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SOCIAL MEDICINE PROJECT
SOCIALLY SIGNIFICANT DISEASE
TYPHOID – KOLKATA, WEST BENGAL, INDIA
PRIYANKA PANCHOLI – 20E

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CONTENTS

– Demographics
– History and Health Care
– What is Typhoid?
– Etiology
– Symptoms
– Diagnosis
– Health Determinants
– History of the Disease
– Prevention
– Treatment
– References

DEMOGRAPHICS

Kolkata, formally known as Calcutta, is the capital city of the Indian state of West Bengal; and former capital of British India. Kolkata is located on the east bank of the Hooghly River and is the second largest city in India, after Mumbai. In 2011, it had a population of 4.497 million, making it the 7th most populous city in India. According to the 2011 census, the population of West Bengal overall was 91,276,115. The ratio of males to females in West Bengal was 46,809,027 and 44,467,088 respectively. 1
The average literacy rate is 86.31% in total in Kolkata city, which is higher than the Indian average of 74%. The male literacy rate on average is 4% higher than females. The literacy rate is approximately the same as the global rate, which is quite high and is an indication that Kolkata is developing. Hinduism represents the largest religion in the city making up 76.51% of the population. Islam is second with 20.60% of the population. Christianity, Jainism, Sikhism and Buddhism all follow at less than 1% each. 2
There are three types of population: stationary (a population pyramid showing an unchanged pattern of fertility and mortality), progressive pyramid (high birth and death rate) and regressive pyramid (low birth and mortality rate). Kolkata appears to have a stationary population, as shown in the pyramid below. 3 Birth and death rates seem to be on the same level, so the population size doesn’t change much. Males and females are generally equal at all ages. 

According to the demographic tradition model, West Bengal was previously in stage 1 till 1961, with very high birth and death rates, leading to a high population growth. In the next 10-30 years following, death rates dropped faster than birth rates, leading to a rapid population growth and the state reached stage 2 of the DTM. Since the 1990’s, due to an improvement in infant and maternal mortality rates there has been a decrease in birth rates and death rates, taking it to stage 3. There are predictions of a demographic balance and stability in West Bengal in the years leading up to 2025. 4

HISTORY AND HEALTHCARE

Health care in Kolkata is much better than many other cities in India. The healthcare system in Kolkata consists of 48 government hospitals, the majority of which are under the Department of Health and Family Welfare, Government of West Bengal and 366 private medical establishments during 2010. 5
According to the National Family Health Survey taken in 2005 only a small portion of households are covered by any form of health insurance. The total fertility rate is calculated by the (number born divided by the number of women aged 14-49) multiplied by 1000. In India overall it is 2.4 and in West Bengal it is 1.8. In Kolkata the total fertility rate is 1.4, which is the lowest among the cities surveyed. In Kolkata 77% of the married women use contraception, which is the highest among the cities that were surveyed; however the use of modern contraceptive methods is very low, at 46%. The infant mortality rate (IMR) is the the number of deaths in the first year of life divided by the number of live births, multiplied by 1000. The IMR in Kolkata is 41 per 1000 live births.
The WHO scale of birth rate is categorised into two: by low birth rate and high birth rate. Low is classed as less than 15% and high is above 25%. In West Bengal, in 2001 the birth rate was 20.5 and in 2015 it was 15.5. This is a significant decrease and is almost classed as low now.

There are many reasons why people are getting sick and dying in West Bengal. Among the main are tuberculosis, respiratory infections, diarrhoeal and nutritional diseases. Others include tetanus, meningitis, hepatitis and maternal conditions. Non communicable diseases that occur are cardiovascular diseases, cancer, diabetes and epilepsy. 6
Approximately 30% of woman and 18% of men in Kolkata are obese. A large proportion of people suffer from diseases such as diabetes and asthma. Tropical diseases like malaria, dengue and chikungunya are prevalent in Kolkata, although their incidence is decreasing.

Prevalence is the proportion of cases in the population (new and old) at a given time and indicates how widespread the disease is. Incidence is more related to only new cases, and looks at the risk of contracting the disease.

WHAT IS TYPHOID?

