Last December, Khalid Shaikh missed 20 days of school and had to be hospitalised for nearly two weeks, as he battled a serious bout of typhoid that gave him fever, splitting headaches, stomach and body pain.

His family spent Rs 1 lakh on his treatment.

The 15-year-old and his friend had eaten food from a street vendor. Both ended up with typhoid, a water-borne disease caused by the bacteria Salmonella Typhi that attacks multiple organs, causes vomiting and, in rare cases, leads to death. The bacteria spreads through contaminated food and water, often in unsanitary environments.

India accounts for more than half of the global typhoid burden.

When Shaikh first developed a headache and stomach ache, a local doctor prescribed antibiotics. Then followed high fever that recurred every four hours. He was admitted to a hospital in Jogeshwari, a western suburb of Mumbai. When his fever did not subside, his parents shifted him to the Kokilaben Dhirubhai Ambani hospital.

“The doctors there suspected typhoid,” his mother Shabina Shaikh said. The teenager was given a strong dose of antibiotics because milder ones did not work on him. Twenty days after discharge, the typhoid relapsed. This time, he was in hospital for three more days.

Shaikh is a classic example of antimicrobial resistance, a condition in which the drug is not able to kill or control the bacteria because the bug grows resistant to it.

Antibiotic therapy is the only treatment option for typhoid. “Increasing hospitalisation and treatment is leading to antimicrobial resistance,” said Shaikh’s treating doctor Tanu Singhal, an infectious disease specialist.

As a result, doctors often have to resort to increasing the dosage of drugs.

In south Mumbai’s Bombay hospital, physician Dr Gautam Bhansali said until a few years ago, typhoid patients responded well to a daily dose of 1 gram ceftriaxone, an antibiotic that prevents bacteria from growing. “Now I have to use 2 grams twice a day,” he said. “This means additional cost of treatment but also increases resistance risk in the bacteria,” he said.

All these factors – antimicrobial resistance, the high burden of the disease and its treatment cost – led the National Technical Advisory Group on Immunisation, or NTAGI, a body that advises the government on vaccinations, to strongly recommend introducing the typhoid vaccination in 2022, a year before Shaikh contracted typhoid.

In its recommendation, a technical committee of NTAGI warned that India could record 4.6 crore typhoid cases and 89,300 deaths in a 10-year period “if nothing was done”.

It advised the government to provide free typhoid vaccines for children aged between nine months and 12 months and conduct a one-time campaign in schools under the universal immunisation programme to vaccinate older children.

In the same meeting, the group had also recommended introducing the human papillomavirus, or HPV, vaccine against cervical cancer, the second-most common cancer amongst women, in India’s immunisation programme.

While the health ministry has agreed in principle to introduce the HPV vaccine, on typhoid it remains undecided even after two years.

The case for a typhoid vaccine

The World Health Organization first recommended typhoid vaccination for countries where typhoid was endemic in 2008. But discussions in India began much later.

The health ministry decided to conduct typhoid surveillance to assess the disease burden only in 2016. Until then, there was no data on its incidence.

A Surveillance for Enteric Fever in India, or SEFI, consortium began to collect data from 18 sites, including urban and rural regions.

Between 2017 and 2020, the consortium generated enough data to suggest that typhoid incidence varies, from low in rural areas – 12 cases per one lakh children admitted in hospitals for fever – to very high in some urban populations – 1,622 cases per one lakh children.

In Vellore, Delhi and Kolkata, typhoid incidence was higher than 500 cases per lakh children. In sites where only hospital data was surveyed, Chandigarh and Anantpur had a high incidence of the disease. The study also looked at the use of antibiotic drugs for typhoid and found it 2.5 times higher in Pune than in other sites.

Overall typhoid incidence was found to be higher than measles or rubella, vaccines for which are a part of the universal immunisation programme in India.

“There was enough data to suggest that typhoid burden is high. In a lot of cases, it is not even diagnosed,” said Dr Gagandeep Kang, a former member of NTAGI and chairperson of the typhoid working group that recommended the vaccine.

An 11-year-old typhoid patient at a private hospital in Saraspur in Ahmedabad in November 2014. Credit: AFP.

In 2018, the ministry began a pilot study to assess the impact of vaccination. For this, health workers immunised 3.2 lakh children aged between nine months and 14 years with a conjugate vaccine in Navi Mumbai.

The study, carried out between 2018 and 2021, found that vaccination reduced the risk of infection by 56%. Dr Shanta Datta, the study's co-author from National Institute of Cholera and Enteric Diseases, said this was “enough evidence for a vaccine to be used” in the national programme.

