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    Crump JA, Mintz ED, 2010. Global trends in typhoid and paratyphoid fever. Clin Infect Dis 50: 241246.

  • 2.

    Whitaker JA, Franco-Paredes C, del Rio C, Edupuganti S, 2009. Rethinking typhoid fever vaccines: implications for travelers and people living in highly endemic areas. J Travel Med 16: 4652.

    • Search Google Scholar
    • Export Citation
  • 3.

    Crump JA, 2019. Progress in typhoid fever epidemiology. Clin Infect Dis 68 (Suppl 1): S4S9.

  • 4.

    Deen J, von Seidlein L, Andersen F, Elle N, White NJ, Lubell Y, 2012. Community-acquired bacterial bloodstream infections in developing countries in south and southeast Asia: a systematic review. Lancet Infect Dis 12: 480487.

    • Search Google Scholar
    • Export Citation
  • 5.

    Buckle GC, Walker CL, Black RE, 2012. Typhoid fever and paratyphoid fever: systematic review to estimate global morbidity and mortality for 2010. J Global Health 2: 010401.

    • Search Google Scholar
    • Export Citation
  • 6.

    Darton TC et al. 2017. The STRATAA study protocol: a programme to assess the burden of enteric fever in Bangladesh, Malawi and Nepal using prospective population census, passive surveillance, serological studies and healthcare utilisation surveys. BMJ Open 7: e016283.

    • Search Google Scholar
    • Export Citation
  • 7.

    Islam K, Sayeed MA, Hossen E, Khanam F, Charles RC, Andrews J, Ryan ET, Qadri F, 2016. Comparison of the performance of the TPTest, tubex, typhidot and widal immunodiagnostic assays and blood cultures in detecting patients with typhoid fever in Bangladesh, including using a bayesian latent class modeling approach. PLoS Negl Trop Dis 10: e0004558.

    • Search Google Scholar
    • Export Citation
  • 8.

    Sheikh A et al. 2009. Salmonella enterica serovar typhi-specific immunoglobulin A antibody responses in plasma and antibody in lymphocyte supernatant specimens in Bangladeshi patients with suspected typhoid fever. Clin Vaccine Immunol 16: 15871594.

    • Search Google Scholar
    • Export Citation
  • 9.

    Khanam F et al. 2013. Evaluation of a typhoid/paratyphoid diagnostic assay (TPTest) detecting anti-Salmonella IgA in secretions of peripheral blood lymphocytes in patients in Dhaka, Bangladesh. PLoS Negl Trop Dis 7: e2316.

    • Search Google Scholar
    • Export Citation
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    Clinical and Laboratories Standards Institute, 2016. Performance Standards for Antimicrobial Susceptibility Testing; Twenty Sixth Informational Supplement. CLSI Document M100-S26. Wayne, PA: Clinical and Laboratory Standards Institute, 36.

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    CLSI, 2012. Performance Standards for Antimicrobial Susceptibility Testing: Twenty Second Informational Supplement Ed, CLSI Document M100S-S22. Wayne, PA: CLSI.

    • Search Google Scholar
    • Export Citation
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    Mogasale V, Maskery B, Ochiai RL, Lee JS, Mogasale VV, Ramani E, Kim YE, Park JK, Wierzba TF, 2014. Burden of typhoid fever in low-income and middle-income countries: a systematic, literature-based update with risk-factor adjustment. Lancet Glob Health 2: e570e580.

    • Search Google Scholar
    • Export Citation
  • 13.

    Crump JA, Luby SP, Mintz ED, 2004. The global burden of typhoid fever. Bull World Health Organ 82: 346353.

  • 14.

    Lee JS, Mogasale VV, Mogasale V, Lee K, 2016. Geographical distribution of typhoid risk factors in low and middle income countries. BMC Infect Dis 16: 732.

    • Search Google Scholar
    • Export Citation
  • 15.

    Lozano R et al. 2012. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease Study 2010. Lancet 380: 20952128.

    • Search Google Scholar
    • Export Citation
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    Tasdemir HA, Albayrak D, 1989. Antibiotics used for paratyphi B infections resistant to classical treatment and the results of their use. Mikrobiyol Bul 23: 3539.

    • Search Google Scholar
    • Export Citation
  • 17.

