key: cord-260583-n20y2zep
authors: Haqqi, Aleena; Khurram, Muhammad; Din, Maryam Salah Ud; Aftab, Muhammad Nauman; Ali, Muhammad; Ahmed, Haroon; Afzal, Muhammad Sohail
title: COVID‐19 and Salmonella Typhi co‐epidemics in Pakistan: A real problem
date: 2020-07-15
journal: J Med Virol
DOI: 10.1002/jmv.26293
sha: 
doc_id: 260583
cord_uid: n20y2zep

Recent articles have pointed the impact of co-epidemics/co-infections of COVID-19 and other infectious diseases on an already overburdened healthcare infrastructure 1, 2 . With the present toll of COVID-19 cases reaching beyond 10,922,324 infected cases and claiming 523,011 lives 3 . This article is protected by copyright. All rights reserved.

reported along with COVID-19. 5 Such conditions would result in the havoc and would take a heavy toll on the public health sector thus losing lives as a result of an inability to cater all patients at the same time with a limited financing and healthcare resources. 6 Typhoid fever is a public health concern mainly in middle and lowerincome countries due to their poor sanitation and unhygienic environ- February 2020, from Sindh province of Pakistan. Among these almost 16 thousand cases were characterized as extensively drug-resistant typhoid cases (XDR). The estimated attack rate of typhoid was calculated to be 15.5/10 000 population. This strain of typhoid is resistant to all antibiotic treatments available for its treatment, which makes it extremely costly and challenging to treat. The outbreak of typhoid in Pakistan is currently characterized as XDR, which has infected more than 19 thousand people, most of them are from Sindh province of Pakistan. 9 In November 2019, Pakistan became the first-ever country to introduce WHO recommended typhoid conjugate vaccine. 10 A total of 220 patients were tested for Salmonella Typhi in Lahore from 15th March to 15th June 2020. Lahore is a metropolitan city and showed the highest burden of COVID-19 in Punjab Province. Study group includes 122 (55.4%) male and 98 (44.5%) females. Out of total patients tested 48% patients were found to be typhoid positive. Typhoid was most prevalent in the age group of 21 to 40 years (44%), followed by 25% in 41 to 60, 24% in 0 to 20, and lowest of 7% in 61 to 80 years.

The overall incidence of typhoid was observed to be higher in males as shown in Figure 2 . Since 2016, the highest incidence of XDR typhoid was reported in the year 2019 to be 9994 infected individuals. 11 The year wise distribution of typhoid cases is shown in Figure 3 . 12 There is no data available from the whole country therefore available data from Sindh Province is shown in the figure. The surveillance and reporting of typhoid in Pakistan is quite inadequate and haphazard. To conclude the actual prevalence of typhoid in Pakistan is difficult due to low sample size and unavailability of proper clinical diagnosis.

According to a study conducted by Umer Rashid and co-workers, typhoid was most prevalent in age ranging from 21 to 30 (42.32%) followed by age group based incidence in 11 to 20 (30.42%) and 1 to provision of filtered water, and good sanitation. 13 According to several reports the export of XDR typhoid has been observed in many countries; United States, United Kingdom, Australia, Denmark, Taiwan, and Canada from Pakistani travelers. 14 The morbidity and mortality reported from Asia constitute 90% of all cases worldwide. In Asia, the estimated disease burden is based on the compilation of clinically diagnosed patients of typhoid by the government with uncertain denominators. The specified typhoid clinical diagnosis requires access to a competent laboratory that is scarce in such developing countries. Typhoid can range from acute to severe symptoms that occur after 0 to 36 days after the onset of the disease. In poor resource countries medications are usually prescribed without the proper diagnosis in such cases. Besides, to the presentation of nonspecific symptoms of typhoid, they are similar to other diseases like malaria, dengue, and COVID-19. Due to the common symptoms of these diseases, it is difficult to identify the actual underlying cause without the proper diagnosis tests. 15 In the COVID-19 pandemic, healthcare workers are overburdened with the high influx of patients with COVID-19 in hospitals, in such situations rise in the number of typhoid cases has also been observed. Doctors are facing complications in the diagnosis and differentiating both diseases due to almost common symptoms like fever, fatigue, body pain, and diarrhea in some cases. Out of a total of 20 000 typhoid patients, 8000 cases have been identified in five major hospitals of Lahore, Punjab, Pakistan. 5 The government of Pakistan has taken various measures for the containment of the virus, but they are proving to be insufficient as the numbers of COVID-19 infected cases are continually on the rise.

The overburdened and poor health infrastructure of Pakistan's health system due to COVID-19 is at the brink of collapsing. In such cases, another epidemic in the country can prove to be quite devastating. To 

The authors declare that there are no conflict of interests.

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