Typhoid Vaccine

Routine typhoid vaccination is not recommended in the United States, but typhoid vaccine is recommended for:

• Travelers to parts of the world where typhoid is common. (NOTE: typhoid vaccine is not 100% effective and is not a substitute for being careful about what you eat or drink).
• People in close contact with a typhoid carrier.
• Laboratory workers who work with Salmonella Typhi bacteria.

Inactivated typhoid vaccine (shot)

• One dose provides protection. It should be given at least 2 weeks before travel to allow the vaccine time to work.
• A booster dose is needed every 2 years for people who remain at risk.

Live typhoid vaccine (oral)

• Four doses: one capsule every other day for a week (day 1, day 3, day 5, and day 7). The last dose should be given at least 1 week before travel to allow the vaccine time to work.
• Swallow each dose about an hour before a meal with a cold or lukewarm drink. Do not chew the capsule.
• A booster dose is needed every 5 years for people who remain at risk. Either vaccine may safely be given at the same time as other vaccines.

What should I look for?

• Look for anything that concerns you, such as signs of a severe allergic reaction, very high fever, or behavior changes.Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would start a few minutes to a few hours after the vaccination.

What should I do?

• If you think it is a severe allergic reaction or other emergency that can't wait, call 9-1-1 or get the person to the nearest hospital. Otherwise, call your doctor.
• Afterward, the reaction should be reported to the Vaccine Adverse Event Reporting System (VAERS). Your doctor might file this report, or you can do it yourself through the VAERS web site at http://www.vaers.hhs.gov, or by calling 1-800-822-7967.

VAERS is only for reporting reactions. They do not give medical advice.

Commercially available in US as an oral live, attenuated vaccine (typhoid vaccine live oral Ty21a; Vivotif)102 103 115 and as a parenteral inactivated Vi polysaccharide vaccine (typhoid Vi polysaccharide vaccine; Typhim Vi).102 115 123 Other typhoid vaccines (e.g., inactivated whole-cell vaccines, inactivated protein-conjugated Vi polysaccharide vaccines) may be available in other countries.102 141

Prevention of Typhoid Fever

Prevention of typhoid fever in US travelers planning to visit areas with a recognized risk of exposure to Salmonella enterica serovar Typhi.102 103 115 123

Prevention of typhoid fever in individuals with intimate exposure (e.g., household contact) to a known typhoid carrier.102 103 123

Prevention of typhoid fever in laboratory personnel with frequent contact with Salmonella Typhi bacilli.102 103 123

Typhoid fever is a potentially severe and occasionally life-threatening, febrile, enteric illness caused by Salmonella Typhi.102 103 105 115 138 139 141 Usually acquired by ingestion of food and/or water contaminated with feces from individuals who have typhoid fever or are chronic typhoid carriers.102 103 105 115 138 139 141 Overall case-fatality rate in patients who receive early and appropriate antibacterial treatment is typically <1%;102 if left untreated, case-fatality rate may be ≥10–20%.102 141 Approximately 2–4% of individuals with acute typhoid fever develop a chronic carrier state.103 123

Typhoid fever is uncommon in the US, but endemic in many less well-developed areas of the world that have poor sanitation and primitive water systems.102 115 138 139 About 22 million cases of typhoid fever and about 200,000 typhoid-related deaths occur annually worldwide.115 In the US, about 300–400 confirmed cases of typhoid fever are reported annually,102 115 almost all in recent travelers to other countries (most commonly southern Asia).102 115 139

USPHS Advisory Committee on Immunization Practices (ACIP) and CDC state that routine vaccination against typhoid fever not recommended for individuals residing in the US,102 115 but preexposure vaccination is recommended for those at high risk of exposure to Salmonella Typhi.102 115

