Choosing between four-capsule oral live Vivotif (NDC 69945-0102) and a single intramuscular Typhim Vi injection (CPT 90691) determines your pre-flight calendar, when you can start Atovaquone-Proguanil or Doxycycline, home refrigerator handling, booster duration, and cash cost across Maryland, Washington, D.C., and Northern Virginia.
Four-capsule oral live Vivotif (Salmonella Typhi Ty21a, NDC 69945-0102) protects immunocompetent travelers aged 6 years and older for 5 years at $95 to $149 via DMV retail pharmacy coupons, provided capsules stay refrigerated at 35.6°F to 46.4°F and finish 72 hours before proguanil or antibiotics. Single-shot intramuscular Typhim Vi (CPT 90691) covers ages 2 and up for 2 years with zero antimalarial interactions.
SECTION 01 // FORMULARY HEAD-TO-HEAD
Enteric fever caused by Salmonella enterica serovar Typhi remains one of the highest-incidence vaccine-preventable infections among Capital Region outbound travelers visiting South Asia (India, Pakistan, Bangladesh, Nepal), West and East Africa (Nigeria, Ghana, Kenya, Ethiopia), and Andean or Amazonian Latin America. In the United States, clinicians and immunization pharmacists dispense two distinct FDA-licensed typhoid biologics that operate through completely different immunological mechanisms, storage chains, and billing channels.
Vivotif (manufactured by Bavarian Nordic, current pack NDC 69945-0102-01, legacy cross-reference NDC 0944-0496, medical billing code CPT 90690) is an oral live-attenuated bacterial vaccine containing viable Salmonella Typhi strain Ty21a inside acid-resistant enteric-coated capsules. Because your neighborhood retail pharmacy dispenses the four-capsule foil blister directly to you for home administration on alternating days, it adjudicates through prescription drug discount cards (such as GoodRx or SingleCare) or commercial pharmacy benefits without a clinic injection fee. By contrast, Typhim Vi (Sanofi Pasteur, NDC 49281-0790-20, CPT 90691) is a sterile, non-live purified Vi capsular polysaccharide solution administered as a single 0.5 mL intramuscular deltoid injection at a travel clinic, county health department, or immunizing pharmacy counter.
| Clinical or Dispensing Parameter | Vivotif (4-Capsule Oral Live) | Typhim Vi (Single IM Injection) |
|---|---|---|
| Active Antigen & Platform | Live-attenuated Salmonella Typhi Ty21a (galE epimerase-deficient mutant; >= 2 x 109 viable CFU per capsule) |
Inactivated purified Vi capsular polysaccharide (25 mcg per 0.5 mL sterile prefilled syringe; phenol-preserved) |
| US Codes (CPT & NDC) | CPT 90690 NDC 69945-0102-01 |
CPT 90691 (+ 90471 admin) NDC 49281-0790-20 |
| Minimum FDA-Approved Age | Age >= 6 years (must swallow whole capsule intact without chewing) | Age >= 2 years (preferred pediatric typhoid vaccine for ages 2 to 5) |
| Primary Dosing Schedule | 4 capsules total: swallow 1 capsule on Days 1, 3, 5, and 7 | 1 single 0.5 mL IM dose into deltoid (or anterolateral thigh in young children) |
| Pre-Departure Lead Time | Complete Day 7 capsule >= 7 days before exposure (>= 14 days total; >= 11 days if starting Malarone) | Inject >= 14 days prior to potential exposure (still preferred over oral if departing in < 10 days) |
| US ACIP Booster Interval | Every 5 years under continued or repeated endemic exposure | Every 2 years under continued or repeated endemic exposure |
| Cold-Chain Storage Responsibility | Strict Home Fridge 2°C to 8°C (35.6°F to 46.4°F); room-temperature exposure kills live bacteria | Clinic Fridge Only; zero patient cold-pack transport or home refrigerator risk |
| Stomach & Liquid Administration Rule | Empty stomach >= 1 hour before a meal (or >= 2 hours after eating) with cold or lukewarm water (<= 37°C / 98.6°F) | No fasting, meal timing, or beverage temperature restriction |
| Antibiotic & Proguanil Conflict | 72-Hour Washout Mandatory before/after systemic antibiotics, sulfonamides, or Atovaquone-Proguanil |
Zero Drug Conflict; co-administer on same day as Malarone, Doxycycline, or azithromycin |
| Pregnancy & Immunosuppression | Contraindicated in HIV (CD4 < 200), biologics, chemotherapy, high-dose steroids, pregnancy, and acute GI illness | Permitted When Indicated; safe non-replicating polysaccharide for immunocompromised hosts |
| DMV Self-Pay & Part D Benchmark | $95 to $149 GoodRx retail Rx $125 Fairfax County Health |
$148 to $184.99 retail cash $0 Medicare Part D / $210 to $245+ private |
APOTHECARY DISPENSING LABEL SPECIMEN // HOME BLISTER PROTOCOL
NDC 69945-0102-01 | STORE IN REFRIGERATOR AT 35.6°F TO 46.4°F (2°C TO 8°C) IMMEDIATELY UPON PICKUP (DO NOT FREEZE). Inspect foil blister integrity before leaving the Maryland, D.C., or Virginia pharmacy counter. Swallow 1 capsule whole (never chew, crush, or open) on Day 1, Day 3, Day 5, and Day 7 roughly 60 minutes prior to breakfast with a full glass of cool tap or bottled water. Never swallow with hot coffee, hot tea, carbonated soda, alcohol, or warm milk. Wait at least 72 full hours after swallowing Capsule #4 on Day 7 before taking your first pre-flight tablet of Atovaquone-Proguanil (Malarone), Doxycycline, or any systemic antibacterial agent.
