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Published Date: 2019-10-15 10:06:50
Subject: PRO/EDR> Typhoid fever - Europe: Ireland, XDR ex Pakistan, ECDC, alert
Archive Number: 20191015.6727235
TYPHOID FEVER - EUROPE: IRELAND XDR ex PAKISTAN, ECDC, ALERT
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[1]
Date: Thu 10 Oct 2019
Source: Vax-Before-Travel [edited]
https://www.vaxbeforetravel.com/xdr-typhoid-fever-has-been-identified-ireland-first-time


The Health Protection Surveillance Centre in Ireland reported an increase in typhoid fever notifications in travelers returning from Pakistan [http://ndsc.newsweaver.ie/epiinsight/1npbbpsg5wm]. According to the Irish authorities on [9 Oct 2019], there have been 23 cases of _Salmonella enterica_ serovar Typhi (_S._ Typhi) in 2019. This is the 1st time that cases of XDR typhoid fever have been identified by the national reference laboratory in Ireland.

The European Centre for Disease Prevention and Control (ECDC) reported 12 of these cases had a recent travel history to Pakistan [see item [2] below]. Unfortunately, 3 of these 12 cases of typhoid fever with travel history in Pakistan were infected with extensively drug-resistant (XDR) strains.

According to the WHO/EMRO bulletin, 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, having 67 percent of the cases. Pakistan is the world's 6th-most populous country with a population exceeding 210 million people, located in South Asia.

The XDR _S._ Typhi strain acquired a plasmid that confers resistance to multiple antibiotics, including the 1st-line antibiotics chloramphenicol, ampicillin, and trimethoprim-sulfamethoxazole, as well as fluoroquinolones and 3rd-generation cephalosporins, says the ECDC. The strain remained susceptible to azithromycin and carbapenems. The increased resistance in typhoid fever limits treatment options and poses a threat to international spread.

In response, the US Centers for Disease Control and Prevention (CDC) issued a Level 1 Travel Alert regarding traveling to Pakistan in 2019 [https://wwwnc.cdc.gov/travel/notices/watch/xdr-typhoid-fever-pakistan]. This 'Practice Usual Precautions' Travel Alert published on [30 Sep 2019], is very important since, in rare cases, typhoid fever can be fatal.

According to the Pakistan Tourism Development Corporation, about 1.75 million tourists visited Pakistan in 2017 alone.

The CDC says 'if you are going to South Asia, including Pakistan, protect yourself against typhoid infection by getting a typhoid fever vaccination.' The CDC's Advisory Committee on Immunization Practices (ACIP) recommends 2 typhoid fever vaccines, an oral vaccine, Vivotif, and an injectable vaccine, Typhim VI. The oral vaccine Vivotif is approved for people 6 years of age or older and should be taken as directed, at least one week before departure. The injectable vaccine is approved for people 2 years of age or older. Travelers should receive the injectable vaccine Typhim VI at least 2 weeks before departure. Neither vaccine is 100 percent effective, so travelers should also practice safe eating and drinking while traveling abroad, says the ACIP.

Typhoid fever is a serious disease caused by the bacterium _Salmonella_ Typhi, spread by contaminated food and water. Humans are the only source of these bacteria. The incubation period of typhoid and paratyphoid infections is 6-30 days, says the CDC. Symptoms of typhoid fever often include high fever, weakness, stomach pain, headache, cough, and loss of appetite. People may have diarrhea or constipation.

If you travel abroad and get sick while traveling, seek medical care ASAP. If you get sick after returning to the United States, seek medical care and tell your health care provider where and when you traveled. Do not prepare food for other people, says the CDC.

An estimated 26 million cases of typhoid fever and 5 million cases of paratyphoid fever occur worldwide each year, causing 215 000 deaths.

Also, the CDC says to ensure you are up-to-date on several vaccinations before visiting Pakistan. These vaccines and related medications can be found at most travel pharmacies in the USA.

Travel Alert news is published by Vax-Before-Travel [https://www.vaxbeforetravel.com/pakistan-travel-alert-regarding-extensively-drug-resistant-xdr-typhoid-fever-issued-cdc].

