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Treatment of Patients with Vomiting

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1. General and Supportive Measures

• Correct fluid and electrolyte imbalances (IV or oral rehydration as appropriate).
• Identify and treat the underlying cause (e.g., bowel obstruction, diabetic ketoacidosis, raised intracranial pressure, medications, infections).
• Withhold oral intake temporarily if vomiting is severe; gradually reintroduce clear fluids.
• Consider nasogastric tube decompression if obstruction is suspected.
• Non-pharmacological options: acupressure at the P6 (Nei Guan) point has shown benefit in some settings, particularly postoperative nausea and vomiting (PONV). Ginger (6-gingerol, 6-shogaol components act on 5-HT3, D2, NK1, and histamine receptors) has antiemetic properties in multiple clinical settings.

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2. Pharmacological Treatment by Drug Class

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A. Anticholinergic / Antihistamine Agents

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B. Dopamine Receptor Antagonists (D2 blockers)

Metoclopramide as a prokinetic: It also stimulates gastric emptying via 5-HT4 receptor facilitation and D2 antagonism - useful in gastroparesis.

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C. Serotonin (5-HT3) Receptor Antagonists

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D. Neurokinin-1 (NK1) Receptor Antagonists

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E. Corticosteroids

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F. Atypical Antipsychotics

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G. Cannabinoids

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H. Benzodiazepines

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I. Prokinetic Agents (Macrolide Antibiotics)

• Erythromycin (motilin receptor agonist): stimulates antroduodenal contractions. Narrow dose range of efficacy; associated with tachyphylaxis and risk of sudden cardiac death (especially with CYP3A inhibitors).
• Azithromycin, clarithromycin: similar motilin receptor action, used off-label in gastroparesis.

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3. Treatment by Clinical Scenario

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4. Refractory and Structural Options

• Gastric electrical stimulation (neurostimulator implant)
• Peroral endoscopic pyloromyotomy (POP) - endoscopic procedure to divide the pyloric muscle

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5. Special Populations

• Pregnancy: First-line is pyridoxine (Vitamin B6) ± doxylamine (FDA-approved combination). Phenothiazines and ondansetron are used in more severe cases; however, some data suggest a possible link between ondansetron and cardiac septum defects (inconsistent evidence - consult current guidelines).
• Children (PONV): Ondansetron is the preferred agent; aprepitant and dexamethasone are also used. Promethazine is avoided in children under 2 years.
• Elderly: Anticholinergic agents should be used cautiously due to delirium risk. Extrapyramidal reactions with dopamine antagonists are more common.

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Recent Evidence

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Medicines to Delay Menstruation

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1. Norethisterone (NET) - First-line, Licensed Option

How it works

Dosing Protocol

Important Notes

• Not a contraceptive at this dose - additional contraception is needed to avoid pregnancy.
• Because it is partly converted to ethinyl estradiol, it carries a VTE (venous thromboembolism) risk similar to combined oral contraceptives. Women with a history of VTE, thrombophilia, or other VTE risk factors should not use norethisterone for this purpose.

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2. Medroxyprogesterone Acetate (MPA) - Alternative (Off-label)

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3. Depot Medroxyprogesterone Acetate (DMPA) - Injection

• No periods in ~30% of users within the first 3 months
• Increases to ~55% amenorrhea after 1 year
• Not suitable for short-term, one-off period delay (due to its prolonged, irreversible effect over 12 weeks)
• Fertility may take up to 12 months to return after stopping

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4. Combined Oral Contraceptive Pill (COCP) - For Pill Users

• Skipping the pill-free interval (or the placebo/inactive pills) and starting the next active pack immediately.
• This can be done for one or more cycles.
• This is the simplest option for those already on the COCP.

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Contraindications / Cautions for Progestogen-Based Delay

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Common Side Effects

• Breakthrough / irregular spotting
• Headache, nausea
• Breast tenderness
• Mood changes, bloating
• Acne

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Summary Table

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Clinical note: Period delay medications require a medical consultation. The choice of agent depends on the patient's medical history, VTE risk factors, and any concurrent medications. Norethisterone is the standard first-line option for healthy women with no VTE risk factors.

