Typhoid Vaccine

Class: Vaccines
ATC Class: J07AP01
VA Class: IM100
Brands: Typhim Vi, Vivotif

Introduction

Live, attenuated vaccine (Vivotif)^{101 102 103 b} and inactivated vaccine (Typhim Vi).^{101 102 123 b} Typhoid vaccine live oral (Vivotif) contains the Ty21a strain of Salmonella typhi.^{101 102 103} Parenteral typhoid Vi polysaccharide vaccine (Typhim Vi) contains purified cell surface polysaccharide antigens extracted from S. typhi of the Ty2 strain.^{101 102 123} Typhoid vaccines are used to stimulate active immunity to typhoid fever.^{101 102 103 123} Different typhoid vaccines (e.g., whole-cell vaccines) may be available in other countries.^{101 102 114 126 134 135}

Uses for Typhoid Vaccine

Prevention of Typhoid Fever

Prevention of typhoid fever in individuals at risk of intimate exposure to a known typhoid carrier (e.g., continued household contact), in those traveling to areas where typhoid fever is endemic because of poor food or water sanitation, and in laboratory workers with frequent contact with Salmonella typhi bacilli.^{102 103 123 b}

Typhoid fever is an acute, life-threatening febrile illness caused by S. typhi bacteria transmitted via food and/or water contaminated with feces, urine, vomitus, or respiratory secretions from typhoid fever carriers.^a Typhoid fever is uncommon in the US, but is endemic in many less well-developed areas of the world that have poor sanitation and primitive water systems.^{101 137} WHO estimates that about 22 million cases of typhoid fever occur with about 200,000 related deaths annually.^{101 c} Approximately 2–4% of individuals with acute typhoid develop a chronic carrier state.^{103 123} CDC receives reports of about 400 cases of typhoid fever each year in the US, mostly among recent travelers to other countries.^{101 102 b}

USPHS Advisory Committee on Immunization Practices (ACIP) and AAP do not currently recommend routine immunization against typhoid fever for individuals residing in the US.^{102 103 123} Although immunization against typhoid fever was recommended in the past for individuals in the US attending summer camps or residing in areas where natural disasters (e.g., flooding) had occurred or for control of common-source outbreaks of typhoid fever, this no longer is considered necessary because of the low probability of exposure in the US.^{102 103 123} Routine immunization against typhoid fever is warranted for sewage workers only in areas with endemic typhoid.¹⁰²

ACIP and AAP recommend vaccination using oral live typhoid vaccine (Vivotif) or parenteral inactivated typhoid vaccine (Typhim Vi) for adults, adolescents, and children at high risk of exposure to S. typhi bacilli.^{101 102 b} Efficacy of these vaccines appears to be comparable when administered as recommended;^{102 105 107 109 111 114 115 116 117 118 119 120 121 123 124 125 126} however, 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 immune status of the vaccinee.^{102 123 126} Because Vivotif is self-administered over a 1-week period and compliance errors (i.e., dosing errors, improper storage) have been reported, Typhim Vi may be preferred in patients in whom compliance is likely to be a problem.¹³¹

Individuals with acute typhoid infection and those who are chronic typhoid carriers should not receive typhoid vaccine.^{103 123}

Vivotif and Typhim Vi will not prevent typhoid fever caused by Salmonella species other than S. typhi (e.g., S. paratyphi type A or B) and will not prevent infections caused by other bacteria known to cause enteric disease.^{103 123}

Preexposure Vaccination Against Typhoid Fever in High-risk Groups

Preexposure vaccination in individuals who are or will be at high risk of exposure to S. typhi.^{101 102 b}

Household contacts of known typhoid carriers should be vaccinated with typhoid vaccine because of increased risk of exposure to typhoid fever.^{102 103 123 b}

Travelers to areas where there is a recognized risk of exposure to typhoid fever (e.g., many countries in Africa, Asia, Central and South America) should be vaccinated against typhoid fever.^{101 103 123 137 b} Although vaccination is not currently required for international travel,^{101 137} it is recommended for travelers who may have prolonged exposure to contaminated food and drink in areas with persistent typhoid epidemics or in smaller villages or rural areas outside the usual tourist itinerary.^{101 123 137 b} In addition to vaccination, travelers 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 S. typhi.^{101 103 123 b} (See Limitations of Vaccine Effectiveness under Cautions.)

