Drug-resistant typhoid infections are emerging as a major public health and economic crisis in India, disproportionately affecting children and placing an overwhelming financial burden on households. At a time when antimicrobial resistance (AMR) is becoming a global concern, India’s struggle with typhoid highlights how rising drug resistance is not just a clinical challenge but a deeply socio-economic one.
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A new study published in the journal The Lancet estimates that antibiotic-resistant typhoid accounted for at least 87% of India’s total economic burden from the disease in 2023. Conducted by researchers from institutions including the London School of Hygiene and Tropical Medicine and Christian Medical College Vellore, the study puts the overall economic cost of typhoid at a staggering Rs 12,300 crore.
Typhoid fever, caused by the bacterium Salmonella Typhi, spreads through contaminated food and water and continues to remain a persistent public health challenge in India. Patients typically present with prolonged fever, fatigue, headache, and abdominal pain, and in severe cases require hospitalisation. Complications can be life-threatening, including sepsis, intestinal perforation, internal bleeding, altered mental status, and infected arterial aneurysms—conditions that demand urgent medical intervention and contribute significantly to mortality.
Who bears the biggest burden?
The study highlights that the economic burden of typhoid fever in India is not evenly distributed, with children and households bearing the highest costs. According to the analysis, children under the age of 10 accounted for more than half of the total economic burden. Higher infection rates in younger populations, combined with the need for prolonged care and monitoring, significantly increased healthcare costs in this group.
The financial impact is also heavily skewed towards families. Households bore approximately 91% of the total expenses related to typhoid treatment, covering not just hospital bills but also transportation, medicines, and income loss due to illness. The study estimates that around 70,000 families experienced catastrophic health expenditure - defined as healthcare costs consuming a substantial portion of household income.
The burden extends beyond direct medical costs. Productivity losses were also substantial, with researchers estimating losses of Rs 4260 crore using the human capital approach. However, this estimate dropped sharply under the friction-cost approach, highlighting uncertainties in measuring indirect economic impacts.
The study further notes that the economic burden is geographically concentrated. “Maharashtra, Uttar Pradesh, Andhra Pradesh (including Telangana), Tamil Nadu, and West Bengal together accounted for 51% of the national costs.” This suggests that targeted, state-level interventions could play a critical role in reducing the overall burden.
What is driving the cost?
A key driver behind the high economic burden is the rise of fluoroquinolone-resistant (FQR) infections. Fluoroquinolones are commonly used antibiotics that typically help reduce fever within a few days. However, growing resistance has made treatment longer, more complicated, and significantly more expensive.
The study states, “We developed a decision-tree model using Indian empirical data on typhoid epidemiology, care-seeking, clinical outcomes, and estimated direct and indirect costs for hospitalised and non-hospitalised typhoid fever patients.” Using this model, researchers estimated the total economic burden at Rs 12,300 crore, with fluoroquinolone-resistant infections accounting for 87% of the total costs.
Importantly, the study points out that “most economic costs in FQR typhoid fever stem from their high prevalence; only a smaller share of this burden is directly attributable to resistance itself.” This means that while resistance increases costs, the widespread occurrence of resistant infections amplifies the overall financial burden.
The cost-of-illness associated with resistant infections was significantly higher in both hospitalised and non-hospitalised patients. “The high financial burden and catastrophic expenditure among hospitalised typhoid fever patients show the need for better financial risk protection,” the study notes. Previous research has also shown that 18–27% of families resort to distress financing, including borrowing money or selling assets, to cope with treatment costs.
Understanding the study’s key contributions
The study makes several important contributions to understanding typhoid’s economic burden in India. As the authors explain, “Our study made three main contributions. First, the study presented national estimates of the economic burden of typhoid fever in India by integrating disease burden, AMR, and costs in a single framework.”
Second, it quantified the impact of antimicrobial resistance on costs at a national scale. “We quantified the economic consequences of FQR and showed that resistant infections accounted for the majority of national costs, a finding not previously demonstrated at scale.”
Third, the study identified where and among whom the burden is most concentrated. It found that children under 10 years, particularly those aged 5–9, bear the highest burden. Together with children aged six months to four years, these groups account for more than half of the total economic impact.
The findings also have policy implications. The study highlights the potential benefits of introducing typhoid conjugate vaccines (TCVs), noting that “from a societal perspective, TCV can significantly reduce household OOPE, catastrophic expenditures, and productivity losses due to premature mortality.” While government savings may be modest, the reduction in out-of-pocket expenditure could be substantial.
Interestingly, when compared to other infectious diseases in India, the economic burden of typhoid is lower than that of dengue and malaria. However, unlike these diseases, typhoid already has multiple licensed vaccines available in India and is recommended by national immunisation bodies, making prevention strategies more immediately actionable.
