Saying goodbye to typhoid the vaccine way

I sat across Isabel* staring at her with my mouth open. I could not fathom how she was still alive. She was the real definition of “It is not your time yet.”

Isabel always knew she was different from other children. The scar on her abdomen was her distinguishing factor; running along the midline, extending from just below her sternum, skirting her belly button and ending just above her pubis. It wasn’t pretty either, resembling a centipede, typical of nylon stitches. Though not a shy teen by any means, she found it easier to keep it out of sight than explain it.

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At the tender age of seven, Isabel fell ill with mild diarrhoea and fever. She was nursed at home with oral rehydration solution and paracetamol and was better for a few days before headaches, fatigue and fever set in. By the time she got to the local health centre, her fevers were rising, with severe vomiting and debilitating headaches. Isabel was admitted and the clinical officer, with limited laboratory support, initiated broad-spectrum antibiotics and anti-malarials, covering for the two most likely conditions, malaria and meningitis. Alongside hydration and fever control, she appeared to improve and was discharged home after 10 days. 

A week later, Isabel’s fever came back full swing. She was curled up in a ball, sick with severe abdominal pain and vomiting. At the health centre, the clinical officer immediately referred her to the district hospital 24km away. Isabel remembers the tortuous journey in the rickety four-wheel ambulance on the worn murram road, with her father cradling her head and her mother weeping silently. 

She was promptly received at the emergency department, urgently stabiliSed and three hours later, wheeled to theatre for surgery. Isabel tearfully said goodbye to her parents as she was handed over to the surgical team, while they settled on the bench outside to wait, whispering a prayer for her survival. 

The surgeons went to work, finding multiple intestinal perforations in the terminal part of her small intestines, the ileum; a common complication of typhoid fever. This was the infection bedeviling Isabel, resulting in the perforations due to inadequate treatment occasioned by resource constraints.

The surgery was grueling but Isabel hung in there. There was pus all over her abdomen as intestinal contents had leaked into the abdominal cavity, causing sepsis. Despite the challenges, Isabel pulled through, and three weeks later, she went home. 

For years, Isabel joked that it appeared she paid for all future medical issues in that one instance. She had no other contact with the health system until childbirth. Despite regular clinic visits with a private obstetrician, Isabel’s scar was never discussed beyond ascertaining the surgery that was done. 

The pregnancy was a breeze with no complications. Towards the end of pregnancy, her obstetrician noted that the baby was quite big; and together, they settled for a caesarian delivery due to an estimated foetal weight of 4,350g on ultrasound. 

Isabel was checked into hospital the night before surgery. At 6am, she was transferred onto the operating table and put under spinal anesthesia, with the obstetrician starting the surgery. She recalls the theatre going silent as the doctor exclaiming. She heard him ask for the general surgeon before the anaesthesiologist put her under general anaesthesia. 

Five hours

Isabel was on the operating table for five hours; for a surgery that was expected to last an hour. While opening her abdomen, the obstetrician inadvertently nicked her small intestines, which were adherent to her anterior abdominal wall, unexpectedly requiring general surgeon on board. It took them two hours just to separate all the scar tissues and loops of gut that were preventing the team from accessing the uterus to remove the baby. 

The baby was delivered safely and transferred to the newborn unit while the surgical team remained on the table, fighting to tidy up Isabel’s abdomen, repair the injury sustained and prevent infection. Eventually, she was wheeled to the high-dependency unit. 

The recovery journey took months. Isabel stayed in hospital for four weeks, with two additional surgeries due to complications; one of which ended up leaving her with an ileostomy (an opening on the abdominal wall that brings out the ileum, and the intestinal contents are collected in a bag attached to the skin). She survived sepsis and electrolyte imbalance occasioned by the ileostomy, calling for ICU care. 

Weeks later, she was readmitted to have the ileostomy closed. It took over a year to feel like herself again. She wistfully recalls how she missed out on her baby’s first year of life, from breastfeeding, to early bonding, to diaper change and bath time. However, she is grateful for her daughter and would do it all over again just to have her. 

In Kenya, we have seen a downward trend of confirmed typhoid cases in the past two decades. This is great news, but it has made us complacent in securing clean water, proper sanitation and hygiene for all Kenyans. As a result, this infection, which afflicts up to nine million people worldwide, 110,000 of whom die, is making a comeback. 

Known to exclusively affect humans, especially ages five to nine, typhoid fever, also known as enteric fever, is most endemic in South-East Asia; transmitted primarily through the fecal-oral route (pretty much ingesting faeces), and consumption of contaminated food or water. Rarely, it can be sexually transmitted through anal sex. Patients who are immunosuppressed, those with malaria and sickle cell anemia, are prone to more severe infections. 

It takes about six to 30 days from infection to show symptoms. Inadequate treatment results in complications; including meningitis, lung abscesses, inflammation of heart muscles, intestinal perforation, severe bloody diarrhoea, injury to the liver and pancreas, enlargement of the liver and spleen, and osteomyelitis.

Diagnosis of typhoid fever is done through blood or bone marrow cultures, expensive tests that are not widely available. Other tests that may suggest diagnosis include testing for the bacterial antigens in stool, and the age old Widal test that looks for presence of antibodies against the bacteria in the body. These have limited accuracy but are used where that is all there is. 

With the rise of antimicrobial resistance, the Salmonella typhi and Salmonella paratyphi, the bacteria that cause typhoid fever, are hitting back hard, with rising resistance to antibiotics. As a result, alongside strengthening our sanitation, proper waste disposal, eradicating open defecation and ensuring access to clean water, we urgently need to up our game. 

The Ministry of Health through the National Vaccines and Immunisation Programme with the support of the Kenya National Immunisation Technical Advisory Group have rolled out the Typhoid Conjugate Vaccine in Kenya, to be given to all children aged up to 14 years. 

It is worth noting that this vaccine has been available in the private sector for years for those who can pay for it. But in the spirit of equity, it is now being availed to all children by the ministry. It joins our expanding arsenal of vaccines in place to protect out populations. No one, absolutely no one, deserves to go through what Isabel did!

Dr Bosire is a gynaecologist/obstetrician