“It’s difficult, but we’ll find a way”: a new vaccine against typhoid rolls out in a flood-devastated province of Pakistan

Armed with vials of Typhoid Conjugate Vaccine, health workers in Balochistan are doing what they can to protect children threatened by a pincer movement of global crises: antimicrobial resistance on the one hand and climate change on the other.

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A vaccination team going on a boat (locally made with plastic barrels) to vaccinate children against Typhoid, during the TCV campaign in Sohbatpur city. Credit: Gavi/Asad Zaidi
 

 

It was early October in Sohbatpur, Balochistan. The sky was clear, the sun was bright and electricity poles sprouted weirdly out of the floodwater. A metre or more above a sunken road, a raft made of a wooden charpoy and four plastic barrels lilted across the drowned town.

Sluiced in contaminated, insect-thick water, communities in the flood zone were at heightened risk of epidemic diseases, including typhoid.

On board, four health workers and a punting boatman perched with the unperturbable repose of passengers waiting at a sleepy rural railway station. A vaccine cooler box and a sharps disposal container marked ‘biohazard’ rested between them. Overhead, a banner announced the vessel’s purpose like a flag: “Typhoid campaign” it read – “from 3-15 October, get your children from 9 months to 15 years vaccinated against typhoid.”

The campaign, the first-ever rollout of the Typhoid Conjugate Vaccine (TCV) in this province, was not designed as a disaster relief mission. Long-planned and already once-delayed by the COVID-19 pandemic, this was the final leg of a phased nationwide TCV introduction drive, aiming to add 5.5 million to the 30 million Pakistani children that have been immunised against Salmonella typhi in waves over the last three years.


October’s campaign introduced the typhoid conjugate vaccine to urban portions of Balochistan, Khyber Pakhtunkhwa, Gilgit Baltistan and Azad Jammu and Kashmir, reaching 5.5 million children, including 200,000 people displaced from rural areas.

 



But the monsoon this year poured a catastrophic quantity of water down on Pakistan. In August, Balochistan, one of two provinces and two administrative territories whose urban areas were targeted in this campaign, got seven times more rain than usual. At the end of that month, climate minister Sherry Rehman said that a third of the country was under water. By September, an estimated 10 million had been displaced nationwide – more than 600,000 of them sheltering in camps. Balochistan alone reported more than 240,000 houses wrecked or damaged.

Sluiced in contaminated, insect-thick water, communities in the flood zone were at heightened risk of epidemic diseases, including typhoid.

“Our entire area is drowned in water due to floods since last two months. My house is also under water. Elders, women, and kids are sick – with malaria, typhoid, measles.”

“It’s a waterborne disease, so the spread of typhoid can certainly increase in floods and crowded situations,” says epidemiologist Allyson Russell, Programme Manager for cholera and typhoid at Gavi. Conducting the TCV campaign became suddenly considerably more urgent, and much more difficult: “was it even going to be possible? A lot of the roads and bridges were destroyed, and a lot of the cold chain had been impacted,” Russell recalls thinking. “But the Pakistan country team, with support from Provincial EPI leadership and partner agencies on the ground, was really adamant. They reassured us and said: you know, it’s difficult, but we’ll find a way.”

Hakim Zadi, a midwife and frontline TCV campaign vaccinator, disembarks from a locally-made raft. Across Balochistan, villages and periurban enclaves have turned into islands. Credit Gavi/Asad Zaidi
Hakim Zadi, a midwife and frontline TCV campaign vaccinator, disembarks from a locally-made raft. Across Balochistan, villages and periurban enclaves have turned into islands.
Credit Gavi/Asad Zaidi

In Sohbatpur, the barrel-and-charpoy ark scraped onto higher, dryer ground – a strip of tarmacked road now mistakable for a bridge. Its passengers disembarked. “We went by boat to vaccinate all the children – there were five kids needing TCV, five needing measles vaccine and four got polio drops,” reported Hakim Zadi, a midwife from the District Headquarters (DHQ) Hospital, smiling mildly.

