National Guideline for Prevention,

Treatment and Control of Scrub Typhus in Bhutan

Department of Public Health

Ministry of Health
Royal Government of Bhutan
November 2016
ii | Treatment and Control of Scrub Typhus in Bhutan
 Foreword

Scrub Typhus is a notifiable zoonotic disease in Bhutan. It is one of the neglected

and commonest emerging and re-emerging diseases. Bhutan is located within the
endemic belt of scrub typhus but the disease remained as an unrecognized, under-
diagnosed and under-reported with often fatal consequences until 2009. Since the
first reported outbreaks from Gedu in 2008 to 2009 of undifferentiated fever which
was later confirmed as scrub typhus, the disease has now become increasingly
recognised as the cause of significant public health burden in the country. Therefore,
a comprehensive guideline for prevention, treatment and control of Scrub Typhus
in Bhutan is felt necessary for the successful management of the disease in Bhutan.

This first edition of the Scrub Typhus guidelines 2016 is developed by a small working
group consisting of experts from public health, Ministry of Health (MoH); animal
health of the Ministry of Agriculture and Forest (MoAF); FNPH, KGUMSB; CNR, RUB;
JDWNRH; and Army Hospital, Lungtenphu.

This guideline provides ready reference on all aspects of Scrub Typhus: diagnosis,
treatment, surveillance and control program and will be updated based on the
epidemiology of the disease and emerging needs.

(Dr Karma Lhazeen)

DIRECTOR
Department of Public Health

Treatment and Control of Scrub Typhus in Bhutan | iii

iv | Treatment and Control of Scrub Typhus in Bhutan
 TABLE OF CONTENTS
1. Background................................................................................................................................... 8
2. Causative agent.........................................................................................................................11
3. Reservoir host.............................................................................................................................11
4. Pathogenesis...............................................................................................................................11
5. Immunity......................................................................................................................................12
6. Modes of Transmission............................................................................................................12
7. Life cycle.......................................................................................................................................12
8. Risk factors...................................................................................................................................14
9. Clinical Features of scrub typhus.........................................................................................15
9.1 Mild to moderate form of scrub typhus..................................................................16
Fever Pattern:....................................................................................................................16
9.2 Severe form of scrub typhus.......................................................................................16
9.3 Eschar...................................................................................................................................17
9.4 Location of eschar on body of scrub typhus patient..........................................18
10. Differential Diagnosis...............................................................................................................19
11. Laboratory Diagnosis...............................................................................................................22
11.1 Specific laboratory tests................................................................................................22
11.2 Supportive laboratory investigations......................................................................24
11.2.1 Hematology..........................................................................................................24
11.2.2 Biochemistry........................................................................................................24
11.2.3 Radiography.........................................................................................................24
12. Treatment.....................................................................................................................................26
12.1 Case Definition.................................................................................................................26
12.1.1 Definition of Suspected/Clinical case.........................................................26
12.1.2 Definition of Probable case.............................................................................26
12.1.3 Definition of Confirmed case.........................................................................26
12.2 Antibiotic Treatment......................................................................................................27
12.2.1 Basic Health Unit (BHU) level.........................................................................27
13. Surveillance.................................................................................................................................29
13.1 Surveillance systems......................................................................................................29
13.1.1 Passive surveillance System............................................................................29

Treatment and Control of Scrub Typhus in Bhutan | v

 13.1.2 Indicator and Event based surveillance system through National
Early Warning, Alert and Response Surveillance (NEWARS)...................29
13.1.3 Sentinel surveillance.........................................................................................30
13.1.4 Population-based survey.................................................................................30
13.2 Case reporting..................................................................................................................30
13.2.1 Case reporting through HMIS........................................................................30
13.2.2 Case reporting in NEWARS..............................................................................31
13.2.3 Event/Outbreak reporting in NEWARS.......................................................31
14. Prevention and Control...........................................................................................................32
14.1 Public Health Intervention...........................................................................................32
14.1.1 Human Level........................................................................................................33
14.2 Environmental management......................................................................................34
14.3. Rodent and vector control.................................................................................35
14.3.1 Control strategies for rodents........................................................................35
14.3.2 Control strategies for mites............................................................................35
15. References....................................................................................................................................36

vi | Treatment and Control of Scrub Typhus in Bhutan

List of contributors

Name Affiliation
1. Dr Tapas Gurung Medical Superintendent, CRRH, Gelephu
2. Dr Kezang Namgyal Medical Specialist, JDWNRH
Medical Specialist, Lungtenphu Army Hospital,
3. Dr Tashi Dema
Thimphu
Regional Coordinator for One Health Fellowship
4. Dr Sithar Dorjee
Program, Massey University
Chief Laboratory Officer, Royal Center for Disease
5. Mr Sonam Wangchuk
Control, DoPH
6. Dr Chendu Dorji One Health Fellow (MVM), Massey University
7. Dr Kezang Dorji One Health Fellow (MPH), Massey University
8. Dr Kinley Penjor One Health Fellow (MPH), Massey University
9. Dr Kinley Penjor One Health Fellow (MVM), Massey University
10. Dr Tandin Zangpo One Health Fellow (MPH), Massey University
11. Dr Yoenten Phuentshok One Health Fellow (MVM), Massey University
12. Dr Dorji Tshering Chief Medical Officer, Bajo Hospital, Wangduephodrang
13. Dr Chencho Dorjee Dean, FNPH, KG-UMSB
14. Mr Wangchuk FNPH, KG-UMSB
15. Mr Kuenzang Dorji FNPH, KG-UMSB
16. Mr Rinizin Kinga Jamtsho Program Officer, Zoonoses Disease Program, DoPH
17. Dr Tej Nath Nepal Chief Medical Officer, Tsirang District Hospital
18. Dr Chabilal L Adhikari General Practitioner, JDWNRH
19. Dr Ratna Bahadur Gurung NCAH, DoL
20. Dr Rinzin Pem RLDC, DoL, Wangdiphodrang
21. Dr Jigme Tenzin Lecturer, CNR, RUB
22. Ms Sonam Pelden Sr. Laboratory Officer, Royal Center for Disease Control
23. Tashi Choden Sr. Laboratory Officer, Microbiology Lab, JDWNRH
24. Mr Jit Bahadur Gurung ACVO, Royal Center for Disease Control

