Article Strategies to Improve Coverage of Typhoid Conjugate Vaccine (TCV) Immunization Campaign in Karachi, Pakistan Farah Naz Qamar 1,*, Rabab Batool 1, Sonia Qureshi 1 , Miqdad Ali 1, Tahira Sadaf 1, Junaid Mehmood 1, Khalid Iqbal 2, Akram Sultan 3, Noah Duff 4 and Mohammad Tahir Yousafzai 1 1 Department of Pediatrics and Child Health, Aga Khan University Hospital, National Stadium Rd, Aga Khan University Hospital, Karachi City, Sindh 74800, Pakistan; [email protected] (R.B.); [email protected] (S.Q.); [email protected] (M.A.); [email protected] (T.S.); [email protected] (J.M.); [email protected] (M.T.Y.) 2 Kharadar General Hospital, Agha Khan Road, Nawab Mahabat Khanji Rd, Kharadar Karachi, Sindh 74000, Pakistan; [email protected] 3 E.P.I Sindh, Ex I.I Depot Rafiqui Shaheedi Road, Karachi Cantonment, Karachi, Sindh 75510, Pakistan; [email protected] 4 Sabin Vaccine Institute, 2175 K Street, NW, Suite 400, Washington, DC 20037, USA; Noah.Duff@Sabin.org * Correspondence: [email protected] Received: 29 October 2020; Accepted: 16 November 2020; Published: 19 November 2020 Abstract: The emergence and spread of extensively drug-resistant (XDR) typhoid in Karachi, Pakistan led to an outbreak response in Lyari Town, Karachi utilizing a mass immunization campaign with typhoid conjugate vaccine (TCV), Typbar TCV®. The mass immunization campaign, targeted Lyari Town, Karachi, one of the worst affected towns during the XDR typhoid outbreak. Here we describe the strategies used to improve acceptance and coverage of Typbar TCV in Lyari Town, Karachi. The mass immunization campaign with Typbar TCV was started as a school- and hospital-based vaccination campaign targeting children between the age of 6 months to 15 years old. A dose of 0.5 mL Typbar TCV was administered intramuscularly. A mobile vaccination campaign was added to cope with high absenteeism and non-response from parents in schools and to cover children out of school. Different strategies were found to be effective in increasing the vaccination coverage and in tackling vaccine hesitancy. Community engagement was the most successful strategy to overcome refusals and helped to gain trust in the newly introduced vaccine. Community announcements and playing typhoid jingles helped to increase awareness regarding the ongoing typhoid outbreak. Mop-up activity in schools was helpful in increasing coverage. Networking with locally active groups, clubs and community workers were found to be the key factors in decreasing refusals. Keywords: extensively drug-resistant typhoid; outbreak; mass immunization campaign; typhoid conjugate vaccine 1. Introduction Typhoid fever, an infection caused by Salmonella enterica subspecies enterica serovar Typhi (S. Typhi) [1,2], is a major cause of febrile illness in many low- and middle-income countries, accounting for an estimated 10.9 million annual infections and more than 116,000 deaths globally [3,4]. The only effective way to treat typhoid fever is with antibiotics, however, the rate of drug-resistant typhoid cases has been increasing globally since the 1990s, particularly in endemic communities in South Asia and sub-Saharan Africa [5]. Vaccines 2020, 8, 697; doi:10.3390/vaccines8040697 www.mdpi.com/journal/vaccines Vaccines 2020, 8, 697 2 of 12 In Pakistan, the increasing rate of resistance to first- and second-line antibiotics has led to a growing dependence on third generation cephalosporins (ceftriaxone and cefixime) for the treatment of typhoid fever infections [6]. In November 2016, extensively drug-resistant (XDR) S. Typhi—resistant to first- and second-line antibiotics as well as third generation cephalosporins—was reported in Hyderabad, Sindh Province, Pakistan [7]. Over the ensuing months, this new strain quickly spread to the neighboring city of Karachi, where, from January 2017 to June 2019, 6107 cases of blood culture confirmed typhoid was reported. Of these, 63% were XDR [8]. The emergence of XDR typhoid fever in Pakistan has seriously limited the treatment options for the illness, leaving only azithromycin as an effective oral antibiotic treatment option. To reduce the need for antibiotic therapy and reduce the risk of growing drug resistance, prevention of typhoid through vaccination is the most feasible option. [9]. In 2017, the World Health Organization pre-qualified the typhoid conjugate vaccine, Typbar TCV®(Bharat Biotech International Limited, Hyderabad, India), recommending that introduction of TCV should be prioritized in settings with a high burden of typhoid illness or drug-resistant strains [10]. Thereafter, the vaccine was first used as part of the response to the rapidly spreading XDR typhoid outbreak in Hyderabad, Pakistan in February 2018, in which Aga Khan University Hospital (AKUH) successfully