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Typhoid Fever and XDR Typhoid

Pakistan is home to a drug-resistant strain (XDR typhoid). Why a blood culture matters, why not to self-medicate, and the vaccine that protects.

Dr. Sana Fatima Updated 8 November 2026 8 min read Draft · awaiting Dr. Sana's medical review

At a glance

  • WHO estimates about 9 million typhoid cases and 110,000 deaths a year worldwide (2019 estimates). 1
  • Children under 5 account for about 40% of enteric fever deaths, and risk peaks at 12–23 months of age (2021 data). 2
  • Pakistan had about 8% of the world's enteric fever cases and 11% of its deaths in 2021. 2
  • XDR typhoid emerged in Hyderabad, Sindh, in November 2016 and resists five groups of antibiotics. 3
  • A single blood culture finds only about 50% of cases, but it is still the best test. 4
  • One dose of typhoid conjugate vaccine (TCV) was 95% effective against culture-confirmed typhoid in Hyderabad children. 5

What it is

Typhoid fever is an infection caused by a germ called Salmonella Typhi, which lives only in people. Children catch it by swallowing food or water contaminated with the stool of someone who carries the germ. The germ spreads into the blood, causing a long, high fever that can affect the whole body. 11Typhoid fact sheet — World Health Organization, 2023. who.int

Symptoms

  • Start: symptoms begin 6–30 days after infection, usually after 8–14 days. 44Typhoid and Paratyphoid Fever, Yellow Book 2026 — US CDC, 2025. cdc.gov66Advisory for Prevention and Treatment of Typhoid Fever — NIH Pakistan, 2018. nih.org.pk
  • Days 1–4: the fever climbs each day, often to 39–40°C, and is highest in the evening. 4
  • First week onwards: tiredness, headache, poor appetite, tummy pain, and constipation or diarrhoea. 177Typhoid fever — NHS, 2025. nhs.uk
  • Preschool children often have milder symptoms, so typhoid can be missed. 6
  • Weeks 2–3: about 10–15% of patients in hospital develop complications. 4

See a doctor urgently if

  • Tummy pain is sudden or getting worse, which can mean the bowel has burst (intestinal perforation). 47
  • There is black or bloody stool, or vomited blood (intestinal bleeding). 47
  • Your child is confused, or very drowsy and hard to wake. 4
  • Fever is still high after 5 days of antibiotics, or comes back. 47

Who is most at risk

  • Young children, especially in their second year of life. 22Piovani D et al. Global burden of enteric fever, 2017–2021 (GBD 2021) — eClinicalMedicine, 2024. pmc.ncbi.nlm.nih.gov
  • Families in South Asia, which had about 62% of the world's cases in 2021. 2
  • Homes without safe water or sanitation. 16
  • Caregivers of a patient, travellers to affected areas, and unvaccinated children. 6

How it is diagnosed

  • Blood culture is the standard test. It grows the germ and shows which antibiotics will work. Take the sample before antibiotics start. A negative result does not fully rule typhoid out. 46
  • Widal test: it cannot tell a current infection from a past infection or a vaccine. 4
  • Typhidot: Pakistan's National Institute of Health (NIH) says Widal and Typhidot have little diagnostic value. 6 A Cochrane review found Typhidot (about 78–84% sensitive, 77–79% specific) too inaccurate to replace culture. 88Wijedoru L et al. Rapid diagnostic tests for enteric fever — Cochrane, 2017. cochrane.org

Treatment

  • The doctor chooses the antibiotic, ideally after a blood culture, and matches it to the sensitivity report. 6
  • XDR means resistance to five drug groups: chloramphenicol, ampicillin, co-trimoxazole, fluoroquinolones (such as ciprofloxacin) and third-generation cephalosporins (such as ceftriaxone and cefixime). 33Klemm EJ et al. Emergence of an XDR Salmonella Typhi clone — mBio, 2018. pmc.ncbi.nlm.nih.gov6
  • What still works for most XDR strains:
  • Azithromycin by mouth for uncomplicated illness. 34 WHO calls it the only reliable, affordable oral option in poorer settings. 99Disease Outbreak News: Typhoid fever, Pakistan — WHO, 2018. who.int
  • A carbapenem such as meropenem, given by drip in hospital, for severe illness. 34
  • Fever often takes 3–5 days to settle. Finish the full course. 47
  • Never give antibiotics yourself. Antibiotics given before a culture can hide the germ, and overuse drives resistance. A few strains now resist azithromycin and carbapenems too. 461010Nizamuddin S et al. Carbapenem-resistant Salmonella Typhi, Pakistan, 2022 — Emerging Infectious Diseases, 2023. pmc.ncbi.nlm.nih.gov