Treatment and Control of Scrub Typhus in Bhutan | vii

 Disclaimer:

This guideline on treatment, prevention and control of Scrub Typhus infection is

developed based on a review of the currently available evidence and best practices,
and may be revised in light of future developments in the field.

The contributors mentioned in this guideline have made considerable efforts to ensure
the information upon which they are based is accurate and up to date. Users of these
guidelines are strongly recommended to confirm that the information contained,
especially drug doses, is correct by way of independent sources. The authors accept
no responsibility for any inaccuracies, information perceived as misleading, or the
success of any treatment regimen detailed in the guidelines and disclaim all liability
for the accuracy or completeness of a guideline, and disclaim all warranties, express
or implied to their incorrect use. Ultimately, health care professionals must make
their own treatment decisions about care on a case-by case basis, after consultation
with their patients, using their clinical judgement, knowledge and expertise. A
guideline is not intended to take the place of physician’s judgment in diagnosing
and treatment of particular patients. Guidelines may not be complete or accurate.

viii | Treatment and Control of Scrub Typhus in Bhutan

Acronyms

ALT Alanine transaminase

ALP Alkaline phosphatase
ARDS Acute respiratory distress syndrome
AST Aspartate transaminase
BHU Basic health unit
CBC Complete blood count
DIC Disseminated intravascular Coagulation
DMO District medical officer
DNA Deoxyribonucleic acid
ELISA Enzyme linked immunosorbent assay
TLC Total leucocytes count
FAQ Frequency asked question
ICT Immunochromatographic test
IFA Immunofluorescence Assay
IgA Immunoglobulin A
IgM Immunoglobulin M
IgG Immunoglobulin G
IPA Indirect Immunoperoxidase Assay
Kda Kilodalton
Kg Kilogram
MAT Microscopic agglutination test
mg Milligram
MoH Ministry of Health
NS1 Non-structural protein 1
OD Optical Density
PCR Polymerase chain reaction
POU Pyrexia of Unknown Origin
RCDC Royal Centre for Disease Control
RFT Renal function test
WHO World Organization for Health

Treatment and Control of Scrub Typhus in Bhutan | ix

x | Treatment and Control of Scrub Typhus in Bhutan
1. BACKGROUND

Scrub typhus also known as “Tsutsugamushi disease”, caused by gram-negative

obligate intracellular bacterium Orientia tsutsugamushi is one of the neglected and
commonest emerging and re-emerging diseases. Globally, over one billion people
are estimated to be at risk of contracting scrub typhus and about one million are
reported to be infected by scrub typhus annually in the endemic region of the world.
Today, the geographical prevalence and endemicity of the disease has expanded
to a many regions of the world in a vast area called the ‘tsutsugamushi rectangle’
from earlier ‘tsutsugamushi traingle’, which extended from “northern Japan and far
eastern Russia in the north, to northern Australia in the south, and to Pakistan and
Afghanistan in the west as shown in Figure 1 (Seong et al., 2001; De Silva et al., 2012;
Bhattacharyya and Rapsang, 2013; Yadav et al., 2013; Lim, 2014; Ramyasree et al.,
2015). While the precise incidence of disease is unknown, it is reported to be on the
resurgence with considerable morbidity and case fatality can range from 30-45%
if not diagnosed promptly and treated in the endemic countries (Batra, 2007). The
vector of scrub typhus is present in most countries of the South-East Asia Region
where it is endemic in many geographical regions in India, Indonesia, Maldives,
Myanmar, Nepal, Sri Lanka and Thailand. Many outbreaks have been reported and
recorded from multiple places of India like Assam, Darjeeling, Sikkim, Uttarkhand,
Manipur, Meghalaya, Shimla and Tamil Nadu (Blewitt, 1938; Sayen et al., 1946; Kumar
et al., 2004; Mahajan et al., 2006; Batra, 2007; Sharma et al., 2009; Ahmad et al., 2010;
Singh et al., 2010; Gurung et al., 2013).

Figure 1: Tsutsugamushi rectangle (inset: Previously Tsutsugamushi Triangle) for

scrub typhus and the affected countries in Asia.

Treatment and Control of Scrub Typhus in Bhutan | 1

Bhutan is located within the endemic belt of scrub typhus and thus people are
prone to contracting the infection. However, the Scrub typhus has remained as
an unrecognized, under-diagnosed and under-reported disease with often fatal
consequences until 2008. Since the first reported outbreaks from Gedu in 2008 of
undifferentiated fever which was later confirmed as scrub typhus, the disease has now
become increasingly recognised as one of the cause of undifferentiated fever illness
which continues to be significant public health concern in the country (Wangchuk et
al., 2009). In the last few years, the disease has been reported from hospitals across
the country and it is now a notifiable disease in the country as shown in Figure 3
(Ministry of Health, 2014). From 2009-12, the Royal Centre for Disease Control (RCDC)
tested 320 samples received from the districts of which 101 (32%) were reported
as positive for scrub typhus while 1044 samples tested from 14 hospitals across the
country in 2014-15 showed positivity rate of 26% (Tshokey et al., 2016). Scrub typhus
outbreaks have been periodically reported and the recent outbreak in 2014 at a
school in Athang, Wangdue district where 8-10% of the students were affected, and 2
deaths epidemiologically linked to the outbreak (Phuntsho et al., 2014) highlighting
the widespread endemicity of the disease in the country.