administered 207,000 doses of Typbar TCV during a mass immunization campaign [11]. Building upon this success, in April 2019 AKUH began a mass immunization campaign in Lyari Town, Karachi, where large numbers of XDR typhoid cases were reported. While Pakistan’s immunization coverage remains chronically low across all regions, immunization coverage is lowest in Sindh Province, with only 35% of the population receiving immunization as part of Pakistan’s Expanded Programme for Immunization (EPI) [12]. Polio eradication continues to be a national emergency for Pakistan. However, due to suboptimal coverage of the polio vaccine, with significant pockets of continuously missed children despite repeated supplementary polio immunization campaigns, the virus continues to circulate and spread, resulting in recurrent outbreaks [12]. In addition, a lack of community awareness, misconceptions, religious beliefs, illiteracy, rumors, and fears related to vaccines circulating through social media are contributing factors to vaccine hesitancy and resistance within communities [13–15]. Typhoid fever most commonly affects children, with 90% of XDR typhoid fever cases in Karachi occurring among children <15 years of age [11]. We started a vaccination campaign aimed to vaccinate 80,000 children between 6 months and 15 years of age with Typbar TCV (intramuscularly as a single 0.5 mL dose) in Lyari Town, Karachi. Here we report the strategies used during the Typbar TCV campaign to improve vaccination coverage in Lyari Town, Karachi, Pakistan. 2. Materials and Methods 2.1. Setting Lyari Town, population 846,434, is one of the oldest and most densely populated urban slum settlements in Karachi. Lyari is divided into 11 smaller administrative units, called union councils, which make up the town [16]. The town has a rich political and ethnic culture, yet it has also faced decades of social and political chaos and has been riddled with crime, violence, poverty, overpopulation, and radical politics [17]. This, in turn, has impeded the economic development of basic services. Lyari Town frequently faces acute water shortages, a near total lack of adequate sanitation amenities, prolonged power failures, intolerable housing conditions, illegal encroachment of municipal land, and poorly maintained roadways. Additionally, a concentration of numerous warehouses and industrial units storing and manufacturing hazardous materials have intensified the agonies of the people in this overcrowded locality [16,18]. These conditions contribute to environmentally transmitted infections, such as typhoid fever, in the urban slum population [19,20]. Vaccines 2020, 8, 697 3 of 12 2.2. Planning of the Immunization Campaign The mass immunization campaign was conducted from 10 April 2019 until 24 October 2019. Wedesignedtheimmunizationcampaignasaschool-basedandahospital-basedcampaign. Theschool-based vaccination was conducted at all public and private schools in Lyari Town. The hospital-based vaccination campaign was based at 3 key hospitals serving the population of Lyari Town: Lyari General Hospital, Kharadar General Hospital and Aga Khan Secondary Care Hospital. A mobile vaccination camp was added to target non-school-going young children. The aim of the school-based campaign was to cover school-going children between 2 years and 15 years of age. The hospital-based campaign was set up at existing EPI centers and hospitals and aimed to cover children of the younger age group who visited the hospitals for their routine childhood immunization and to cover non-school-going children. 2.2.1. School-Based Campaign The first step for successful school coverage was the identification of all public and private schools in Lyari. Community health workers (CHWs) were trained to record GIS (geographic information system) coordinates of all the schools in Lyari Town and we created a map to help the school-based team navigate all the addresses. We mapped a total of 436 schools in Lyari Town. The campaign was conducted in 2 phases: pre-vacation and post-vacation. The pre-vacation phase was from 10–30 April 2019, prior to the start of the summer vacation on 4 May 2019, when the school-based vaccination was stopped. During the first phase, a total of 53 schools were covered. The schools reopened on 1 July 2019, and the post-vacation phase of the school-based campaign was conducted from 3 July to 24 October 2019 and covered the remaining schools. Dates for conducting the campaign at each school were pre-decided after a meeting with the school administration and parental consents were taken prior to the campaign. Consent forms were sent with children for parental signatures and were collected prior to the campaign. On the day of vaccination, teams set up a small vaccination