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Drugs to Delay Menstruation

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1. Norethisterone (NET) - First-line, Licensed

• Dose: 5 mg three times daily (TDS)
• Start: At least 3 days before expected period
• Duration: Up to 3-4 weeks
• Brand names: Primolut N, Utovlan
• Return of period: 2-3 days after stopping
• Note: Partially converts to ethinyl estradiol - carries VTE risk. Not a contraceptive at this dose.

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2. Medroxyprogesterone Acetate Tablets (MPA) - Off-label

• Dose: 10 mg two to three times daily
• Brand: Provera
• Use when: Norethisterone is contraindicated (e.g., VTE risk, migraine with aura)
• Advantage: Does not convert to ethinyl estradiol - lower VTE risk
• Return of period: ~3 days after stopping

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3. Combined Oral Contraceptive Pill (COCP) - For Women Already on the Pill

• Simply skip the pill-free interval (or placebo pills) and start the next active pack immediately
• Most convenient option for existing COCP users
• Can be done for one or more consecutive cycles

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4. Depot Medroxyprogesterone Acetate (DMPA) Injection - Long-term Only

• Dose: 150 mg IM every 12 weeks
• Causes amenorrhea in ~30% at 3 months, ~55% at 1 year
• Not suitable for a short one-off delay - effect lasts 12 weeks and fertility return can take up to 12 months
• Used when long-term menstrual suppression is desired

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Quick Reference Table

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Key Contraindications

• Avoid norethisterone in: history of VTE, thrombophilia, migraine with aura
• All progestogens: contraindicated in pregnancy, active liver disease, hormone-sensitive cancers
• Drug interactions: Rifampicin, phenytoin, carbamazepine, ritonavir reduce efficacy (enzyme inducers)

Always consult a clinician before using any of these agents - the appropriate choice depends on individual medical history and VTE risk profile.

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Drugs for Diarrhea

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1. First-line: Oral Rehydration

• Oral Rehydration Salts (ORS) - WHO formula (sodium, potassium, glucose, water)
• In severe dehydration: IV fluids (Normal Saline or Ringer's Lactate)
• Zinc supplementation (in children) reduces duration and severity

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2. Opiate / Opioid-Based Antidiarrheals (Motility Reducers)

Caution: Avoid loperamide and diphenoxylate when fever >38.5°C or blood is in the stool (risk of prolonging infection / toxic megacolon in C. difficile).

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3. Enkephalinase Inhibitor

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4. Intraluminal / Adsorbent Agents

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5. Antisecretory Agents

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6. Bile Acid-Binding Resins

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7. Antibiotics (for Infectious Diarrhea)

Note: Avoid antibiotics empirically in suspected Salmonella (risk of prolonging carriage) and STEC E. coli O157 (risk of HUS).

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8. Drugs Specific to IBS with Diarrhea (IBS-D)

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9. Fiber Supplements (Stool Normalizers)

• Psyllium (10-20 g/day)
• Calcium polycarbophil (5-10 g/day)

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Summary by Diarrhea Type

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Treatment for Fever with Chills (Rigors)

Understanding the Symptom

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Step 1: Identify and Treat the Underlying Cause

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Step 2: Symptomatic / Antipyretic Treatment

A. Antipyretics

Combination/alternating paracetamol and ibuprofen every 3 hours is used in practice for persistent high fever, particularly in children, to provide more sustained temperature reduction.

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B. Treatment of Chills / Rigors Specifically

• Keep the patient warm - do not cool with cold packs or ice during the chill/shivering phase (this worsens shivering and discomfort). Apply blankets.
• Wait for the fever to peak - once shivering stops and patient becomes hot/sweaty, cooling measures can be applied.
• Pethidine (Meperidine) 25-50 mg IV - specifically reduces the severity of rigors during amphotericin B infusions, post-transfusion reactions, and other drug-induced rigors. It suppresses shivering via kappa-opioid and NMDA receptor mechanisms.
• Chlorpromazine 10-25 mg IV - sometimes used to abolish severe rigors (suppresses shivering center).

