Prepared by Mufti Adil Farooki, MD, Shaykh Mateen Khan, MD and Dr. Ramzan Judge, PharmD

Summary:

The injectable vaccine Typhim Vi is permissible for Muslims as a vaccine for typhoid fever and is preferred over oral Vivotif.

Background:

Enteric fever, also known as “typhoid fever”, is a severe systemic illness characterized by fever and abdominal pain caused by the bacteria Salmonella enterica serotype Typhi. Typhoid fever infects roughly 21.6 million people (incidence of 3.6 per 1,000 population) and kills an estimated 200,000 people every year[1].

From the CDC[2]:

“People who are actively ill with typhoid fever and people who are carriers of the bacteria that cause typhoid fever can both spread the bacteria to other people.  When someone eats or drinks contaminated food or drink, the bacteria can multiply and spread into the bloodstream, causing typhoid fever.

Typhoid fever can be a life-threatening disease.  Symptoms of infection include persistent high fever, weakness, stomach pain, headache, diarrhea or constipation, cough, and loss of appetite.

People who do not get treatment can continue to have fever for weeks or months. As many as 30% of people who do not get treatment die from complications of typhoid fever. There are fewer antibiotic treatment options as drug-resistant typhoid bacteria has become more common in many parts of the world.

Typhoid fever is common in many regions of the world, including parts of East and Southeast Asia, Africa, the Caribbean, and Central and South America.  Typhoid fever is not common in the United States.”

CDC Indications for Vaccination:

According to the CDC, routine typhoid vaccination is not recommended in the United States, but is recommended for[3]:

• 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.

Vaccines Available in the United States

There are two typhoid vaccines available in the United States: Vivotif, an oral vaccine, and Typhim Vi, an injectable vaccine.

1. Vivotif[4]
   • Manufacturer: Crucell Switzerland LTD
   • Form: capsule
   • Contains:  Viable S. typhi Ty21a, Non-viable S. typhi Ty21a,sucrose, ascorbic acid, amino acids, lactose, magnesium stearate, bovine gelatin
   • Culture Medium: digest of yeast extract, an acid digest of casein, dextrose and galactose
2. Typhim Vi[5]
   • Manufacturer: Sanofi Pasteur
   • Form: injection
   • Contains: purified Vi polysaccharide, formaldehyde, phenol, polydimethylsiloxane, disodium phosphate, monosodium phosphate, sodium chloride, sterile water
   • Culture Medium: semi-synthetic medium. Casein derived raw materials are used early in manufacturing during the fermentation process

Discussion and Recommendations:

For Muslims who require typhoid vaccination, the injectable form, Typhim Vi, is permissible to use.  The capsule form, Vivotif, contains bovine gelatin, which is hydrolyzed collagen extracted from collagen-containing tissue like skin and bones. The cows from which this material is derived are not slaughtered in accordance with Islamic law. Due to the difference of opinion regarding bovine gelatin’s permissibility for consumption, it is preferable and more cautious for Muslims to use the injectable form of the vaccine.

From an Islamic perspective, preventing a health threat such as typhoid fever in high-risk patients is considered to be a necessity[6]. People for whom typhoid vaccination is indicated are considered to be at high risk for getting the infection with a significant potential for serious complications[7],  and infections may be difficult to treat due to rising antibiotic resistance[8]. Although the injectable form is preferred, Muslims may use the oral form if the injectable form is not accessible or is contraindicated (due to allergies or hypersensitivity).

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[1] J Prev Med Hyg. 2017;58(1):E1–E8.

[2] https://www.cdc.gov/vaccines/hcp/vis/vis-statements/typhoid.html

[3] ibid

[4] https://www.fda.gov/media/75988/download

[5] https://www.fda.gov/media/75993/download

[6] For further discussion, see https://muslimmed.org/category/vaccines/use-of-vaccines-with-impermissible-ingredients/

[7] N Engl J Med. 1984;310(2):82.

[8] https://www.cdc.gov/typhoid-fever/symptoms.html