Figure 2: Scrub typhus cases reported in Bhutan for the year 2015

Based on evidence gathered in the past years and the study conducted on temporal
descriptive epidemiology of scrub typhus for the year 2015 showed that the disease
is endemic in the country and seasonal coinciding with monsoon season which starts
from July and end in October. The seasonality also coincides with peak agriculture
activities in the country. However, the scrub typhus is sporadic and reported
throughout the year as shown in Figure 3.

2 | Treatment and Control of Scrub Typhus in Bhutan

Figure 3: The temporal trend of scrub typhus cases observed for the year 2015 in Bhutan
(Source: unpublished report of Descriptive epidemiology of scrub typhus in Bhutan for
the year 2015)

2. CAUSATIVE AGENT

Scrub typhus is a chigger borne disease caused by bacterium Orientia tsutsugamushi.

It is an obligate intracellular gram negative bacterium from the genera Orientia that
survive on invertebrates and arthropods. The scrub typhus is transmitted to humans
and other vertebrates host by larval stage of chigger mites (trombiculid mites).
Trombiculid mites are small, only 1-2 millimetres in length and red in colour.

3. RESERVOIR HOST

The reservoir host of scrub typhus are the chiggers and rodents particularly wild rats
of subgenus Rattus sp. The field rodent and vector mites act as reservoir and between
the two the infection perpetuates in nature.

4. PATHOGENESIS

When the infected chigger bites humans, it inoculates pathogens orientia

tsutsugamushi into the skin. The pathogen then multiplies at the inoculation site
and forms papule. The papule ulcerates and became necrotic resulting in eschar
formation with regional lymphadenopathy which may progress to generalised
lymphadenopathy within few days (Cennimo, 2015). The O. tsutsugamushi
predominately infects the endothelial cells, even though it may also infect other cells
like macrophages, lymphocytes, dendritic cells and polymorphonuclear leucocytes

Treatment and Control of Scrub Typhus in Bhutan | 3

(PMNs). Orientia tsutsugamushi invades the host cells by phagocytosis and are
taken into phagosomes. It then lyses the phagosome membrane and enters the
cytoplasm. The bacterium propagates in the host cytoplasm via binary fission and
groups of budding orientia are produced after 2-3 days of incubation period. The
proinflammatory cytokines and chemokines are secreted by activated dendritic
cells and macrophages inflammatory proteins are responsible for the leucocytes
recruitment to the inflammatory sites (Mansueto et al., 2012). The endothelial cell
damage results in subsequent endothelial dysfunction with leakages of blood into
the tissues producing rash and oedema. This is followed by acute phase of responses
and alteration in the coagulation mechanism resulting sometimes into disseminated
intravascular coagulation (DIC). The infection also alters cytokines networks together
with transient immune dysregulation characterized by reduction in circulating
peripheral T lymphocytes, CD4+ cells and perivascular infiltration by T lymphocytes,
B cells, macrophage and CD4+ cells. All these pathologic changes causes “vasculitis”
Which can lead to multi-organ failure resulting in the development of fatal
complications.

5. IMMUNITY

Immunity against O. tsutsugamushi in humans are affected by antigenic diversity of

the agent, cross-protection are weak and transient among heterogeneous strain. The
protective immunity to homologous strains is high and long-lasting (1–3 years) while
protective immunity to heterologous strains is low and short-lived (1–3 months). The
vaccine for scrub typhus is not yet available at present due to antigenic diversity and
weak cross-protection against different strains.

Both humoral and cell mediated immunity plays an important role in recovery
from scrub typhus disease. Humoral immune response inhibits O. tsutsugamushi by
blocking surface components necessary for attachment to and/or penetration of
target cells and supports the view that antibody inhibits a specific event required in
the infection process. It also reduce the organisms’ capacity to enter cells by altering
nonspecific attractions between infectious agents and the target cells (Chattopadhyay
and Richards, 2007). The cell mediated immune response helps in the production of
antigen specific lymphocytes which results in the activation of macrophages and
plays an important role in recovery from scrub typhus (Chattopadhyay and Richards,
2007).

6. MODES OF TRANSMISSION

Scrub typhus is maintained in the mites through both transovarian and trans-stadial
transmissions and is transmitted to humans by Larval stage of “Chiggers” which are

4 | Treatment and Control of Scrub Typhus in Bhutan

the only stage of the trombiculid mites that feeds on vertebrate hosts. The organism
is maintained in the salivary glands of the mites and are transmitted to susceptible
vertebrates through skin by bites of infected chiggers.

7. LIFE CYCLE

The life cycle of trombiculid mites has a sequence of several stages: egg, prelarva,
larva, protonymph, deutonymph, trytonymph and adult (Mullen G and (Acari), 2002)
(Figure 4). The eggs are generally laid in the soil and, after a week, they hatch into
an inactive non-feeding prelarva. After another week, a six-legged larva emerges,
commonly called chigger. Chiggers then attaches to a host, most likely a rodent, and
feeds from 3 to 5 days before dropping to the ground and moving into an inactive
transitional stage, the protonymph. Then, the mite develops into a stage with eight
legs, the deutonymph, which subsequently moves to another quiescent stage, the
trytonymph, to finally produce the eight-legged adult. While in the deutonymph and
adult stages, the mites typically predate on small arthropods and their eggs.

