‘Drug-resistant typhus is the last warning signal’: Disease spreads in Pakistan as antibiotics fail | Global Development

FFrom his sickbed, eight-year-old Ukasha could see his siblings playing with a ball in the yard. His head ached and his body felt too heavy to move. Ukasha had typhus – an illness from which he should have recovered in a matter of days. A month had passed.

In the worst cases, typhoid can be fatal. Ukasha's family was concerned and even moved his bed outside to give him fresh air and sunlight. Now he could sit up straight, smile at the view in front of him and finally even eat his favorite food: eggs.

His classmate, 12-year-old AbuZar, also spent months in bed with typhus. At the height of the infection, he would wake up in the middle of the night, burning hot and drenched in sweat.

Children throughout the village on the outskirts of Peshawar in northern Pakistan were sick.

Typhoid fever, also known as typhus, is an infection caused by contaminated food or water. If left untreated, one in five people die from it. However, it is cured with a simple course of antibiotics. If the medication is taken in a timely manner, most people should be well again within a few days.

But the antibiotics used to treat typhus are now failing. The bacteria, Salmonella typhihave developed resistance to the antibiotics that were supposed to kill them. This pattern is repeated all over the world; the problem of resistant infections is global and knows no borders.

When he fell ill, Ukasha's father took him to the Hayatabad Medical Complex, a hospital in Peshawar. He was soon diagnosed with the contagious disease typhoid.

The hospital was overcrowded, with four to five patients per bed in the children's ward, so Ukasha's father took him home for the remainder of his treatment.

“Typhoid used to be treatable with a series of tablets, but now patients end up in hospital,” says Jehan Zeb Khan, the hospital’s clinical pharmacist.

Ukasha was caused by extremely drug-resistant typhus (XDR) – a strain of the “superbug” that emerged in Pakistan in 2016. XDR typhus is resistant to almost all antibiotics used to treat the disease, so treatment options are limited and the mortality rate is higher.

Of the approximately 9 million people worldwide who contract typhus each year, the vast majority are infected with a drug-resistant strain. Pakistan has the highest rate in South Asia: more than 15,000 cases of XDR typhus have been officially reported in the country – and some outbreaks, like the one in Ukasha's village, go unrecorded.

The risk of contracting typhoid fever is higher when a community lacks clean water and sanitation. A neglected sewage system, for example, can contaminate the water and worsen the problem.

Pakistan has one of the lowest rates in the world when it comes to access to clean water close to home, and it is estimated that contaminated water is responsible for around 80 percent of all illnesses in the country.

“There is no reason why we should have typhoid today when we have adequate access to clean water and sanitation,” says Dr. Maria Neira, World Health Organization health director.

Ukasha's father was convinced that a contaminated water tank at the boys' school had led to the outbreak in their village. When the Bureau of Investigative Journalism contacted the school, it said nothing had been reported.

“Access to clean water is one of the foundations of public health that should not be denied to anyone,” says Neira. “Wherever there is a lack of hand hygiene and the [lack of] When hand-washing facilities are available in health facilities, there is an overlap with cases of drug-resistant typhus.

“Drug-resistant typhus presents a unique challenge,” she adds. “It is preventable and is closely linked to poverty – people's vulnerability and lack of access to water and sanitation.”

Pakistan has vaccinated more than 30 million children against typhoid since 2019, but these efforts have focused mainly on the south of the country, where XDR typhoid first emerged. Pakistan is home to more than 100 million children, and the infection has spread north.

Laboratory tests were crucial to Ukasha's recovery. Doctors were able to identify the strain that caused the infection, which can be treated with just three antibiotics. The variant was resistant to all other antibiotics normally recommended for typhoid.

Ukasha needed meropenem – a “last resort” drug used only for the most serious illnesses. He received 22 injections, two a day. Each injection was a significant financial burden for the family.

HHow could such a drug-resistant strain of typhoid develop? Over time, bacteria develop the ability to defend themselves against antibiotics that are designed to kill them. The more frequently bacteria are exposed to antibiotics, the more this ability can spread.

Overuse of antibiotics is one of the main reasons for the emergence of drug-resistant bacteria. Global antibiotic consumption increased by almost half between 2000 and 2018, with the largest increases in South Asian countries such as Pakistan.

This overuse is partly because typhoid has similar symptoms to malaria, dengue fever and Covid-19, all of which are caused by viruses and microbes that cannot be controlled with antibiotics. However, when appropriate testing is not available, doctors may prescribe antibiotics “just in case,” especially in places where access to health care is limited.

Rapid tests for typhoid can also produce false positive results. Without follow-up laboratory testing, rapid tests can lead to overdiagnosis and more patients receiving unnecessary antibiotics.

Experts in Pakistan have gone so far as to blame these tests for the rise in drug-resistant typhus. Although health authorities have banned the rapid tests Typhidot and Widal, they remain widely available.

When AbuZar was admitted to the hospital, he was treated with azithromycin, one of the few antibiotics still effective against XDR typhus. However, doctors have since observed strains of typhus that no longer respond to it.

Superbugs are not bound by national borders. Cases have been identified in 16 other countries, including India, China, Qatar, the UK and the USA. The US health authority CDC has warned all travelers to Pakistan to take precautions against the superbug.

This week, world leaders are meeting at the United Nations in New York to address drug-resistant infections and negotiate a political declaration for member states.

“XDR typhus is the last warning signal. After that, we reach a stage where the superbug no longer responds to any drugs. That means we will go back to the time when typhus was an even more deadly disease. And that is what really worries us,” says Khan.

In Pakistan, Ukasha and AbuZar felt well enough after their treatment to return to school. However, within a few days, both developed fevers again.

This article was created in collaboration withand with reports from, the office for investigative journalism

The Bill Gates Foundation, which funds independent journalism on the global development side, is also one of the funders of the typhoid vaccination program mentioned in this article.