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Almost exactly a year ago, in mBio: The Gathering Storm: Is Untreatable Typhoid Fever on the Way?, we looked at the first large outbreak of extensively drug-resistant (XDR) typhoid - which emerged in the Sindh region of Pakistan (includes Karachi & Hyderbad) in late 2016.
Salmonella Typhi, the causative agent of Typhoid Fever, is a bacterium that has no known natural reservoir outside of humans. It is usually acquired via the fecal-oral route, often by consuming food or drink that has been handled by someone who is shedding the Salmonella Typhi bacteria.While still common in some developing countries, Typhoid fever is rarely seen anymore in the United States, unless it is brought in by someone who has traveled abroad. Last summer the CDC issued a Level 2 travel advisory for Extensively Drug-Resistant Typhoid in Pakistan (excerpts below).
Warning - Level 3, Avoid Nonessential TravelAlert - Level 2, Practice Enhanced PrecautionsWatch - Level 1, Practice Usual PrecautionsKey Points
- There is an ongoing outbreak of extensively drug-resistant (XDR) typhoid fever in Pakistan that does not respond to most antibiotics.
- During 2018, cases have been reported in the United Kingdom and in the United States among travelers returning from Pakistan.
- All travelers to Pakistan are at risk of getting XDR typhoid fever. Those who are visiting friends or relatives are at higher risk than are tourists and business travelers.
- Travelers to South Asia, including Pakistan, should take precautions to protect themselves from typhoid fever, including getting a typhoid fever vaccination.
- Travelers to these areas should also take extra care to follow safe food and water guidelines.
What is the current situation?
Health officials in Pakistan have reported an ongoing outbreak of XDR typhoid fever that began in Hyderabad in November 2016. The strain of Salmonella Typhi does not respond to most antibiotics used to treat typhoid fever. The outbreak has spread to the city of Karachi and to multiple districts, and several deaths have been reported. In 2018, three cases of XDR typhoid fever were reported in travelers — one who returned to the United Kingdom, and two who returned to the United States.
Public health authorities in Pakistan are identifying possible typhoid fever cases, starting typhoid vaccination campaigns in the most affected districts, and spreading educational messages about proper handwashing and safe food and water practices.
In the United States, public health officials have increased efforts to quickly interview and test samples from patients with suspected typhoid fever.
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Because of the ongoing risk that additional Typhoid infected travelers will return to the United States, the CDC will hold a COCA Call tomorrow geared for clinicians. I'll return with a brief postscript after the break:
Extensively Drug-resistant Salmonella Typhi Infections Emerge Among Travelers to or from Pakistan—United States, 2016–2018= Free Continuing Education
Date: Tuesday, March 19, 2019
Time: 2:00pm-3:00pm (Eastern Time)
A few minutes before the webinar begins on Tuesday, March 19, 2019, please click the link below to join the webinar:
https://zoom.us/j/901838238External
Or iPhone one-tap :
US: +16468769923,,901838238# or +16699006833,,901838238#
Or Telephone:
Dial(for higher quality, dial a number based on your current location):
US: +1 646 876 9923 or +1 669 900 6833
Webinar ID: 901 838 238
International numbers available: https://zoom.us/u/acJ1rDOiGuExternal
Please join the COCA Call webinar with digital audio, video and presentation formats from a PC, Mac, iPad, iPhone or Android device.
Overview
Typhoid fever is caused by Salmonella enterica serotype Typhi (Typhi). Typhi is an important public health problem in developing countries. The estimated global burden of Typhi is 12 to 27 million cases annually. During 2016–2018, an extensively drug-resistant (XDR) Salmonella Typhi strain—only susceptible to azithromycin and carbapenems—emerged in Pakistan. More than 5,300 cases have been reported in the ongoing outbreak. During 2016–2018, typhoid fever was diagnosed in 29 patients in the United States with recent Pakistan travel; 5 had XDR Typhi.
The Centers for Disease Control and Prevention (CDC) recommends pre-travel vaccination and adherence to safe food and water practices to prevent typhoid fever. Empiric azithromycin should be used to treat patients with suspected, uncomplicated typhoid fever who have traveled to or from Pakistan. Carbapenems should be used for patients with suspected severe or complicated typhoid fever who have traveled to or from Pakistan. During this COCA Call, clinicians will learn about CDC recommendations for diagnosing, managing, and preventing XDR typhoid.
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Last month the CDC issued a CDC Traveler's Advisory: Drug-Resistant Pseudomonas aeruginosa Infections In Mexico, after a number of U.S. residents acquired the infection following elective invasive procedures at a healthcare facility in Tijuana.
This month the CDC reports the 590th Candida auris infection since the first U.S. case was Identified in the summer of 2016. This fungal infection was first isolated in Japan in 2009. It was initially found in the discharge from a patient's external ear (hence the name `auris').
All reminders that due to our increasingly mobile society, even rare infectious diseases can spread quickly from anywhere in the world. The reality in this 21st century is: an outbreak anywhere - whether it be bacterial, viral, or fungal - is a potential threat everywhere.