Figure 4: Schematic description of the trombiculid’s life cycle (reproduced from

Takahashi et al. 2003)

The larval stage of the mite is the only parasitic stage in the life cycle. The chigger
usually attaches and feeds from only one host, which is generally a small mammal,
but may include birds and even reptiles or amphibians. Humans are the accidental
host. Trombiculid larvae generally do not cause direct harm to hosts from feeding,

Treatment and Control of Scrub Typhus in Bhutan | 5

although humans often experience intense local skin reactions when the mites
attach. In the process of feeding, the chiggers transmit or receive micro-organisms
that use mites as means of transport among potential hosts. Since the bacteria can
be transmitted only when the mite is in the larval stage, the seasonal occurrence of
the disease is directly related to the time of emergence of the larval mites.

8. RISK FACTORS

Various studies in India, China, Korea and Laos suggest In Bhutan, the unpublished
the following to be important risk factors for scrub typhusresults of the case-control
(Kim et al., 2008; Sharma et al., 2009; Vallee et al., 2010; Lyu
study on scrub typhus done in
et al., 2013; Zhang et al., 2014) 2015 showed the following to
be risk factors to scrub typhus
(Tandin et al., 2015):
1. Living in endemic areas: 1. Harvesting cardamom
• near grass lands 2. Working in farms
• at the edge of the village • With bare hands
• in houses without cement floor • In short sleeves
• in households with low income with larger 3. Living in traditional
household members houses or huts
2. Engaging in 4. Not having toilet inside
• tea plantation the house
• vegetable fields 5. Sitting and sleeping on
• farm work and working in forests grasses without mats
• orchard 6. Clearing bushes
• harvesting (crops, fruits, chestnut and cardamom) 7. Harvesting vegetables
3. Working in 8. Rearing goats
• short sleeves
• bare hands
• military zones
4. Activities like:
• sitting or sleeping on grass without mat
• storing firewood in and around their homes
• piling weeds in the houses and yard
• playing in bush (children)
5. Presence of rodents around house
6. Poor personal hygiene and sanitation
7. Exposure to lice and tick
8. Defecating and urinating outdoors

9. CLINICAL FEATURES OF SCRUB TYPHUS

Scrub typhus presentation varies from mild and self-limiting to severe fatal condition.
Following an incubation period of one to three weeks, disease onset is characterized
6 | Treatment and Control of Scrub Typhus in Bhutan
by fever, headache, myalgia, respiratory and gastrointestinal symptoms. The classic
case presents with an eschar, which is a pathognomonic feature of scrub typhus
(Rathi and Rathi, 2010). The clinical spectrum of scrub typhus mimics enteric fever,
leptospirosis, malaria, dengue, viral and other rickettsial diseases and unless there is
a high degree of suspicion, it is likely to be missed as a cause of pyrexia of unknown
origin (PUO). Therefore, any case fulfilling the case definition of scrub typhus (Refer
to the Surveillance Section of this document) must be initiated with specific antibiotics
at the earliest. The frequency of commonly observed clinical signs and symptoms
among the patients of scrub typhus in Bhutan in the year 2015 by descriptive study
are presented in (Figure 5).

Figure 5: Percentage of commonly observed clinical signs and symptoms in scrub typhus
patients in Bhutan (unpublished result of descriptive epidemiology of scrub typhus
cases observed for the year 2015)

The clinical features presentation of scrub typhus may differ based on the stages of
infection and severity as follows:

9.1 Mild to moderate form of scrub typhus

The patient commonly presents with an acute flu like symptoms:
• Fever
1st week: Systemic toxic symptoms
• Headache
• Myalgia 2nd week: Complications
• Rashes (maculopapular) 3rd week: Convalescence
• Nausea, vomiting and abdominal pain
• Cough
• Regional or generalized lymphadenopathy

Treatment and Control of Scrub Typhus in Bhutan | 7

 • Eschar (appears from 5th day of illness)

Fever Pattern:
Patients infected with scrub typhus present with high grade fever (100% of patients)
and respond rapidly to an appropriate antibiotic treatment. The duration of fever
ranged from 1 to 17 days, with average duration of 6.6 days and the average highest
body temperature was 39.2o C. In a descriptive study conducted on surveillance,
clinical profile and diagnostic issues in Shandong in China by Zhang et al. (2012), all
patient had fever of which 35.3% had continued fever, 23.5% had remittent fever,
34.3% had irregular fever, and 6.9% were unclear of fever type.

9.2 Severe form of scrub typhus

The patient presents with an acute fever with multi-organ dysfunction with one or
more of the following features:
• Jaundice
• Acute Kidney Injury
• Hypotension
• Meningo-encephalitis
• Pneumonitis/Acute respiratory distress syndrome (ARDS)
• Haemoptysis & hematemesis
• Septic shock
• Myocarditis
• DIC (Disseminated Intravascular Coagulation)

Pneumonia is one of the most frequent complications of scrub typhus, which manifests
as a non-productive cough and breathlessness and leads to ARDS which could be
life-threatening. Severe complications besides acute respiratory distress syndrome
(ARDS) include hepatitis, renal failure, meningo-encephalitis and myocarditis may
occur in varying proportions of patients.