Typhoid is one of the leading causes of morbidity and mortality across the world. Typhoid fever is a serious illness, potentially fatal if left untreated, and is caused by a bacteria called Salmonella typhimurium. The bacteria resides in the intestines and bloodstream of humans. It spreads between individuals via direct contact with the faeces of an infected person. Animals can’t carry the disease, so transmission is always human to human. From the bloodstream, it spreads to other tissues and organs. The host’s immune system can not do much to fight back because the bacteria can live within the cells, unable to be destroyed by the immune system.
Typhoid fever is common in developing countries and affects about 12.5 million people a year.
It is more prevalent in areas where hand-washing is less frequent – in non-industrialised countries.
The infection can be transmitted through contaminated food and drinking water. It can also be passed on by carriers who are not aware they are carrying the bacteria and will experience no symptoms. Annually, there are around 5,700 cases in the United States, and 75% of these begin during international travelling. Globally, approximately around 21.5 million people a year contract typhoid. 7

An epidemic is an outbreak of disease that attacks many people at the same time and can spread through communities. Pandemics are when an epidemic spreads throughout the world.
Typhoid Fever is an example of a recurring epidemic. It is an infectious disease that can spread rapidly to many people; and is not a global disease outbreak. One of the biggest typhoid fever epidemics of all time broke out between 1906 and 1907 in New York, where 10,771 people passed away annually. In 1914 a vaccine was licensed and an antibiotic treatment became available in 1948. Now, typhoid is rare in the United States, however it still has the ability to spread through direct contact with infected people. 8

ETIOLOGY

Typhoid is caused by the bacteria S. typhi and spread through foods, drinks and drinking water that are contaminated with infected fecal matter. If contaminated water is used to wash groceries, it can further spread it, faster. Some people can be asymptomatic carriers which means they carry the bacteria but show no symptoms. Other people can harbour the bacteria after their symptoms have gone. Sometimes, the disease can reappear. Those who are positive when tested as carriers may not be allowed to work with children or older people until medically tested clear. 7

SYMPTOMS

Symptoms can range from mild to severe, depending on the individual. They include a high fever, diarrhoea and vomiting, headache, loss of appetite and gastrointestinal problems. The symptoms can appear from 3 days to 3 months later; but onset of illness usually occurs 1-3 weeks after exposure. 9 Other common symptoms that arise are muscle aches, a rash, exhaustion and confusion. If left untreated, the later effects will get worse and there can be life-threatening complications. It can then take weeks or even months to fully recover, and there is still the risk that symptoms can return again. 10

DIAGNOSIS

The doctor is likely to suspect typhoid based on the above symptoms and by observing medical and travel history. The diagnosis is usually confirmed by identifying the presence of the bacteria in a culture of blood, stool, urine or taking a bone marrow sample (the most sensitive test). The sample encourages the growth of S. typhi and then examined under a microscope. Other testing methods include detecting antibodies to typhoid bacteria in the blood; or a test that checks for typhoid DNA in the blood. 11
In medical diagnosis, test sensitivity is the ability of a test to correctly identify those with the disease (true positive rate). Whereas test specificity is a true negative rate – the ability of the test to correctly identify those without the disease.

HEALTH DETERMINANTS

There are four classes for social determinants of health: genetic/biological, environmental, lifestyle (making up 50%) and healthcare systems. These are different factors that affect the disease. The most relevant health determinants include gender, age, race and status. Others are poverty, unequal access to health care and a lack of education.
According to research that took place in 2009 on the Malawi-Mozambique border, 303 cases were identified. They were categorised by age group and sex. This graph shows 295 cases with known age and sex. 12 You can see that for most ages, the number of cases of females is much higher,  except 5-9 and 15-19 years. The highest prevalence is between the ages 10 and 14 for both genders. Overall, the younger ages appear to be at greatest risk of contracting the disease.
However, looking at India in general, the peak mortality rate for men was higher than that of women, which was 14.5 per 100,000 women; and men was 15.1 deaths per 100,000 men (in 2013). 
The burden of disease is the impact of a health issue, measured by indicators such as finance, mortality and morbidity. It takes a portion of the life expectancy. For example, looking at two individuals: one who has HIV and the other who has suffered a stroke – the patient with the stroke has a higher disease burden because they would lose more years of healthy life. It can be quantified in QALYs (quality-adjusted life years) or DALYs (disability adjusted life years).
Typhoid fever has a major part of the disease burden in developing regions such as the Indian sub-continent. The health burden of typhoid in India peaks at age 1-4. It harms men and women at the lowest rate at ages above 80. In 2013, there was 1,289.5 years of healthy life lost per 100,000 men and 1238.7 per 100,000 women. 13 
In the year 2015 alone, in total there were 642 deaths caused by typhoid and paratyphoid fevers. Over half of these (377 deaths) were male and the other 265 were females. This is a significant difference, proving that males are more prone to contracting the disease. 14
Another determinant is race. Between 1900 and 1920, it was a massive issue in American cities. Typhoid was one of the leading causes of death. Due to this waterborne disease, black people died roughly twice the rate whites did. Luckily by 1940, typhoid was nearly eradicated. 15
Typhoid is passed between people through poor hygiene, for example inadequate or no hand washing after using the toilet. In some areas this may not even be a possibility. The disease would therefore be particularly problematic in areas with poor sanitation. Underprivileged and deprived regions would especially be affected. The wealthier portion of the population are unlikely to be in situations with poor hygiene and therefore won’t ingest contaminated matter.

