Typhoid fever in children: tests, treatment and the vaccine

Typhoid is a bacterial infection that spreads through unsafe food and water, and it is still common in Indian children. It usually causes a fever that builds up over several days. A blood culture is the best test, the Widal test often misleads, and the right antibiotic matters because resistance is high in India. A single dose of the typhoid conjugate vaccine gives good protection. Here are the questions parents ask Dr Dutta most.

What is typhoid fever and how do children get it?

Typhoid is an infection caused by a bacterium called Salmonella Typhi. A child catches it by swallowing food or water contaminated with the stool of an infected person.^1,2

The germ lives only in humans.¹ So every case starts with someone, often a person who handles food, who carries the bacteria. A closely related germ called Paratyphi causes paratyphoid, which looks the same and is treated the same way. Doctors call both "enteric fever".²

In India, common sources are street water, pani puri water, cut fruit, ice, and juices made with unboiled water.

How common is typhoid in Indian children?

Typhoid remains common. A study that followed 6,000 children in South Delhi found about 6 cases of typhoid for every 1,000 children each year.³

Enteric fever overall had dropped by 35% compared with the same area 20 years earlier, but still a large burden. It was highest in children aged 10 to 15.³ Younger children and toddlers get it too, though they may show milder or less typical signs.

What are the symptoms of typhoid in children?

The main symptom is a fever that keeps going for days, often rising a little each day. Children also feel tired, have a headache and nausea, and may have tummy pain with constipation or loose stools.¹ Many also lose their appetite.

The fever usually builds up slowly over 3 to 7 days, with body aches and a general feeling of being unwell.² Some children have a faint rash. Nausea and vomiting can occur.¹

A child with typhoid often looks more tired and "toxic" than a child with a simple viral fever. But no symptom is unique to typhoid, so the diagnosis needs testing.

How is typhoid different from dengue, malaria or a viral fever?

From symptoms alone, you often cannot tell. Telling typhoid apart from other fevers is hard even for doctors.²

A complete blood count is a sensible first test. A normal or low white cell count with few eosinophils (a type of white blood cell) points towards typhoid, and the same test helps doctors think about malaria and dengue.⁴

Timing gives clues too. Dengue and most viral fevers peak early and settle within a week. Typhoid tends to build up and continue into the second week if it is not treated. That is why a fever lasting more than 3 days in the monsoon or summer should be seen by a doctor, not managed with paracetamol alone.

Which test confirms typhoid in a child?

A blood culture is the gold standard. It proves the infection and shows which antibiotics will work.⁴

Blood culture finds the germ most often in the first week of illness, and its overall success rate is only about 50%.⁴ So a negative culture does not fully rule typhoid out, and doctors sometimes treat on clinical grounds. Blood or bone marrow culture remains the reference test despite this weakness.²

In an Indian study of children with fever, cultures were more likely to be positive in older children, in those with higher fevers, and when more blood was sent.⁵ So Dr Dutta asks for the culture before starting antibiotics, with an adequate blood sample.

Is the Widal test reliable for typhoid?

Not very. The Widal test is often negative early in the illness and often falsely positive in Indian children, so a single Widal result should not decide treatment.

The Indian Academy of Pediatrics task force notes that the Widal test may miss as many as 30% of children whose typhoid is proven by culture. It advises doing it only after 5 to 7 days of fever, by the tube method, and reading the result with caution. It discourages the quick slide Widal because of its high rate of false positives.⁴

In places where typhoid is common, many healthy people already have some Widal antibodies, so results must be read against local background levels.⁴ A "positive" report in the first few days of a viral fever is therefore common. Dr Dutta sees many children given antibiotics for typhoid they never had because of this test.

Are Typhidot and other rapid typhoid tests accurate?

They are only moderately accurate. They can miss real cases and can also label children wrongly as having typhoid.

A Cochrane review of 37 studies found the main rapid tests (TUBEX, Typhidot and Test-It) had moderate accuracy. In an imagined group of 1,000 patients with fever, 300 of whom had typhoid, Typhidot would miss about 66 cases and wrongly flag about 161 patients who did not have it.⁶

Dr Dutta uses these tests only as a rough guide alongside the child's illness and the blood count, never as the final word.

What antibiotics treat typhoid in India now?

In India, typhoid is now usually treated with azithromycin by mouth or ceftriaxone by injection. Older drugs like ciprofloxacin often fail here.

A 2026 review of Indian data found that since 2015, about 82% of typhoid germs were resistant to fluoroquinolones (the ciprofloxacin and ofloxacin family). Resistance to third-generation cephalosporins (such as ceftriaxone and cefixime) and to azithromycin was about 3% each.⁷ International experts also advise against ciprofloxacin for typhoid caught in South Asia.²

A large trial in Nepal, Bangladesh and Pakistan found that adding cefixime to a 7-day course of azithromycin did not reduce treatment failure. The authors concluded that azithromycin alone is enough for uncomplicated typhoid.⁸ Children who are very sick, vomiting, or cannot take tablets usually need hospital and injections.

Why is typhoid antibiotic resistance such a worry?

Every unnecessary antibiotic helps resistant germs spread. Typhoid that resists almost all tablets already exists in our region.