9.3 Eschar
An “eschar” is a pathognomonic feature and typical marker of scrub typhus which
resembles “cigarette burn” or “punched out” lesion with central hollow covered by
necrotic tissues and surrounded by pink areola measuring 5-20mm in diameter.
Eschar positivity is observed among scrub typhus patients ranging from 15%-100%
with mean of 56% (Dass et al., 2011; De Silva et al., 2012; Seong et al., 2001; Sinha et
al., 2014).Other sources describes eschar positivity rate from 7-97% in scrub typhus
cases as well (DHR-ICMR, 2015) . Eschars are mostly seen in hidden area of body:
axilla, groins and under the breasts, but it can occur in any part of the body (lower
extremities, neck and chest region, abdomen) and therefore, its search should be
made meticulously in private (Figure 6).

8 | Treatment and Control of Scrub Typhus in Bhutan

 Figure 6. Picture of eschars seen in patients of scrub typhus cases in Bhutan (Picture
courtesy Dr. Kesang Dorji, Dr Yoenten Phuentshok and Dr Tandin Zangpo, Bhutan One
Health Fellows of 2014-2016)

9.4 Location of eschar on body of scrub typhus patient

Usually a single eschar is found but multiple eschars have also been documented
as well (Kim et al., 2007). Eschars are found in relatively warm and moist body parts
such as neck, arm pits, waist, and groin (Figure 7).

Figure 7: Body parts where eschars are commonly seen in patients of scrub
typhus Source:(Kim et al., 2007)
Treatment and Control of Scrub Typhus in Bhutan | 9
 10. DIFFERENTIAL DIAGNOSIS
• Other rickettsial diseases
• Enteric fever
• Malaria
• Dengue
• Leptospirosis
• Chikungunya
• Japanese encephalitis

Table 1. Rickettsial diseases and their causative agents that have similar clinical features
as that of scrub typhus and should be considered for differential diagnosis.
Diseases Rickettsial agent Insect vectors Mammalian reservoirs
Typhus group
a. Epidemic typhus R. prowazekki Louse Humans
b. Murine typhus R. typhi Flea Rodents
Spotted fever group
a. Indian tick typhus R. conorii Tick Rodents, dogs
b. Rocky Mountain R. rickettsii Tick Rodents, dogs
spotted fever
c. Rickettsial pox R. akari Mite Mice
Others
a. Q fever C. brunette Nil Cattle, sheep, goats
b. Trench fever Rochalimaea Quintana Louse Humans
Source: Reproduced from Guidelines for Diagnosis and Management of Rickettsial
Diseases in India, 2005; available at: http://www.icmr.nic.in/guide/DHR-ICMR%20
Guidelines%20on%20Ricketesial%20Diseases.pdf

For differential diagnosis of scrub typhus with rickettsial and other diseases, the
following laboratory tests can be used to distinguish each of these diseases.
Disease Laboratory tests
Typhoid (enteric fever) Blood culture*
Malaria Blood smear (thick and thin smear) and RDT
Dengue RDT, PCR* and ELISA*
Japanese encephalitis ELISA* and PCR
Leptospirosis RDT, MAT*and ELISA*
Chikungunya ELISA* and PCR
Q-fever PCR
Spotted fever (Indian tick typhus) murine PCR* and IFA
typhus, Louse-borne typhus
*Tests available at the RCDC
Source: Reproduced from Guidelines for Diagnosis and Management of Rickettsial
Diseases in India, 2005; available at: http://www.icmr.nic.in/guide/DHR-ICMR%20
Guidelines%20on%20Ricketesial%20Diseases.pdf (DHR-ICMR, 2015)

10 | Treatment and Control of Scrub Typhus in Bhutan



Algorithm for the diagnosis of scrub typhus

Algorithm for the diagnosis of scrub typhus


Acute Fever with Headache &Myalgia
Headache/Myalgia


History and Physical Examination



History of Exposure / Fulfills No History of Exposure

clinical Definition


RDT
Eschar (+) Eschar (-)

Positive Negative
RDT

Treat
� Dengue
� Malaria
Positive Negative Treat
� Leptospirosis
� JE
� Typhoid
� Exclude
Treat Others T
Other Or
s � False -ve
Positive Negative
O scrub typhus

r
� F
al
� Follow up
s Specific
� Reconfirmation or
e Treatment
� Treat as scrub
-
typhus
v
e

sc Figure 9: Flow chart for diagnosis of scrub typhus
Figure 9: Flow chart for diagnosis of scrub typhus
r
u
11. LABORATORY
b DIAGNOSIS
ty

p
11.1 Specific laboratory
h tests
Specific blood testing is required to confirm scrub typhus infection. Many different
u
s
tests are available
to confirm scrub typhus with varying degree of sensitivity and
specificity; Immunofluorescence Assay (IFA) and Indirect Immunoperoxidase Assay

(IPA), PCR, ELISA and RDT. Although IFA and IPA are considered to be the gold standard
RDT
tests but those tests are currently not available in Bhutan and also expensive
21 and

require highlyeat
trained laboratory staff to perform the tests including PCR and ELISA.
The commonly used test is RDT and ELISA. ELISA is suitable test for large number of

Treatment and Control of Scrub Typhus in Bhutan | 11

 serum samples.

The RDT detects antibodies (IgM, IgG, IgA) of O. tsutsugamushi while ELISA detects
IgM anybodies only and Therefore probability of detecting true scrub typhus positive
is high if blood sample from suspected case is collected after one week from the
date of onset of illness. Adequate antibody titre in serum develop towards the end of
1st week and remain in circulation for a month for IgM. However, IgG antibody titre
remains for years.