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C. Physical / Non-pharmacological Cooling

• Tepid sponging (lukewarm water, not cold - cold causes shivering)
• Remove excess clothing/blankets
• Increase air circulation / fans
• Cold IV fluids for hyperthermia (temperature >41°C) or heatstroke

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Step 3: Supportive Care

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Step 4: When to Escalate / Seek Urgent Care

• Temperature >39.5°C not responding to antipyretics
• Hypotension, tachycardia, confusion (sepsis/septic shock)
• Petechial or purpuric rash (meningococcal disease)
• Neck stiffness, photophobia (meningitis)
• Recent travel to malaria-endemic area
• Immunocompromised patient (HIV, chemotherapy, steroids)
• Newborn or infant <3 months old
• No improvement after 48-72 hours of treatment

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Quick Summary Table

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Treatment of Porcupine Thorn (Quill) Injury in Humans

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Why Porcupine Quills Are Dangerous

• Each quill has microscopic retrograde barbs that grip soft tissue and prevent spontaneous expulsion
• Quills can migrate inward through muscle, fat, and fascial planes - reaching joints, eyes, body cavities, lungs, heart, or major vessels if not removed promptly
• They are vegetative/organic material - Tintinalli's Emergency Medicine specifically notes that "thorns, spines, wood splinters, and other vegetative materials should be promptly removed because they cause intense and excessive inflammation"
• They carry a significant risk of abscess, cellulitis, and deep infection

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Step 1: Immediate First Aid (Before Reaching Medical Care)

• Keep the injured area still and immobile - movement drives barbs deeper
• Note how many quills are visible and their locations
• Apply a clean dressing loosely over the area
• Seek medical attention promptly

• Do not cut the quills - cutting them makes removal harder (the hollow shaft collapses, increasing barb grip) and risks breaking them beneath the skin level
• Do not rub or press on quills - this drives them deeper
• Do not attempt forceful removal without proper instruments and anesthesia
• Do not squeeze or crush the quill

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Step 2: Medical Assessment

History

• Time of injury (quills migrate with time - hours matter)
• Number and location of quills penetrated
• Whether quills broke at the skin surface
• Tetanus vaccination status

Examination

• Full body survey - quills can be hidden in the mouth, axillae, groin, scalp
• Assess for signs of deep penetration (chest pain, dyspnoea, reduced eye movement, joint pain)
• Check neurovascular status distal to injury site

Imaging

• X-ray - quills are often not radiopaque but can show indirect signs (air, displacement of tissues)
• Ultrasound - very useful for locating superficial-to-moderate depth quills and guiding removal
• CT scan - gold standard for deep or migrating quills, especially in the thorax, abdomen, or near joints

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Step 3: Quill Removal

Anesthesia

• Local anesthetic (e.g., 1% lidocaine) infiltrated around each quill before removal
• For multiple quills, extensive penetration, or uncooperative patients: procedural sedation or general anesthesia may be required

Technique (based on Roberts & Hedges' Clinical Procedures in Emergency Medicine)

1. Hold the skin taut with one hand around the quill site
2. Grasp the quill firmly at its base (as close to the skin as possible) with forceps/needle holders
3. Apply steady, firm, direct traction along the axis of penetration (in the direction the quill entered) - do not wiggle or rotate
4. If the quill is deeply embedded: make a small incision with a No. 11 scalpel blade down to the quill tip to expose and free it before extraction
5. Inspect the wound after removal for retained fragments
6. Irrigate the wound thoroughly with normal saline under pressure
7. Do not primarily suture puncture wounds from quill removal - leave open to drain

Deep / Migrated Quills

• Quills near vessels, joints, eyes, or body cavities require specialist surgical removal (orthopaedic, ophthalmic, thoracic, or general surgery as appropriate)
• Operative removal under fluoroscopic or ultrasound guidance in theatre

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Step 4: Wound Care After Removal

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Step 5: Pharmacological Treatment

Pain Relief

• Paracetamol 500 mg-1 g every 6 hr PO
• NSAIDs (ibuprofen 400 mg every 8 hr) for anti-inflammatory effect and analgesia
• Stronger analgesia (codeine, tramadol) for deeper injuries