Across Balochistan, health workers on the coalface of the TCV campaign were pulling double duty, stocking their vaccine cold-boxes with not only vials of the typhoid shot, but also with doses of Measles-Rubella and Oral Polio Vaccine; doing what they could to stifle the spread of other pathogens fuelled by the crisis conditions.

“Our entire area is drowned in water due to floods since last two months. My house is also under water,” Zadi said. “Elders, women, and kids are sick – with malaria, typhoid, measles.” In October, Balochistan recorded diarrhoea rates that were five times higher than normal, and more than one in nine children under five who were admitted to health facilities were suffering from severe acute malnutrition.

It wasn’t just a regular rough monsoon. In research published in September, scientists were able to demonstrate that the deluging rains were both made more likely and also exacerbated by climate change.

Everywhere in Jaffarabad district, tents stamped with the logo of the National Disaster Management Authority (NDMA) crowded the margins between roadways as dusty and perversely dry as bonemeal, and lakes that were only recently fields. The camps gave the impression of a disaster paused between rescue and recovery. Solar panels stood propped outside tent doors, radios chattered, cattle dozed under leaf-and-pole sunshades.

Displaced families like these lack access to sanitation facilities, said Dr Saleem Raza Jamali, District Health Officer. “In open defecation, the chance of an epidemic is very high.”

Hakim Zadi (left), a trained midwife prepares a TCV shot for Tahseen, aged two. In Sohbatpur city, as in other parts of Pakistan, many displaced families are sheltering in tents after the summer’s floods inundated their homes. Credit Gavi/Asad Zaidi
Hakim Zadi (left), a trained midwife prepares a TCV shot for Tahseen, aged two. In Sohbatpur city, as in other parts of Pakistan, many displaced families are sheltering in tents after the summer’s floods inundated their homes.
Credit Gavi/Asad Zaidi

Tethered goats offered gestures of futile defiance from tent entryways as the yellow-vested vaccinators made the rounds of the clustered children within. Syringes were drawn up, little arms bared. Toddlers cried tears of angry objection. Big kids made stoic big-kid faces. Zadi disposed of a used syringe and flashed a little girl a smile while an assistant coloured her pinky finger with permanent marker – a signal she was vaccinated. One more down, many more to go.

“The campaign we are working on is for poor and needy children,” she said. “We are giving them typhoid vaccinations so these children can be safe, and don’t get ill.”

An urban residential area in Sohbatpur town, which is still heavily under water months after the rains. Credit Gavi/Asad Zaidi
An urban residential area in Sohbatpur town, which is still heavily under water months after the rains.
Credit Gavi/Asad Zaidi

It wasn’t just a regular rough monsoon. In research published in September, scientists were able to demonstrate that the deluging rains were both made more likely and also exacerbated by climate change. Temperatures reached absurd highs on the subcontinent earlier this year, with the city of Jacobabad in Pakistan aching in 51 degree heat one May day. The warmer air held more moisture; it accelerated glacial melt. Before Pakistan’s monsoon broke in earnest, meteorologists were issuing flood warnings

Pakistan has been at the epicentre of the global spread of what is called Extensively Drug-Resistant Typhoid Fever (XDR-TF). It has now been reported in all provinces.

“Climate change is certainly changing the landscape of disease transmission and control . It’s not just flooding – it’s also droughts,” said Gavi’s Allyson Russell. The suggestion is plain: the picture confronting Balochistan’s battling health workers – the deluged homes, the starving kids, the barrel-raft – is not a glimpse of a bit of bad luck, but instead, the view from the vanguard of a planetary crisis.

In fact, Pakistan right now sits caught in the cross-current of two existential global health disasters: climate change on the one hand, and antimicrobial resistance (AMR) on the other.