    Shimoni Z, Pitlik S, Leibovici L, Samra Z, Konigsberger H, Drucker M, Agmon V, Ashkenazi S, Weinberger M, 1999. Nontyphoid Salmonella bacteremia: age-related differences in clinical presentation, bacteriology, and outcome. Clin Infect Dis 28: 822827.

    • Search Google Scholar
    • Export Citation
  • 18.

    Crump JA, Youssef FG, Luby SP, Wasfy MO, Rangel JM, Taalat M, Oun SA, Mahoney FJ, 2003. Estimating the incidence of typhoid fever and other febrile illnesses in developing countries. Emerg Infect Dis 9: 539544.

    • Search Google Scholar
    • Export Citation
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    Vogelsang TM, Boe J, 1948. Temporary and chronic carriers of Salmonella typhi and Salmonella paratyphi B. J Hygiene 46: 252261.

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    Buchwald DS, Blaser MJ, 1984. A review of human salmonellosis: II. Duration of excretion following infection with nontyphi Salmonella. Rev Infect Dis 6: 345356.

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    Lackany A, Wahdan MH, Gaafar MT, Mourad AS, 1976. The epidemiology of the carrier state among enterica patients in Alexandria. J Egypt Public Health Assoc 51: 233245.

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    Wang LX, Li XJ, Fang LQ, Wang DC, Cao WC, Kan B, 2012. Association between the incidence of typhoid and paratyphoid fever and meteorological variables in Guizhou, China. Chin Med J 125: 455460.

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    Dewan AM, Corner R, Hashizume M, Ongee ET, 2013. Typhoid fever and its association with environmental factors in the Dhaka metropolitan area of Bangladesh: a spatial and time-series approach. PLoS Negl Trop Dis 7: e1998.

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    Baker S et al. 2011. Combined high-resolution genotyping and geospatial analysis reveals modes of endemic urban typhoid fever transmission. Open Biol 1: 110008.

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    Sur D, Ali M, von Seidlein L, Manna B, Deen JL, Acosta CJ, Clemens JD, Bhattacharya SK, 2007, Comparisons of predictors for typhoid and paratyphoid fever in Kolkata, India. BMC Public Health 7: 289.

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Case Report: Salmonella Enterica Serovar Paratyphi B Infection in a Febrile Ill Child during Enhanced Passive Surveillance in an Urban Slum in Mirpur, Dhaka

Farhana Khanamicddr,b, (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh;

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Nazmul Hasan Rajibicddr,b, (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh;

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Susan TonksOxford Vaccine Group, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom

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Md. Khalequzzamanicddr,b, (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh;

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Andrew J. PollardOxford Vaccine Group, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom

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John D. Clemensicddr,b, (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh;

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Firdausi Qadriicddr,b, (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh;

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and the STRATAA study teamicddr,b, (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh;
Oxford Vaccine Group, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom

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Paratyphoid fever is one of the major causes of morbidity of febrile illnesses in endemic regions. We report a case of high-grade fever in an infant who was positive for Salmonella enterica serovar Paratyphi B (S. Paratyphi B) both in blood and stool cultures. The baby was enrolled in the passive surveillance of multicenter, multicomponent epidemiological study of enteric fever (Strategic Typhoid alliance across Africa and Asia; STRATAA) conducted in a population of 110,000 residents over 2 years in an urban slum, Dhaka, Bangladesh. This is the only patient who was positive for S. Paratyphi B in blood and stool among more than 6,000 febrile ill patients enrolled in the passive surveillance. The report shows the significance of surveillance to identify changes in the epidemiology of enteric fever.

INTRODUCTION

Typhoid and paratyphoid fever are collectively known as enteric fever, and the greatest burden of enteric fever is seen among impoverished populations who do not have access to clean drinking water and proper sanitation.1,2 Salmonella enterica serovar Typhi (S. Typhi) and serovar Paratyphi (S. Paratyphi A, B, and C) are the etiologies of enteric fever. In recent decades, S. Paratyphi A has been the dominant cause of paratyphoid fever in South Asia,3 and sporadic reports for S. Paratyphi B and C are available.1,4,5

