Typhoid fever

Overview

Typhoid fever is an infection caused by a bacterium (germ) called Salmonella Typhi. The germ lives only in humans. It leaves the body in the stool (faeces) of a sick person or a carrier, and reaches other people through food, drink or water that has been touched by that stool. Once swallowed, the bacteria pass through the gut wall into the blood and spread to the liver, spleen, gallbladder and bone marrow. This is why typhoid is a whole-body illness, not just a stomach upset.

The World Health Organization estimates around 9 million cases and about 110,000 deaths worldwide every year. Most happen in places where clean water and good sanitation are lacking, and children are the group most often affected. South Asia, including Pakistan, carries a large share of the world's cases.

Pakistan faces an extra problem. Since late 2016 a strain of typhoid that resists most of the usual antibiotics, called extensively drug-resistant (XDR) typhoid, has spread from Hyderabad and Karachi in Sindh across the country. Only a few medicines still work against it. With correct antibiotics, almost everyone recovers; without them, typhoid can last a month and can kill. The good news is that typhoid can be prevented. A newer typhoid conjugate vaccine (TCV) is now part of Pakistan's routine childhood vaccination schedule, and safe water, hand washing and clean food stop the germ from spreading.

Symptoms

• Fever that rises step by step over a few days and then stays high, often worst in the evening
• Headache and a general feeling of being unwell, weak and very tired
• Loss of appetite and nausea (feeling sick)
• Stomach (abdominal) pain and bloating
• Constipation in many adults, or diarrhoea, which is more common in children
• Chills and body aches
• Dry cough or sore throat in some people
• Small pink spots on the chest or belly (rose spots) in a minority; these are hard to see on darker skin
• Confusion, drowsiness or agitation in severe illness
• A slightly enlarged liver or spleen that a doctor may feel during examination

Causes and risk factors

Causes

• Swallowing Salmonella Typhi bacteria in water or ice contaminated with human stool
• Eating food prepared by someone who has typhoid or is a carrier and did not wash their hands
• Raw fruit, salad or vegetables washed in unsafe water, or unpasteurised milk
• Close contact with a person who is ill or a long-term carrier who still passes the germ in their stool
• A closely related germ, Salmonella Paratyphi, causes a similar but usually milder illness called paratyphoid fever; together they are called enteric fever

What makes it more likely

• Living in or visiting areas without safe drinking water, proper toilets and sewage disposal
• Children, who have the highest rates of illness; in Pakistan in 2017 children under 15 made up most typhoid cases and deaths
• Not being vaccinated against typhoid
• Eating street food, food left uncovered, or drinks with ice made from unsafe water
• Poor hand washing, especially after using the toilet and before cooking or eating
• Low stomach acid, for example from acid-lowering medicines, which lets more bacteria survive
• Recent antibiotic use that disturbs the normal gut bacteria, and poor nutrition
• Having a household member who is a chronic carrier

Complications

Serious problems usually appear in the second or third week of illness if typhoid is not treated properly. The gut wall can bleed, or a hole can form in the intestine (perforation), which causes severe belly pain and infection inside the abdomen (peritonitis) and needs urgent surgery. The brain can be affected, causing confusion, delirium or fits. Other possible problems include liver inflammation, anaemia (low blood count), kidney failure, pneumonia and, in pregnancy, miscarriage. About one in ten people whose treatment was not enough get the fever back one to three weeks after feeling better (relapse). A small number of people become chronic carriers: they feel well but keep passing the germ in their stool for a year or more, often because it hides in the gallbladder, and they can infect others.

Diagnosis

Typhoid is hard to tell apart from other fevers such as malaria or dengue by symptoms alone, so testing is needed. Your doctor will ask about your water and food, contact with sick people and recent travel, and will examine your belly. The most reliable test is a blood culture, where a sample of blood is grown in the laboratory to see if the germ appears. It works best in the first week of fever and before antibiotics are started; sometimes more than one sample is needed because a single culture misses up to half of cases. The culture also shows which antibiotics the germ is sensitive to, which is essential in Pakistan because of XDR strains.

A full blood count is often done; white cells may be low or, in young children, high, and platelets may be low. Stool cultures mainly help in finding carriers rather than in diagnosing a fresh illness. Quick antibody blood tests such as the Widal test are widely used in Pakistan but are unreliable: they often give a positive result in people who do not have typhoid, so CDC advises against relying on them. In malaria areas a malaria test is usually done at the same time.

Treatment

1. See a doctor early. Do not start antibiotics from a pharmacy on your own; a blood culture taken before antibiotics gives the best chance of a correct diagnosis and the right medicine.
2. Antibiotics are the main treatment and shorten the illness and lower the risk of complications. Because resistance is so common in Pakistan, the choice depends on local resistance patterns and, once available, the culture result. Your doctor decides the medicine, the dose and how long to take it.
3. For uncomplicated typhoid in Pakistan, where XDR strains are common, a macrolide antibiotic (azithromycin) taken by mouth is the usual first choice, as it is one of the few oral medicines that still works. Third-generation cephalosporins (ceftriaxone or cefixime) are used only when the laboratory shows the strain is sensitive to them.
4. For severe or complicated typhoid, or when XDR typhoid is suspected, treatment is given in hospital by injection, usually with a carbapenem antibiotic. Fluoroquinolones such as ciprofloxacin are no longer useful in Pakistan because almost all strains resist them.
5. Supportive care at home or in hospital: rest, plenty of fluids (oral rehydration solution if there is diarrhoea or vomiting), light nourishing meals, and paracetamol for fever and aches. Very severe cases with shock or brain involvement may be given steroid medicine in hospital.
6. Finish the whole antibiotic course even when you feel better. If the fever has not improved after about five days of treatment, go back to the doctor; the medicine may need to be changed.
7. Emergency surgery is needed if the intestine perforates or bleeds heavily. After recovery, your doctor may ask for stool tests to check that you are not still carrying the germ, especially if you handle food for others.