Antibiotics

• Antibiotics are not routinely needed for clean, promptly removed superficial quills
• Prescribe antibiotics if:
  • Quills present for >24 hours before removal
  • Signs of infection (redness, warmth, purulent discharge, cellulitis)
  • Incision required for removal
  • Deep penetration (joint, hand, face)
  • Immunocompromised patient
• Antibiotic choice: Cover skin flora + anaerobes:
  • Co-amoxiclav (amoxicillin-clavulanate) 625 mg every 8 hr for 5-7 days (first-line)
  • Doxycycline + metronidazole if penicillin allergic
  • If established abscess/cellulitis: add MRSA cover (flucloxacillin or trimethoprim-sulfamethoxazole)

Anti-inflammatory

• NSAIDs reduce the intense local inflammatory reaction to organic vegetative material
• Short course of oral corticosteroids is occasionally considered for severe inflammatory reactions around deeply embedded quills

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Step 6: Tetanus Prophylaxis

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Step 7: Follow-up and Monitoring

• 48-72 hour wound review for all but the most trivial quill injuries
• Watch for: new swelling, pain, warmth, abscess formation, restricted joint movement, or new neurological symptoms
• Any new symptoms weeks after the injury should prompt imaging - quills can migrate silently and cause delayed complications (joint infection, pulmonary abscess, intraocular injury)

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Summary

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Aspirin for Severe Chest Pain (Suspected Acute Coronary Syndrome)

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Why Aspirin Works: Mechanism of Action

• Irreversibly acetylating cyclooxygenase-1 (COX-1) in platelets
• This blocks the conversion of arachidonic acid to thromboxane A2 (TXA2)
• TXA2 is a potent vasoconstrictor and platelet aggregation inducer
• Without TXA2, the platelet activation cascade is blunted and clot growth is inhibited

The net antithrombotic effect reflects the balance between reduced TXA2 (pro-thrombotic) and reduced prostacyclin (anti-thrombotic) - but at low doses, the platelet COX-1 effect dominates.

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Dosing in Acute Severe Chest Pain (ACS)

Why Chew, Not Swallow?

Tintinalli's Emergency Medicine: "For reliable antiplatelet effect, an initial dose of 162 to 325 mg is recommended."

Goldman-Cecil Medicine: "Aspirin achieves peak levels within 15-20 minutes and platelet inhibition within 40-60 minutes after administration."

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Aspirin as Part of Dual Antiplatelet Therapy (DAPT)

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Evidence Base

• Aspirin reduces non-fatal MI and non-fatal stroke by approximately one-third and vascular death by about 25% in high-risk patients
• The ISIS-2 trial (landmark RCT) showed aspirin alone reduced 5-week vascular mortality by 23% in STEMI
• For cardiovascular protection, 81 mg/day is as effective as higher doses and causes less GI bleeding

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Contraindications / Cautions

Important: Always consider aortic dissection before giving aspirin in severe chest pain - tearing/ripping pain radiating to back, unequal BP in arms, wide mediastinum on CXR are warning signs. Aspirin would be harmful in dissection.

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Full ACS Management (Aspirin in Context)

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Primary Prevention - When NOT to Give Aspirin Routinely

• Aspirin for primary prevention (no prior heart disease) is now not recommended for adults >70 years due to bleeding risk outweighing benefit
• In younger adults, the benefit-to-risk ratio only becomes favorable when 10-year ASCVD risk ≥10%
• This is distinct from the acute ACS scenario where aspirin is always indicated (absent true contraindications)

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Summary

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Ointments, Creams, and Topical Treatments for Mouth Ulcers

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1. Topical Corticosteroids (First-line)

Key tip: Apply corticosteroid paste as soon as the ulcer appears (prodromal stage) for best results. The Orabase vehicle is specifically formulated to adhere to moist oral mucosa and protect the ulcer.

A 2022 network meta-analysis of 36 RCTs found triamcinolone (p-score 0.15) to be the optimal topical choice overall, with an excellent safety profile - no adverse events in 259 subjects.