A multicenter, multicomponent epidemiological study was carried out to determine the age-stratified burden of enteric fever (Strategic Typhoid alliance across Africa and Asia; STRATAA) conducted in field sites in Bangladesh, Nepal, and Malawi from August 2016 to January 2019.6 More than 6,000 febrile ill patients were enrolled in the STRATAA passive surveillance study in Bangladesh in Mirpur, Dhaka, and microbiological culture of blood and stool from patients was carried out to allow assessment of the enteric fever disease burden. A high burden of typhoid and paratyphoid fever was found in both children and adults. In Bangladesh, the overall crude incidence rate of blood culture–confirmed S. Typhi was 161 per 100,000 person-years of observation (pyo). For S. Paratyphi A, the rates in Bangladesh and Nepal were 117 and 37 per 100,000 pyo in the 5- to 9-year age-group, respectively. In Malawi, there were no cases of S. Paratyphi A and S. Paratyphi B (unpublished observations). We report here a case of an 11-month-old female infant from whom S. Paratyphi B was isolated from both blood and stool at enrollment in a health facility. This is the only case of S. Paratyphi B infection for febrile illness surveillance of three study sites.

CASE PRESENTATION

A febrile female infant, aged 11 months, was brought by her parents to a passive surveillance facility, which was part of the STRATAA surveillance study (Mirpur Field Clinic; MFC) in June 2018 with a history of fever for the past 3 days. The baby was previously healthy. She did not have any significant past medical history, and she was not taking any medication.

Her parents gave a history of vomiting and diarrhea. On examination, the infant was found to be lethargic and irritable, and was crying persistently; she showed signs of some dehydration. The axillary temperature was 39.5°C (103.1°F). There was no evidence of hepatosplenomegaly, and the pulse rate was 110 beats/minutes. The parents of the patient did not give a history of ingestion of street food during the 2 weeks before the onset of symptoms. The mother of the baby explained that they consume boiled water for drinking and use boiled water for preparing food for the infant.

There was no history of antibiotic intake before blood collection. Blood culture was undertaken (BacT/Alert, bioMérieux, Durham, NC) using 3 mL of blood, and stool culture was also performed. Biochemical and serological testing of the bacterial isolates from blood and stool confirmed the diagnosis.79 Salmonella enterica serovar Paratyphi B (S. Paratyphi B) was identified, and disk diffusion was used to assess antimicrobial sensitivity using Clinical and Laboratories Standards Institute guidelines.10 Strains isolated from blood and stool were both sensitive to all of the tested antibiotics (amoxiclav, ampicillin, cotrimoxazole, ciprofloxacin, chloramphenicol, azithromycin, cefixime, and ceftriaxone). The minimum inhibitory concentration value was determined by the E test for the tested antibiotics (Bio Merieux, Craponne, France). Other laboratory investigation of the patient showed raised C-reactive protein (2.26 mg/dL; reference range: 0.01–0.50 mg/dL).

Treatment of the patient was initiated empirically with azithromycin (10 mg/kg/day) after the collection of blood and stool specimens. Oral rehydration solution, zinc, and paracetamol were also given on the day of enrollment. The patient did not respond for 3 days to treatment and came back to the MFC with a history of high-grade fever. On examination, the axillary temperature was 37.5°C (99.5°F), and the patient was toxic. Azithromycin treatment was replaced with cefixime (20 mg/kg/day) once the results of the antibiotic susceptibility testing were available. Because the fever had not subsided after 3 days of azithromycin treatment and there is no validated guideline for azithromycin susceptibility for S. Paratyphi B,11 a switch to cefixime was made empirically at the discretion of the attending physician. The patient was followed up, and physical examination was carried out regularly. No other focus of infection was found. The patient’s condition improved gradually with the treatment of cefixime. Temperature subsided after 9 days of antibiotic treatment, and the patient had fully recovered on day 11 of follow-up.

Follow-up of the patient was carried out at 1 and 6 months following presentation at enrollment, and two stool specimens were collected from the patient, but all cultures were negative. To investigate possible transmission links, stool specimens were collected for microbiological culturing from the household members of the patient.6 None of them were positive for S. Typhi or for S. Paratyphi A/B.