SECTION 02 // INTERACTIVE CLINICAL WORKBENCH
The single most frequent dispensing error we audit among Dulles (IAD) and BWI travelers bound for West Africa, India, or South America is picking up oral Vivotif capsules and generic Atovaquone-Proguanil on the same afternoon, then swallowing both during the final week before takeoff. Use the pharmacist scheduler below to check whether your departure countdown accommodates all four Vivotif capsules plus the required 72-hour antimicrobial separation buffer, or whether you should switch immediately to single-dose intramuscular Typhim Vi.
Pharmacist Dispensing Note: Ask your Maryland, D.C., or Virginia prescriber to e-prescribe Vivotif Oral Capsule Delayed Release (NDC 69945-0102-01, #1 pack of 4 capsules) to Costco #214 Beltsville, Giant, or Safeway, and carry an insulated lunch pouch on pickup day.
Understanding why Vivotif fails under improper co-administration prevents costly false confidence abroad. Unlike injectable Typhim Vi (which presents purified surface Vi polysaccharide directly to circulating B-lymphocytes without replication), oral Ty21a is a live chemical mutant deficient in the enzyme UDP-galactose-4-epimerase (galE). When live Ty21a bacteria reach the terminal ileum, they invade intestinal M-cells overlying Peyer's patches and undergo three to four divisions in the presence of exogenous galactose. Because they lack functional epimerase, incomplete lipopolysaccharide intermediates accumulate intracellularly and cause harmless self-lysis, triggering robust mucosal secretory IgA (sIgA) and systemic cell-mediated immunity without causing clinical typhoid fever.
Two physical or chemical insults abort that replication cascade before mucosal priming ever begins:
Ty21a organisms die rapidly below pH 3.5. Each hydroxypropyl methylcellulose phthalate enteric-coated capsule is engineered to stay sealed inside acidic gastric juice (pH 1.5 to 2.0) and dissolve only once duodenal bicarbonate raises intraluminal pH above 5.5 to 6.0. Taking a capsule right after a heavy meal delays gastric emptying and buffers stomach pH upward prematurely, while swallowing with hot coffee or hot tea (> 37°C / 98.6°F) softens the enteric polymer inside the esophagus and stomach.Proguanil (half of Atovaquone-Proguanil, metabolized via CYP2C19 to cycloguanil) inhibits bacterial dihydrofolate reductase; Doxycycline blocks the 30S bacterial ribosomal subunit; Azithromycin blocks the 50S subunit; and fluoroquinolones (Ciprofloxacin) inhibit DNA gyrase. CDC ACIP and FDA package labeling therefore enforce a strict 72-hour antimicrobial-free window before Capsule #1 and for 72 hours after Capsule #4. Note that Chloroquine and Mefloquine showed minimal in vitro inhibition in updated FDA labeling when separated appropriately, though clinical travel pharmacists still verify exact pack insert rules whenever blood schizonticides overlap.SECTION 03 // QUANTITATIVE DOSING TIMELINE
When counting backward from a Dulles (IAD) or BWI departure to a malaria-endemic corridor, Vivotif requires a minimum 11-to-12-day runway solely to clear antimicrobial conflict, and 14 full days (completing Capsule #4 seven days before endemic arrival) to reach peak mucosal sIgA protection. Examine the visual separation window below before requesting an oral prescription.
Typhim Vi.