“Typhoid is a serious disease. If not treated, people could die. Considering the risk it presents, a vaccine is the safest option to prevent the infection,” Datta told Scroll.

Another study published this year analysed the cost of the Navi Mumbai vaccination drive. For the government, the cost of the vaccine and related supplies was Rs 127.70 per person, while the cost of delivering it ranged from Rs 30 to Rs 44.

In the private sector, the cost of typhoid conjugate vaccine, currently manufactured by Bharat Biotech, Biological E and Zydus Cadila, is much higher, ranging between Rs 1,500 and Rs 2,000. But there is no data on how many people have taken this shot. “Awareness about it is quite low,” Dr Singhal, from Kokilaben Dhirubhai hospital, said.

Till March 2023, the World Health Organization has prequalified two conjugate vaccines against typhoid, both have long-lasting immunity – Bharat Biotech’s Typbar TCV and Biological E’s Typhibev.

An urban problem

But several experts argue that a vaccine might not be the answer to India’s typhoid burden.

Epidemiologist and virologist Dr Jacob T John argued that typhoid does not uniformly infect the entire population. “It is an urban phenomenon.” Which is why, he added, immunising the entire population indiscriminately is not the best solution.

He gave the example of Japanese Encephalitis, which affects a select population, and said interventions on typhoid should only be made in limited geographic regions.

“The presence of typhoid indicates something is wrong with the water supply,” John said. “If we chlorinate and filter water, typhoid will not occur. This will also eliminate other water-related infections like cholera and dysentery. That is a cheaper solution”.

Kang, the former NTAGI member, however, said there is enough evidence to suggest typhoid poses a threat to public health. “Our priorities are people who are the poorest and most vulnerable, and they are also the ones most at risk of typhoid – for example, urban slum areas,” she said.

This pool cannot buy vaccines on their own. Kang said the technical group recommended that the government try out different mechanisms to immunise them – either through a phased introduction in which children of various age groups are immuned in phases, or targeted introduction of vaccines, in which immunisation is carried in pockets with high typhoid incidence.

A boy drinks water from a municipal tanker on a hot summer day in New Delhi in May 2022. Credit: Reuters.

Another expert on typhoid, Dr Jacob John, who is a community health professor in Christian Medical College, Vellore, said if the government is able to conduct targeted immunisation in the urban population, then the typhoid burden can be controlled. “But we must remember that urban and rural areas are not water-tight compartments. There is migration between the two,” he said.

Jacob John also headed the Surveillance for Enteric Fever in India study and said that typhoid incidence has not reduced over the years despite best efforts to improve sanitation. “When we get to good sanitation, like the West, we will not need a vaccine,” he said. “But that will not happen in the immediate future. We still need a huge quantum of investment to improve our water supply and sanitation. And because it will take a long time, we need other solutions.”

The answer, he said, could lie in introducing vaccines in the universal immunisation programme. “We are seeing cases of drug resistant bacteria in Pakistan. Gujarat is noting cases of resistance too. There are reports of ceftriaxone and azithromycin resistance. Which means we are left with fewer antibiotics to work,” he said.

Other constraints

A member of the NTAGI, who did not want to be identified, said that the delay in introduction of the typhoid vaccine was due to “other priorities” and “constraints” of the health ministry.

The vaccine is recommended for children aged between nine and 12 months. In this window, the measles, mumps and rubella vaccines also have to be administered. Health officials say that two or more shots in such a short span may not be welcomed by parents.

The current focus is on measles coverage, where India is lagging at present, the official added.

For many families dealing with the fallout of typhoid, these arguments ring hollow.

It has been a month since Neeshka Kothare, aged 20, first developed a sore throat and then recurring fever, followed by bouts of vomiting. She continues to have a high-grade fever for a few hours every day. She was diagnosed with typhoid earlier this month.

Kothare was recently part of an education tour to Bhopal. She suspects unclean drinking water served to them spread infection amongst all students. Students and teachers complained of sore throat, and some like Kothare, worsened, developing typhoid and a persistent fever of over 99 degrees.

Earlier this month, Kothare required intravenous injection of antibiotics for three days. She still has fever and continues to take cefuroxime antibiotics. Before this, she was put on azithromycin, another antibiotic to treat infections.

“If I knew about a vaccine, we would have given it to her. It is not-an-easy-to-tackle infection,” her mother Sanjana Kothare, a lawyer, told Scroll.

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.