HIV-infected individuals should not receive Vivotif since the vaccine contains live, attenuated bacteria.^{102 103 122} If typhoid vaccine is indicated, HIV-infected individuals may receive Typhim Vi.^{102 122} USPHS/IDSA Prevention of Opportunistic Infections Working Group recommends use of Typhim Vi in HIV-infected individuals at risk of exposure to typhoid fever.¹³⁶ (See Individuals with Altered Immunocompetence under Cautions.)

Typhoid Vaccine Dosage and Administration

Administration

Vivotif is administered orally;¹⁰³ Typhim Vi is administered by IM injection.¹²³

Oral Administration

Vivotif: Administer orally.^{101 102 103 b d} Do not administer parenterally.¹⁰³

Take on an empty stomach (approximately 1 hour before or 2 hours after a meal).^{101 102 103 114 b d}

Do not chew or open the enteric-coated capsules.^{103 114 d} Swallow whole with cool or lukewarm (≤37°C [body temperature]) liquid (water).^{101 102 103 b d}

Do not drink alcohol within 2 hours after the dose.^d (See Specific Drugs under Interactions.)

It is essential that remaining capsules be stored in a refrigerator until the vaccination series is completed.¹⁰³ (See Storage under Stability.)

IM Administration

Typhim Vi: Administer by IM injection.^{101 102 123 b} Do not administer IV.¹²³

IM injections preferably should be made into the deltoid area in adults and into the deltoid or the vastus lateralis in children.¹²³ To ensure delivery into muscle, IM injections should be made at a 90° angle to the skin using a needle length appropriate for the individual's age and body mass.¹⁰⁰

Administer undiluted.¹²³ Do not mix with any other vaccine or solution.^{100 123 b}

Avoid use of the gluteal area or any area where there may be a nerve trunk.¹²³ Generally, do not administer vaccines into buttock muscle in children because of potential for injection-associated injury to the sciatic nerve.¹⁰⁰

Avoid injection of vaccines into or near blood vessels.¹²³

Dosage

Dose and dosing schedule vary according to the individual's age and specific vaccine administered (Vivotif, Typhim Vi).^{103 123 b} Follow dosage recommendations for the specific preparation used.¹⁰²

Pediatric Patients

Preexposure Vaccination Against Typhoid Fever in High-risk Groups

Children and Adolescents 6–18 Years of Age (Vivotif)

Oral

Primary immunization consists of 4 doses.^{101 102 103 b} Each dose consists of one enteric-coated capsule.^{102 103}

Give first dose on a selected date; give second, third, and fourth doses every other day after the first dose over a 1-week period.^{101 102 103 b}

Primary immunization with the recommended vaccination series before an expected exposure to typhoid fever ensures the highest level of protection.^{102 103} Those who complete the 4-dose series at least 1 week prior to possible typhoid exposure probably will be protected.^{102 103 b c d}

Data not available concerning use of Vivotif as a booster in individuals who received primary immunization with a different typhoid vaccine.^{102 103} ACIP states that the 4-dose Vivotif vaccination series is a reasonable alternative for booster immunization in individuals previously vaccinated with a parenteral inactivated typhoid vaccine.¹⁰²

Duration of immunity and need for subsequent doses not fully determined.^{102 103 b} For travelers or individuals at continued or repeated risk of exposure to typhoid fever, additional (booster) doses (i.e., 4-dose vaccination series) are recommended every 5 years.^{102 103 b} (See Duration of Immunity under Cautions.)