DISCUSSION

Several studies incorporating existing burden data and modeling approaches at different geographical locations have contributed to the understanding of the global burden of typhoid fever.3,1214 Although few data exist on the global burden of S. Paratyphi infection,1,5,13,15 S. Paratyphi B has an epidemiologic significance and causes outbreaks.16

The case report describes the detection of S. Paratyphi B infection in one patient who was enrolled in the passive surveillance conducted in a population of 110,000 residents over 2 years in Bangladesh. The patient presented to the healthcare facility with a high-grade fever and was enrolled in the study as a suspected case of typhoid fever, as clinically paratyphoid fever is indistinguishable from typhoid fever and laboratory confirmation is required for accurate diagnosis of the disease.17,18 Salmonella enterica serovar Paratyphi B was isolated from both blood and stool of the patient. During the acute stage of Salmonella infection, patients excrete the organism in their stool, and convalescent and chronic carriers may continue shedding of organism in stool specimens after the resolution of symptoms.1924 However, stool culture was negative in our patient on follow-up at 1 and 6 months after presentation, and negative stool cultures were also obtained from her family members.

The household members of the child patient had no complaints of enteric fever, and their stool culture results did not show any evidence of being asymptomatic carrier of S. Paratyphi B. The infant also did not have any history of contact with animals. Hence, the patient could have acquired the infection from the environment while playing in surroundings around the household. Recent studies have suggested that children are more likely to be infected by fecal contamination from the environment in slum settings with contaminated water bodies and open sewers.2528 Improvement of sanitation system will be beneficial for the children who are at risk for acquisition of enteric fever from the environment.29

Resistance to first-line antibiotics (chloramphenicol, ampicillin, and cotrimoxazole) has complicated antibiotic choice to treat the patients with typhoid and paratyphoid fever.30,31 Third-generation cephalosporins, fluoroquinolones, and azithromycin are widely used to treat enteric fever.30,31 Delayed defervescence has been reported for the currently used antibiotics, except fluoroquinolones (ofloxacin and gatifloxacin).3234 Fluoroquinolones are now not recommended for the treatment of enteric fever patients empirically in South Asia as a result of the spread of antimicrobial resistance.3436 Although antibiotic susceptibility testing indicated that the strain isolated from both blood and stool was sensitive to azithromycin, the patient did not respond despite 3 days of treatment. The breakpoints for azithromycin in the treatment of typhoidal Salmonellae are uncertain,37 and there are few clinical data on response to treatment in S. Paratyphi A infection.38 In addition, there are no validated guidelines for azithromycin susceptibility in S. Paratyphi A/B37; hence, further studies are needed to define optimal management for treatment of S. Paratyphi B infection. Good responses are expected with the use of third-generation cephalosporin,34 and, therefore, the antibiotic was switched to cefixime. However, after initiation of appropriate treatment, it generally takes long time (96–145 hours) for defervescence from enteric fever,39,40 as was seen in our patient.

This report shows the presence of S. Paratyphi B in South Asia, where S. Paratyphi A is considered as the main cause of paratyphoid fever,41,42 and highlights the importance of surveillance to identify changes in the epidemiology of enteric fever, particularly in the context of introduction of new typhoid conjugate vaccines to control typhoid, which may promote emergence of paratyphoid as a more significant cause of enteric fever.

Acknowledgments:

We are thankful to the Bill & Melinda Gates Foundation (no. 617 OPP1141321) and the Wellcome Trust Strategic Award (no. 106158/Z/14/Z) for their support. The icddr,b is also grateful to the Government of Bangladesh, Canada, Sweden, and the United Kingdom for providing core/unrestricted support.

REFERENCES

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    Crump JA, Mintz ED, 2010. Global trends in typhoid and paratyphoid fever. Clin Infect Dis 50: 241246.

  • 2.

    Whitaker JA, Franco-Paredes C, del Rio C, Edupuganti S, 2009. Rethinking typhoid fever vaccines: implications for travelers and people living in highly endemic areas. J Travel Med 16: 4652.

    • Search Google Scholar
    • Export Citation
  • 3.

    Crump JA, 2019. Progress in typhoid fever epidemiology. Clin Infect Dis 68 (Suppl 1): S4S9.

  • 4.

    Deen J, von Seidlein L, Andersen F, Elle N, White NJ, Lubell Y, 2012. Community-acquired bacterial bloodstream infections in developing countries in south and southeast Asia: a systematic review. Lancet Infect Dis 12: 480487.

    • Search Google Scholar
    • Export Citation
  • 5.

    Buckle GC, Walker CL, Black RE, 2012. Typhoid fever and paratyphoid fever: systematic review to estimate global morbidity and mortality for 2010. J Global Health 2: 010401.

