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Extensively Drug-Resistant Typhoid Fever in Pakistan

Warning - Level 3, Avoid Nonessential Travel
Alert - Level 2, Practice Enhanced Precautions
Watch - Level 1, Practice Usual Precautions

What is typhoid fever?

Typhoid fever is a serious disease caused by the bacterium Salmonella Typhi that is spread by contaminated food and water. Symptoms of typhoid fever often include high fever, weakness, stomach pain, headache, cough, and loss of appetite. Some people have diarrhea or constipation. In rare cases, typhoid fever can be fatal. Treatment with antibiotics is essential. Vaccination helps to protect people from getting typhoid fever.

Key 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.

What can travelers do to prevent typhoid fever?

Get the typhoid vaccine

All travelers (even short-term travelers) to South Asia, including Pakistan, should get vaccinated against typhoid fever. Two typhoid fever vaccines are available in the United States — an oral vaccine and an injectable vaccine. The oral vaccine can be given to people at least 6 years old and should be given at least one week before travel. The injectable vaccine can be given to people at least 2 years old and should be given at least two weeks before travel.  

Practice safe eating and drinking habits

Because the bacteria that cause typhoid fever are spread through contaminated food and water, you can reduce your risk of infection in several ways:

  • Follow safe food and water guidelines.
  • Wash your hands often, especially before eating.
  • Avoid eating food prepared by anyone who is sick or has recently been sick.

If you get sick during or after travel

If you travel abroad and get sick while traveling, seek medical care. If you get sick after returning to the United States, seek medical care and tell your health care provider where and when you traveled. Learn more about typhoid fever, how to prevent it, and what to do if you think you have it at CDC’s typhoid fever page for travelers.

Information for Health Care Professionals

The XDR strain of Salmonella Typhi is resistant to most antibiotics (ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, ciprofloxacin, and ceftriaxone) used to treat typhoid fever. Health care providers should:

  • Obtain a complete travel history (asking about travel to South Asia, including Pakistan) from patients with suspected typhoid fever.
  • Collect stool and blood cultures from patients with suspected typhoid fever and request antimicrobial susceptibility testing on isolates.
  • Be aware that the Pakistan outbreak strain remains susceptible to azithromycin and carbapenems:
    • Azithromycin is effective for uncomplicated (diarrhea or bacteremia without secondary complications) typhoid fever and should be used to treat patients with suspected uncomplicated typhoid fever who have traveled to Pakistan. When culture and sensitivity results are available, adjust treatment accordingly. Adult azithromycin dosage is usually 1,000 mg orally once then 500 mg orally daily OR 1,000 mg orally once daily for at least 5–7 days. Pediatric azithromycin dose is 20 mg/kg orally once then 10–20 mg/kg orally once per day (maximum 1,000 mg per day) for at least 5–7 days.
  • Carbapenems should be used for patients with suspected severe or complicated typhoid fever who have traveled to Pakistan. Severe or complicated typhoid fever would include, but not be limited to, patients with gastrointestinal complications  (such as typhoid-related intestinal perforation, peritonitis, intestinal hemorrhage, hepatitis), neurologic complications (such as typhoid encephalopathy, including altered consciousness, delirium, confusion), or bacteremia with sepsis or shock. When culture and sensitivity results are available, adjust treatment accordingly. Consider getting an infectious diseases consultation for these patients.
  • Be aware that relapses can occur, often 1–3 weeks after clinical improvement.
  • Be aware that most (90%) Salmonella Typhi isolates from patients coming from South Asia have decreased susceptibility or resistance to fluoroquinolones, including ciprofloxacin; therefore, fluoroquinolones should not be used as empiric treatment for suspected typhoid fever in patients who have traveled to this area.
  • Report all cases of confirmed typhoid fever to the appropriate local or state health departments.

Traveler Information

Clinician Information