Children and Adolescents 2 –18 Years of Age (Typhim Vi)

IM

Primary immunization consists of a single 25-mcg dose.^{102 123 b} Each dose consists of 0.5 mL from the commercially available prefilled single-dose syringe or multidose vial.^{102 123 b}

Those who receive the recommended dose given at least 2 weeks prior to possible exposure to typhoid fever probably will be protected.^{102 123 b c}

Data not available concerning use of Typhim Vi for booster immunization in individuals who received primary immunization with a different typhoid vaccine.^{102 123 b} ACIP states that a single dose of Typhim Vi is a reasonable alternative as a booster for individuals previously vaccinated with another parenteral inactivated typhoid vaccine.¹⁰²

Duration of immunity and need for subsequent doses not fully determined.^{102 123 114 b} For travelers or individuals at continued or repeated risk of exposure to typhoid fever, an additional (booster) dose of 0.5 mL is recommended every 2 years.^{102 123 114 b} (See Duration of Immunity under Cautions.)

Adults

Preexposure Vaccination Against Typhoid Fever in High-risk Groups

Adults ≥19 Years of Age (Vivotif)

Oral

Primary immunization consists of 4 doses.^{102 103 b} Each dose consists of one enteric-coated capsule.^{102 103}

Give first dose on a selected date; give second, third, and fourth doses every other day after the first dose over a 1-week period.^{102 103 b}

Primary immunization with the recommended vaccination series before an expected exposure to typhoid fever ensures the highest level of protection.^{102 103} Those who complete the 4-dose series at least 1 week prior to possible typhoid exposure probably will be protected.^{102 103 b}

Data not available concerning use of Vivotif as a booster in individuals who received primary immunization with a different typhoid vaccine.^{102 103 b} ACIP states that the 4-dose Vivotif vaccination series is a reasonable alternative as a booster for individuals previously vaccinated with a parenteral inactivated typhoid vaccine.¹⁰²

Duration of immunity and need for subsequent doses not fully determined.^{102 103 114 b} For travelers or individuals at continued or repeated risk of exposure to typhoid fever, additional (booster) doses (i.e., 4-dose vaccination series) are recommended every 5 years.^{103 114 b} (See Duration of Immunity under Cautions.)

Adults ≥19 Years of Age (Typhim Vi)

IM

Primary immunization consists of a single 25-mcg dose.^{102 123 b} Each dose consists of 0.5 mL from the commercially available prefilled single-dose syringe or multidose vial.^{102 123 b}

Those who receive the recommended single dose at least 2 weeks prior to possible exposure to typhoid fever probably will be protected.^{102 123 b}

Data not available concerning use of Typhim Vi for booster immunization in individuals who received primary immunization with a different typhoid vaccine.^{102 123 b} ACIP states that a single dose of Typhim Vi is a reasonable alternative as a booster for individuals previously vaccinated with another parenteral inactivated typhoid vaccine.¹⁰²

Duration of immunity and need for subsequent doses not fully determined.^{102 123 b} For travelers or individuals at continued or repeated risk of exposure to typhoid fever, an additional (booster) dose of 0.5 mL is recommended every 2 years.^{123 b} (See Duration of Immunity under Cautions.)

Special Populations

Hepatic Impairment

No specific dosage recommendations.

Renal Impairment

No specific dosage recommendations.

Geriatric Patients

No specific dosage recommendations.

Cautions for Typhoid Vaccine

Contraindications

• 
  

  Oral live typhoid vaccine (Vivotif): Hypersensitivity to any ingredient in the formulation.^{101 103} Also contraindicated in individuals with altered immunocompetence and in those with acute febrile illness.^{101 102 103}

  
  


• 
  

  Parenteral inactivated typhoid vaccine (Typhim Vi): Hypersensitivity to any ingredient in the formulation.^{101 123} Also contraindicated in individuals with previous hypersensitivity reactions to any typhoid vaccine.^{101 102 123 b}

  
  

Warnings/Precautions

Warnings

Individuals with Altered Immunocompetence

Because severe complications have been reported following vaccination with live, attenuated virus or bacterial vaccines in individuals with altered immunocompetence (e.g., patients with leukemia, lymphoma, generalized malignancy, asymptomatic or symptomatic HIV infection, those receiving immunosuppressive therapy)¹⁰¹ and because safety of oral live typhoid vaccine (Vivotif) has not been established in immunocompromised individuals, this vaccine should not be used in such individuals.^{101 102 103 122} However, ACIP states that Vivotif can be used, if indicated, in patients who have altered immunocompetence because of asplenia, renal failure, diabetes, alcoholism, or alcoholic cirrhosis.¹²²