    • Search Google Scholar
    • Export Citation
  • 6.

    Darton TC et al. 2017. The STRATAA study protocol: a programme to assess the burden of enteric fever in Bangladesh, Malawi and Nepal using prospective population census, passive surveillance, serological studies and healthcare utilisation surveys. BMJ Open 7: e016283.

    • Search Google Scholar
    • Export Citation
  • 7.

    Islam K, Sayeed MA, Hossen E, Khanam F, Charles RC, Andrews J, Ryan ET, Qadri F, 2016. Comparison of the performance of the TPTest, tubex, typhidot and widal immunodiagnostic assays and blood cultures in detecting patients with typhoid fever in Bangladesh, including using a bayesian latent class modeling approach. PLoS Negl Trop Dis 10: e0004558.

    • Search Google Scholar
    • Export Citation
  • 8.

    Sheikh A et al. 2009. Salmonella enterica serovar typhi-specific immunoglobulin A antibody responses in plasma and antibody in lymphocyte supernatant specimens in Bangladeshi patients with suspected typhoid fever. Clin Vaccine Immunol 16: 15871594.

    • Search Google Scholar
    • Export Citation
  • 9.

    Khanam F et al. 2013. Evaluation of a typhoid/paratyphoid diagnostic assay (TPTest) detecting anti-Salmonella IgA in secretions of peripheral blood lymphocytes in patients in Dhaka, Bangladesh. PLoS Negl Trop Dis 7: e2316.

    • Search Google Scholar
    • Export Citation
  • 10.

    Clinical and Laboratories Standards Institute, 2016. Performance Standards for Antimicrobial Susceptibility Testing; Twenty Sixth Informational Supplement. CLSI Document M100-S26. Wayne, PA: Clinical and Laboratory Standards Institute, 36.

    • Search Google Scholar
    • Export Citation
  • 11.

    CLSI, 2012. Performance Standards for Antimicrobial Susceptibility Testing: Twenty Second Informational Supplement Ed, CLSI Document M100S-S22. Wayne, PA: CLSI.

    • Search Google Scholar
    • Export Citation
  • 12.

    Mogasale V, Maskery B, Ochiai RL, Lee JS, Mogasale VV, Ramani E, Kim YE, Park JK, Wierzba TF, 2014. Burden of typhoid fever in low-income and middle-income countries: a systematic, literature-based update with risk-factor adjustment. Lancet Glob Health 2: e570e580.

    • Search Google Scholar
    • Export Citation
  • 13.

    Crump JA, Luby SP, Mintz ED, 2004. The global burden of typhoid fever. Bull World Health Organ 82: 346353.

  • 14.

    Lee JS, Mogasale VV, Mogasale V, Lee K, 2016. Geographical distribution of typhoid risk factors in low and middle income countries. BMC Infect Dis 16: 732.

    • Search Google Scholar
    • Export Citation
  • 15.

    Lozano R et al. 2012. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease Study 2010. Lancet 380: 20952128.

    • Search Google Scholar
    • Export Citation
  • 16.

    Tasdemir HA, Albayrak D, 1989. Antibiotics used for paratyphi B infections resistant to classical treatment and the results of their use. Mikrobiyol Bul 23: 3539.

    • Search Google Scholar
    • Export Citation
  • 17.

    Shimoni Z, Pitlik S, Leibovici L, Samra Z, Konigsberger H, Drucker M, Agmon V, Ashkenazi S, Weinberger M, 1999. Nontyphoid Salmonella bacteremia: age-related differences in clinical presentation, bacteriology, and outcome. Clin Infect Dis 28: 822827.

    • Search Google Scholar
    • Export Citation
  • 18.

    Crump JA, Youssef FG, Luby SP, Wasfy MO, Rangel JM, Taalat M, Oun SA, Mahoney FJ, 2003. Estimating the incidence of typhoid fever and other febrile illnesses in developing countries. Emerg Infect Dis 9: 539544.

    • Search Google Scholar
    • Export Citation
  • 19.

    Vogelsang TM, Boe J, 1948. Temporary and chronic carriers of Salmonella typhi and Salmonella paratyphi B. J Hygiene 46: 252261.

  • 20.

    Im J et al. 2016. Prevalence of Salmonella excretion in stool: a community survey in 2 sites, Guinea-Bissau and Senegal. Clin Infect Dis 62 (Suppl 1): S50S55.