Prevention

  • TCV: Pakistan was the first country to add TCV to routine immunisation, starting in Sindh in November 2019. 1111TCV reaches Punjab province, Pakistan — Gavi, 2021. gavi.org
  • Catch-up campaigns for ages 9 months to 15 years ended in 2022. 1212TCV rolls out to remaining provinces — Coalition Against Typhoid, 2022. coalitionagainsttyphoid.org
  • TCV is now one dose at 9 months, free at government (EPI) vaccination centres. 121313Kraay ANM et al. Impact and predicted benefits of TCV in two Pakistani provinces — Lancet Regional Health Southeast Asia, 2025. doi.org1414Physicians call for vaccination amid rising typhoid cases — Dawn, 2026. dawn.com
  • In a large trial, one dose protected 78% of children over about 4 years. 1515Patel PD et al. TCV efficacy: final 4-year analysis, Malawi — Lancet, 2024. doi.org
  • Safe water: drink boiled or treated water, and only use ice made from safe water. 6
  • Handwashing with soap after the toilet and before cooking or eating. 6
  • Food: eat freshly cooked hot food, wash fruit and vegetables, use boiled or pasteurised milk, and avoid leftovers. 16
  • Cooking: a person with typhoid should not cook for others. 1

The situation now (2025–2026)

  • Worldwide: WHO's fact sheet (dated 30 March 2023) gives about 9 million cases and 110,000 deaths a year, from 2019 estimates. 1 The Global Burden of Disease study (2021 data, published 2024) counted 9.3 million enteric fever cases and 107,500 deaths, down 15% and 19% from 2017. 2
  • XDR in Pakistan:
  • 339 XDR samples were confirmed from November 2016 to September 2017. 3
  • WHO counted 5,274 XDR cases among 8,188 typhoid cases in Sindh by 9 December 2018. 9
  • By 2020, about 70% of typhoid germs sequenced in Pakistan were XDR. 1616Carey ME et al. Global diversity and AMR of typhoid pathogens — eLife, 2023. doi.org
  • New resistance:
  • Carbapenem-resistant strains have been reported from Pakistan (report published December 2025). 1717Simon S et al. Carbapenem-resistant Salmonella Typhi in a traveler from India — Emerging Infectious Diseases, 2025. wwwnc.cdc.gov
  • In Punjab in 2024–25, 2 of 65 XDR samples (3.1%) resisted azithromycin. 1818Khalid H et al. XDR Salmonella Typhi in Pakistani children — Sage Open Pediatrics, 2026. pmc.ncbi.nlm.nih.gov
  • TCV:
  • Gavi reports more than 30 million Pakistani children vaccinated in campaigns, as of 16 December 2025. 1919Reaching 80 million children with typhoid conjugate vaccines — Gavi, 2025. gavi.org
  • TCV cut cases by about 49% in Sindh and 66% in Punjab in its first two years, but protection faded faster in Sindh (published April 2025). 13
  • June 2026: doctors in Khyber Pakhtunkhwa reported a seasonal rise in typhoid, including resistant cases. They gave no figures. 14

What the research says

  • Kraay et al., Lancet Reg Health Southeast Asia 2025surveillance impact analysis with modelling, Sindh and Punjab, 2019–2023
    TCV cut incidence by 48.9% (Sindh) and 66.2% (Punjab) over two years, but the effect shrank yearly; Sindh may need repeat campaigns. doi:10.1016/j.lansea.2025.100581
  • Patel et al., Lancet 2024randomised controlled trial, n = 28,130 children aged 9 months to 12 years, Malawi
    One TCV dose was 78.3% effective over a median of 4.3 years. doi:10.1016/S0140-6736(23)02031-7
  • Yousafzai et al., Lancet Glob Health 2021prospective cohort, n = 23,407 children aged 6 months to 10 years, Hyderabad
    TCV was 95% effective against culture-confirmed typhoid and 97% against XDR typhoid. PMC8315145
  • Nizamuddin et al., Emerg Infect Dis 2023case report, n = 1, Peshawar, 2022
    An unvaccinated 7-year-old relapsed with an XDR strain that had gained carbapenem- and azithromycin-resistance genes. PMC10617351
  • Khalid et al., Sage Open Pediatrics 2026single-centre prospective cohort, n = 65 children with XDR typhoid, Punjab, 2024–25
    96.9% of samples were azithromycin-susceptible and 100% meropenem-susceptible; fever lasted over 3 days in 64.6%. PMC12811554

Questions parents ask

Is typhoid contagious?

Yes, through stool getting into food, water or onto hands, not through the air. Handwashing protects the family. About 1–4% of treated people keep carrying the germ. 14

How long does the fever last on treatment?

Usually 3–5 days. If it has not settled after 5 days, go back to your doctor. 47

What should my child eat?

There is no special typhoid diet. Give plenty of fluids and normal home-cooked food. No food needs to be avoided. 20

Can typhoid come back?

Yes. Up to 10% of patients relapse, usually 1–3 weeks after recovering, and need more antibiotics. 47

Is a positive Widal test enough?

