school based typhoid fever immunisation . prospects & problems · 1. bernard ivanoff, typhoid...
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School based typhoid fever School based typhoid fever immunisationimmunisation..Prospects & problems Prospects & problems
T. Jacob JohnVellore, India
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Background document: The diagnosis, treatment and p revention of typhoid fever World Health Organization, WHO/V&B/03.07
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UK: Lessons from successfulschool based vaccination programs
�Routine rubella at 13 yrs of age: 1971-1994
�BCG at 10-14 yrs: 1953-2005
�dT booster at 13-18 yrs: 1960 onwards
�Nationwide campaign measles/rubella at 5-16: 1994
�Mening. C campaign at 5-18 yrs: 1999-2000
�All “voluntary” and free of charge
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Viet Nam: success storySchool based vaccination.
�Measles vaccination by school based campaign in 2002-2003:
�Coverage achieved: 99%
�When governments apply their minds and money, programs succeed
�The secret is to enable and ensure accountability to be accepted by governments
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Many successful demonstration projectsof school based typhoid fever vaccination
�Viet Nam (Hue city: DOMI study, Vi)
� Indonesia (DOMI study Vi)
�Pakistan (DOMI study Vi)
�Chile (M Levine studies – Ty21a oral)
�No doubt projects work; up scaling and institutionalizing for sustainability not yet proven
�What happens in 2nd yr and thereafter?
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Statement of principle
�School based vaccination, or any vaccination modality in public health, is not an end in itself, but a means to an end.
�Unless we define the “end” and apply methods of measuring it by stated time-target, and of monitoring it en route, we may look like “peddlers of product” and not “preventers of pathology” (that we really are)
�Unless “we” – them and us, can celebrate disease prevention, we cannot expect demand creation from them -- and the Sisyphean curse will not be cured.
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National Family Health SurveyNearly 200,000 interviewed
Immunisation coverge %
1992-93 1998-99 2005-06
Uttar Pradesh: 20 20 23
Bihar: 11 12 33
National: 35 42 44
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Delhi slum and Tamil Nadu village
� Lancet 1999; 354: 734 (A Sinha, MK Bhan) showed incidences of:
<5 yrs: 27/1000 person yrs5-19 yrs: 12/1000 person yrs19-40 yrs: 1/1000 person years (in urban, overcrowded slums in Delhi, with piped water supply, often contaminated with coliforms)
� M Datta, unpublished:
In rural community, overall incidence 1/100 of Delhi data.No case < 19 years of ageEvery adult case had h/o visit to Chennai and eating in restaurantLocal bore well water system, with or without tank storage.
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EPIDEMIOLOGY
Typhoid fever, a severe disease present all over the world
Endemic mode Sporadic modeEndo-epidemic mode
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•• PrevalentPrevalent worldwideworldwide -- SalmonellosisSalmonellosis increasingincreasing•• Incidence Incidence alwaysalways higherhigher in in studiesstudies for vaccine for vaccine efficacyefficacy
-- 16 16 -- 33 million cases / 33 million cases / yearyear worldwideworldwide (1, 2))(1, 2))
-- DevelopingDeveloping world : 540 / 10world : 540 / 10 55 / / yearyear
-- DevelopedDeveloped world : 0.2 / 10world : 0.2 / 10 55 / / yearyear
((HighestHighest : Papua New : Papua New GuineaGuinea : 1208 / 10: 1208 / 105 (1)5 (1)
IndonesiaIndonesia : 810 / 10: 810 / 105 (3)5 (3)
-- 0.5 to 0.7 million 0.5 to 0.7 million deathsdeaths / / yearyear((mortalitymortality AsiaAsia : 12 : 12 -- 32 %)32 %)
1. Tikki Pang et al., Typhoid fever and other Salmonellosis: a continuing challange, Trends in Microbiology, Vol.3, No 7, July, 1995; pp 253-255.2. Levine MM. Typhoid Fever Vaccines. In: Plotkin S.A., Mortimer EA, Editors. Vaccines, Philadelphia, Saunders. 1994: 597-633.3. Simanjuntak CH et al. Oral Immunization against typhoid fever in Indonesia with Ty21a Vaccine Lancet 1991; 338:1055-59.