Rapid diagnostic test (RDT) or Point of Care (POC) is used for scrub typhus
differential diagnosis which detects the 56-kDa major surface protein antigens
from representative O. tsutsugamushi including Gilliam, Karp, and Kato strains. The
current commercially available RDT can detect IgG, IgM, and IgA antibodies to O.
tsutsugamushi. The sensitivity and specificity of RDT differ from brands to brands. In
a Thai study, the sensitivity and specificity for SD bioline ranges from 66.7% (95% CI
57.1–75.1%) and 98.4% (95% CI 91.5–99.7%), respectively (Silpasakorn et al., 2012),
whereas a Korean study reported sensitivity of 72.6% (Lee et al., 2014) for the same
kit. The results of this study show that the fever duration before the first serologic
testing can affect the ICT results. Other studies using the ICT also demonstrated a
low sensitivity at the time of admission, but showed a trend of gradual increase in
positivity. Therefore, when interpreting the ICT results, clinicians should exercise
caution because a substantial number of patients with confirmed scrub typhus were
negative for this test, particularly in the early days of illness.

ELISA is commonly used test for screening and confirming the scrub typhus infection.
The ELISA used for confirmatory diagnosis at national, regional referral including
Phuntsholing hospital and RCDC is “IgM capture ELISA” which is high sensitivity and
specificity. ELISA is not cost effective to be used in district hospitals and BHU-I because
of low sample size. The presence of IgM antibodies in serum indicates recent infection
of O. tsutsugamushi. The IgM ELISA targets antibodies to the 56-kDa antigenic protein.
The sensitivity and specificity of IgM ELISA (InBios) which is currently used in Bhutan
has 93% and 91% (Blacksell et al., 2016) and cut-off of Optical Density (OD) value
optimize for Bhutanese’s population is 0.5.

The Polymerase Chain Reaction (PCR) is also used for detection of scrub typhus and
it is available at RCDC, However, PCR is recommended for surveillance and research
purpose at the moment. PCR detects O. tsutsugamushi DNA both in the whole blood
and eschar samples. The target gene for PCR is the major 56 Kda and/or 47 Kda surface
antigen gene. The results are best obtained within 1st week because of presence of
rickettsemia (O.tsutsugamushi) in first 7-10 days. The sensitivity and specificity of
these various diagnostic tests are given below in Table 1.

12 | Treatment and Control of Scrub Typhus in Bhutan

Table 1: Test accuracy parameters of different diagnostic tests used for scrub typhus
Type of Assay Sensitivity Specificity Remarks
IFA 70% 95% Gold standard
ELISA (InBios) 93% 91% Patients presenting early into the
illness may have low antibody levels
(false negative)
PCR : 56kDa 57% 98% Sensitivity is better when buffy coat is
47kDa 63% 96% used
16s RNA Gene 87% 100%
Rapid diagnostic tests Patients presenting early into the
• ICT (SD BioLine) 76% 77% illness may have low antibody levels
• ICT (PanBio) 73% 97% (false negative)
• ICT (Inbios) 84% 85%
Source: Reproduced from Professor GM Varghese’s (CMC, Vellore, India) Power point
presentation made during the International Conference on Scrub Typhus, Thimphu,
Bhutan 2015

Table 2. Specific tests available for scrub typhus diagnosis in Bhutan

Level of health facility Laboratory diagnostics available

RCDC, Serbithang, Thimphu PCR, ELISA and RDTs
National and Regional Referral Hospitals ELISA, RDTs
Phuntsholing Hospital ELISA,RDTs
District Hospital/BHU-1/BHU RDTs

11.2 Supportive laboratory investigations

The supportive laboratory investigations such as hematology, biochemistry and
radiography are useful for assessing the severity and development of complications
of scrub typhus patients. They aid in making decision for appropriate management
of patients.

11.2.1 Hematology
• Total Leucocytes Count (TLC) during the early phase of disease
may be normal but become elevated to >11,000/cu.mm during
later course of the disease.
• Thrombocytopenia with <100,000/cu.mm is observed in the
majority of patients.

11.2.2 Biochemistry
• Elevation in the levels of transaminase (aspartate transaminase
(AST), alanine transaminase (ALT), bilirubin, ALP (Alkaline

Treatment and Control of Scrub Typhus in Bhutan | 13

 phosphatase) are commonly observed.
• Deranged RFT are also observed

11.2.3 Radiography
Bronchopneumonia is commonly observed in scrub typhus. On
chest radiography following features are observed (Choi YH 2000,
Song 2004, Charoensak 2006):
• Pulmonary abnormalities (59-70%):
• Bilateral reticulonodular infiltration (40-51%)
• Septate line (36%)
• Consolidation (25%)
• Ground glass opacity (25%)
• Hilar enlargement (1.5-25%)
• Cardiomegaly (13-28.5%)
• Pleural effusion (10.8-42.6%)

(a) (b) (c)

Figure 10. Examples of X-ray showing mostly bilateral infiltrates: (a) X-ray of a patient
with scrub typhus showing bilateral lower lobe interstitial infiltrates; (b) X-ray of a
30-year old woman presenting with fever of 10 days, non-productive cough of 5 days
and complaining of breathlessness. X-ray shows bilateral reticulonodular (interstitial)
opacities in the lower lobes before treatment; (c) X-ray of the same patient taken 2
days after admission to a tertiary care centre with severe breathlessness. X-ray now
shows bilateral extensive air-space consolidation suggestive of an acute respiratory
distress syndrome.

Source: Reproduced from DHR-ICMR Guidelines on Diagnosis and Management of

Rickettsial Diseases in India.

