of a vaccine for shigellosis in Kaeng Koi district, Saraburi province, Thailand.

Shigellosis is an important cause of morbidity and mortality throughout the world. Approximately, 1.1 million deaths occur a year due to this disease, making it the fourth leading cause of mortality worldwide. This paper explores local interest in and potential use of a vaccine for shigellosis in Thailand where Shigella poses an important public-health concern. Data for this study were collected during June-November 2002 from 522 subjects surveyed using a sociobehavioural questionnaire in Kaeng Koi district in central Thailand. The community demand and likely use of a vaccine were examined in relation to the Health Belief Model, which provides analytical constructs for investigating the multiple issues of local readiness to accept and access a new vaccine. As the key outcome variable, most respondents showed interest in receiving a vaccine against dysentery which they thought would provide useful protection against the disease. However, there was only a moderate number who perceived dysentery as serious and themselves as susceptible to it, although it was perceived to cause some burden to and additional expense for families. Most people identified a number of groups who were thought to be especially vulnerable to dysentery, such as the elderly, pre-school, and school-age children, and poor labourers. Other outcomes of the study included the identification of acceptable and convenient sites for its delivery, such as government health clinics and private clinics, and respected sources for information about the vaccine, such as health clinic personnel and community health volunteers. This information suggests that components of the Health Belief Model may be useful in identifying community acceptance of a vaccine and the means of introducing it. This health information is important for planning and implementing vaccine programmes.

A qualitative investigation of antiretroviral therapy among injection drug users.

Recent advances in antiretroviral therapy for HIV/AIDS have improved the quality of life and life expectancies of many with this fatal disease. Nevertheless, a significant proportion of individuals from disadvantaged groups, which traditionally have had difficulty accessing high-quality health care in the United States, have not benefited from these treatments. For example, injection drug users (IDUs), now a principal source of new cases of AIDS, have received antiretroviral therapy at significantly lower rates than other groups. Whereas numerous studies have described this group quantitatively, few studies have examined in depth the influences that lead to IDUs' problematic relationship with HIV/AIDS treatment. The study described here is based on a longitudinal survey of 516 IDUs. A quantitative analysis was conducted with 103 HIV-positive IDUs and an in-depth qualitative analysis was performed with a subsample of 34 HIV-positive IDUs. This paper presents findings on the consequences of antiretroviral therapy use and nonuse among these individuals, focusing on their perspectives regarding this treatment regimen. Findings suggest that problematic access to, and usage of, antiretroviral therapy is related to wider societal problems of drug abuse, access to health care and housing, and the social and historical divisions that impact the lives of IDUs and their communities. Efforts to improve the availability and the adherence to antiretroviral therapy among IDUs should involve these individuals as a critical component in the design of culturally appropriate and supportive health care services.

HIV risk behaviors in African-American drug injector networks: implications of injection-partner mixing and partnership characteristics.

AIMS: We explore the mechanisms by which 'partnership-level' variables--the mix of characteristics of individuals who inject drugs together--affect the incidence of HIV risk behaviors, including receptive syringe sharing, and facilitate or impede the spread of HIV. DESIGN: We apply multivariate analysis techniques to data on injection partnerships (pairs of individuals who inject drugs together) collected using a network sample of 401 African-American IDUs in Washington, DC. FINDINGS: Drug injectors tended to select injection partners of the same gender and similar age, but risk behaviors were most common in partnerships between individuals who are dissimilar in both gender and age. Partners who had a sexual relationship, injected drugs frequently together, smoked crack-cocaine regularly, injected speedball (heroin mixed with cocaine) regularly and/or had close social ties were more likely to engage in risky injection practices than otherwise similar partners. These factors account largely for the association between the gender-age mix of the partnership and injection risk behavior. CONCLUSIONS: Among African-American IDUs in Washington DC, partnership-level variables appear critical in the transmission of HIV.