# Geographic and Behavioral Determinants of Typhoid and Antimicrobial Resistance in Children Across Urban, Rural, and Nomadic Populations of Punjab, Pakistan

## TL;DR

This study found high typhoid rates and antibiotic resistance in children in Punjab, Pakistan, with nomadic and low-income groups most affected, highlighting the need for vaccines, better hygiene, and antibiotic control.

## Contribution

The study identifies geographic and behavioral risk factors for typhoid and antimicrobial resistance in diverse populations of Punjab, Pakistan.

## Key findings

- 41.5% of children tested had typhoid, with higher rates in nomadic and low-income groups.
- 88.8% of typhoid isolates showed resistance to ciprofloxacin, linked to specific resistance genes.
- Nomadic populations had higher MDR rates (49.3%) but lower XDR rates compared to urban and rural areas.

## Abstract

What are the main findings?
A high burden of typhoid (41.5% proportion of culture-positive cases) among children in Punjab, especially affecting nomadic and low-income populations.Extensive antimicrobial resistance is prevalent, with 88.8% of isolates resistant to ciprofloxacin and 83.7% and 73.8% to trimethoprim-sulfamethoxazole and ampicillin, respectively, which was strongly linked to the presence of sul1, sul2, dfrA7, and blaTEM genes.

A high burden of typhoid (41.5% proportion of culture-positive cases) among children in Punjab, especially affecting nomadic and low-income populations.

Extensive antimicrobial resistance is prevalent, with 88.8% of isolates resistant to ciprofloxacin and 83.7% and 73.8% to trimethoprim-sulfamethoxazole and ampicillin, respectively, which was strongly linked to the presence of sul1, sul2, dfrA7, and blaTEM genes.

What are the implications of the main findings?
The findings highlight the urgent need for expanded typhoid conjugate vaccine (TCV) coverage, improved water, sanitation, and hygiene (WASH) infrastructure, and antibiotic stewardship in high-burden communities.Integrating behavioral education with molecular surveillance is critical for controlling typhoid transmission and monitoring emerging antimicrobial resistance in Pakistan.

The findings highlight the urgent need for expanded typhoid conjugate vaccine (TCV) coverage, improved water, sanitation, and hygiene (WASH) infrastructure, and antibiotic stewardship in high-burden communities.

Integrating behavioral education with molecular surveillance is critical for controlling typhoid transmission and monitoring emerging antimicrobial resistance in Pakistan.

Background/Objectives: This study aimed to determine the antimicrobial susceptibility patterns of multidrug resistant (MDR) and extensively resistant (XDR) Salmonella enterica serovar Typhi (S. Typhi) strains among children, along with the associated behavioral and environmental risk factors across different population groups in multiple districts of Punjab, Pakistan. Methods: A cross-sectional study was conducted across 20 districts in Punjab, Pakistan. Structured questionnaires were used to assess sociodemographic and behavioral determinants. Blood cultures from febrile children were obtained for the isolation and identification of S. Typhi, followed by antimicrobial susceptibility testing and screening for the resistance genes. Results: A total of 900 blood samples were collected and 41.5% were positive for S. Typhi. The proportion of culture-positive cases were higher among children aged 6–12 years (34.8%). Sociodemographic and behavioral analysis revealed that children from low-income households (PKR < 20,000 showed significantly higher infection rate (67.1%, p < 0.001). Antimicrobial susceptibility testing revealed high resistance rates against several antibiotics: Ciprofloxacin (88.8%), Trimethoprim/sulfamethoxazole (83.7%), Ampicillin (73.8%) and Chloramphenicol (72.7%). However, all isolates remained susceptible to carbapenems and azithromycin. The prevalence of MDR and XDR S. Typhi in urban areas was 28.1% and 60.8%, respectively, while rural areas showed 22.6% MDR and 20.6% XDR. In contrast, nomadic populations exhibited a higher rate of MDR (49.3%) but a lower XDR prevalence of 18.6% with significant geographic variations in resistance patterns. Molecular analysis revealed a high prevalence of resistance genes, including sul1 (83.7%), sul2 (79.7%), followed by dfrA7 (81.3%), catA1 (64.9%) and blaTEM (60.5%), blaCTX-M-1 (12.5%), blaCTX-M-15 (25.9%) and qnrS (88.8%), respectively. Conclusions: The study underscores a persistent typhoid burden and widespread antimicrobial resistance among children in Punjab. Targeted vaccination, antibiotic stewardship, public health education are urgently needed, especially among the nomadic population, where healthcare access and hygiene awareness are limited.