Burden of typhoid fever and antimicrobial resistance in India (2023): a modelling study

Background: India is one of the countries with a high typhoid fever burden. In 2022, the National Technical Advisory Group on Immunisation recommended including the typhoid conjugate vaccine (TCV) in the Universal Immunisation Programme. In this study, we aimed to estimate the 2023 burden of typhoid fever and its antimicrobial resistance (AMR) to inform targeted vaccine introduction strategies. Methods: We used a decision tree model to estimate typhoid cases, hospitalisations, complications, and deaths. Incidence and clinical parameters were derived from a multicentre Indian study, with state-wise AMR prevalence from a systematic review. Two co-primary and four alternative scenarios were presented to validate the robustness of the findings. Findings: We estimated 4.9 million (95% UI: 4.4-5.6) typhoid cases and 7850 (4300-14,900) deaths in India in 2023. Of 730,000 (534,000-970,000) hospitalisations, 600,000 (435,000-799,000; 82%) were attributable to fluoroquinolone-resistant. Under primary scenario A, children