When vaccination against typhoid fever indicated, either typhoid vaccine live oral Ty21a or typhoid Vi polysaccharide vaccine can be used unless contraindicated.102 105 115 Consider that the vaccines have different contraindications (see Contraindications under Cautions) and different minimum age limits for use in children (see Pediatric Use under Cautions).102 103 123 Other factors to consider when selecting a typhoid vaccine include immunization schedule, response time, patient compliance, storage facilities, and immunocompetence of the vaccinee (see Warnings/Precautions under Cautions).102 123 126 Because typhoid vaccine live oral Ty21a is self-administered over a 1-week period and compliance errors (i.e., dosing errors, improper storage) may occur, typhoid Vi polysaccharide vaccine may be preferred if compliance is likely to be a problem.131

Efficacy of typhoid vaccine live oral Ty21a and typhoid Vi polysaccharide vaccine appear to be comparable when administered as recommended;102 105 107 109 111 114 115 116 117 118 119 120 121 123 124 125 126 neither vaccine is expected to provide protection against typhoid fever in all vaccine recipients.102 103 105 115 123

Typhoid vaccines will not provide protection against S. enterica serovar Paratyphi or any Salmonella other than Salmonella Typhi and will not provide protection against other bacteria known to cause enteric disease.103 123

Typhoid vaccines are not used for treatment of typhoid fever and should not be used in individuals with acute Salmonella Typhi infection or in chronic typhoid carriers.103 123

There is no evidence to support use of typhoid vaccine to control common source outbreaks or disease following natural disasters or in individuals attending rural summer camps.103 123

Preexposure Vaccination Against Typhoid Fever in High-risk Groups

Travelers to areas with a recognized risk of exposure to Salmonella Typhi should be vaccinated against typhoid fever.103 105 115 123 The disease is endemic in many less well-developed areas of the world that have poor sanitation and primitive water systems.115 138 141

CDC recommends typhoid vaccination for travelers to many Asian, African, and Latin American countries, but no longer recommends typhoid vaccination for travelers to certain Eastern European and certain Asian countries.102 115 138 141 In recent years, most US cases of typhoid fever reported in individuals who had traveled to southern Asia (especially the Indian subcontinent including India, Bangladesh, or Pakistan) or Africa.115 139

Although risk is greatest for travelers who have prolonged exposure to possibly contaminated food and beverages in areas with persistent typhoid epidemics or in smaller cities and villages or rural areas outside usual tourist itinerary, even short-term travel (<1 week) to high-incidence areas is associated with risk for typhoid fever.102 115

In addition to vaccination, individuals traveling to areas with risk of typhoid fever should use caution in selecting food and water in these areas since the vaccines are not 100% effective and vaccine-induced immunity can be overwhelmed by a large inoculum of Salmonella Typhi.103 105 115 123 (See Limitations of Vaccine Effectiveness under Cautions.)

Vaccination against typhoid fever and other precautions (safe food and water precautions, frequent handwashing) are especially important for travelers to high-risk areas because fluoroquinolone-resistant and multidrug-resistant Salmonella Typhi have become common or are reported with increasing frequency in many regions of the world (e.g., Indian subcontinent, Africa).102 115 139 141

The most recent information regarding geographic areas with a recognized risk of typhoid fever and additional information on vaccination and other precautions for prevention of typhoid fever are available from CDC at and .115 138

Close contacts of chronic typhoid carriers with intimate exposure (e.g., household contact) to a documented Salmonella Typhi chronic carrier (defined as excretion of Salmonella Typhi in urine or stool for >1 year) should be vaccinated against typhoid fever.102

Laboratory personnel routinely exposed to cultures of Salmonella Typhi or specimens containing the bacilli or who work in laboratory environments where these cultures or specimens are routinely handled should be vaccinated against typhoid fever.102

Other Vaccines

Typhoid vaccine live oral Ty21a: May be administered concurrently with or at any interval before or after inactivated vaccines, recombinant vaccines, polysaccharide vaccines, toxoids, or parenteral live vaccines.134 If use of the live, attenuated typhoid vaccine is warranted, do not delay because of administration of other live virus vaccines (injectable or intranasal).102 134

