The Ministry of Health and Population is planning to launch a nation-wide vaccination campaign against typhoid from April 8. Around seven million children between the ages of 15 months and 15 years will be immunised with a vaccine during the month-long campaign, according to officials.
“The vaccine will also be included in the regular immunisation list once the campaign is over,” Sagar Dahal, chief of the National Immunisation Programme, told the Post.
Once the typhoid vaccine is included in the regular immunisation list, the number of vaccines provided through regular immunisation programmes will reach 13.
Typhoid fever, usually called typhoid, is a highly contagious disease caused by Salmonella typhi, which spreads through contaminated food or water. Studies have shown that the disease can be fatal in up to 10 percent of the reported cases.
Typhoid fever has been found throughout the world but the problem is acute in the areas where safe drinking water and sanitation is a problem. Nepal has also recorded major typhoid outbreaks in the past, but very few cases have been reported in the last few years.
Although authorities concerned are in the final phase of launching the vaccine campaign, there are divided opinions among experts about it.
Some say mass vaccination against typhoid and the jabs’ inclusion in the regular immunisation list is needed, as it lessens the morbidity and mortality rates, but others believe authorities are launching the programme without having convincing scientific evidence on the prevalence of the disease.
Those not very keen on typhoid mass vaccination say the programme should be made more specific by launching it in the hotspots and the areas where the condition of drinking water and sanitation is very poor.
“We don’t have convincing and scientific evidence about the typhoid disease burden in the country,” Dr Baburam Marasini, former director at the Epidemiology and Disease Control Division, said. “It would be better, if we could make the programme more evidence-based.”
In 2015, the Epidemiology and Disease Control Division had carried out a study in Chitwan and Kathmandu to know the prevalence of typhoid.
Doctors involved in the study found typhoid cases but not in significant numbers.
“We found that hospitals were not performing stool cultures in significant numbers; typhoid cases were fewer,” said Marasini, who was director at the Epidemiology and Disease Control Division, then.
The Ministry of Health and Population said that data of the last five years show that around 450,000 people get sick with typhoid every year. And typhoid is among the top three diseases that are caused by contaminated food and water, and the fourth cause of hospitalisation in Nepal, according to the data of the last three years maintained by the Health Management Information System.
Officials at the Health Ministry said that a study carried out at Patan Hospital in the past found 1,062 people per 100,000 have been infected with typhoid.
The number of infected people over 100 in every 100,000 is considered a high prevalence.
Experts, however, question the authenticity of the Health Management Information System’s data.
“Our Health Management Information System cannot keep the record of all the people inoculated with particular vaccines and vaccine doses, so how can we rely on the information it provides?” questioned a former official at the Department of Health Services, requesting anonymity. “How many stool samples were tested to claim 450,000 people were infected with typhoid every year. And do we have the capacity to test those samples?”
Vaccines for other diseases, which are being provided in the regular immunisation programme work life long, but that is not the case with the typhoid vaccine, which has to be taken every five years.
As the government has been including the said vaccine in the regular immunisation list, why not include the cholera vaccine, some wonder.
Experts also raised questions about the sustainability of the programme after the inclusion of the typhoid vaccine in the regular immunisation list, as aid agencies do not always provide the jabs. On top of that, typhoid is not like any other disease which can be eradicated, as it can occur in areas where sanitation and water conditions are poor.
“We have not had a major outbreak of typhoid for the last several years,” said Dr Senendra Upreti, former secretary for Health. “But that does not mean the problems will not arise again.”
Doctors say that without improving water and sanitation conditions, problems of other waterborne diseases cannot be addressed. To improve water and sanitation problems, long-term investments and multisectoral approaches are needed, they say.
“Instead of including the typhoid vaccine in the regular immunisation list, authorities could launch the programme in the areas where drinking water and sanitation is problematic,” an official at the Department of Health Services, said, asking not to be named. “No vaccine is 100 percent effective and infection of typhoid largely depends on how healthy food and water we eat and drink.”
Health Ministry officials claimed that inclusion of typhoid vaccine doesn’t increase economic burden, as the vaccine doses and all logistical expenditures have been provided by the Global Alliance for Vaccine and Immunisation.
They claimed that the cost of typhoid vaccination will not be high compared to the morbidity rate even after the aid agencies stopped the support in the vaccination.
“Typhoid patients have been found throughout the country and hundreds of thousands of people get infected every year with the disease,” Dr Bibek Kumar Lal, director at the Family Welfare Division, said. “And what is concerning is antimicrobial resistance is very high in the antibiotic used in the typhoid treatment. So we opted for typhoid vaccination.”
The Health Ministry said the World Health Organisation has provided a pre-qualified certificate to the typhoid conjugate vaccine, which Nepal has planned to include in the regular immunisation programmes and nationwide campaigns.
The National Immunisation Advisory Committee had also recommended for inclusion of the typhoid vaccine in the regular immunisation list.
Symptoms of typhoid include weakness, stomach pain, headache, diarrhea or constipation, cough and loss of appetite.
Doctors say problems of typhoid and other waterborne diseases will not stop unless the condition of water and sanitation improves.
“If the vaccine is effective and scientific evidence supports that vaccination is necessary there is nothing wrong in including the vaccine in the regular immunisation list,” said Dr Bhagwan Koirala, chairman of Nepal Medical Council, the national regulatory body of medical doctors. “But vaccination cannot be a replacement of the water and sanitation programme and data must support that vaccination is necessary.”