tion of sewage water with rotavirus infection. Furthermore, Ahmad et al. (2016) detected amoeba along with rotavirus in Karachi. The contamination of drinking water with wastewater increases the risk for transmis- sion of rotavirus because this virus can sur- vive better in the environment compared with other enteric viruses. As far as control measures are concerned, rotavirus vaccina- tion has decreased the positivity and severity rate of infection globally. The Government of Pakistan included the rotavirus vaccine in its Expanded Program on Immunization in 2017. Nevertheless, further vaccine advocacy campaigns might be required for these immu- nization programs to be successful. Cholera Cholera is an enteric infection caused by Vib- rio cholera and spread by consumption of con- taminated food and water (Jutla et al., 2017). Cholera is characterized by vomiting and pro- fuse watery diarrhea. In severe cases, cholera can cause dehydration and death. Cholera has been prevalent in South Asia throughout his- tory. Among more than 200 serogroups, only O1 and O139 of V. cholera are associated with outbreaks. The prevalent strains in Pakistan are Pakistani subclade I (PSC-I) and Pakistani subclade II (PSC-II) (Shah et al., 2014). The intake of fecal-contaminated water is the leading cause of cholera. Cholera out- breaks are seasonal in Pakistan and other South Asian countries. Natural disasters such as floods lead to the mixing of drinking water with feces or fecal-contaminated water. Thus, the occurrence of disease outbreaks increases after these events. Approximately 13% of Pakistan’s popula- tion still defecates in open spaces because of the lack of proper toilets. Other factors such as limited access to sanitation, poor hygiene, and inadequate water supply also can contribute to cholera outbreaks (Oguttu et al., 2017). Cholera is a notifiable disease in Pakistan; however, the quality of surveillance data is poor due to the lack of standard data collection techniques, limited focus on skill development of healthcare sta, and the lack of motivation and responsibility in collecting and handling data (Qazi & Ali, 2009). Due to the lack of an appropriate reporting system, the exact magnitude of cholera is di- cult to determine (Lopez et al., 2020). To over- come this issue, WHO launched the Disease
Early Warning System (DEWS) in Pakistan in 2005 for the quick investigation of disease outbreaks nationally and to devise appropriate strategies for mitigating the spread of cholera in disaster-aected areas, especially earth- quake-prone areas. This system is responsible for the Integrated Disease Surveillance and Response (IDSR) system at the level of prov- inces in coordination with public health labo- ratories in the Sindh and Punjab Provinces. From 2005–2009, DEWS responded to 261 alerts and 46 outbreaks of diarrhea in Pakistan (Rahim et al., 2010). Two cases of cholera were reported in Rawalpindi, which led to further investigation and surveillance. Overall, 30 active cases of cholera and 2 deaths were iden- tified. Of the aected people, 47% of cases were attributed to consumption of well water and 40% of cases were attributed to consumption of tap water. The water sources were found posi- tive for V. cholera serotype Inaba and coliforms. Floods were the likely cause of the well water and tap water contamination (Akram, 2018). From 2011–2014, DEWS/IDSR reported millions of cases of diarrhea across Pakistan. The annual data of the confirmed cholera cases in Pakistan are mentioned in parenthe- ses: 2011 (527), 2012 (144), 2013 (1,069), and 2014 (1,218). Subsequently in Punjab, it was shown that 8.9% of acute diarrhea cases were suspected to be due to cholera from 2013–2016 (Lopez et al., 2020). Recently, heavy rains and devastating floods in Paki- stan have resulted in several cholera out- breaks. Flood-aected areas were deprived of clean drinking water, leading people to con- sume contaminated water, which then led to outbreaks of cholera in multiple cities. For example, 2,000 acute diarrheal cases were reported in Lahore alone from April through May 2022. Water contamination due to the substandard drainage system is believed to be responsible for these outbreaks (Naveed et al., 2022). A cross-sectional study conducted on 191 patient stool samples in Nishtar Hospital in Multan revealed that 11% of samples were positive for cholera (Ishfaq et al., 2022). Another study reported a con- taminated drinking water-associated cholera outbreak comprising 90 suspected patients at the Dr. Ruth K. M. Pfau Civil Hospital Kara- chi (Abbasi et al., 2023). Despite a continued rise in the incidence of cholera, a thorough understanding of the disease’s major epidemiological aspects is still
missing. There is a dire need to elucidate the major determinants of this disease. The exist- ing gaps in knowledge can guide researchers, policymakers, and health professionals to devise appropriate disease control strategies at a local level. Proper disposal of feces from infected people can prevent disease transmission. Cholera out- breaks can be prevented by the chlorination of stored water and proper hand hygiene. The Government of Pakistan has tried several ways to reduce the impact of cholera, especially after recent floods. For example, the govern- ment has established diarrhea treatment cen- ters and diagnostic facilities in flood-aected areas. Additionally, it has ensured the provi- sion of clean drinking water in these areas. Government-initiated community engagement programs included recruitment of social mobi- lizers and the provision of water-purifying tab- lets. In addition to these initiatives, the govern- ment has emphasized the chlorination of water and sanitation awareness. Typhoid Typhoid is a systemic infection caused by Salmonella Typhi via the ingestion of con- taminated food or water. This bacterium is a Gram-negative rod that can be detected by a variety of serological and molecular tools. A prospective population-based surveil- lance study in five Asian countries deter- mined that the incidence of typhoid in Pakistan was the second highest, followed by India (Ochiai et al., 2008). This study found that in Pakistan, the overall incidence of typhoid fever was 573 per 100,000 people per year in children between the ages of 2 and 4 years. The incidence decreased, how- ever, to 452 per 100,000 people per year in children and adolescents between the ages of 2 and 15 years. Owais et al. (2010) examined the incidence of typhoid in children <2 years in southern areas of Pakistan and found that the incidence was 443 per 100,000 children. Khan et al. (2012) determined the risk factors associated with the occurrence of typhoid fever in children and adolescents between 2 and 16 years and found that the incidence of the disease increased with increasing popu- lation density, although incidence decreased with advancing age. What is noteworthy is that a reduced incidence of typhoid was observed in households that consumed clean drinking water (Khan et al., 2012).
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