#14,455
Eighteen months 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.
Since then we've revisited this story several times, including a CDC COCA call held last March (see Extensively Drug-resistant Salmonella Typhi Infections Emerge Among Travelers to or from Pakistan), where the CDC described the nearly three-year old outbreak as:
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.Just two weeks ago Taiwan's CDC announced their first positive XDR-Typhoid case detected in a traveler who recently visited Morocco, India, Pakistan and Indonesia (see Taiwan CDC Reports 1st (imported) Case Of XDR-Typhoid).
Today the ECDC reports an increase in imported XDR-Typhoid cases from that region in the following news release:
Increase of XDR Typhoid fever in travellers returning from Pakistan
News story
9 Oct 2019
The Health Protection Surveillance Centre in Ireland reported an increase in typhoid fever notifications in travellers returning from Pakistan. Australia, Canada, Denmark, Taiwan, the United Kingdom and the United States are some of the countries which have also detected XDR typhoid fever cases among travellers returning from Pakistan.
The Health Protection Surveillance Centre in Ireland reported an increase in typhoid fever notifications in travellers returning from Pakistan. According to the Irish authorities and as of week 38, 23 cases of Salmonella enterica serovar Typhi (S. Typhi) cases have been notified in 2019, out of which 12 had a recent travel history to Pakistan and seven were below 15-years of age. Three of the 12 cases of typhoid fever with travel history in Pakistan were infected with extensively drug-resistant (XDR) strains. This is the first time that cases of XDR typhoid fever have been identified by the national reference laboratory in Ireland.
According to the WHO/EMRO bulletin published in August, Pakistan is experiencing a continuous surge of XDR S. Typhi since 2016. As of August 2019, 10 365 cases of XDR typhoid fever were reported from 23 districts in Sindh province, with the Karachi district being the most affected (67% of the cases).
The XDR S. Typhi strain acquired a plasmid which confers resistance to multiple antibiotics including first-line antibiotics (i.e. chloramphenicol, ampicillin, and trimethoprim-sulfamethoxazole), fluoroquinolones and third-generation cephalosporins. The strain remained susceptible to azithromycin and carbapenems. The increased resistance in typhoid fever limits treatment options and poses a threat for international spread.
Australia, Canada, Denmark, Taiwan, the United Kingdom and the United States are some of the countries which have also detected XDR typhoid fever cases among travellers returning from Pakistan.
Travellers to Pakistan should be reminded of the need for vaccination against typhoid fever before travelling, as well as proper food hygiene and hand washing practices during the travel. Healthcare providers should be made aware of the possibility of XDR S. Typhi infection in patients returning from Pakistan.
Another reminder - as if we needed one - that in 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.