No. Widal can be positive because of a past infection or a vaccine. Ask for a blood culture before antibiotics start. 46

Can a vaccinated child still get typhoid?

Yes, but it is much less likely and usually milder. See a doctor if a fever lasts more than a few days. 615

Myth vs fact

  • MythA positive Widal or Typhidot test confirms typhoid.
    FactThese tests have little diagnostic value. Blood culture is the reliable test. 6
  • MythA child with typhoid needs a strict, light diet.
    FactChildren's doctors advise a normal diet, with no foods avoided. 20
  • MythTaking antibiotics early for any fever prevents typhoid.
    FactUnnecessary antibiotics drive resistance. Doctors should do a blood culture first. 6

Sources

  1. 1.Typhoid fact sheet — World Health Organization, 2023. https://www.who.int/news-room/fact-sheets/detail/typhoid
  2. 2.Piovani D et al. Global burden of enteric fever, 2017–2021 (GBD 2021) — eClinicalMedicine, 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC11513656/
  3. 3.Klemm EJ et al. Emergence of an XDR Salmonella Typhi clone — mBio, 2018. https://pmc.ncbi.nlm.nih.gov/articles/PMC5821095/
  4. 4.Typhoid and Paratyphoid Fever, Yellow Book 2026 — US CDC, 2025. https://www.cdc.gov/yellow-book/hcp/travel-associated-infections-diseases/typhoid-and-paratyphoid-fever.html
  5. 5.Yousafzai MT et al. TCV effectiveness in an XDR outbreak, Hyderabad — Lancet Global Health, 2021. https://pmc.ncbi.nlm.nih.gov/articles/PMC8315145/
  6. 6.Advisory for Prevention and Treatment of Typhoid Fever — NIH Pakistan, 2018. https://www.nih.org.pk/wp-content/uploads/2018/08/Advisory-for-prevention-and-treatmentof-Typhoid-Fever-10-August-2018.pdf
  7. 7.Typhoid fever — NHS, 2025. https://www.nhs.uk/conditions/typhoid-fever/
  8. 8.Wijedoru L et al. Rapid diagnostic tests for enteric fever — Cochrane, 2017. https://www.cochrane.org/evidence/CD008892_accuracy-rapid-diagnostic-tests-detecting-typhoid-and-paratyphoid-enteric-fever
  9. 9.Disease Outbreak News: Typhoid fever, Pakistan — WHO, 2018. https://www.who.int/emergencies/disease-outbreak-news/item/27-december-2018-typhoid-pakistan-en
  10. 10.Nizamuddin S et al. Carbapenem-resistant Salmonella Typhi, Pakistan, 2022 — Emerging Infectious Diseases, 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10617351/
  11. 11.TCV reaches Punjab province, Pakistan — Gavi, 2021. https://www.gavi.org/vaccineswork/next-step-lifesaving-typhoid-conjugate-vaccines-reach-punjab-province-pakistan
  12. 12.TCV rolls out to remaining provinces — Coalition Against Typhoid, 2022. https://www.coalitionagainsttyphoid.org/reaching-every-child-in-pakistan-tcv-rolls-out-to-remaining-provinces-completing-nationwide-introduction/
  13. 13.Kraay ANM et al. Impact and predicted benefits of TCV in two Pakistani provinces — Lancet Regional Health Southeast Asia, 2025. https://doi.org/10.1016/j.lansea.2025.100581
  14. 14.Physicians call for vaccination amid rising typhoid cases — Dawn, 2026. https://www.dawn.com/news/2007843
  15. 15.Patel PD et al. TCV efficacy: final 4-year analysis, Malawi — Lancet, 2024. https://doi.org/10.1016/S0140-6736(23)02031-7
  16. 16.Carey ME et al. Global diversity and AMR of typhoid pathogens — eLife, 2023. https://doi.org/10.7554/eLife.85867
  17. 17.Simon S et al. Carbapenem-resistant Salmonella Typhi in a traveler from India — Emerging Infectious Diseases, 2025. https://wwwnc.cdc.gov/eid/article/31/12/25-1234
  18. 18.Khalid H et al. XDR Salmonella Typhi in Pakistani children — Sage Open Pediatrics, 2026. https://pmc.ncbi.nlm.nih.gov/articles/PMC12811554/
  19. 19.Reaching 80 million children with typhoid conjugate vaccines — Gavi, 2025. https://www.gavi.org/vaccineswork/reaching-80-million-children-typhoid-conjugate-vaccines
  20. 20.IAP Task Force: Management of enteric fever in children — Indian Pediatrics, 2006. https://www.indianpediatrics.net/oct2006/884.pdf

This page summarises published research for education. It is not a diagnosis or a treatment plan. Always speak to your child's doctor, and go to the nearest hospital in an emergency.

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