Medicines in Pakistan

Medicines a doctor may use, by group. Each link opens our page for that medicine, with every brand and its official DRAP price. Your doctor decides which medicine and dose are right for you.

Also used (not yet in our price list): Typhoid conjugate vaccine (TCV), the single-injection vaccine used in Pakistan's routine childhood immunisation programme from 6 months of age, Ty21a live oral typhoid vaccine capsules (for people aged 6 years and over; not used in people with weak immunity)

Self-care and prevention

Self-care

• Rest and drink plenty of safe fluids: boiled or bottled water, oral rehydration solution, soups and diluted juices
• Eat small, light, well-cooked meals; there is no need to stop eating
• Take every dose of the antibiotic exactly as your doctor prescribed, until the course is finished
• Use paracetamol for fever and headache as directed; avoid taking antibiotics bought without a prescription
• Wash your hands with soap and water after every toilet visit and before touching food; do not cook or serve food for others until your doctor says you are clear
• Keep your own towel and keep the toilet clean; family members should wash hands carefully too
• Return to the doctor if the fever does not fall within a few days, if belly pain gets worse, or if the fever comes back after recovery

Prevention

• Vaccinate children with the typhoid conjugate vaccine (TCV) through the routine EPI schedule, and catch-up older children when campaigns are offered; adults and travellers can ask their doctor about typhoid vaccination
• Drink only water that has been boiled, filtered or chlorinated, or sealed bottled water; avoid ice unless it is made from safe water
• Eat food that is freshly and thoroughly cooked and served hot; avoid raw salads, cut fruit and street food of uncertain hygiene; peel fruit yourself
• Drink only boiled or pasteurised milk
• Wash hands with soap and water after using the toilet, after changing nappies and before preparing or eating food
• Improve sanitation at home and in the community: use proper toilets, keep sewage away from drinking water, and keep food covered from flies

Common questions

What is XDR typhoid and why is it a problem in Pakistan?

XDR means extensively drug-resistant. Since November 2016 a strain of typhoid that resists the old first-line antibiotics, the fluoroquinolones and the third-generation cephalosporins has been spreading in Pakistan, starting in Hyderabad and Karachi in Sindh. It leaves very few treatment options: azithromycin by mouth for milder cases and carbapenem injections in hospital for severe cases. This is why a blood culture before antibiotics is so important.

Is the Widal test enough to diagnose typhoid?

No. The Widal test and similar rapid antibody tests often show a positive result in people who do not have typhoid, and can miss people who do. CDC advises against relying on them. A blood culture is the reliable test, and it also tells the doctor which antibiotics will work.

How long does typhoid take to get better?

With the right antibiotic, the fever usually settles within about three to five days, and most people feel well within two to four weeks. Without treatment the illness can last a month and can be dangerous. If the fever has not improved after five days of treatment, see your doctor again because the medicine may need to be changed.

Can I get typhoid again after having it?

Yes. Having typhoid gives only partial protection, so a new infection is possible. Also, about one in ten people whose treatment was incomplete get a relapse one to three weeks after recovery. Vaccination, safe water and good hand hygiene still matter after you have had typhoid.

Is the typhoid vaccine safe for children, and which one is used in Pakistan?

Pakistan uses the typhoid conjugate vaccine (TCV), given as a single injection to children from 6 months of age through the routine immunisation programme. It was launched in Sindh in November 2019 in response to the XDR outbreak and is being rolled out to other provinces. Large studies found it highly protective in the first years after vaccination. The vaccine is not 100% effective, so safe food and water habits remain important.

Sources

1. WHO. Typhoid (2023).
2. CDC. Clinical Guidance for Typhoid Fever and Paratyphoid Fever (2024).
3. CDC. Clinical Overview of Typhoid Fever and Paratyphoid Fever (2024).
4. WHO Disease Outbreak News. Typhoid fever – Pakistan (2018).
5. WHO EMRO. Pakistan introduces typhoid conjugate vaccine (TCV) into routine immunization schedule in world first (2019).
6. CDC Travel Health Notices. Extensively Drug-Resistant Typhoid Fever in Pakistan (2019).
7. StatPearls (NCBI Bookshelf). Typhoid Fever - StatPearls - NCBI Bookshelf (2024).
8. MedlinePlus. Typhoid fever: MedlinePlus Medical Encyclopedia (2025).

Prepared from the sources listed below by the MedInfoBase team. Last reviewed 16 October 2026. This page is general health information, not medical advice. It gives no doses and does not replace a doctor: talk to your doctor or pharmacist before starting, stopping or changing any medicine. How we write and check our pages.

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