# Economic burden of typhoid fever by antimicrobial resistance in India: a modelling study 2023

## TL;DR

This study estimates the economic impact of typhoid fever in India in 2023, showing that drug-resistant cases and children under ten contribute the most to costs.

## Contribution

The study provides the first detailed economic analysis of typhoid fever in India, disaggregated by age, region, and antimicrobial resistance.

## Key findings

- Fluoroquinolone-resistant typhoid infections accounted for 87% of total costs in India in 2023.
- Children under ten years of age contributed over half of the total economic burden of typhoid fever.
- Households bore 91% of typhoid-related expenses, with 70,000 families facing catastrophic health expenditure.

## Abstract

Typhoid fever and rising antimicrobial resistance contribute towards substantial morbidity in India. Introduction of typhoid conjugate vaccine in national immunisation schedule is under consideration to address this growing disease burden. In this study we estimated the economic burden of typhoid fever for 2023, disaggregated by age, provincial states of India, and fluoroquinolone resistance, from societal and government perspectives, to support national vaccination policy.

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. To reflect age-specific uncertainty in hospitalisation patterns and resulting economic burden, we used two primary scenarios. We estimated productivity losses due to premature mortality using the human capital approach, with the friction-cost approach as an alternative. We assessed uncertainty through probabilistic sensitivity analysis.

The economic burden of typhoid fever in India in 2023 was estimated at INR 123.0 billion (95% UI 76.7–215.5; US$ 1.5 billion, 0.9–2.6), including a cost of INR 13.0 billion (6.6–27.0; US$ 157 million, 80–326) to the public health system (government perspective). Fluoroquinolone-resistant infections accounted for 87% of total costs. Children under ten years of age incurred the highest economic burden, contributing over half of the total costs. Households bore 91% of expenses, and 70,000 families faced catastrophic health expenditure. Maharashtra, Uttar Pradesh, Andhra Pradesh (including Telangana), Tamil Nadu, and West Bengal were the states estimated to account for 51% of the national costs. Productivity loss was INR 42.6 billion (15.7–111.1; US$ 515 million) based on the human capital approach and declined by 99.8% under the friction-cost approach.

Typhoid fever imposes a significant economic burden in India, shaped by fluoroquinolone resistance, children less than ten years of age, and high-burden provincial states of the country, resulting in considerable household financial strain. Our findings provide key evidence to support the introduction of the typhoid conjugate vaccine, enhance antimicrobial resistance control, and guide national health financing policies.

WISE programme; International Vaccine Institute; 10.13039/501100023693Vaccine Impact Modelling Consortium; Japan Agency for Medical Research and Development.