Top 5 Countries Most at Risk of XDR Typhoid Outbreaks, According to a Recent Global Study

Imagine a deadly fever so drug-resistant that common antibiotics no longer work, and it spreads faster than we expect because of travel, urban crowding, and fragile water systems. That’s the reality of extensively drug-resistant (XDR) typhoid today. First identified in Pakistan in 2016, it's now expanding its reach. A recent global study combines travel patterns with local disease burdens to spotlight which countries are at greatest risk of large-scale XDR typhoid outbreaks. Here are the top five.

How researchers determined risk

The 2023 study from Yale School of Public Health used two core metrics. One: volume of air and land travel from Pakistan where XDR typhoid has relentlessly spread. Two: local incidence rates of typhoid fever—which reflect how fertile the ground is for an outbreak once the bacteria land. Together these factors predict a country’s vulnerability. The result? A list of nations with high exposure and weak barriers.

The five countries on highest alert

Here are the top five that stand out as most at risk, along with why:

• Afghanistan – This country bears one of the highest typhoid burdens globally, with an estimated incidence exceeding 700 cases per 100,000 per year. It also shares an open, porous border and heavy migration flow with Pakistan. These combine to create near-constant risk of introduction and spread of XDR typhoid.
• Bangladesh – With median estimated incidence above 500 cases per 100,000, the outbreak of ceftriaxone-resistant typhoid in Bangladesh in 2024 shows local emergence of resistance, not just importation. The country’s dense population and sanitation challenges offer little resistance to spread once the strain arrives.
• India – India’s high typhoid burden, especially in urban centers, paired with large numbers of travelers to and from Pakistan, positions it as a probable next ground zero for wider XDR spread. Recent studies from Gujarat found multi-antibiotic resistant strains already resisting ceftriaxone and other key drugs.
• Malaysia – While typhoid incidence is lower than in South Asia, Malaysia receives a substantial number of travelers from Pakistan. That, in addition to pockets of poor water and hygiene infrastructure, makes it susceptible to imported XDR cases becoming local outbreaks.
• Thailand – Like Malaysia, Thailand is exposed via international travel. Its typhoid burden rate is high enough—nearly 200 cases per 100,000—to sustain transmission if XDR strains are introduced. Its public health systems may find novel XDR appearances especially challenging to contain.

Emerging threats and warning signals

These “most at risk” countries are not just hypothetical cases. Bangladesh already saw an outbreak of ceftriaxone-resistant S. Typhi in 2024, underlining how XDR isn’t just imported—it can sometimes arise in place through antibiotic pressures. India’s Ahmedabad region recorded multiple drug-resistant isolates of the H58 lineage between 2022-23, resisting frontline drugs including ceftriaxone. Meanwhile, global surveillance tools show increasing resistance to azithromycin—the only reliable oral antibiotic left against many XDR strains—in places such as Bangladesh, Nepal, and India.

Travel patterns are also amplifying the risk. Countries that ranked highest in traveler flow from Pakistan in 2019 are disproportionately those already reporting XDR cases. Even countries like Saudi Arabia and United Arab Emirates, despite receiving more travelers, have reported few documented cases—though low reporting and surveillance gaps may hide real spread.

Strategies to avert health disaster

How do we prevent these risks turning into crises? A multilayered response is essential:

• Vaccination: Accelerating rollout of typhoid conjugate vaccines is critical. Countries like Pakistan, India (in selected cities), Nepal, and others have begun—but many at-risk nations remain without wide coverage.
• Surveillance: Better lab capacity to detect XDR types, including genomics tools, is needed. Many high-risk countries currently lack sufficient blood culture or antibiotic susceptibility testing.
• Antibiotic stewardship: Restricting misuse of key drugs like ceftriaxone and azithromycin to slow selective pressure—so XDR strains don’t emerge locally as they have elsewhere.
• Water, sanitation, hygiene (WASH): Investing in clean water and sanitation infrastructures, especially in urban slums, reduces transmission dramatically. Clean water is the frontline defense when antibiotics fail.

Without swift action in these areas, the window to stop XDR typhoid from becoming endemic in more countries may close.

Conclusion: XDR typhoid once felt like a distant danger beyond Pakistan’s borders. But studies now show that countries like Afghanistan, Bangladesh, India, Malaysia, and Thailand are highly vulnerable—some already experiencing resistance. With imminent risk, those nations, and the global health community, must act decisively to vaccinate, surveil, and defend water quality. The cost of waiting will be severe—but the tools to prevent global spread are already in hand.