If typhoid vaccination is considered necessary in individuals with altered immunocompetence, parenteral inactivated typhoid vaccine (Typhim Vi) theoretically would be a safer alternative than the oral vaccine.^{102 122} However, the vaccine may be less immunogenic in immunocompromised individuals than in immunocompetent individuals.^{122 123} ACIP currently states that recommendations concerning use of parenteral inactivated typhoid vaccine in individuals with altered immunocompetence generally are the same as those for individuals who are not immunocompromised.¹²²

Individuals with GI Disorders

Oral live typhoid vaccine (Vivotif) should not be used in individuals with acute GI illness since the vaccine requires replication in the gut for effectiveness.^{103 b d} Postpone initiating the vaccination series in patients with persistent diarrhea or vomiting.^{103 d}

Sensitivity Reactions

Hypersensitivity Reactions

Allergic reactions (e.g., anaphylactic shock, pruritus, rash, urticaria, difficulty breathing, hypotension, serum sickness) have been reported rarely with typhoid vaccine.^{103 123}

A history of previous sensitivity reactions to typhoid vaccine should be obtained prior to administration.^{102 123}

Epinephrine and other appropriate agents should be readily available in case anaphylaxis or other serious allergic reaction occurs.¹²³

General Precautions

Transmission of Vaccine Bacteria

Oral typhoid vaccine (Vivotif) contains live, attenuated bacteria.¹⁰³ Secondary transmission of vaccine bacteria has not been documented following administration of Vivotif; however, these organisms may be shed transiently in the stools of vaccinees.^{102 103}

Concomitant Illness

A decision to administer or delay vaccination in an individual with a current or recent febrile illness depends on the severity of symptoms and etiology of the illness.¹⁰⁰

Manufacturer of Vivotif states that the vaccine should not be administered to individuals during an acute febrile illness. ¹⁰³ Manufacturer of Typhim Vi states that the vaccine may be given to individuals with acute infection or febrile illness if withholding the vaccine poses greater risk to the patient.¹²³

ACIP states that minor acute illness, such as mild diarrhea or mild upper respiratory tract infection (with or without fever) generally does not preclude vaccination, but vaccination should be deferred in individuals with moderate or severe acute illness (with or without fever) until they have recovered from the acute phase of the illness.¹⁰⁰

Individuals with Bleeding Disorders

Parenteral inactivated typhoid vaccine (Typhim Vi): Because bleeding may occur following IM administration in individuals with thrombocytopenia or a bleeding disorder (e.g., hemophilia) or in those receiving anticoagulant therapy, use caution in such individuals.^{100 123}

ACIP states that vaccines may be given IM to individuals who have bleeding disorders or are receiving anticoagulant therapy if a clinician familiar with the patient's bleeding risk determines that the preparation can be administered with reasonable safety.¹⁰⁰ In these cases, use a fine needle (23 gauge) to administer the vaccine and apply firm pressure to the injection site (without rubbing) for ≥2 minutes.¹⁰⁰ If patient is receiving antihemophilia therapy, administer the IM vaccine shortly after a scheduled dose of such therapy.¹⁰⁰

Advise individual and/or their family about the risk of hematoma from IM injections.¹⁰⁰

Limitations of Vaccine Effectiveness

May not protect all vaccine recipients against typhoid fever infection.^{103 123 b} Vaccine-induced immunity can be overwhelmed by large inocula of S. typhi.¹⁰² Even travelers who have been immunized against typhoid fever should take precautions to avoid contact with or ingestion of potentially contaminated food or water.¹⁰³

Oral live typhoid vaccine (Vivotif): Optimum immune response may not be achieved unless the complete 4-dose vaccination series is used.^{101 102 103 b} Individuals who complete the 4-dose series at least 1 week prior to possible typhoid exposure probably will be protected.^{101 102 103 b}