In Pakistan, typhoid resistant to both ciprofloxacin and ceftriaxone is common.² India has not yet seen this on the same scale, and in Indian data resistance to ceftriaxone and azithromycin is still low.⁷ We want to keep it that way.

So please do not start antibiotics left over from a sibling, or buy them over the counter after a Widal report. Give the full course your doctor prescribes, at the right dose.

How long does typhoid fever last?

Without treatment, typhoid can last weeks, and serious problems tend to appear in the second week.² With the right antibiotic, the fever usually takes about 4 to 5 days to settle.

In a trial in Vietnam, children and adults given azithromycin or gatifloxacin took a median of about 106 hours to become fever free.⁹ Parents often expect the fever to vanish in a day or two and want to switch medicines. A slow, steady fall is normal.

Tiredness and poor appetite can last another week or two. If the fever has not settled after about 7 days of treatment, your doctor will look again for complications or resistance.

What should my child eat during typhoid?

Your child can eat normal, soft, home-cooked food. There is no need to starve a child with typhoid or keep them on liquids only.

Offer small, frequent meals: khichdi, dal-rice, curd rice, idli, mashed potato, eggs, banana, and plenty of fluids including ORS if there are loose stools. Make sure everything is freshly cooked and served hot, and that drinking water is boiled or safely filtered.

Weight loss during typhoid is common. Good feeding during and after the illness helps your child recover strength faster.

What are the complications of typhoid?

Most children recover fully with timely treatment. Serious complications are more likely when the illness goes untreated into the second week.²

WHO notes that severe cases can lead to serious complications or even death.¹ The ones doctors watch for include bleeding from the gut, a hole in the bowel, confusion, and spread of infection to other organs.

Seek urgent care if your child has severe tummy pain or a hard, swollen tummy, black or bloody stools, drowsiness or confusion, or is not passing urine.

Can typhoid come back, or can my child carry it?

Yes. Some people still carry the germ in their stool after they feel well, and can pass it on.¹ The fever can also come back after treatment in some children, which is why doctors check on them again.

WHO advises completing the prescribed antibiotic course, washing hands with soap after the toilet, and not preparing food for others while recovering.¹ If fever returns within a few weeks of finishing treatment, see your doctor again rather than restarting old tablets.

What is the typhoid conjugate vaccine and at what age is it given?

The typhoid conjugate vaccine (TCV) is a single injection that can be given from 6 months of age.¹

The older typhoid vaccines are not approved for children under 2 and do not give long-lasting protection. The plain Vi polysaccharide injection is for age 2 and above, and the oral capsule only for children over 6.¹ The conjugate vaccine is joined to a carrier protein, which helps young children's immune systems respond. Two such vaccines have been prequalified by WHO since 2017, and WHO advisers recommended them for routine childhood use in countries where typhoid is common.¹

It is often given alongside other routine infant vaccines. Ask your paediatrician what fits your child's schedule.

How well does the typhoid vaccine work?

Very well. In large trials, one dose prevented about 80% to 85% of culture-proven typhoid in children.

• Nepal, children 9 months to 16 years: 81.6% protection.¹⁰
• Malawi, children 9 months to 12 years: 80.7% protection.¹¹
• Bangladesh, children 9 months to under 16 years: 85% protection, and 81% in those vaccinated under age 2.¹²

In India, a city-wide campaign in Navi Mumbai reduced typhoid among children by about 56% at the community level.¹³ In the Nepal trial, side effects such as fever were about as common as with the comparison vaccine.¹⁰

Does my child need a typhoid booster?

Possibly. Protection from one dose fades over the years, fastest in children vaccinated very young.

In the Bangladesh trial, estimated protection fell to about 50% in years 3 to 5 after the dose. Antibody levels fell fastest in children vaccinated before age 2.¹⁴ This is why a second dose is now being discussed for children vaccinated in infancy.

My advice: keep your child's vaccine record, and ask your paediatrician about a second dose a few years after the first, especially before school age. The vaccine also does not cover paratyphoid, so food and water safety still matter.

How can I protect my child from typhoid through food and water?

Safe water, hot freshly cooked food and handwashing prevent most typhoid. Vaccination adds protection on top.^1,2

• Boil drinking water if you are not sure it is safe.¹
• Give milk that has been boiled or is pasteurised.¹
• Serve food hot and freshly cooked. Avoid ice unless you know it was made from safe water.¹
• Wash fruit and vegetables well, and peel them when you can.¹
• Wash hands with soap often, especially after using the toilet.¹
• Avoid street pani puri, cut fruit, roadside juices and chutneys for young children, especially in summer and monsoon.

Carry boiled water from home when you go out with your child.

When should I take my child with fever to a doctor for typhoid?

See a doctor if your child has:

• fever lasting more than 3 days, or fever that rises day by day
• fever with tummy pain, vomiting, constipation or loose stools
• a child who is unusually tired, drowsy, confused or not eating
• fever that continues after 7 days of typhoid treatment, or returns after it

Go to hospital urgently for severe tummy pain, a hard or swollen tummy, blood in the stool or black stools, repeated vomiting, very little urine, or drowsiness. Please do not start antibiotics at home on the basis of a Widal report alone.