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2. Amlexanox 5% Paste (Anti-inflammatory, Non-steroidal)

• FDA-approved (1996) - the first treatment specifically licensed for aphthous ulcers in immunocompetent patients
• Mechanism: Anti-inflammatory; inhibits leukotrienes and histamine; exact mechanism in aphthous ulcers is not fully established
• Dose: Apply to ulcer 4 times daily (after meals and at bedtime)
• Effect: Accelerates complete healing; reduces pain ~1.3 days sooner than no treatment
• Side effects: Mild transient burning/stinging at application site
• Best for: Patients who cannot use corticosteroids or prefer a non-steroid option
• Brand names: Aphthasol (USA), various generics

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3. Topical Anesthetics (Pain Relief)

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4. Antiseptic / Antimicrobial Agents

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5. Protective / Barrier Agents

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6. Combination Products (OTC)

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7. Systemic Treatments (for Severe / Recurrent Cases)

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Practical Step-by-Step Treatment Guide

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Important: When to See a Doctor

• Ulcer does not heal within 3 weeks
• Ulcer is painless (may indicate malignancy)
• Ulcer is >1 cm, deep, or has raised irregular edges
• Multiple recurrent episodes - may indicate underlying disease (Crohn's, Behçet's, celiac disease, HIV, SLE, vitamin B12/folate/iron deficiency)

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Treatment of Hypothermia

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Classification by Severity

When a low-reading thermometer is unavailable, classify by clinical signs. Standard clinical thermometers do not read below 35°C and will miss hypothermia.

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ECG Finding: J (Osborne) Wave

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Management Algorithm (European Resuscitation Council)

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Step-by-Step Treatment

All Stages: Immediate General Measures

1. Remove wet clothing - even damp clothing accelerates heat loss dramatically
2. Insulate - dry blankets, sleeping bags, space/foil blanket; cover head (large proportion of heat is lost here)
3. Horizontal position - prevent orthostatic collapse; avoid unnecessary movement (can trigger VF)
4. Gentle handling - rough movement of a hypothermic patient can precipitate ventricular fibrillation
5. Monitor ECG, core temperature, vitals continuously
6. Do not give alcohol - causes peripheral vasodilation and worsens heat loss

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Stage 1 - Mild Hypothermia (35-32°C): Passive/Active External Rewarming

Target rewarming rate: 0.5-1.0°C per hour is acceptable for most mild cases.

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Stage 2 - Moderate Hypothermia (<32-28°C): Active External + Minimally Invasive Core Rewarming

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Stage 3 - Severe Hypothermia (<28°C): Active Core Rewarming

Prefer transfer to an ECLS (Extracorporeal Life Support) center for Stage III if cardiac instability develops or cardiac arrest is imminent.

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Stage 4 - Hypothermic Cardiac Arrest (HT IV): CPR + ECLS

• Check for vital signs for up to 1 minute before starting CPR (pulse may be very slow and faint)
• Start CPR - chest compressions and ventilation at standard rate; do NOT reduce rate
• Defibrillation: If VF is present, attempt up to 3 defibrillation shocks. If core temperature is <30°C, delay further shocks until rewarmed to >30°C (defibrillation is ineffective at very low temperatures)
• Epinephrine (adrenaline):
  • Withhold if core temp <30°C
  • If core temp >30°C: give at extended intervals (6-10 min) rather than standard 3-5 min intervals
• Do not terminate CPR until patient is rewarmed or ECLS team makes that decision
• "No one is dead until warm and dead" - survival has been reported with core temperatures as low as 13.7°C
• Transport to ECLS center for extracorporeal rewarming (ECMO or CPB) - this offers the best chance of survival in cardiac arrest
• If ECLS is not available within 6 hours: continue CPR + non-ECLS core rewarming in a peripheral hospital

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Fluid and Electrolyte Management

Avoid Lactated Ringer - the hypothermic liver cannot metabolize lactate efficiently.

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Complications of Rewarming

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Special Situation: Trauma Hypothermia

• Rewarming alone corrects coagulopathy if PT/aPTT are normal when plasma is tested at 37°C
• Clotting factor replacement is only indicated if PT/aPTT are prolonged even at 37°C
• Avoid cool IV fluids; use fluid warmers; warm the OR

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Summary Table

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Drugs for the Treatment of Typhoid (Enteric Fever)

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Background: The Resistance Problem

Critical note: Fluoroquinolone resistance is now high on the Indian subcontinent. Nalidixic acid-resistant strains predict clinical fluoroquinolone failure even when lab MIC appears susceptible. Fluoroquinolones should no longer be used as first-line empirical therapy in travelers from South/Southeast Asia.

