yphoid fever is endemic in Pakistan, with yearly outbreaks in summertime and peak monsoon seasons. In 2016, the country reported the world’s first case of typhoid fever caused by the highly drug-resistant bacterial strain, Salmonella Typhi (XDR S. Typhi). This novel strain, resistant to most recommended antibiotics for typhoid fever, poses a serious threat to public health. The World Health Organisation documented 5,200 cases of XDR S. Typhi in Pakistan, from 2016 to 2018. In 2019, it recommended the introduction of the typhoid conjugate vaccine, TCV, in the country’s expanded programme for immunisation (EPI). The Global Alliance for Vaccine and Immunisation Organisation disbursed $59.7 million in 2019 to finance a catch-up campaign to control the spread of XDR S. Typhi in Pakistan’s most vulnerable province, Sindh. Following the unprecedented flooding in Pakistan, thousands of flood-induced migrants in Sindh have moved to urban areas and are forced to live in poor environmental conditions, increasing their likelihood of contracting typhoid fever. Policymakers must act strategically to ensure local and international efforts to control cases of XDR S. Typhi are not compromised.

The TCV vaccination campaigns were unfolded in the country in phases beginning in 2019. Sindh was targeted in the first phase as it was the epicentre for XDR S. Typhi cases in Pakistan. In 2021, the campaign’s second phase was launched in the Punjab province. The federal government relished over the smooth roll-out of the vaccination campaigns despite the Covid-19 pandemic, which had shifted the primary focus of all healthcare institutions to the virus-infected patients. After the unprecedented flooding in Sindh, Karachi alone faced a mass migration of over 50,000 flood-affected people. These migrants have settled into slums and lower-income areas, which are prone to the following problems: 1) lack of access to safe drinking water; 2) unclean living conditions; 3) lack of sanitation amenities; and 4) lack of access to proper healthcare facilities. Typhoid fever is caused by Salmonella poisoning. Patients get infected after consuming contaminated food or drink. Migrants in Sindh are unvaccinated against Typhoid fever and are forced to live in conditions which increase the likelihood of contraction of the illness.

Following the unprecedented flooding in Pakistan, thousands of flood-induced migrants in Sindh have moved to urban areas and are forced to live in poor environmental conditions, increasing their likelihood of contracting typhoid fever.

The Global Antibiotic Research and Development Partnership (GARDP), a global initiative for the development of novel drugs for combatting drug-resistant illnesses, has not included XDR S. Typhi in its 2025 agenda. It is evident the international community is unwilling to invest further capital in combatting the spread of a Typhoid fever strain which is mostly prevalent in developing countries like Pakistan. The federal government of Pakistan is focused on the timely roll-out of immunisation catch-up campaigns all over the country. However, the large number of flood-induced migrants living in vulnerable environments in urban areas of Sindh face an urgent and direct threat of typhoid fever contraction. Policymakers must ensure they cater to the change in provincial vulnerabilities before announcing further immunisation campaigns.

Pakistan is one of the few South Asian countries which still faces the risk of the formation of newer drug-resistant strains of typhoid fever. The National Institute of Health, Islamabad, issued an urgent advisory circular in 2018 against the use of ‘Widal’ and ‘Typhidot’ as diagnostic tests for typhoid fever. The tests give false positive results for the illness, and patients are prescribed antibiotics without reason. Despite clear instructions by the NIH, diagnostic laboratories continue to use the tests due to ease of availability. This gross misuse of antibiotics has made Pakistan vulnerable to newer drug-resistant strains of typhoid fever.

The United Nations Population Fund in Pakistan has documented a steady increase in the migrant population in Sindh’s urban areas since the 1970s. These migrants, settling in lower-income environments, are vulnerable to misdiagnosis of typhoid fever due to a shortage of proper healthcare facilities in such areas. With the increasing effects of climate change and rising levels of poverty, the migrant population is expected to rise further in urban areas. The local government allocates sufficient funds to facilitate the establishment of proper diagnostic units in lower-income areas to avoid misdiagnosis of illnesses like typhoid fever, which leads to misuse of antibiotics, leading to drug resistance.

Currently, three drugs remain effective against the XDR S. Typhi strain: 1) Azithromycin (oral), 2) Carbapenems, and 3) Tigecycline (parenteral). Due to ease of intake, oral drugs are preferred by patients, making azithromycin the most prescribed drug for typhoid fever. Pakistan’s policymakers face another crucial dilemma. A private study has documented azithromycin as the most consumed drug for the treatment of Covid-19 patients in Pakistan since the beginning of the pandemic. With the excessive use of this antibiotic, there is an immediate threat of the development of antibiotic resistance. It is pertinent to develop novel antibiotics for XDR S. Typhi before the bacterium becomes resistant to azithromycin, the last orally administered antibiotic which remains effective against the drug-resistant typhoid strain. However, developing countries like Pakistan lack the resources required for drug development, and the international community is limiting financing of research for the drug-resistant typhoid strain. Pakistan’s federal government must ensure Sindh’s provincial government has the resources required to launch a typhoid fever catch-up campaign specifically for the flood-induced migrant population to avoid an outbreak.

The writer is a public policy graduate from the Suleman Dawood School of Business, LUMS. She is currently working in the IT Governance department of a leading bank in Pakistan