Between 1 November 2003 and 30 October 2004, 127 lab-confirmed enteric fever cases were detected in a population of 56,946 (in Kolkata). 63% were due to typhoid fever and 37% were paratyphoid fever. Paratyphoid fever is not as severe and symptoms are weaker. The incidence of paratyphoid was lower than typhoid fever.
Paratyphoid patients were older (mean age 17.1 years) and typhoid patients had a mean age of 14.7 years. Literacy of typhoid patients was low (65%) compeered to paratyphoid patients (76%). Furthermore, typhoid cases were more frequently Muslims (58%) as the percentage of Muslim households was significantly higher in high risk areas for typhoid.
Only 15% of the households in the study own a telephone, 18% owned a refrigerator and 69% had to rent accommodation rather than owning their own place. Typhoid fever cases were most likely to live in rented accommodations (79%).
Majority of the population that was studied used latrines; and the percentage of latrine users was even higher among typhoid and paratyphoid patients. Among typhoid cases, 59% claimed to always wash their hands after defecation, in contrast to 67% of the general population.
Among typhoid cases, 95% stated that they used tap water for drinking, meaning the other 5% obtain drinking water from other sources such as ponds.
The area studied was a congested slum with roughly 2560 people living in a 50 metre radius. The density was higher for typhoid fever cases. 16

Standardisation would have had to take place in studies, in order to compare indicators from two or more populations. This technique allows control for compositional differences between different groups, otherwise the indicator that is being examined can be influenced.

HISTORY OF THE DISEASE

Over the course of history, typhoid has infected numerous people and was responsible for many deaths. It still continues today but to a lesser extent. The pathogen responsible for the disease wasn’t established until late in the 19th century, and the first effective vaccine was introduced about a year later. This really helped the highly susceptible populations like those in the military.
Military and war environments have been subjected to typhoid throughout history. A massive 80,000 soldiers died as a result of typhoid fever in the American Civil War. Also during the Spanish-American War, there were infections both on the field and in training camps.
Mary Mallon, or Typhoid Mary, was the most widely known carrier of typhoid fever. She was the first identified person in the US to carry the pathogen without experiencing any symptoms. She was a cook and was thought to have infected 51 people, 3 of which were fatal. She was forcibly isolated to quarantine twice (1907 and 1915). In 1915 during the second time she wasn’t released and died in isolation at the age of 69. 17

Research over a decade ago suggested that the typhoid fever burden in the slums of Kolkata may have been vastly underestimated. In 2006, a community-based study in an urban site was conducted. In a population of 60,452 people, 3605 fever episodes were detected over a 12-month period. There seemed to be high-risk neighbourhoods where typhoid was found in multiple households. 18

Looking at the disease in Kolkata history specifically, there has been a decline in cases over the years. Grouping the studies by decade shows that the significant decline is largely due to the high prevalence of cases in hospital studies during 1980 and 2000; compared with more recent studies. These studies seem to have almost halved the number of cases from 1960 to 2015. 19
Crude death rate is the number of deaths in a population in a certain area during a certain year, per 1,000. It is the number of deaths divided by the total population, multiplied by 100. A death rate of under 10/1,000 is ‘normal’. According to the CIA World Factbook, as of 2016, the crude death rate for the whole world is 7.8 per 1,000. It has decreased since 2009 when it used to be 8.37 per 1,000. In 2001, in West Bengal it was 6.8 and in India it was 8.4. 20 In the year 2014, the death rate had decreased to 6.1 in West Bengal and again to 5.9 in 2015. 21

PREVENTION

Multiple prevention methods are: primordial (avoiding the risk), primary (decreasing the risk), secondary (diagnosing those at risk, screening) and tertiary (those who are already sick).
Prevention programs such as the Typhoid Fever Surveillance in Africa Program (TSAP) exist.  TSAP is an immunisation program that depends on data from surveillance networks and disease burden estimates. It then prioritises target areas and groups most at risk. This program was established by the International Vaccine Institute through standardised surveillance in multiple countries. 22

In developing countries, simple factors such as safe drinking water, improved sanitation and adequate medical care could prevent the spread of typhoid, however they are challenging to achieve. The best way to control the infection is to provide vaccination to the highest risk populations and is recommended to travellers going to regions where typhoid is common.
Currently there are two vaccines against typhoid that have been approved by WHO (World Health Organisation): Ty21a and ViCPS. Ty21a is a capsule, taken orally and ViCPS is a single injection. Neither of these are completely effective solutions, so there guidelines must be followed.
To prevent infecting yourself, one should wash their hands frequently, avoid drinking contaminated water, wash teeth using bottled water, avoid ordering drinks with ice, only eat thoroughly cooked foods, avoid eating raw vegetables unless peeled and avoid food and drink sold by street vendors. 23
To prevent infecting others it is best to follow doctors instructions and to take antibiotics following the whole course, avoid preparing food for others until the infected person is no longer contagious and again frequently wash hands.