    • Search Google Scholar
    • Export Citation
  • 21.

    Buchwald DS, Blaser MJ, 1984. A review of human salmonellosis: II. Duration of excretion following infection with nontyphi Salmonella. Rev Infect Dis 6: 345356.

    • Search Google Scholar
    • Export Citation
  • 22.

    Sharp JC, 1970. Convalescent excretion of Salmonellae and Shigellae. Health Bull 28: 1922.

  • 23.

    Abboud ES, Wahba AH, 1966. Enteric fever carriage with special reference to the incidence of paratyphoid C in Egypt. J Egypt Public Health Assoc 41: 319327.

    • Search Google Scholar
    • Export Citation
  • 24.

    Lackany A, Wahdan MH, Gaafar MT, Mourad AS, 1976. The epidemiology of the carrier state among enterica patients in Alexandria. J Egypt Public Health Assoc 51: 233245.

    • Search Google Scholar
    • Export Citation
  • 25.

    Wang LX, Li XJ, Fang LQ, Wang DC, Cao WC, Kan B, 2012. Association between the incidence of typhoid and paratyphoid fever and meteorological variables in Guizhou, China. Chin Med J 125: 455460.

    • Search Google Scholar
    • Export Citation
  • 26.

    Dewan AM, Corner R, Hashizume M, Ongee ET, 2013. Typhoid fever and its association with environmental factors in the Dhaka metropolitan area of Bangladesh: a spatial and time-series approach. PLoS Negl Trop Dis 7: e1998.

    • Search Google Scholar
    • Export Citation
  • 27.

    Baker S et al. 2011. Combined high-resolution genotyping and geospatial analysis reveals modes of endemic urban typhoid fever transmission. Open Biol 1: 110008.

    • Search Google Scholar
    • Export Citation
  • 28.

    Sur D, Ali M, von Seidlein L, Manna B, Deen JL, Acosta CJ, Clemens JD, Bhattacharya SK, 2007, Comparisons of predictors for typhoid and paratyphoid fever in Kolkata, India. BMC Public Health 7: 289.

    • Search Google Scholar
    • Export Citation
  • 29.

    Akullian A et al. 2015. Environmental transmission of typhoid fever in an urban slum. PLoS Negl Trop Dis 9: e0004212.

  • 30.

    Dahiya S et al. 2019. Current antibiotic use in the treatment of enteric fever in children. Indian J Med Res 149: 263269.

  • 31.

    Mishra C, Jha A, Ahmad M, Singh S, Ansari A, 2017. A comparative study between cefixime and ofloxacin in the treatment of uncomplicated typhoid fever attending a tertiary care teaching hospital .Med Phoenix 2: 37.

    • Search Google Scholar
    • Export Citation
  • 32.

    Sharma P, Dahiya S, Manral N, Kumari B, Kumar S, Pandey S, Sood S, Das BK, Kapil A, 2018. Changing trends of culture-positive typhoid fever and antimicrobial susceptibility in a tertiary care north Indian hospital over the last decade. Indian J Med Microbiol 36: 7076.

    • Search Google Scholar
    • Export Citation
  • 33.

    Chandey M, Multani AS, 2012. A comparative study of efficacy and safety of azithromycin and ofloxacin in uncomplicated typhoid fever: a randomised, open labelled study. J Clin Diagn Res 6: 17361739.

    • Search Google Scholar
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Author Notes

Address correspondence to Firdausi Qadri, icddr,b, (International Centre for Diarrhoeal Disease Research, Bangladesh), 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka-1212, Bangladesh. E-mail: fqadri@icddrb.org

Authors’ addresses: Farhana Khanam, Nazmul Hasan Rajib, Md. Khalequzzaman, John D. Clemens, and Firdausi Qadri, Infectious Diseases Division, ICDDRB, Dhaka, Bangladesh, E-mails: farhanak@icddrb.org, nazmul.hasan@icddrb.org, kzaman@icddrb.org, jclemens@icddrb.org, and fqadri@icddrb.org. Susan Tonks and Andrew J. Pollard, Department of Paediatrics, Oxford Vaccine Group, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom, E-mails: susan.tonks@paediatrics.ox.ac.uk and andrew.pollard@paediatrics.ox.ac.uk.

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