TYPHOID FEVER TYPHOID FEVER -- THE PROBLEM THE PROBLEM
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•• Incidence in Incidence in AsiaAsia :: 1000 / 101000 / 105 5 / / yearyear (1)(1)
•• Cases in South East Cases in South East AsiaAsia :: 4.36 4.36 -- 6.98 million / 6.98 million / yearyear
•• MortalityMortality in in AsiaAsia :: 12 12 -- 32 % (32 % (despitedespite treatmenttreatment ))
•• TravelTravel relatedrelated typhoidtyphoid :: IndiaIndia : 105 : 105 -- 118 / million travellers / 118 / million travellers / yearyearSE SE AsiaAsia : 7.2 / million travellers : 7.2 / million travellers (2)(2)
1. Bernard Ivanoff, Typhoid Fever: Global Situation and WHO Recommendations. Southeast Asian Journal of Tropical Medicine and Public Health, Vol 26 Suppl. 2, 1995, pp.1-6
2. Editorial, Typhoid Vaccination: weighing the option, Lancet; Vol. 340: Aug 8, 1992, 341-342
TYPHOID IN ASIATYPHOID IN ASIA
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- Among the highest in the world- Incidence : 1206 / 10 5 / year
600,000 - 1300000 cases / year
- Mortality : >20,000 deaths / year
- Age : 91% of cases in 3 - 19 years age
Simanjuntak Cyrus H et al. Oral Immunization against typhoid fever in Indonesia with Ty21 a Vaccine, Lancet 1991; 338:1055-59.
EPIDEMIOLOGIC SITUATION: INDONESIAEPIDEMIOLOGIC SITUATION: INDONESIA
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• Most cases in children and young adults (1)
Peak : 5 - 20 years age
80% : < 40 yeas age
1 - 4 years age < 5 - 9 years age group(Despite a similar risk of exposures) (2)
Source :
1. Michael L Bennish, Immunization against Salmonella typhi. Infectious Diseases in Clinical Practice,
Vol.4, No.2.
2. Mahle WT, Levine MM : Salmonella typhi infection in children younger than five year of age.
Pediatr Infect Dis J 1993, 12: 627-631.
TYPHOID FEVER TYPHOID FEVER –– RISK BY AGERISK BY AGE
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Incidence according to ageIncidence according to age
0
50
100
150
200
250
300
Inci
denc
e (p
er 1
00,0
00)
0-4years
10-14years
20-24years
35-44years
55-64years
Age groups
Typhoid fever
Levine M.M. et al., PAHO; 1985: 37-53. Chile 1977-1981
EPIDEMIOLOGY: ENDEMIC AREAEPIDEMIOLOGY: ENDEMIC AREA
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0
10
20
30
40
50
60
< 1 year 1-4 year 5-14 years 15-44 years > 45 years
0
10
20
30
40
50
60
1965 1991(b) 1991(a)
AGE DISTRIBUTION: INDIAAGE DISTRIBUTION: INDIAC
ase s
/ 10
5 P
opu l
atio
n
A. K. DUTTA et al., Typhoid Fever - an Asian perspective, APPSPGAN Teaching Workshop, Galle, Sri Lanka, October, 1998
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• Age : Shift to the left (upto 60% < 5 years age)
• Many < 2 years age
• Variable clinical picture in young children
• Either typhoid-like (>2 yrs) or not so (<2 yrs)
• Common presentation: fever, diarrhoea
pain abdomen, refusal to feed, seizures,
radiological bronchopneumonia,
pronounced hepatosplenomegaly, no leukopenia
• Blood culture not often done in young children
Johnson A, Aderle WI, Enteric fever in childhood, J. Trop. Med. Hygiene 1981, Vol. 84, 29-55
Pandey KK, Srinivasan S, Typhoid fever below 5 years, I nd. Pediatr., 1990 Vol. 278, 153-156
TYPHOID FEVER (TYPHOID FEVER (ChildrenChildren ) ) THE DISEASE PROFILETHE DISEASE PROFILE
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1948 : 1st successful treatment with Chloram.1950 : 1st resistance to Chloram. - England1960 : Worldwide Chloram. resistance1960 - 1984 : Increasing resistance to front line
drugs (TMZ, Ampicillin/Amoxy.)1984 : MDRST reported in Thailand1987 : MDRST - China1990 : MDRST - India1991 : MDRST - Malaysia and Pakistan
1997 : 1st reports of Quinolone resistance
MDRST : MDRST : MicrobiologicalMicrobiological : > 2 : > 2 antibioticsantibiotics in vitro in vitro ClinicalClinical : All : All threethree 1st line 1st line antibioticsantibiotics
TYPHOID TYPHOID -- THE CHANGING PROFILE THE CHANGING PROFILE ((MicrobiologicalMicrobiological ))
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MDRST :MDRST : 40 - 50 % in Children15 - 50 % in Children < 5 years age
COUNTRYCOUNTRY % ISOLATES% ISOLATES
• INDIA : 40 - 92 %• PAKISTAN : 20 - 77 %• VIETNAM : 50 - 88.7 %• CHINA : 50 %• SINGAPORE : 16 - 25 %• KUWAIT : 5 %• IRAN : 37 %
TYPHOID TYPHOID -- THE CHANGING PROFILE THE CHANGING PROFILE ((MicrobiologicalMicrobiological ))
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• Prolonged Pyrexia upto 8 weeks
• Marked Toxaemia
• Increased incidence of Diarrhoea
• Increased incidence of Tender HSM
• Higher incidence of Complications- Acute nephritic Syndrome- D.I.C.