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Antibiotic Treatment Table (Harrison's 22e, Table 171-1)

Empirical Treatment (before susceptibility results)

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Fully Susceptible Strains

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Multidrug-Resistant (MDR) Strains (resistant to chloramphenicol, ampicillin, TMP-SMX)

Note: Oral cefixime is effective but may have a higher clinical failure rate and longer time to defervescence compared to fluoroquinolones.

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Nalidixic Acid-Resistant / Fluoroquinolone-Reduced-Susceptibility Strains

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Extensively Drug-Resistant (XDR) Strains (resistant to all of above except azithromycin and carbapenems)

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Drug Details and Clinical Notes

1. Ceftriaxone (Third-generation Cephalosporin) - Preferred for Severe Cases

• Dose: 2 g IV once daily (children: 75-80 mg/kg/day)
• Best option for severe, hospitalized, or complicated typhoid
• Effective against MDR and fluoroquinolone-resistant strains
• Duration: 10-14 days (can shorten to 5-7 days if clinical response good)
• Can step down to oral cefixime once patient improves

2. Azithromycin (Macrolide) - Preferred for Uncomplicated Outpatient Cases

• Dose: 1 g/day orally x 5-10 days (children: 20 mg/kg/day)
• Drug of choice for uncomplicated typhoid in areas with fluoroquinolone resistance
• Achieves high intracellular concentrations - effective against intracellular S. Typhi
• A 2022 systematic review of 27 RCTs found no significant difference in treatment failure between ceftriaxone, fluoroquinolones, and azithromycin

3. Ciprofloxacin (Fluoroquinolone)

• Dose: 500 mg BD PO or 400 mg IV every 12 hours x 5-7 days
• Historically the drug of choice but now limited by widespread resistance on the Indian subcontinent and South/Southeast Asia
• Still effective for fully susceptible strains and in regions with low resistance
• Do not use empirically for travelers returning from South Asia without susceptibility data

4. Chloramphenicol (Historical / Resource-Limited Settings)

• Dose: 25 mg/kg TDS PO or IV x 14-21 days
• Was the original drug of choice (introduced 1948) - dramatically reduced mortality from 20% to <1%
• Now largely replaced due to MDR strains and risk of aplastic anaemia (1 in 25,000-40,000 patients)
• May still be used in resource-limited settings where susceptibility is confirmed

5. Amoxicillin / Ampicillin

• Dose: 1 g TDS PO or 2 g IV q6h x 14 days
• Only for fully susceptible strains; MDR strains are resistant
• Alternative when other agents are not available

6. Trimethoprim-Sulfamethoxazole (Co-trimoxazole)

• Dose: 160/800 mg (TMP/SMX) BD x 7-14 days
• Only for fully susceptible strains; commonly resistant in MDR
• Alternative in resource-limited settings

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Severe / Complicated Typhoid: Additional Measures

• Add dexamethasone 3 mg/kg initial dose IV, then 1 mg/kg every 6 hr x 8 doses
• Reduces mortality in severe disease
• Continue IV ceftriaxone or meropenem

• IV fluid resuscitation
• Antipyretics (paracetamol - not aspirin, due to dengue co-infection risk in endemic areas)
• Blood transfusion if significant GI bleeding
• Monitor for and manage complications: intestinal perforation (surgical), DIC, hepatitis, myocarditis

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Chronic Carrier Treatment

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Summary: Drug of Choice by Situation

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Prevention (Vaccines)

Conjugate vaccines (TCV) are now WHO-preferred, especially for children <5 years, as unconjugated vaccines are poorly immunogenic in young children.

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Typhoid Vaccines Available in India

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Overview of Vaccine Types Available in India

Note: The oral Ty21a vaccine (Vivotif) is currently not available in India as of recent guidelines.

