World’s first outbreak of extensively drug-resistant (XDR) typhoid fever outbreak that began in Pakistan’s Hyderabad district in Sindh province has spread since its identification in November 2016. Every year, XDR typhoid cases in the province surpass the previous year’s numbers.

During November and December 2016, XDR cases stood at 11, followed by 730 cases in 2017 and 4,825 cases in 2018. So far in 2019, from January 01 to February 17, 586 new XDR typhoid fever cases have been reported from all over the province.

Overuse and misuse of antibiotics builds a drug resistance among the population which is posing serious threat to public health. The Health Department has been unable to check quackery which is seen as the main reason for increasing health complications.

Typhoid fever is a potentially deadly illness caused by Salmonella Typhi that is typically transmitted through contaminated water and food. Antibiotics are medicines used to treat or prevent infections caused by bacteria. Typhoid turns XDR when the strain of Salmonella Typhi does not respond to most antibiotics used to treat the fever.

"There have been four typhoid-related deaths in Sindh since the outbreak, out of which three were in 2017. Since then there has been no death," Dr Masood Ahmed Solangi, Director General Health Services Sindh, told TNS.

From 2016 when it was first detected till February 17 this year, as many as 6,152 XDR Typhoid cases were reported from all over the province, the Sindh Health Department claimed. However, independent figures put the number at 9,000.

The Health Department’s report says from 2016 to 2019, Karachi remained on top with 4,269 cases while Hyderabad faced 1,600 cases, Mirpurkhas 106 cases, Badin 43 cases, Jamshoro 35 cases and Sanghar 30 cases. Similarly Sukkur faced 17 cases, Dadu 10 cases, Larkana and Naushehro Feroz 7 cases each, Kashmore 5 cases, Tando Muhammad Khan 4 cases, Ghotki and Shikarpur 3 cases each, Tharparkar, Umerkot and Jacobabad 2 cases each and Shaheed Benazirabad faced one case.

"Conjugate typhoid vaccine campaign is being carried out in affected areas of district Hyderabad through collaboration of department of Health and Aga Khan University Hospital. Till date 161,000 children have been vaccinated in Hyderabad," DG Sindh, Dr Solangi, informed.

Health experts link the spread of XDR typhoid with several factors including over-prescription and improper use of antibiotics.

Dr S M Qaisar Sajjad, Secretary General Pakistan Medical Association (PMA), holds the Sindh Health Department responsible for the outbreak by not taking action against quacks who are practising everywhere, even in Karachi.

Health experts question the quality of diagnostic laboratories which produce false reports. If a laboratory diagnoses an illness, any doctor would prescribe antibiotics. "It is high time the government examined the quality of laboratories. To discourage self-medication, the government needs to ensure that nobody gets drugs from a medical store without prescription of a qualified doctor.

"If the situation remains the same, many life-saving antibiotic drugs will not remain effective. We are already witnessing resistance against treatment of tuberculosis," Dr Sajjad warned.

Sindh Health Department has remained under fire, either for alleged corruption charges or for lack of bureaucratic and political will to improve the healthcare infrastructure. One example is delay in making the Sindh Healthcare Commission functional. Sindh Healthcare Commission Act was passed in 2013. It took the Sindh government four years to make the SHCC operational. It was made possible on court’s intervention. Re-launched in February 2018, the SHCC directorate of anti-quackery was established in October 2018.

Dr Ayaz Bukero, Director Anti-Quackery Department SHCC, admits that had there been no delay in making the commission functional, the department would have been able to nab quacks.

"Unqualified and unregistered practitioners are prescribing medicines -- mostly irrational use of antibiotics.

"There is an ongoing drive against quacks all over Sindh. In the first round, Sindh Healthcare Commission has sealed 95 clinics of quacks. They were operating in Karachi South District, Badin, Tando Muhammad Khan, Mirpurkhas, Tando Allahyar and Jacobabad," Dr Bukero informed while over 400 have been issued warnings, he said.

"Government is going to start a census of medical healthcare facilities in Sindh. After census there will be registration of medical facilities. Following registration we will be able to take more effective action against quacks," the Sindh Healthcare Commission’s Director of Anti-Quackery informed.

The Sindh Health Department or the SHCC does not have a record of number of all public and private medical healthcare facilities and is forming policies on estimates.

Water quality issue is serious in Sindh province. In fact, water supply issue has become chronic in recent times.

In 2017, the Supreme Court of Pakistan formed Sindh Water Commission on the petition of Advocate Shahab Osto regarding water and sanitation issues in Sindh. A report submitted before the Supreme Court disclosed that on average 85 percent of Sindh’s population is not getting water that is fit for consumption that included provincial capital Karachi where 90 percent of the water was not potable. Another report stated that untreated sewage water is thrown in 750 water bodies all over Sindh that include canals, rivers, nullahs and lakes. Furthermore, water is supplied to households without any filtration.

"The projects which were initiated following the findings of the Commission in August 2017 may take some time to complete. So the water quality would become worse in the next four to five years, until projects regarding water filtration are completed," Advocate Osto told TNS.

"In Larkana alone, untreated sewage is thrown at 27 points at Rice Canal that flows inside the city," he added.

Similarly, water supply quality has not improved in Hyderabad, Sindh’s second populous city from where XDR Typhoid outbreak began.

Dr Rasool Bux Mahar, a faculty member at US-Pakistan Center for Advanced Studies in Water, Mehran University of Engineering & Technology (MUET) Jamshoro is working on a research project on the quality of water supply in Hyderabad and adjacent areas. He said, "Hyderabad’s untreated waste water is being mixed in its water resources like Phuleli Canal and others. Hospital waste is also being thrown here. Same water is being supplied to the city.

"Also water supply and sewerage lines are parallel and close to each other and in deteriorating condition. So sewage water gets mixed in water supply in this way also. Not only Hyderabad, but the adjoining Jamshoro and Kotri towns are also badly affected."

Pakistan Medical Association has issued guidelines for precautionary measures which advise people to "take safe (boiled) drinking water, avoid ice from the market, wash fruits, vegetables and utensils with boiled water, wash hands with soap before eating and after going to toilet."