Parenteral inactivated typhoid vaccine (Typhim Vi): Individuals who receive a single dose given at least 2 weeks prior to possible typhoid exposure probably will be protected.^{101 102 123}

May not prevent infection in individuals who do not achieve protective antibody titers; the minimum titer needed to confer immunity has not been established.^{103 123}

Vivotif and Typhim Vi provide protection only against S. typhi.^{103 123} These vaccines do not provide protection against other Salmonella species (e.g., S. paratyphi A or B).¹²³

Duration of Immunity

Duration of protection and need for subsequent doses after initial and additional (booster) doses of typhoid vaccine not fully determined.^{102 103 114 123} Natural infection with S. typhi generally confers lifelong immunity; however, the nature of this immunity is complex and includes both humoral and cell-mediated components.^a

Oral live typhoid vaccine (Vivotif): Although additional long-term follow-up studies are needed, limited evidence suggests that protective levels of antibodies following the recommended 4-dose vaccination series may persist for at least 5 years.^{102 103} Additional (booster) doses (i.e., 4-dose oral vaccination series) of Vivotif recommended every 5 years if continued or renewed exposure to typhoid fever is expected.^{102 103}

Parenteral inactivated typhoid vaccine (Typhim Vi): Limited data indicate that antibody titers remain elevated for at least 12 months after a single dose in children 5–15 years of age residing in typhoid-endemic areas and for at least 36 months in healthy US adults.^{123 128 129} Additional (booster) dose of Typhim Vi recommended every 2 years if continued or renewed exposure to typhoid fever is expected.¹²³

Improper Storage and Handling

Improper storage or handling of vaccines may result in loss of vaccine potency and reduced immune response in vaccinees.¹⁰⁰

Oral live typhoid vaccine (Vivotif): Unstable when exposed to ambient temperatures.^{103 126 131} Remaining capsules must be stored in a refrigerator until the vaccination series is completed.¹⁰³ Do not administer Vivotif that has been mishandled or has not been stored at the recommended temperature (2–8°C).^{103 126 131} (See Storage under Stability.)

Parenteral inactivated typhoid vaccine (Typhim Vi): Not adversely affected by elevated temperatures (e.g., those that occur in tropical areas).^{124 126} Therefore, the parenteral vaccine may be preferred in situations in which continuous refrigeration cannot be ensured.^{124 126}

Inspect all vaccines upon delivery and monitor during storage to ensure that the appropriate temperature is maintained.¹⁰⁰

Specific Populations

Pregnancy

Oral live typhoid vaccine (Vivotif) and parenteral inactivated typhoid vaccine (Typhim Vi): Category C.^{103 123}

Safety data not available on use of typhoid vaccines in pregnant women.^{101 102 b} Typhoid vaccine should be given to pregnant women only if clearly needed.^{103 123}

AAP states that Vivotif is contraindicated in pregnant women.^b

Because Typhim Vi is an inactivated vaccine, the theoretical risk to the fetus is expected to be low.¹⁰⁰ AAP states that use of Typhim Vi may be considered on an individual basis.^b When giving a vaccine during pregnancy, delaying vaccination until the second or third trimester, if possible, is a reasonable precaution to minimize the possibility of teratogenicity.^{123 b}

Lactation

Not known whether antigens contained in typhoid vaccine are distributed into milk following oral or IM administration.^{103 123} Use with caution in nursing women.^{103 123}

Because inactivated vaccines (e.g., Typhim Vi) do not multiply within the body, they should not pose any unusual problems for lactating women or their infants.^{100 101}

The manufacturers state that there currently are no data to warrant use of typhoid vaccines in nursing women in an attempt to provide passive transfer of antibodies to protect an infant from typhoid fever.^{103 123}

Pediatric Use

Oral live typhoid vaccine (Vivotif): Safety and efficacy not established in children <6 years of age.^{102 103} Although efficacy not established, limited evidence indicates adverse effects were uncommon when the vaccine was used in children 1–5 years of age†.¹⁰² Has not been studied in children <1 year of age.¹⁰²