Limitations of the study
Despite its comprehensive approach, the study acknowledges several limitations that may affect the interpretation of its findings. One key limitation is that the 2023 estimates were based on epidemiological data from 2017 to 2020. This assumes that there have been no major changes in disease transmission or healthcare-seeking behaviour since then.
The authors note, “Some inputs were drawn from studies conducted at different times and in different settings, and the corresponding uncertainty intervals may not fully reflect structural or contextual variation at the national level.” This introduces a degree of uncertainty in the estimates.
From a costing perspective, the study may underestimate government expenditure. The cost data used predates the expansion of Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana, which has the potential to shift private hospitalisation costs to public insurance and reduce out-of-pocket expenditure.
Another limitation is related to data sources. The cost-of-illness data for non-hospitalised patients were collected in an urban setting (Navi Mumbai), which may not accurately reflect national averages. Additionally, large hospitals are often overrepresented in such studies, potentially leading to higher cost estimates.
The study also used the same unit cost inputs across all age groups, even though treatment costs may vary depending on disease severity, hospital stay duration, and level of care required. As a result, age-specific economic estimates may not fully capture these differences.
There is also significant uncertainty in estimating productivity losses. “There is substantial uncertainty in the productivity loss due to premature mortality,” the study notes, pointing to a 99.8% reduction in estimates when using the friction-cost approach instead of the human capital approach.
Importantly, the analysis did not include patients who did not seek formal healthcare, which may result in conservative estimates of the overall burden. It also excluded broader costs such as surveillance, vaccination programmes, and macroeconomic impacts like tourism losses, suggesting that the true societal burden of typhoid may be even higher.
Experts highlight gaps
Explaining the growing crisis, Prof. Dr Sanjeev Bagai, Padma Shri awardee and Senior Consultant Paediatrician & Nephrologist, said typhoid continues to be one of the most common food-, water-, and hygiene-related infections among children in India. He noted that poor sanitation and unsafe practices make young children, especially those under five, particularly vulnerable.
“Typhoid is among the commonest food- and water-borne diseases in paediatric age groups, largely driven by unhygienic conditions and poor sanitation,” he said.
Dr Bagai pointed out that a major contributor to drug resistance is the irrational use of antibiotics. In many cases, treatment is started without proper diagnosis, and antibiotics are misused or stopped midway.
“The approach is often incorrect. Treatment is started empirically without confirming typhoid, and antibiotics like ciprofloxacin and ofloxacin are used rampantly and misused,” he explained. “As soon as the fever subsides, the antibiotic is discontinued, which promotes resistance.”
He added that improper combinations and overuse of antibiotics allow the bacteria to adapt. “Whenever antibiotics are used irrationally, either in wrong combinations or stopped abruptly, the organism genetically acquires resistance.”
Highlighting the scale of the problem, Dr Bagai said the actual burden of typhoid may be far higher than reported. While around 5 million cases are estimated, he believes the real number could be significantly undercounted.
On diagnosis, he stressed that testing is often misinterpreted or poorly timed.
“The Widal test should be done after five to seven days of fever and repeated to show a rising titre. Early testing leads to misleading results,” he said. He cautions against the widespread use of less reliable tests like Typhidot.
Importantly, he underlined that blood culture remains the gold standard for diagnosis and should be done before starting antibiotics. “Once even a single dose of antibiotic is given, it can affect the culture sensitivity. Blood culture should always be sent before treatment begins,” he advised.
Dr Bagai warned that rising resistance, including to quinolones, cephalosporins, and even azithromycin, is making typhoid harder to treat and increasing the risk of complications and deaths. He called for stricter monitoring of antibiotic use and greater awareness among both doctors and patients.
“The need of the hour is better surveillance of antibiotic misuse and a more rational approach to treating common fevers like typhoid,” he said.
He also flagged the role of unqualified practitioners in worsening the crisis, noting that misuse of medicines without proper prescriptions continues to fuel resistance in the community.
Adding to this, Dr Harish Chafle, Senior Consultant Chest Physician and Sleep Disorders Specialist at Gleneagles Hospitals, Mumbai, highlighted that children remain the most vulnerable due to both biological and environmental factors.
He explained that children under 10 have developing immunity and are more exposed to unsafe food, water, and hygiene conditions, which increases their risk of infection. This not only impacts their health but also leads to missed school days and added financial strain on families due to treatment and caregiving needs.
“Children are more exposed to unhygienic conditions and have lower immunity, which increases their risk of typhoid and adds to the overall healthcare burden,” he said.
On prevention, Dr Chafle underscored the importance of vaccination. “Typhoid conjugate vaccines are effective and serve as a strong preventive tool for the Indian population,” he noted, adding that awareness and timely consultation are key.
“People should consult their doctors about typhoid vaccination as a preventive step,” he advised.
This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS
