Typhoid control needs more vaccine, less antibiotic

Reports now highlight a surge in typhoid cases, a concern not only because of the commonality of the infection but also due to the potential for inappropriate or excessive antibiotic use. Typhoid is a vaccine-preventable bacterial disease, but in India, diagnosis and treatment remain inconsistent. The main issue stems from the lack of a simple, reliable, and accessible diagnostic test.

The widely used Widal test may not accurately diagnose acute typhoid, as background antibodies and past exposure or vaccination can complicate interpretation. Blood culture is the conventional method, yet it also has its downsides. The WHO notes that the sensitivity of a single blood culture is around 55-60 percent, influenced by blood volume and prior antibiotic exposure.

This leads to a problematic cycle: patients with persistent fever may receive antibiotics before seeking care, undergo a blood culture with a negative result, and clinicians may then escalate or change antibiotics. This approach contributes to antimicrobial resistance (AMR), especially in a country already grappling with increasing resistance to Salmonella typhi.

To address this, a focus should be on why antibiotics are being used as the primary solution for a vaccine-preventable disease. India has a WHO-prequalified typhoid conjugate vaccine (TCV), Typbar-TCV, and additional Indian TCV products have been prequalified. However, the scale and proper use of the vaccine remain insufficient.

Vaccination should complement, not replace, efforts in clean water, sanitation, food safety, and improved diagnostics. The first step should be to enhance surveillance, with hospitals and laboratories systematically documenting suspected and culture-confirmed cases, antimicrobial susceptibility patterns, and prior antibiotic exposure.

Diagnostic stewardship should also be integrated into antimicrobial stewardship, with blood cultures ideally obtained before antibiotics are administered with proper laboratory practices. India needs to invest in a more accurate point-of-care or rapid diagnostic test for typhoid and reconsider the role of TCV in its public-health strategy.

To tackle the rising typhoid cases, the focus should be on improving diagnostics, strengthening surveillance, adopting responsible antibiotic use, and most importantly, prevention. India shouldn't be forced to choose between better diagnostics and vaccination; both are necessary.