Typhoid Vi polysaccharide vaccine: Specific interaction studies not available.123 Because it is an inactivated vaccine, it generally can be administered concurrently with (using different syringes and different injection sites) or at any interval before or after inactivated vaccines, recombinant vaccines, polysaccharide vaccines, toxoids, or live vaccines.134

Specific Drugs

Storage

Oral

Typhoid vaccine live oral Ty21a: 2–8°C in a dry place protected from light.103

Must be shipped and stored only at 2–8°C.103 Potency adversely affected by exposure to temperatures exceeding 2–8°C.103

Any remaining capsules must be placed back in a refrigerator after each dose until 4-dose vaccination series completed.103

Does not contain thimerosal or any other preservatives.103

Parenteral

Typhoid Vi polysaccharide vaccine: 2–8°C.123 Do not freeze.123

Does not contain thimerosal, but contains phenol 0.25% as a preservative.123

Applies to typhoid vaccine, live: oral delayed release capsule

General

The most common adverse events were abdominal pain, nausea, headache, fever, diarrhea, vomiting, and skin rash.[Ref]

Gastrointestinal

Common (1% to 10%): Abdominal pain, nausea, diarrhea, vomiting, constipation, abdominal cramps[Ref]

Other

Common (1% to 10%): Fever, influenza-like illness
Postmarketing reports: Asthenia, malaise, tiredness, shivering[Ref]

Dermatologic

Common (1% to 10%): Skin rash, urticarial exanthema
Postmarketing reports: Urticaria in the trunk and/or extremities, dermatitis, exanthema, pruritus, urticaria[Ref]

Nervous system

Common (1% to 10%): Headache
Postmarketing reports: Paresthesia, dizziness[Ref]

Hypersensitivity

Postmarketing reports: Non-fatal anaphylactic shock, anaphylaxis[Ref]

Musculoskeletal

Postmarketing reports: Arthralgia, myalgia[Ref]

Metabolic

Postmarketing reports: Anorexia[Ref]

Some side effects of typhoid vaccine, live may not be reported. Always consult your doctor or healthcare specialist for medical advice. You may also report side effects to the FDA.

6 years and older:
1 capsule orally, on days 1, 3, 5, and 7, 1 hour before a meal, with cold or lukewarm fluids

Comments:
-The course should be completed at least 1 week before potential exposure to S. typhi.
-Efficacy has been shown to persist for at least 5 years
-Routine immunization is not recommended.
-Immunization is recommended for travelers to areas with a recognized risk, persons with close exposure to a S. typhi carrier, and laboratory workers who work frequently with S. typhi.

No adjustment recommended

Summary of Use during Lactation

The Centers for Disease Control and Prevention and several health professional organizations state that vaccines given to a nursing mother do not affect the safety of breastfeeding for mothers or infants and that breastfeeding is not a contraindication to typhoid vaccine. Breastfed infants should be vaccinated according to the routine recommended schedules.[1][2][3]

Drug Levels

Maternal Levels. Relevant published information was not found as of the revision date.

Infant Levels. Relevant published information was not found as of the revision date.

Effects in Breastfed Infants

Limited data indicate that breastfeeding can enhance the response of the infant to certain vaccine antigens.[1][3][4]

Effects on Lactation and Breastmilk

Relevant published information was not found as of the revision date.

References

1. General recommendations on immunization --- recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60 (RR-2):1-64. PMID: 21293327

2. Gruslin A, Steben M, Halperin S et al.. Immunization in pregnancy: No. 220, December 2008. Int J Gynaecol Obstet. 2009;105:187-91. PMID: 19367691

3. American Academy of Pediatrics Committee on Infectious Diseases, Kimberlin DW, Brady MT et al. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics. 2015.

4. Pabst HF. Immunomodulation by breast-feeding. Pediatr Infect Dis J. 1997;16:991-5. PMID: 9380478