KARACHI: Sahibi’s two grandsons — two-year-old Nadeem and seven-year-old Badshah — live with her under the Lily Bridge near Cantt Station in a makeshift house made of cardboard and jute in what can be described as nothing but subhuman conditions. They are the perfect candidates for getting vaccinated for the new typhoid vaccine that will be introduced in Sindh on Nov 18.

While Sahibi knows typhoid means “very high fever”, she does not know about the campaign or that it is free of cost. “I can take these kids but I don’t know where. Can you tell me?” she asks.

Apparently, activists have also not been informed about the campaign. “We could have helped the government in convincing parents to bring their kids to the vaccination centres,” said Shumaila Muzammil, who looks after the Karachi office of SPARC, a child rights organisation, but who was totally unaware of the campaign.

A few yards from her, sitting on a charpai with two daughters, three-year old Muskan and a year-old Bindiya is Reshma. She has completed the routine immunisation course for both the children at a 'sarkari' hospital in Garam Chashma. "Maybe I can get them vaccinated for typhoid also," she said.

Dr Arshad Karim Chandio, national programme manager, Expanded Programme on Immunisation, told Dawn that this was a national introduction starting from Sindh covering 460 urban union councils.

New typhoid vaccine will be introduced in Sindh on 18th

In Sindh they aim to vaccinate over 10 million children aged between nine months and 15 years for two weeks followed by a transition to routine immunisation of nine-month-old infants once the campaign ends. The vaccine will be introduced in Punjab next year followed nationally in 2021. Pakistan will be the first country in the world to introduce a one-dose vaccine, injected intramuscularly Typhoid Conjugate Vaccine.

“Prevention through vaccination is currently the most effective solution to reduce the burden of typhoid in endemic areas,” he told Dawn and added: “We have enough vaccines, and these have already been sent to the Sindh EPI, and there will be no stock-outs,” said Dr Chandio but conceded that there could be accessibility issues.

Although the government is making an “immense effort” and may well be able to reach the children in schools (about 44 per cent), paediatrician Dr D.S. Akram wondered about the street kids or those working as domestic help and at tea stalls, mechanic shops etc, who do not go to school (some 20pc) and whether the 95pc coverage would be achieved.

“They [government] would need to be super-efficient and depend upon massive community demand creation,” said Dr Zulfiqar Bhutta, founding director of the Aga Khan University’s (AKU’s) Centre of Excellence in Women and Child Health. “It may not be possible to meet their target in a single campaign.”

HELP, a non-governmental organisation Dr Akram is associated with, has been asked to facilitate the government by mobilising and persuading parents to take their children to fixed EPI centres or outreach sites set up during the campaign.

“The government has realised it cannot reach so many kids on its own and needs the help of civil society organisations,” said Dr Akram. However, she doubts if it will be able to meet its target. “The awareness of the disease — typhoid, the advantages of getting the kids vaccinated, busting the myths around vaccination — should have started four weeks before the campaign. I have not seen anything on TV or heard about it on the radio,” she said.

But why this sudden need to vaccinate all these children against typhoid?

It all started some three years back when healthcare practitioners reported getting people diagnosed with typhoid in Hyderabad and Karachi but who were infected with strains of the bacteria resistant to drugs used to treat the disease.

The foremost reason why typhoid became untreatable was the “injudicious use of antibiotics prescribed by doctors”, said Dr Akram Sultan, project director, EPI-Sindh. But he also blamed the people’s “irrational use” and resorting to “self-medication” and pressuring the doctor for “immediate relief”.

It became a global concern when last year, epidemiologists at the US-based Centres for Disease Control and Prevention traced a strain of extensively drug-resistant (XDR) typhoid bacteria to Pakistan and said it would survive and spread easily.

Dilapidated infrastructure, a broken down sanitation system, leaking sewerage lines, more than half the city residents living in katchi abadis, poor hygiene practices and a dismal healthcare system are perfect breeding ground for Salmonella enterica serovar Typhi bacteria, said Dr Mumtaz Lakhani, secretary general of the Pakistan Paediatric Association.

“Obviously these need to be addressed if we are to rid ourselves of this disease, but we cannot wait for that to happen and the next best solution is to prevent the children from getting this disease,” said Dr Lakhani. She said the WHO-approved vaccine had minimal or no side effects and was effective for about 10 years.

The AKU researchers have investigated the trends from as far back as 1990. “There was a decline of typhoid in the 1990s but this has remained stagnant since 2005,” said Dr Jai Das, one of the researchers, speaking to Dawn. The AKU also led a vaccination campaign in schools in select towns of Karachi in 2010-11 and vaccinated around 120,000 children.

They published their findings (based on laboratory findings from its own labs and two other institutions) — Trends, Associations, and Antimicrobial Resistance of Salmonella Typhi and Paratyphi in Pakistan, in 2018 — and found a strong association of water and sanitation indicators to literacy levels with typhoid. While there is no reliable data for food safety in Pakistan, the study stressed improving food safety protocols and implementation of regulations.

And as indicated by Dr Sultan, the study also attributed the resistance to antibiotics to its careless use in Pakistan, both as prescribed by general practitioners and its easy availability.

But when in 2016 they found this new phenomenon, XDR, the “first in the world, it drew a huge response and attention”, said Dr Das. It was the AKU that had found out about the XDR typhoid bacteria in the sewerage in Hyderabad in 2016.

As a pilot in the year 2018-19, led by Dr Farah Qamar, they vaccinated more than 200,000 children in Hyderabad in areas from where these cases were erupting. The latest Global Burden of Disease analysis estimates that, in 2017, Pakistan had 515,914 typhoid cases, 63 percent of which were among children under 15 years of age.

"It is a good step that the government is taking in rolling out this vaccine," said Dr Das, but added: "The strain is also found in adult population" who will not benefit from this vaccination that is targeted towards children only. For a long term sustainable solution, he said we have to look beyond vaccination.

The same was noted by Dr Bhutta. "With a large proportion of cases also among adults, and the possibility of carriers it is likely that large-scale immunization campaigns would need to include adults as well as focus on additional preventive measures. It should be recognized that Pakistan needed to focus on improving water quality, hygiene and sanitary conditions and also strictly implement food safety regulations”.

Published in Dawn, November 14th, 2019