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

2026-04-01T00:00:00Z

Title: Economic burden of typhoid fever by antimicrobial resistance in India: a modelling study 2023 Authors: V. Mogasale, Vijayalaxmi; John, Jacob; Ray, Arindam; Farooqui, Habib Hasan; Mogasale, Vittal; Hutubessy, Raymond; Dhoubhadel, Bhim Gopal; Edmunds, W. John; Clark, Andrew; Abbas, Kaja Abstract: Background 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. Methods 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. Findings 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. Interpretation 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.

Burden of antimicrobial resistance in culture-confirmed Salmonella Typhi isolates in India from 1977 to 2024: A systematic review and meta-analysis

2026-04-01T00:00:00Z

Title: Burden of antimicrobial resistance in culture-confirmed Salmonella Typhi isolates in India from 1977 to 2024: A systematic review and meta-analysis Authors: Mogasale, Vijayalaxmi V.; Zhang, Peixuan; John, Jacob; Farooqui, Habib Hasan; Ray, Arindam; Mogasale, Vittal; Parry, Christopher M.; Dhoubhadel, Bhim Gopal; Edmunds, W. John; Clark, Andrew; Abbas, Kaja Abstract: Background Antimicrobial-resistant (AMR) Salmonella Typhi (S. Typhi) is a persistent public health threat in India. We conducted a systematic review and meta-analysis to estimate the prevalence and temporal trends of AMR S. Typhi across Indian states to inform prevention and treatment strategies. Methods We systematically reviewed antimicrobial resistance in S. Typhi isolates from India, including studies published up to March 31, 2025, with no start-date restriction. We screened eligible articles from PubMed-MEDLINE, EMBASE, Scopus, Web of Science, and AMR surveillance networks and excluded studies on chronic carriers and travellers. We assessed risk of bias using the Risk Of Bias In Non-randomised Studies - of Exposures (ROBINS-E) tool. We conducted meta-analysis using a random-effects model to estimate the prevalence of multidrug resistance (MDR; resistance to chloramphenicol, ampicillin, and co-trimoxazole) and resistance to fluoroquinolones, third-generation cephalosporins, and azithromycin across five-year periods, Indian states, and age groups (<18 versus all ages). Results We analysed data from 188 of 4,430 identified studies. MDR declined from 65% (95% CI 63-67) in 1990-94 to nearly 0% (95% CI 0-1) >= 2020. Fluoroquinolone resistance rose from 2% (95% CI 1-2) in 1990-94-85% (95% CI 84-86) in 2015-19, then declined slightly, with similar trends in children but marked variation across Indian states. Resistance to third-generation cephalosporins, azithromycin, and carbapenems remained below 5%, 8%, and 2%, respectively. Our meta-analysis of studies with samples collected from 2015 onwards showed a pooled summary resistance estimate of 82% (95% CI 74-87) for fluoroquinolones, 3% (95% CI 2-4) for third-generation cephalosporins, and 3% (95% CI 1-6) for azithromycin. Conclusion Fluoroquinolone resistance in S. Typhi in India is high but is declining, while resistance to third-generation cephalosporins and azithromycin is low. As many isolates originated from major cities, caution is warranted when generalising nationally. Continued AMR surveillance is crucial to guide vaccination strategies and treatment decisions.

Long-term impact of health policy and management training for health experts from the LMICs: 2022 Dr. LEE Jong-wook fellowship program

2026-04-01T00:00:00Z

Title: Long-term impact of health policy and management training for health experts from the LMICs: 2022 Dr. LEE Jong-wook fellowship program Authors: Rajaguru, Vasuki; Park, Jun Su; Choi, Soo Hyeok; Kim, Sunmin; Seo, Jungeun; Kim, Yumin; Jung, Hyejin; Kim, Tae Hyun Abstract: Background Strengthening health leadership and management capacity in low- and middle-income countries (LMICs) is critical for building resilient health systems. The Dr. Lee Jong-wook Fellowship Program (LJWFP), implemented by the Korea Foundation for International Healthcare, was designed to equip public health administrators with competencies in policy implementation and system strengthening. However, long-term behavioural impacts of such programs are rarely evaluated beyond satisfaction and knowledge gains. This study assessed the long-term impact of the 2022 LJWFP cohort on competency achievement, satisfaction and workplace application using the Kirkpatrick evaluation framework. Methods This mixed methods study analysed data from 13 fellows who participated in the 2022 LJWFP. Quantitative data were collected through pre- and post-training assessments, participant surveys and supervisor and peer evaluations. Qualitative evidence was obtained through follow-up assessments and structured field visits. Descriptive statistics summarized key outcomes and Pearson's correlation analysis examined associations among competency achievement, training satisfaction and workplace application over a 2-y follow-up period. Results The program demonstrated high training satisfaction, with substantial gains in knowledge and competency. The correlation between competency achievement and satisfaction was moderate and statistically significant (r=0.488, p<0.05), whereas the relationship between competency and field application was moderate but not statistically significant (r=0.445, p<0.05). A strong, statistically significant correlation was observed between satisfaction and field application (r=0.776, p<0.001), suggesting that participants who were more satisfied with the training were more likely to apply their learning in practice. Conclusions The program effectively enhanced leadership skills and supported post-training applications. Future iterations should integrate mentorship and follow-up mechanisms, expand digital learning tools and measure system-level impact longitudinally. These findings highlight the value of context-tailored fellowships in advancing public health leadership and governance in LMICs.

Trends in noticing and responses to cigarette and heated tobacco product warnings among Koreans who use tobacco: findings from the 2020-2023 ITC Korea Surveys

2026-04-01T00:00:00Z

Title: Trends in noticing and responses to cigarette and heated tobacco product warnings among Koreans who use tobacco: findings from the 2020-2023 ITC Korea Surveys Authors: Cho, Yoo Jin; Quah, Anne C. K.; Fong, Geoffrey T.; Cho, Sung-il; Kang, Heewon; Kim, Gil-yong; Kim, Su Young; Seo, Hong Gwan; Lee, Sungkyu; Thrasher, James F. Abstract: Background South Korea is the only country to mandate graphic health warnings on both cigarettes and heated tobacco products (HTPs), with updates required every 2 years. Few studies have assessed real-world responses to warnings for HTPs, whose popularity has grown around the world, including in Korea.Methods Data were analysed from the 2020, 2021 and 2023 International Tobacco Control Korea Surveys, administered online. Respondents were adults who reported at least weekly use of cigarettes (n=11 280) or HTPs (n=5731). Weighted logistic regression models examined attention (eg, often/very often vs never/rarely/sometimes), cognitive responses (eg, thinking about risks a lot vs a little/not at all) and cessation-related responses (eg, forgoing use vs none) to cigarette and HTP warnings. Each outcome was analysed separately by product use frequency and survey year, adjusting for sociodemographics and quit intentions, with model-implied estimates derived using post-estimation commands.Results As warnings were updated from 2020 to 2023, attention increased for both products, including noticing warnings for cigarettes (37% to 50%) and HTPs (26% to 50%), but cessation-related responses generally decreased, particularly for HTPs (eg, agreement that warnings make quitting HTPs more likely decreased from 20% to 12%). People who reported weekly use (vs daily use) consistently showed lower attention but higher cessation-related responses for both products.Conclusions Despite growing attention to warnings over time, cognitive and cessation-related responses to warnings declined from 2020 to 2023, especially for HTPs. These findings suggest attenuation of warning effects and the potential need to expand the warning content.