SECTION 04 // CAPITAL REGION TARIFF BENCHMARK
Search queries for typhoid vaccine CVS and typhoid vaccine Walgreens exceed 3,200 monthly searches nationwide because major retail chains advertise travel immunizations online while burying cash prices behind six-step intake screens. Across Prince George's County (20705 Beltsville, 20782 Hyattsville, 20742 College Park), Montgomery County (20910 Silver Spring), Washington, D.C., and Northern Virginia, out-of-pocket typhoid immunization costs span a 2.5x spread depending on which dispensing channel you select.
| DMV Dispensing Venue Archetype | Formulation Dispensed | 2026 Verified Cash / Benefit Range | Prescription & Operational Workflow |
|---|---|---|---|
| Retail Supermarket / Warehouse Pharmacy + GoodRx (Costco #214 Beltsville, Giant #375 DC NE, Safeway, Harris Teeter) |
Vivotif 4-Cap Oral Pack( NDC 69945-0102-01) |
$95.00 to $149.00 ($0 clinic visit fee if PCP e-prescribes) |
Lowest self-pay route for families and 5-year frequent flyers. Ask your primary care clinician or telehealth provider to send an electronic prescription; call pharmacy 24 hours ahead so wholesaler delivers refrigerated stock. |
| Fairfax County Health Department (Fairfax, Annandale, Reston District Offices near IAD) |
Oral Typhoid (Vivotif) or Injectable Typhoid |
$125.00 published Oral Typhoid fee (+ small admin fee) | Published Northern Virginia public health schedule; ideal when combining with Fairfax County's published $360 YF-VAX Yellow Fever appointment. |
| UMD Health Center International Travel Clinic (140 Campus Dr, College Park, MD 20742) |
Typhim Vi IM Shot (CPT 90691) or Oral Rx |
$135.00 to $165.00 shot + $15-$55 visit fee | Located 3.8 miles south of former 20705 Cherry Hill Rd pharmacy; pair directly with UMD's benchmark $200 Yellow Fever vaccine to avoid duplicate consult charges. |
| CVS Pharmacy / MinuteClinic & Walgreens #19851 (Beltsville US-1, Silver Spring, DC, Arlington) |
Typhim Vi Single IM Shot (CPT 90691) |
$168.00 to $184.99 cash $0.00 Medicare Part D |
Under Maryland Code Health Occ. Section 12-508, D.C. Municipal Regulations, and Virginia statewide protocol, immunizing pharmacists administer Typhim Vi directly; Medicare Part D beneficiaries pay $0 copay in-network. |
| Private Travel-Medicine Franchises (Silver Spring 20903, Downtown DC, Reston / Tysons) |
Typhim Vi IM Shot or In-House Vivotif |
$195.00 to $245.00+ (plus $95 to $124 CPT 99401 consult) |
Convenient same-day walk-in stock for urgent <72-hour departures, but unbundled consult fees push a standalone typhoid visit above $310 cash without direct insurance billing. |
Pharmacists always counsel outbound travelers on an honest biological boundary: neither Vivotif nor Typhim Vi provides 100% sterilizing protection like Hepatitis A or Yellow Fever vaccines do. Across controlled field trials and Cochrane meta-analyses, both the four-capsule Ty21a oral series and the single-dose Vi polysaccharide shot reduce clinical typhoid incidence by approximately 50% to 80%, and high bacterial inoculums ingested via contaminated ice, raw street salads, unpasteurized dairy, or untreated tap water can overwhelm vaccine-induced immunity.
Furthermore, purified Typhim Vi targets the Vi capsular antigen completely absent from Salmonella Paratyphi A and B (which cause roughly one-quarter of enteric fever cases in South and Southeast Asia), while oral Ty21a shares somatic O-antigens that confer modest partial cross-reactivity against S. Paratyphi B but minimal protection against S. Paratyphi A. Because extensively drug-resistant (XDR) Salmonella Typhi circulating in Pakistan and neighboring corridors resists ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, fluoroquinolones (ciprofloxacin), and third-generation cephalosporins (ceftriaxone), leaving oral azithromycin and intravenous carbapenems as the final reliable empiric agents, strict cooked-hot food and sealed-water precautions remain mandatory alongside vaccination. Compare overall pre-trip budgets in our 2026 DMV Travel Vaccine Cash-Price Ledger and pair your typhoid choice with our Malarone vs. Doxycycline Tablet Calculator.
SECTION 05 // SAFETY & VERIFICATION GATES
Live oral Ty21a is strictly contraindicated in patients receiving TNF-alpha inhibitors, B-cell depleting biologics, systemic corticosteroids (>= 20 mg/day prednisone equivalent for >= 14 days), active chemotherapy, HIV with CD4 < 200 cells/mm3, congenital immunodeficiency, or pregnancy. Order inactivated Typhim Vi (CPT 90691) instead.
Active vomiting, acute secretory diarrhea, or inflammatory bowel flare rapidly expels enteric-coated Vivotif capsules before terminal ileal colonization can occur. Postpone Capsule #1 until 48 hours after acute GI symptoms resolve, or administer intramuscular Typhim Vi.
Sustained stepwise fever, headache, abdominal pain, or relative bradycardia 6 to 30 days after returning from South Asia or Africa requires hospital blood cultures and infectious-disease susceptibility testing (plus immediate malaria blood smears if returning from a malaria zone). Never self-treat suspected enteric fever with leftover fluoroquinolones due to widespread resistance.