Health promotion is the process of enabling the healthy people to essentially obtain more health. It covers a wide range of interventions designed to benefit individual people’s quality of life. Health promotion incorporates good governance for health, health literacy and healthy cities. Disease prevention and health promotion usually work in coordination to each other.

Education is vital as it can have a large impact on the outcome. From a young age, if individuals are informed of the risks and consequences of not only typhoid, but all diseases, it can be very valuable.

TREATMENT

If left untreated, typhoid can be fatal in around 25% of all cases. However, if it is caught early, it can be successfully treated with a course of antibiotic medication. With treatment, fewer than 4 in 100 cases are fatal.
Antibiotic tablets should be taken for 7-14 days. Some strains will have developed a resistance to the antibiotics – this has become increasingly problematic in South East Asia. Symptoms usually improve within a couple of days. Rest is key, along with drinking plenty of fluids and eating regular meals. It is also important to maintain good levels of hygiene.
With severe symptoms such as persistent vomiting and extreme diarrhoea, hospital admission is recommended. In the hospital you will be monitored more closely and be given antibiotic injections and fluids through an intravenous drip. In more rare life threatening complications, surgery may be required.
For some people, symptoms may return and they can also experience a relapse. This usually occurs a week after antibiotic treatment has finished. During the second time around, symptoms are milder and last a shorter amount of time than originally.
If after symptoms have passed, the bacteria still show up in the stool test, the person may be a carrier. For this, a further 28-day course of antibiotics should flush out the bacteria completely. 24

A study took place between 2003 and 2006 to estimate treatment costs for typhoid fever at two hospitals in Kolkata. 93% of the patients were children and 81% was treated at the outpatient department. The average duration of hospitalisation for a child was 8.4 days and for adult patients it was 4.2 days. The average cost of treating children and adults was $16.72 and $72.71 respectively. Recalculation based on the occupancy rate in inpatient wards found that the cost of treating children and adults was $14.53 and $36.44 respectively. 25

There has been hope for many years regarding the eradication of typhoid completely. But, researchers are frequently unravelling new sequences of strains of Salmonella typhi which are resistant to all cheap antibiotics and are close to becoming untreatable. Already 90% of strains in Vietnam are reported to be resistant to most available drugs – even the newly developed ones. 26 The bacteria is restricted to survival in only one species of host which is humankind. If it can be eliminated from humans it would likely eradicate the disease altogether.

REFERENCES

1 https://en.wikipedia.org/wiki/Demographics_of_India
2 http://www.census2011.co.in/census/city/215-kolkata.html
3 http://www.icmr.nic.in/ncrp/pbcr_2012-14/ALL_CONTENT/Annexure/Kolkata_Ann.pdf
4 http://www.ejsit.org/journal3/dec51.pdf
5 https://en.wikipedia.org/wiki/Health_care_in_Kolkata
6 http://www.who.int/bulletin/volumes/88/9/09-073742.pdf
7 https://www.medicalnewstoday.com/articles/156859.php
8 https://www.healthline.com/health/worst-disease-outbreaks-history#Typhoid6
9 https://www.dhs.wisconsin.gov/publications/p4/p42101.pdf
10 https://www.nhs.uk/conditions/typhoid-fever/symptoms/
11 https://www.mayoclinic.org/diseases-conditions/typhoid-fever/diagnosis-treatment/drc-20378665
12 https://www.researchgate.net/figure/221854338_fig1_Figure-3-Typhoid-fever-cases-by-age-group-and-sex-n-295-with-known-age-and-sex
13 http://global-disease-burden.healthgrove.com/l/3584/Typhoid-Fever-in-India
14 http://crsorgi.gov.in/web/uploads/download/MCCD-Report-2015.pdf (http://censusindia.gov.in/)
15 http://www.pitt.edu/~troesken/papers/race8.pdf
16 https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-7-289
17 https://www.news-medical.net/health/Typhoid-Fever-History.aspx
18 https://academic.oup.com/trstmh/article-abstract/100/8/725/1881469?redirectedFrom=fulltext
19 https://spiral.imperial.ac.uk/bitstream/10044/1/33013/3/journal.pntd.0004616.PDF
20 http://wbsc.gov.in/demography/birth%20rate,%20death%20rate,%20infant%20mortality%20rate.htm
21 https://www.wbhealth.gov.in/other_files/Health%20on%20the%20March,%202015-2016.pdf
22 https://academic.oup.com/cid/article/62/suppl_1/S9/2566513
23 https://www.news-medical.net/health/Typhoid-Prevention.aspx
24 https://www.nhs.uk/conditions/typhoid-fever/treatment/
25 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928117/
26 https://www.imperial.ac.uk/college.asp?P=3001

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