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Tackle Nepal’s typhoid problem now

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The news that a promising vaccine has been tested against Ebola is very welcome. But, as we in Nepal know only too well, the development of a vaccine is no guarantee that it will be used. Back in 1987, a successful trial of a typhoid vaccine here in Kathmandu gave the world a new and highly effective way to protect against one of its oldest killers. Yet, ironically, while the tourists and trekkers who have flocked in recent decades to Nepal — one of the countries where typhoid is still endemic — use the vaccine to protect themselves, most local people are denied it.

The Nepalese government cannot afford the US$10 doses of vaccine that could protect millions of its people. But the need is great — particularly since the devastating magnitude-7.8 earthquake that rocked Nepal in April. In many places, whatever water and sewerage systems existed were smashed, and thousands of people still live in temporary shelters and camps, increasing their risk of consuming contaminated water. In recent months, the monsoon (when cases of typhoid typically peak) has made a bad situation worse, and there are sporadic reports of disease outbreaks. These could yet provoke an epidemic in the hardest-hit places, such as the Sindhupalchowk and Gorkha districts.

As typhoid spreads, the risks increase. The most severely affected are school-age children, who are struck down with a fever and abdominal pain for several weeks. Most of these children recover, but many develop complications, including hypotensive shock, perforation of the gut and gastrointestinal haemorrhage. Antibiotic treatment has reduced the fatality rate from historic highs of 20% to 1–4%, but studies suggest that some typhoid strains are becoming resistant. Antibiotics are sold freely over the counter in Nepal and so are widely misused. About one in three people who report to a Kathmandu doctor with suspected typhoid will already have (mis)used an antibiotic.

The aftermath of the earthquake has made many poor people even poorer. With no health insurance, the average Nepali family now has difficulty paying for an ill child to go to hospital. As a result, those children who develop typhoid complications are less likely to recover.

Prevention is key. The World Health Organization (WHO) said as much in 2008, when it recommended programmes to vaccinate school-age children against typhoid. A year later, the WHO South-East Asia Regional Office recommended that such programmes be prioritized for “immediate” implementation. Yet, despite several promises and false starts, this has not happened in Nepal.

The best way to prevent typhoid is to provide access to clean water and sanitation. But it will take decades for Nepal to put the necessary infrastructure in place, and the impact of the earthquake will make it harder still. In the meantime, wide deployment of a vaccine could be a useful — and lifesaving — measure. As part of the post-earthquake recovery plan, Nepal should kick-start a long-promised vaccination programme.

“While tourists and trekkers use the vaccine to protect themselves, most local people are denied it.”

Part of the problem is that the typhoid vaccine recommended by the WHO — the one that was tested in Kathmandu — is among the most expensive. To buy and deliver enough doses, Nepal will almost certainly need financial support. This could come from Gavi, the Vaccine Alliance, based in Geneva, Switzerland, which is committed to increasing access to vaccination in poor countries, or from the profits of pharmaceutical companies. (Incidentally, another useful vaccine, against hepatitis E — a disease with a similar mode of transmission that can prove fatal to pregnant women — was also proven in Kathmandu. It, too, is unavailable to local people.)

At present, just one typhoid vaccine is approved by the WHO. It would be cheaper for Nepali health officials to deploy an alternative vaccine, not pre-qualified by the WHO. It is unclear why they have not yet done so; perhaps they are reluctant to be seen to be going against WHO guidance.

The decision to vaccinate — whichever vaccine is used — must be backed with solid research. Here, there is some progress to report. Early next year, a multi-site project led by researchers at the University of Oxford, UK, will start to map the burden of typhoid fever across Asia and Africa. The objective of this study is to quantify accurately the number of people with typhoid fever and complications of the disease in countries such as Nepal. This information will be useful for vaccination campaigns.

There are other pressing research needs, too. With no new treatments in the pipeline, it is important to track resistance to antibiotics. This can be done with proper microbiological support, including, where possible, genetic studies of the typhoid isolates.

Researchers must also study why some people are more susceptible to the disease more than others. Last year, a preliminary genome-wide association study of people from Nepal and Vietnam implicated the HLA-DRB1 gene as a major contributor to resistance against typhoid fever (S. J. Dunstan et al. Nature Genet. 46, 1333–1336; 2014).

If the Ebola vaccine is as effective as it seems to be, the world will have developed a way to tame this awful disease within 40 years of its first appearance. Reports of typhoid date back almost 2,000 years, but the disease is still killing people. It is not just the new threats that deserve our attention.

Journal name:
Nature
Volume:
524,
Pages:
267
Date published:
()
DOI:
doi:10.1038/524267a

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  1. Buddha Basnyat practises medicine in Kathmandu, where he is director of the Oxford University Clinical Research Unit at Patan Hospital.

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  1. Avatar for Abhishek Sharma
    Abhishek Sharma
    Preventing epidemic risks in Nepal The earthquake-struck Nepal is at high risk of various infectious disease outbreaks. In recent letters, Basnyat and colleagues suggested widespread public-sector vaccinations against typhoid and hepatitis E to manage the outbreak risk. [1,2] However any move to include a separate, expensive vaccine for each disease in Nepal’s national immunization program (NIP) may be ill-advised if not political. Nepal funds only one-third of total NIP expenditure and relies largely on external support, with an estimated funding gap of 48% to meet its 2011-2015 immunization targets. [3] The coverage levels of existing vaccinations are often over-reported and the vaccination programs do not actually result in expected reduction in disease morbidity. [4] Furthermore vaccines may not produce adequate immune response in the affected communities as they are significantly malnourished. Therefore, unless absolutely necessary, including newer vaccines, particularly in the aftershocks of earthquakes and fragmented healthcare system, may have adverse financial and programmatic implications risking coverage of even the traditional NIP vaccinations. In Nepal, communicable diseases spread due to poor access to clean drinking water and adequate toilet facilities which should be targeted as disease preventive strategies. Nepal should not only focus on reconstructing physical infrastructure but address wider public health issues through structural changes in urban design. Better sewage system, water treatment facilities, public education about importance of boiling water and hygienic cooking practices would be more cost-effective and sustainable health strategies to tackle communicable disease burden and should go hand-in-hand with post-disaster reconstruction of Nepal. References: 1. Basnyat B. Tackle Nepal’s typhoid problem now. Nature 524, 267–267 (2015). Available from http://www.nature.com/news/tackle-nepal-s-typhoid-problem-now-1.18194, accessed on August 20, 2015. 2. Basnyat B. et al. Nepali earthquakes and the risk of an epidemic of hepatits E. Lancet 385, 2572–2573 (2015). Available from http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)61110-2.pdf, accessed on August 21, 2015. 3. Nepal Ministry of Health & Population. National Immunization Program: Comprehensive Multi-Year Plan (2011-2016). Available from http://dohs.gov.np/wp- content/uploads/chd/Immunization/cMYP_2012_2016_May_2011.pdf, accessed on August 22, 2015. 4. Onta SR. et al. The quality of immunization data from routine primary health care reports: a case from Nepal. Health Policy Plann 13, 131-9 (1998). Available from http://heapol.oxfordjournals.org/content/13/2/131.long, accessed on August 21, 2015. Authors: Abhishek Sharma (1). Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA. (2). Center for Global Health and Development, Boston University School of Public Health, Boston, Massachusetts, USA. Email: abhi0991@bu.edu Shiva Raj Mishra (1). Nepal Development Society, Bharatpur 10, Chitwan, Nepal. (2). University of Western Australia, 6/15 Crawly, WA, Australia. Email: shivarajmishra@gmail.com
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