Parenteral inactivated typhoid vaccine (Typhim Vi): Safety and efficacy not established in children <2 years of age.^{102 123} Has not been studied in children <1 year of age.^{101 102}

Common Adverse Effects

Oral live typhoid vaccine (Vivotif): Abdominal pain, nausea, headache, fever, diarrhea, vomiting, skin rash.^{101 102 103 114 b d}

Parenteral inactivated typhoid vaccine (Typhim Vi): Injection site reactions (pain, tenderness, erythema, induration),^{102 123 125 130 135 b} malaise/generalized aches,^{123 129 130} headache,^{102 123 125 130 135 b} myalgia/muscle aches,^{123 130} nausea,^{123 125 130} diarrhea,^{123 130} feverishness,^{123 130} decreased activity/lethargy,^{123 130} vomiting.¹²³

Interactions for Typhoid Vaccine

Live Vaccines

Oral live typhoid vaccine (Vivotif): May be administered simultaneously with or at any interval before or after a parenteral live vaccine (e.g., measles, mumps, and rubella virus vaccine live [MMR], varicella virus vaccine live, yellow fever vaccine).¹⁰⁰ Data not available regarding the immunogenicity of Vivotif administered concurrently or within 30 days of other live virus vaccines.¹⁰⁰ However, ACIP and AAFP state that if use of Vivotif is warranted, it should not be delayed because of administration of other live virus vaccines (injectable or intranasal).^{100 102}

Parenteral inactivated typhoid vaccine (Typhim Vi): Specific interaction studies involving Typhim Vi and other vaccines have not been conducted to date.¹²³ However, since Typhim Vi is an inactivated vaccine, it generally can be administered simultaneously with (using different syringes and different injection sites) or at any interval before or after live vaccines.¹⁰⁰

Inactivated Vaccines and Toxoids

Oral live typhoid vaccine (Vivotif): Can be administered simultaneously with or at any interval before or after inactivated vaccines.¹⁰⁰

Parenteral inactivated typhoid vaccine (Typhim Vi): Specific drug interaction studies involving Typhim Vi and other vaccines commonly administered prior to international travel (e.g., hepatitis A, meningococcal, poliovirus, tetanus) have not been conducted to date.¹²³ However, since Typhim Vi is an inactivated vaccine, it generally can be administered simultaneously with (using different syringes and different injection sites) or at any interval before or after other inactivated vaccines.¹⁰⁰

