The first “extensively drug-resistant” strain of typhoid is spreading through Pakistan, leaving scientists concerned about a deadly outbreak and the rise of other drug-resistant diseases.

Five different types of antibiotics have proven ineffective against the new strain, which has infected 850 people across Pakistan, according to the New York Times. Only one known antibiotic remains effective against it, according to the Independent. But one more mutation, and the disease could become altogether untreatable.

Typhoid is spread through food or water contaminated with the feces of a typhoid-infected person. Case mapping shows that the outbreak of the new strain originated in Hyderabad, Pakistan, along the city’s sewage lines, which may have leaked into water sources, the Times reports.

Typhoid causes high prolonged fever, headache, and vomiting, among other symptoms, and can be fatal if left untreated. Approximately 21 million cases and 222,000 typhoid-related deaths occur worldwide every year, according to the World Health Organization (WHO). Four deaths in Pakistan from this particular strain have been confirmed so far and one travel-related case in the United Kingdom, the New York Times reports.

Experts expect the drug-resistant strain to eventually spread worldwide.

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