Special envoy on AMR to the UK government Sally Davies recently made headlines when she compared the scale of the threat posed by AMR to the hazards of the climate crisis. They are also broadly comparable in terms of their inequitable distribution: both perils affect poor countries and poor communities disproportionately. A major study released earlier this year in the Lancet estimated that in 2019, 4.95 million deaths globally were associated with bacterial AMR. The highest rates of death occurred in sub-Saharan Africa and south Asia.

Drug-resistant typhoid is a particular scourge in Pakistan. Since 2016, when a large outbreak of typhoid fever that proved inert to the antibiotic ceftriaxone emerged in Sindh, Pakistan has been at the epicentre of the global spread of what is called Extensively Drug-Resistant Typhoid Fever (XDR-TF). It has now been reported in all provinces.

“Vaccination is really a cost-effective way to tackle AMR,” said Russell, noting that incidence of XDR typhoid has already declined in areas where the vaccine is in use.

WHO’s 2017 prequalification of the first typhoid conjugate vaccine – which offered longer-lasting immunity than previous typhoid jabs, and could be given to younger children – promised relief. Clinical trials pegged the vaccine’s efficacy at an impressive 80-85%, and a 2021 study showed that with ‘moderate deployment’, it was capable of curtailing a major outbreak of XDR-TF.

In 2019, with Gavi’s support, Pakistan began rolling out the jab in ‘catch-up’ drives that included not only toddlers but also teenagers. After October’s campaign, TCV will constitute part of Pakistan’s routine childhood immunisation schedule nationwide.

“Vaccination is really a cost-effective way to tackle AMR,” said Russell, noting that incidence of XDR typhoid has already declined in areas where the vaccine is in use. “You know, with AMR we are worried about the cost to families seeking healthcare. We’re also worried about health care systems being overwhelmed trying to treat an influx of complicated cases. And the best way to tackle this is to prevent the infections and reduce the overall spread of disease in the population.”

Anila, a lady health worker (LHW), administers a shot of TCV Sadiqa, aged ten, at the government girls’ middle school of Bagan Baba in Dera Allah Yar. Credit: Gavi/Asad Zaidi
Anila, a lady health worker (LHW), administers a shot of TCV Sadiqa, aged ten, at the government girls’ middle school of Bagan Baba in Dera Allah Yar.
Credit: Gavi/Asad Zaidi

In Dera Allah Yar, the Jaffarabad district headquarters, the dry ground still sat so low over the water two months after the floods began that it had the provisional appearance of a scab, but one government middle school had dried out enough for lessons to resume

On a sunny Thursday, the vaccinators were paying the pupils a visit. In a classroom, girls in cornflower blue kameezes lined up for their shots. A teacher called Lubna Wahid looked on approvingly. “It’s a very good initiative,” she said. “My message for all mothers, teachers and people from other departments is that they should vaccinate their children to keep them healthy – so that it doesn’t affect their education.”

Pupils from the government girls’ middle school of Bagan Baba in Dera Allah Yar show off marks on their fingers signifying that they have received a dose of TCV. Credit: Gavi/Asad Zaidi
Pupils from the government girls’ middle school of Bagan Baba in Dera Allah Yar show off marks on their fingers signifying that they have received a dose of TCV.
Credit: Gavi/Asad Zaidi

Nearly 26,000 schools nationwide – including this one – were damaged in the rains, disrupting classes for a cohort of students whose learning had already been knocked off-course by the COVID-19 pandemic. Immunisation, Wahid thought, offered a sliver of insurance against further interruption. In that sense, this campaign – which would, by it’s end, succeed in reaching its target of 5.5 million new children protected – was a vote in favour of an apparently elusive return to normalcy.

Behind the busy vaccinators, a blackboard bore traces of a recent English lesson. “The water in the stream and channels is flowing,” it read in chalk. “All the people get busy in the work. The cattle graze in the field.” Outside, in the fields, wading boys cast fishing lines.