Extensively drug-resistant typhoid in Pakistan

Original publication date: January 30, 2019

Updated: August 31, 2023

Current situation

There is an ongoing outbreak of extensively Extensively drug-resistant (XDR) typhoid fever cases have been reported in Pakistan since 2016. Treatment options may be limited as the bacterium that causes XDR typhoid does not respond to most antibiotics. Cases have been reported in travellers returning to Canada from Pakistan.

The risk of being exposed to XDR typhoid may increase in Pakistan during the monsoon season, from June to September. Flooding can increase the risk of getting typhoid as it can decrease access to clean drinking water and proper sanitation.  

About typhoid

Typhoid fever is an illness that is caused by a type of Salmonella bacteria called Salmonella typhi. Extensively drug-resistant typhoid is resistant to at least five different antibiotic classes.

Typhoid fever can be spread to humans through:

• eating food or drinking beverages that have been handled by a person who is infected with typhoid fever
• drinking water that has been contaminated with sewage
• eating shellfish taken from sewage-polluted areas, or eating raw fruits and vegetables which may have been fertilized with human waste
• eating contaminated milk and milk products

All travellers to Pakistan are at risk of getting extensively drug-resistant typhoid fever. 

If you are travelling to visit friends and relatives, you are at higher risk of getting typhoid fever than tourists and business travellers. Travellers visiting family and friends are more likely to eat local food and be exposed to untreated water, which puts them at a greater risk for food and water-borne diseases.

Symptoms of typhoid fever include:

• fever
• cough
• diarrhea
• tiredness
• headache
• loss of appetite
• constipation (difficulty passing feces)
• rash of flat, rose-coloured spots on the abdomen or chest

It usually takes 8 to 14 days before symptoms appear. However, some people may get sick in as little as 3 days. Others may take more than 60 days to become ill. Some people develop no symptoms at all.

In severe cases, the symptoms may worsen and lead to death. These symptoms can include:

• an enlarged liver
• an enlarged spleen
• bleeding in the intestines

Recommendations

Consult a health care professional or visit a travel health clinic at least 6 weeks before you travel.

Before your trip

• Get vaccinated
  • There is a vaccine that protects against typhoid fever.
  • Discuss the benefits of getting vaccinated with a health care professional before travelling.

During your trip

• Eat and drink safely
  • Drink water only if it has been boiled or disinfected or if it is in a commercially sealed bottle.
  • Only eat foods that are well cooked and served hot. Avoid food served at room temperature.
  • Only eat fruits and vegetables if you have washed them in safe water or peeled them yourself.
• Wash your hands as often as possible
  • Wash your hands with soap and water for at least 20 seconds.
  • Use alcohol-based hand sanitizer (containing at least 60% alcohol) if soap and water are not available. It's a good idea to always keep some with you when you travel.

After your trip

• Monitor your symptoms
  • If you develop symptoms similar to typhoid fever during your trip or after your return, see a health care professional and tell them where you have been travelling or living.

Information for Health Care Professionals

The Committee to Advise on Tropical Medicine and Travel (CATMAT) has developed a statement on International Travellers and Typhoid to provide guidance for health care professionals who are preparing travellers to visit areas with a risk of typhoid. 

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