A virulent strain
To the horror of healthcare experts, Hyderabad, Karachi and other parts of Sindh have experienced an unprecedented eruption of extensive drug-resistant ( XDR) typhoid cases over the past two years. An XDR strain is just one step away from being resistant to any drug used to stem typhoid.
Ever since the first case was detected on Nov 30, 2016, the situation has escalated. In the last three years, a total of 10,195 typhoid fever cases have been reported, with a majority suffering from XDR.
Recent reports have confirmed that people diagnosed with XDR typhoid in several non-endemic countries - the US, the UK, Canada, Spain, Australia, Denmark, Taiwan and Ireland - have had a travel history in Pakistan.
This news sent shockwaves across the world health community, prompting an urgency to address the issue at its root. And so, later this month, all eyes will be on Pakistan. It will be the first country globally to introduce typhoid prevention vaccine - Typhoid Conjugate Vaccine (TCV) - in its childhood immunisation programme, at the age of nine months.
Starting from Sindh, the vaccine will then be introduced in Punjab and Islamabad in 2020, and the rest of the country in 2021. Spread over 12 days, up to 10.1 million children between nine months and 15 years of age in all urban areas of the 29 districts of Sindh will be vaccinated.
In the last three years, 10,195 typhoid cases have been reported in Sindh.
But the upcoming campaign to ensure coverage as high as 95 per cent in every town and district will face many challenges.
Almost half the targeted children (44pc) are school-going. The campaign teams will be spending the first four days vaccinating children only in school. Covering public schools may be relatively easy, but reaching private schools and madressahs may pose the same 'trust deficit in public healthcare' problem that previous measles and polio campaigns encountered.
The other hard-to-reach group would be the non-school-going children aged five years and above, which is almost 20pc of the total target. Most vulnerable and difficult to trace, this group includes children working as domestic help, at auto workshops, vendors and street children.
Karachi and Hyderabad are home to a large number of urban slums. A profiling of urban and peri-urban slums identified a total of 1,317 slums in Karachi and
Hyderabad alone. Nearly 75pc of these slums are located in 18 towns of Karachi, while the remaining 25pc are within four towns of Hyderabad. Reaching out to these children also poses a challenge for vaccinators.
Furthermore, it is not just the vaccines that will help control or reduce the burden of typhoid; supplementary efforts for sanitation and hygiene have to complement such efforts. A dismal waste management system, poor access to potable water, and questionable hygiene practices and food preparation methods have left many people vulnerable to the infection which has a significant cost of treatment.
Pakistan launched the Expanded Programme on Immunisation (EPI) in 1978 with the aim to save children from vaccine-preventable diseases. Today, the programme offers 10 vaccines to be administered to a child from birth till 15 months of age: TB, poliomyelitis, diphtheria, whooping cough, tetanus, hepatitis B, haemophilus influenza type B, pneumonia, rotavirus and measles.
Once introduced in the EPI, the TCV will be the 11th antigen added to the list. Starting from Nov 18, 2019, its introduction in Sindh (with support from Gavi, the Vaccine Alliance) comes with a cost of $6.2m. But to the people, like all other 10 vaccines, typhoid will also be available free of cost in routine immunisation programmes for the children of Sindh.
It is time we understood the importance of completing our children's immunisation schedule and put in all efforts towards increasing vaccinations from its present dismal rate of 49pc in the province, according to the Pakistan Demographic and Health Survey 2017-18.
Besides a strong political commitment, active engagement and coordination of all key partners - in polio and nutrition, Lady Health Workers, civil society organisations and pediatric association - must be ensured for the TCV campaign to be successful. Intensive and robust social mobilisation efforts to ensure the target 95pc vaccination coverage can be reached.
The key to the survival of Pakistani babies is simple and costs next to nothing. Exclusive breastfeeding up to at least six months of age (the current rate in the first four months is only 16pc), bringing routine immunisation in every province up to 90pc, and improving water and sanitation quality will not only prevent cases of typhoid, but also help eradicate other diseases.
In a world where numbers are seen as proof of success, the positive thing about immunisation is that its success is quantifiable, and the results are tangible. Let us collectively work to save lives of Pakistani children.