Pakistan became the first country in the world to introduce the typhoid conjugate vaccine (TCV) into its routine immunization program on Friday. The government of Pakistan is launching the national vaccine with a campaign in Sindh Province, which has already been deploying the vaccine on an emergency basis since April 2019 to tackle an ongoing extensively drug-resistant (XDR) typhoid outbreak that began in November 2016.

“Children are disproportionately affected by typhoid and its associated complications, and we strongly believe that TCV would protect our children against potentially fatal disease of typhoid,” said Dr Zafar Mirza, Special Assistant to the Prime Minister on Health said in a press release issued by Gavi, The Vaccine Alliance. “Starting with Sindh Province, where the need is most urgent, the government of Pakistan has planned a phased national introduction strategy with strong, coordinated support from global and local partners.”

Pakistan’s current extensively drug resistant (XDR) outbreak of typhoid, which has infected more than 10,000 people, mostly in Sindh province, is the first-ever reported outbreak of typhoid resistant to all but one oral antibiotic for typhoid. Use of the World Health Organization-recommended TCV has helped protect some individuals against the deadly strain.

Typhoid, a serious illness caused by Salmonella Typhi, is spread through contaminated food and water and disproportionally impacts children and low-resource communities in Asia and sub-Saharan Africa. The Global Burden of Disease study estimates that, in 2017, there were nearly 11 million typhoid cases and more than 116,000 typhoid deaths worldwide.

In 2017, 63% of typhoid cases and 70% of typhoid deaths in Pakistan were among children younger than 15 years of age. TCV is the first typhoid vaccine that can be given to children as young as 6 months of age and confers longer term protection against typhoid.

With funding support from Gavi, the vaccine introduction will begin with a two-week vaccination campaign targeting 10 million children 9 months to 15 years old in urban areas of Sindh Province. It will be followed by a transition to routine immunization of 9-month-old infants in all parts of the province once the campaign ends. The vaccine will be introduced in neighboring Punjab Province and Islamabad next year and then nationally in 2021.

“Typhoid is a highly contagious disease that spreads more quickly and easily when people live in crowded neighborhoods with weak water and sanitation infrastructure. Beginning the vaccination in urban areas is critical in preventing the disease among the communities most at risk,” said Dr. Azra Fazal Pechuho, Provincial Minister of Sindh for Health, and Population Welfare. While she claims vaccination is the best protection against typhoid, the government will also be promoting water, sanitation, and hygiene solutions.

WHO issued its formal recommendation in support of typhoid conjugate vaccine introduction in March 2018 following positive results from clinical trials conducted in Bangladesh. In anticipation of the availability of typhoid conjugate vaccines, Gavi earmarked US$85 million to support eligible countries with the introduction of typhoid conjugate vaccines into their routine immunization programs.

“Before the discovery of antibiotics, typhoid would kill as many as one in five people who contracted it,” said Dr Seth Berkley, CEO of Gavi. “The rise of extreme drug resistant typhoid risks bringing us back to levels of mortality not seen since the 19^th century, posing a risk to all of us.”

Liberia and Zimbabwe are also preparing to introduce the typhoid conjugate vaccine next year with Gavi support, and several other countries are considering use of the vaccine as they review data on the incidence of typhoid in their countries.

For more information see the press release.

Image Credits: CDC.