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1. Typhoid Conjugate Vaccines (TCV) - Recommended First-Line

A. Typbar-TCV (Bharat Biotech, Hyderabad) ⭐ - Gold Standard

• Type: Vi-Tetanus Toxoid (Vi-TT) conjugate
• Age: ≥6 months (licensed for infants, children, and adults up to 45 years)
• Dose: Single 0.5 mL IM injection
• Booster: No routine booster recommended
• Efficacy:
  • 87.1% protection in Oxford human challenge study
  • 98.05% seroconversion in children 6 months-2 years
  • 99.17% seroconversion in children 2-15 years
  • 92% maintained seroconversion at 7 years in follow-up study
• WHO Status: WHO prequalified (2018) - first typhoid vaccine ever WHO prequalified; recommended by WHO-SAGE for routine immunization
• IAP Recommendation: Preferred TCV for India
• IAPSM (2024): Recommends routine use up to 45 years of age in India
• Cost (private sector): Approx. ₹1,300-₹2,500 per dose

B. TyphiBEV (Biological E, Hyderabad)

• Type: Vi-CRM197 conjugate
• Age: ≥6 months
• Dose: Single 0.5 mL IM injection
• Licensed in India: Since 2020
• WHO Status: WHO prequalified (2020) - second TCV to be prequalified
• Booster: No routine booster recommended
• Note: Recommended by WHO-SAGE alongside Typbar-TCV for national immunization programs

C. PedaTyph / Peda-Typh (Biomed)

• Type: Vi-Tetanus Toxoid conjugate
• Age: 6 months and above
• Dose: 2 doses (some formulations)
• Efficacy: 83.87% seroconversion at 1 year; long-term immune response maintained at 30 months
• Booster: A booster dose is recommended at 24-30 months after primary dose (unique among TCVs)
• Cost: ~₹1,000-₹1,500

D. Zyvac TCV (Zydus Cadila)

• Type: Vi-Tetanus Toxoid conjugate
• Age: ≥6 months
• Dose: Single IM injection
• Efficacy: 77.2% seroconversion maintained at 3 years in a study of 117 children
• Booster: No routine booster recommended

E. Vi-rEPA (Investigational / Limited)

• Type: Vi conjugated to recombinant exoprotein A of Pseudomonas
• Doses: 2 doses at 0 and 6 weeks (children >2 years)
• Limited commercial availability in India currently

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2. Unconjugated Vi Polysaccharide Vaccines (ViPS) - Older Generation

ViPS vaccines are less preferred compared to TCVs due to shorter duration of protection, no memory induction, and inability to protect children <2 years. Still used in adults where TCVs are unavailable.

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3. Oral Live Attenuated Vaccine (Ty21a)

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IAP (Indian Academy of Pediatrics) 2025 Recommendations

India's UIP currently provides: BCG, OPV, Hepatitis B, DPT (Pentavalent), IPV, PCV, Rotavirus, MR, Td - Typhoid is not yet in the UIP but IAP and IAPSM strongly advocate for its inclusion given India's high disease burden.

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IAPSM 2024 Position Paper (Adults)

• Routine use of Typbar-TCV for adults up to 45 years in India
• Post-marketing surveillance to monitor long-term safety and effectiveness
• Development of vaccines covering a broader range of Salmonella infections
• Priority vaccination for:
  • Food handlers and sanitation workers
  • Healthcare workers
  • Travelers to endemic areas
  • Military personnel
  • Children in high-burden urban areas

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Comparison Summary

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Key Points to Remember

1. TCVs are superior to ViPS vaccines - better immunogenicity, longer protection, effective from 6 months of age, induce memory
2. Typbar-TCV is the flagship - world's first WHO-prequalified typhoid conjugate vaccine, made in India (Bharat Biotech, Hyderabad)
3. Single dose for most TCVs - simple to administer
4. Not in UIP yet - available in private sector; advocacy ongoing for inclusion in government programme
5. Vaccine does not replace safe water/food hygiene - protective efficacy can be overcome by high inocula
6. S. Paratyphi - no licensed vaccine exists for paratyphoid fever specifically; Typbar-TCV confers some cross-protection