14 | Treatment and Control of Scrub Typhus in Bhutan

 (a) Initial film (b) 10 days follow up

Figure 11. Chest X-ray of a scrub typhus patient: (a) initial film during admission
showing bilateral lower lobe interstitial infiltrates; (b) film taken after 10 days of
follow up of the treatment showing clearing of infiltrates.

Source: reproduced from Professor Yupin Suputtamongkol’s PPT made during the
International Conference on Scrub Typhus held from 20-22 April 2015 in Thimphu, Bhutan

12. TREATMENT

Definitive treatment must be initiated without waiting for laboratory confirmation of

scrub typhus on the basis of clinical and epidemiological evidence (exposure history)
(fulfilling the case definition of Suspected/Clinical or Probable case) at the earliest
possible.

Early diagnosis of scrub typhus is important as it is treatable with inexpensive

and effective antibiotics and if left untreated it can be potentially severe and
fatal. Antibiotic may not be effective once complications set in.

12.1 Case Definition

12.1.1 Definition of Suspected/Clinical case

A patient with an acute undifferentiated febrile illness of 5 days or
more with one or more of the following signs and symptoms: eschar,
headache, rash, cough, general malaise, myalgia, lymphadenopathy,
multi-organ involvement like liver, lung and kidney. If eschar is
present, fever of less than 5 days duration should be considered as
clinical case of scrub typhus.

Eschar should be meticulously searched in the above mentioned

predilection sites of the patient’s body.

Treatment and Control of Scrub Typhus in Bhutan | 15

 12.1.2 Definition of Probable case
A Probable case of scrub typhus is defined as any patient fulfilling
the above clinical case definition and testing positive to rapid test of
scrub typhus (e.g. SD Bioline Tsutsugamushi Test or InBios rapid test
kit).

12.1.3 Definition of Confirmed case

A Confirmed case of scrub typhus is defined as a patient that fulfills
Clinical case or Probable case definition, And/OR

• testing positive to scrub typhus IgM ELISA with an Optical

Density (OD) > 0.5;
OR
• testing positive to O. tsutsugamushi DNA in eschar or whole
blood samples by PCR;
OR
• four-fold increase in an antibody titre of acute and convalescent
sera detected by Indirect Immune Fluorescence Assay (IFA) or
Indirect Immunoperoxidase Assay (IPA) (when available in the
country)

High clinical suspicion is the mainstay of diagnosis of scrub

typhus.

12.2 Antibiotic Treatment

The antibiotics that are effective and recommended are as follows:
• Doxycycline
• Chloramphenicol
• Azithromycin

Antibiotics other than these three antibiotics are either not or less effective for
treating scrub typhus infection and are therefore not recommended.

12.2.1 Basic Health Unit (BHU) level

a. A health care worker should be able to promptly diagnose scrub
typhus based on the Clinical/Suspected case definition.
b. A health care worker should be able to recognize severe form of the
disease. If the patients come with the severe form of the disease
with complications to BHU, the Clinician should immediately treat
16 | Treatment and Control of Scrub Typhus in Bhutan
 with Doxycycline or Azithromycin (if Doxycycline is unavailable)
before referring the patient to the district or referral hospitals.
c. A scrub typhus patient with a complications like ARDS, acute renal
failure, meningo-encephalitis or multi-organ dysfunction must
be referred to district or referral hospitals. When treating a case of
community acquired pneumonia, Doxycycline or Azithromycin (if
Doxycycline is unavailable) should be initiated as the pneumonia
could be a complication of scrub typhus in high risk area.

In case of fever of 5 days or more and after ruling out

leptospirosis, dengue, typhoid, JE and malaria, following
antibiotics must be initiated when scrub typhus is considered
likely (this treatment is also effective against many other
rickettsial diseases except for Q-fever).

Patient category Antibiotic treatment regime

A. Uncomplicated form of scrub typhus at BHU and hospital levels
1. Adults a) Doxycycline 100 mg twice a day duration of 7 days. Patients
should be advised to swallow capsules with plenty of fluid during
meals while sitting or standing.
2. Children Azithromycin in the single dose of 10 mg/kg body weight for 5
days.
3. Pregnant women a) Azithromycin 500 mg in a single dose for 5 days.

Azithromycin is the drug of choice in pregnant women, as

doxycycline is contraindicated
4. In extremely ill Very sick/ill patient but able to ingest orally should be given an
patients initial dose of 200mg Doxycycline stat, followed by 100 mg BD
x 10-14 days as usual (Prof. G. Verghese, Expert opinion, CMC,
Vellore).
Note: Azithromycin 500 mg in a single dose for 5 days is the drug of choice for children
< 8 years, Pregnant women, allergic to Doxycycline and in those documented
resistance to Doxycycline or if Doxycycline not available.
Source: Adapted from DHR-ICMR Guidelines on Diagnosis and Management of
Rickettsial Diseases in India.

12.2.2 District, regional and national referral hospitals levels

• The treatment as specified above in uncomplicated cases.
• In complicated cases the following treatment is recommended:
Patient category Antibiotic treatment regime
B. Complicated form of scrub typhus at district and referral hospital levels

Treatment and Control of Scrub Typhus in Bhutan | 17

 All categories of a) Intravenous doxycycline (wherever available) 100mg twice daily in
patients 100 ml normal saline to be administered as infusion over half an hour
initially followed by oral therapy to complete 7-15 days of therapy.
OR
b) Intravenous Azithromycin in the dose of 500mg IV in 250 ml
normal saline over 1 hour once daily for 1-2 days followed by oral
therapy to complete 5 days of therapy.
OR
c) Intravenous chloramphenicol 50-100 mg/kg/d 6 hourly doses to
be administered as infusion over 1 hour initially followed by oral
therapy to complete 7-15 days of therapy.

d) Management of the individual complications should be done as

per the existing practices.
Source: Reproduced from DHR-ICMR Guidelines on Diagnosis and Management of
Rickettsial Diseases in India.