Specific Drugs

Drug	Interaction	Comments
Alcohol	Vivotif: Alcohol may affect dissolution of the vaccine capsules and may inactivate the vaccined	Vivotif: Avoid alcohol for 2 hours after each vaccine dosed
Anti-infective agents (e.g., sulfonamides)	Vivotif: Potential for anti-infectives with activity against S. typhi to inhibit immune response to the vaccine103 Typhim Vi: Manufacturer states that specific drug interaction studies involving the vaccine and other drugs (e.g., anti-infectives) not conducted to date123	Vivotif: Manufacturer states do not use in individuals receiving anti-infectives;103 d ACIP, CDC, and AAFP state an interval of ≥24 hours should elapse between administration of an anti-infective dose and the vaccine;100 101 102 AAP states that anti-infectives should be avoided for ≥24 hours before the first dose and for 7 days after the fourth vaccine doseb
Antimalarial agents (e.g., chloroquine, mefloquine, proguanil)	Vivotif: Potential for antimalarials with antibacterial activity against Salmonella to inhibit the immune response to the vaccine103 Vivotif: Although mefloquine inhibits growth of S. typhi in vitro, including the Ty21a strain contained in the vaccine,102 132 133 no clinical evidence to date that mefloquine or chloroquine interferes with the immune response to the vaccine103 b Vivotif: Concurrent use of proguanil (200 mg daily; not commercially available in the US as a single-entity preparation) with the vaccine resulted in decreased immune response103 Typhim Vi: Manufacturer states specific drug interaction studies involving the vaccine and other drugs (e.g., antimalarial agents) not conducted to date123	Vivotif: Manufacturer states the vaccine may be administered in patients receiving mefloquine103 To minimize the potential for an inhibitory effect, ACIP states the vaccine should be administered ≥24 hours before or after a mefloquine dose;100 102 132 133 AAP states mefloquine may be administered simultaneously with the vaccineb Vivotif: Although an interval of ≥7 days was previously recommended between vaccination and initiation of chloroquine antimalarial prophylaxis, more recent evidence indicates special precautions not necessary102 103 132 133 b Vivotif: Manufacturer and AAP state that proguanil therapy should be delayed until ≥10 days after the fourth vaccine dose103 b
Hepatitis A (HepA) vaccine	Vivotif: Data not available regarding simultaneous administration with HepA vaccine103 Typhim Vi: Concomitant administration of HepA vaccine and parenteral inactivated typhoid vaccine does not appear to affect the immune response or adverse reactions to the vaccinese
Immune globulin (IGIM, IGIV) or specific immune globulin (HBIG, RIG, TIG, VZIG)	Vivotif: No evidence that immune globulin preparations interfere with the immune response to the vaccine100 101 102 Typhim Vi: Specific drug interaction studies not available123	Vivotif: May be administered simultaneously with or at any time before or after antibody-containing preparations without a substantial decrease in the immune response to the vaccine100 101 Typhim Vi: May be administered simultaneously (using different syringes and different injection sites) or at any time before or after immune globulins100
Immunosuppressive agents (e.g., alkylating agents, antimetabolites, corticosteroids, radiation)	Typhim Vi: Immune response may be reduced in patients receiving immunosuppressive agents122 123	Vivotif: Contraindicated in patients receiving immunosuppressive therapy102 103 122 If typhoid vaccination is considered necessary in individuals receiving immunosuppressive agents, Typhim Vi is recommended102 122
Measles, mumps, and rubella vaccine (MMR)	Vivotif: Data not available regarding the immunogenicity of oral live typhoid vaccine administered concurrently or within 30 days of MMR 100 102	Vivotif: May be administered simultaneously with or at any interval before or after MMR100 102 Typhim Vi: May be administered simultaneously with (using different syringes and different injection sites) or at any interval before or after MMR100
Meningococcal vaccine	Vivotif: Data not available regarding simultaneous administration with meningococcal vaccine103 Typhim Vi: Has been administered concomitantly with MCV4 (Menactra) without reduced antibody response or increased adverse effectsg	Typhim Vi: May be administered simultaneously with MCV4 (Menactra) or at any interval before or after meningococcal vaccine (using different syringes and different injection sites)g
Poliovirus vaccine live oral (OPV; no longer commercially available in the US)	Vivotif: Although there is a theoretical risk that oral typhoid vaccine may interfere with the immune response to OPV,109 no evidence that OPV suppresses the immune response to typhoid vaccine103	Vivotif: Some experts suggest that ≥2 weeks should elapse between the last dose of Vivotifand OPV 109
Tetanus toxoid	Data not available regarding simultaneous administration of tetanus vaccine and Vivotif or Typhim Vi103 123
Varicella vaccine	Vivotif: Specific data not available regarding immunogenicity of oral live typhoid vaccine administered concurrently or within 30 days of varicella vaccine100 102 Typhim Vi: Since this typhoid vaccine is an inactivated vaccine, interactions with live vaccines such as varicella vaccine are unlikely100	Vivotif: May be administered simultaneously with or at any interval before or after varicella vaccine100 Typhim Vi: May be administered simultaneously (using different syringes and different injection sites) or at any interval before or after varicella vaccine100
Yellow fever vaccine	Vivotif: Although specific data not available regarding simultaneous administration, a bivalent vaccine (not commercially available in the US) containing a live oral typhoid vaccine and a cholera vaccine has been administered concomitantly with yellow fever vaccine without a decrease in immune response to the typhoid vaccine or an increase in adverse effectsf Typhim Vi: Yellow fever va