Madagascar should introduce typhoid conjugate vaccines now

Abstract

In December, 2017, WHO prequalified a typhoid conjugate vaccine, recommending its use in people aged 6 months to 45 years residing in typhoid fever-endemic areas.1WHOTyphoid vaccines: WHO position paper—March 2018.Wkly Epidemiol Rec. 2018; 93: 153-172Google Scholar Typhoid conjugate vaccines have also been included in the portfolio of subsidised vaccines managed by Gavi, The Vaccine Alliance.2GaviThe Vaccine AllianceMillions of children set to be protected against typhoid fever.http://www.gavi.org/library/news/press-releases/2017/millions-of-children-set-to-be-protected-against-typhoid-fever/Date: Nov 30, 2017Date accessed: August 28, 2018Google Scholar Typhoid fever surveillance has been done in Madagascar since 2011 as part of the Typhoid Fever Surveillance in Africa Program (TSAP) and the Febrile Illnesses Surveillance in Africa Program. TSAP identified an incidence of 171 per 100 000 individuals aged 5–14 years in a rural setting,3Marks F von Kalckreuth V Aaby P et al.Incidence of invasive salmonella disease in sub-Saharan Africa: a multicentre population-based surveillance study.Lancet Glob Health. 2017; 5: e310-e323Summary Full Text Full Text PDF PubMed Scopus (162) Google Scholar corresponding to five typhoid cases in a study population of 13 188 individuals. The ongoing Severe Typhoid Surveillance in Africa (SETA) programme identified ten typhoid cases in the same Malagasy study site population between February, 2016, and February, 2018 (unpublished data), confirming the aforementioned incidence. SETA also investigates intestinal perforations, a complication observed in untreated typhoid fever patients. Several cases were found at tertiary care facilities in Antananarivo (unpublished data). Madagascar ranks 112th of 117 countries investigated for water, hygiene, and sanitation (WASH) performance,4Cronk R Luh J Meier BM Bartram J WASH performance index report. UNC Gillings School of Global Public Health, 2015http://waterinstitute.unc.edu/wash-performance-index-report/Date accessed: August 28, 2018Google Scholar 40% of the population openly defecate and, in rural settings, only 35% of the population have access to water.5UNICEFMadagascar Ministry of HealthMadagascar WASH sector. Key results framework (2016–2019). UICEF, 2015https://www.unicef.org/madagascar/eng/KeyResultsforWASHsectorarchivecopy.compressed.pdfDate accessed: August 28, 2018Google Scholar Furthermore, the Malagasy health-care-seeking behaviour differs from that of other African populations. The absence of a functioning health-care insurance system coupled with low availability of medical personnel and curative medicines at health-care posts result in nationwide underuse of health care.6Marks F Rabehanta N Baker S et al.A way forward for healthcare in Madagascar?.Clin Infect Dis. 2016; 15: S76-S79Crossref Scopus (12) Google Scholar Severely sick people often remain at home and succumb to disease because families cannot afford transportation and health-care costs. Introduction of typhoid conjugate vaccine will greatly benefit the Malagasy population. National immunisation circumvents the WASH and health-care system shortfalls and will protect the population from an often deadly disease. We surmise that the aforementioned incidences are only a small indication of a larger issue and that the burden in more remote settings is considerably higher. We applaud WHO and Gavi, The Vaccine Alliance, for including typhoid conjugate vaccine in the portfolio of subsidised vaccines and hope for a close collaboration between the Malagasy authorities and Gavi, The Vaccine Alliance, that will ensure a swift introduction of typhoid conjugate vaccine into the routine program. This important measure will protect thousands of Malagasy children who have inadequate access to appropriate health care and water. TSAP and SETA programmes are funded through the Bill & Melinda Gates Foundation (OPPGH5231, OPP1127988); the Febrile Illnesses Surveillance in Africa programme was funded through the Else Kröner-Fresenius-Stiftung (2013_HA263). We declare no competing interests.