TYPHOID TYPHOID -- THE CHANGING PROFILE THE CHANGING PROFILE (MDRST)(MDRST)
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The unjust world of typhoid fever
�Where governments neglect their unavoidable responsibility to prevent and control diseases…
�Where treatment cost is left as the responsibility of the unfortunate person with disease…
�Whereas we declare that health is human right…�The obvious minimum action we must promote is
prevention by vaccination, by the govt. health system, in school and outside school, as the inalienable right of the people.
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School based vaccination is appropriate,where,
�Disease prevention is a priority, and --
�Disease incidence is high in the relevant age group
�There is a health policy (national/local) to control the disease by vaccination
�School based vaccination is a part of the whole –(where typhoid fever is frequent in pre-school age and it is included in national vaccination program)
�Not perceived as “marketing tactic” only
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Who are the involved parties?
� The health system (Public health, EPI, government)
� The school system: Public sector / private sector
� The school health system
� Parents of children (understand, accept, consent?)
� The children themselves (understand, accept, consent?)
� The professional association of care-givers: Pediatrics; public health; nurses
� The public (and the media that inform the public)
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What are the components of TF control?
� (S. typhi rarely amplifies in environment; large inoculum via fecal contamination in water?)
� What are the elements of control?
� How does vaccination fit in? Which vaccine?
� Vi first (all ages) and Ty21a later?
� Which are special groups other than school children?
� One time catch up (Vi), followed by systematic vaccination of new age cohorts? What age? Which vaccine?
� Food hygiene, water quality, what else?
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“Visibility, consensus and action plan”What is the measurable objective?
� Bad disease� Costly to treat, impoverishing individuals/nations� Common disease, but we have not unraveled the variations
in risk/prevalence frequencies. � Location-specific real-time data can come only from a functional
disease surveillance system� Must be controlled: What is the definition?� May be “eliminated” in local communities � Could (theoretically) be even eradicated� But who will champion our cause? Rich countries and the rich in poor
countries have very low risk.
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THANK YOUTHANK YOU
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Estimation of the number of annual casesEstimation of the number of annual cases
Cases ofCases ofTyphoid feverTyphoid fever
IncidenceIncidenceraterate
AfricaAfrica 4 375 0004 375 000 9.3/9.3/0000
West AsiaWest Asia 749 000749 000 7.6/7.6/0000
South and East AsiaSouth and East Asia 6 980 0006 980 000 5/5/0000
South AmericaSouth America 406 000406 000 1.1/1.1/0000
Edelman R. et al., Rev. Infect. Dis., 1986, 8:329-3 49
EPIDEMIOLOGY: ENDEMIC AREAEPIDEMIOLOGY: ENDEMIC AREA
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COUNTRY INCIDENCE CFR
INDIA 500 / 105 (1994)992 / 105 (1997)
1.1 %
PAKISTAN 150,000 cases/year(1990 - 1994)
-
INDONESIA 350-810 / 105 (1995) 10 %
SINGAPORE 5.9 / 105 (1989)1.2 / 105 (1997)
Nil
THAILAND 12 / 105 (1992) 1 %
MALAYSIA 4.46 / 105 (1994) 0.88 %
TYPHOID IN ASIATYPHOID IN ASIA
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•• TyphoidTyphoid isis 5th 5th mostmost commoncommon communicable communicable diseasedisease
•• 1979 1979 -- 1988 : 300,000 cases ; 1000 1988 : 300,000 cases ; 1000 deathsdeaths ??????
•• 1973 : Incidence : 7 . 6 / 1000 ( 1 1973 : Incidence : 7 . 6 / 1000 ( 1 -- 15 15 yearsyears age group )age group )
2.5 million case / 2.5 million case / yearyear
1. Dutta AK, Kanwal S, Nguyen VH, Wood Susan, A stud y of the cost burden of typhoidfever to an individual in India; Ind. J. Clin. Prac., Vol.9, No. 3, Aug’98, 16-29
2. Ichhpujani RL, Bhatia R. Typhoid Fever, First Edit ion 1997, Top Publications - Delhi
EPIDEMIOLOGIC SITUATION: INDIAEPIDEMIOLOGIC SITUATION: INDIA
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Temptations, to be avoided
�To promote the “ritual” and forget the “spirit”
�To exploit opportunity of captive target
�To think “now” and forget sustainability
�Not to plan well, create ambience, reduce anxiety, preparedness to face adverse reactions – immediate and subsequent
�Not to be legally correct, not only morally right
�Not to be transparent