[Byline: Dani Reiter]

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

******
[2]
Date: Wed 9 Oct 2019
Source: European Centre for Disease Prevention and Control (ECDC) [edited]
https://www.ecdc.europa.eu/en/news-events/increase-xdr-typhoid-fever-travellers-returning-pakistan


Increase of XDR typhoid fever in travellers returning from Pakistan
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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 [2019], Pakistan is experiencing a continuous surge of XDR _S._ Typhi since 2016 [https://reliefweb.int/sites/reliefweb.int/files/resources/Epi_Monitor_2019_12_34.pdf ]. 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 [https://www.mja.com.au/journal/2019/first-case-extensively-drug-resistant-typhoid-reported-australia#panel-article], Canada [https://www.sciencedirect.com/science/article/pii/S2214250918302282#!], Denmark [https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2019.24.21.1900289], Taiwan, the United Kingdom and the United States [https://wwwnc.cdc.gov/travel/notices/watch/xdr-typhoid-fever-pakistan] 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.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[It is anticipated that more travelers will be seen with extensively drug resistant (XDR) typhoid fever after returning from Pakistan. The XDR strain of _Salmonella_ Typhi is resistant to most antibiotics (ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, ciprofloxacin, and ceftriaxone) used to treat typhoid fever, but remains susceptible to azithromycin and carbapenems.

Azithromycin is has been shown to be effective for uncomplicated typhoid fever (https://academic.oup.com/jac/article/44/2/243/861087, http://www.atmph.org/article.asp?issn=1755-6783;year=2017;volume=10;issue=1;spage=205;epage=210;aulast=Nair) and is recommended to treat patients with suspected uncomplicated typhoid fever who have traveled to Pakistan. Carbapenems (e.g., imipenem) can be used for patients with suspected severe or complicated typhoid fever who have traveled to Pakistan. Treatment regimens can be adjusted when culture and sensitivity results become available.

The majority of cases of typhoid fever in North America are associated with travel, particularly travel to South Asia (Canada Communicable Disease Report . 5/7/2015, Vol. 41 Issue 5, p89-99) and travelers to Pakistan are at risk of getting XDR typhoid fever. Those visiting friends or relatives are at a greater risk of travel-associated typhoid fever than tourists or business travelers (https://academic.oup.com/cid/article/43/9/1185/425822). Studies have found travelers visiting friends and relatives account for 66% of cases in the United States (https://jamanetwork.com/journals/jama/fullarticle/184464) and 94% of cases in Quebec (https://academic.oup.com/jtm/article/18/6/373/1806353).

Travelers to places where typhoid fever is endemic, such as South Asia, especially India and Pakistan, should protect themselves against typhoid fever by getting a typhoid fever vaccination, and taking extra care to follow safe food and water guidelines, even when visiting friends and family. - Mod.ML

HealthMap/ProMED-mail maps:
Ireland: http://healthmap.org/promed/p/39
Pakistan: http://healthmap.org/promed/p/140
]

See Also

Typhoid fever - USA (05): (TX) imported XDR case, possible secondary case 20190922.6688120
Typhoid fever - Australia: ex Pakistan, multidrug resistance 20190918.6679904
Typhoid fever - USA (04): (UT) detained migrant child 20190627.6541406
Typhoid fever - Pakistan (03): (SD) multidrug resistance 20190626.6539573
Typhoid fever - USA (03): (CA) police officer 20190613.6517254
Typhoid fever - Denmark: ex Pakistan, multidrug resistance 20190524.6483641
Typhoid fever - USA (02): (MA) food worker, imported 20190522.6480973
Typhoid fever - El Salvador 20190403.6402082
Typhoid fever - Pakistan (02): (SD) multidrug resistance 20190220.6326968
Typhoid fever - Pakistan: multidrug resistance 20190212.6313110
Typhoid fever - Zimbabwe: (HA) 2017-2018 20190118.6265333
Typhoid fever - USA: ex Pakistan, multidrug resistance, CDC 2018 20190110.6252390
2018
----
Typhoid fever - Pakistan (07): multidrug resistance, WHO 20181228.6226573
Typhoid fever - Fiji: (NT) 20181207.6191941
Typhoid fever - India: (TN) 20181008.6077839
Typhoid fever - Zimbabwe (02): (MI) waterborne 20180814.5964791
Typhoid fever - Pakistan (06): multidrug resistance, spread, travel alert 20180813.5962991
Typhoid fever - El Salvador (02) 20180729.5935152
Typhoid fever - Pakistan (05): multidrug resistance, spread 20180720.5916006
Typhoid fever - El Salvador 20180618.5860604
Typhoid fever - Pakistan (04): multidrug resistance 20180415.5747027
Typhoid fever - Syria: (HA) refugee & IDP camp 20180323.5706324
Typhoid fever - Pakistan (03): multidrug resistance, fatal 20180223.5646599
Typhoid fever - Pakistan (02): (SD) multidrug resistance, fatal 20180127.5586255
Typhoid fever - Pakistan: (SD) multidrug resistance, fatal, RFI 20180124.5582615
.................................................sb/ml/mj/mpp

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