Please beware that resistant strains of O. tsutsugamushi to doxycycline and/or

chloramphenicol have been reported in South-East Asia. However, all these strains
are sensitive to Azithromycin.

13. SURVEILLANCE
A functional surveillance system is the most essential component of any public
health important disease prevention and control. The objectives of the scrub typhus
surveillance is to monitor changes of disease epidemiology (spatial and temporal
trends); detect outbreaks, understand socio-demographic risk factors, develop
evidence based the prevention and control plans, and evaluate effectiveness of
prevention and control measures of the program.

13.1 Surveillance systems

There are two surveillance systems in place for scrub typhus; passive surveillance
implemented by Health Management Information System and indicator and event
base surveillance system (NEWARS) implemented by Royal Centre for Disease Control
(RCDC).

13.1.1 Passive surveillance System

Health Management and Information System of the Ministry of Health
captures syndromic data for scrub typhus including mortality. The
data are collected by BHUs and hospitals and submitted to district
health office on monthly basis. The district health offices compile
these monthly reports and submit to the HMIS Unit at the Ministry of
Health on quarterly basis. The HMIS unit processes and analyzes the

18 | Treatment and Control of Scrub Typhus in Bhutan

 data, and publishes in the annual health bulletin.

13.1.2 Indicator and Event based surveillance system through National

Early Warning, Alert and Response Surveillance (NEWARS)
Indicator-based surveillance consists of 24 lists of National Notifiable
Diseases and syndromes where scrub typhus and rickettsiosis are
among those list of diseases and syndromes. The system involves
reporting of scrub typhus and rickettsiosis cases and deaths observed
at health facili­ties as per the case definition. If case is clinically
suspected of scrub typhus and positive by RDT/ELISA, the case should
be reported as scrub typhus. However, if case is clinically suspected
of scrub typhus but cannot perform RDT/ELISA and negative case
should be reported as rickettsiosis. The reporting is done in aggregate
under specific age group on weekly basis through web based and or
Short Message Service (SMS) online reporting system. Data obtained
are then analyzed, interpreted and disseminated through quarterly
disease surveillance bulletin to all health workers, policy makers and
relevant stakeholders.

Event Based Surveillance is ad-hoc reporting of cluster and unusual

cases of scrub typhus or rickettseosis. The reporting is done
immediately through web based and or Short Message Service
(SMS) online reporting system. For more details please refer NEWARS
guideline (available at: http://www.phls.gov.bt/web/guidelines-
manuals/)

13.1. 3 Sentinel surveillance

Based on Scrub typhus incidence reported in NEWARS, RCDC will
identify suitable sentinel sites for lab based surveillance sites to
characterize serotypes of scrub typhus and monitor the trend
of serotypes including the drug resistance pattern. The sentinel
surveillance will also include in-depth study of clinical profile, blood
parameters and risk factors based on need of evidences.

13.1. 4 Population-based survey

The routine surveillance systems will not be able to generate the
disease burden of scrub typhus for planning of effective prevention
and control measures including policy discussion. Therefore,
population-based sero-survey or study would be helpful to ascertain
true disease burden and also monitor or evaluate the prevention and
control measures of scrub typhus implemented by the programme.

Treatment and Control of Scrub Typhus in Bhutan | 19

 13.2 Case reporting

13.2.1 Case reporting through HMIS

All BHU’s, BHU-I and hospitals should detect scrub typhus as per the
case definition (Suspected/Clinical or Probable or confirmed) collect,
collate and report under rickettsial disease syndrome (as currently
practiced) monthly in the reporting format to district health office
and quarterly to HMIS.

13.2.2 Case reporting in NEWARS

At BHU’s level, any clinical suspected cases scrub typhus detected
as per the case definition should be collected, collated and report
WEEKLY either in web based or SMS online reporting system by
health workers in-charge of the BHU.

Any BHU-I, hospitals including referrals hospitals, any clinical

suspected cases or probable or laboratory confirmed cases of scrub
typhus detected should be collected, collated by health workers/
clinicians and submit to designated surveillance focal of the hospitals
who will then report WEEKLY either in web based or SMS.

13.2.3 Event/Outbreak reporting in NEWARS

Any cluster and increase in the number of scrub typhus cases
(more than normally expected) in a community, an area, or specific
occupational group of people, should be IMMEDIATELY reported
either in web based or SMS online reporting system by concerned
health workers/clinicians from BHU’s, BHU-I and hospitals including
referrals hospitals. The event reported will be verified and RCDC
will then either initiate or direct district health office for outbreak
investigation. The outbreak investigation of scrub typhus shall be
conducted as per the Disease Outbreak Investigation and Control
Manual of Ministry of Health 2015. (available at: http://www.phls.
gov.bt/web/guidelines-manuals/).

20 | Treatment and Control of Scrub Typhus in Bhutan

 Figure 6. Surveillance and reporting system of scrub typhus cases in Bhutan

14. PREVENTION AND CONTROL

14.1 Public Health Intervention

The public health intervention for prevention and control of scrub typhus is mainly
aimed at advocating hygienic personal protection and eliminating the carriers and
reservoirs of O. tsutsugamushi. As scrub typhus is common among the rural farming
population and other occupational groups such as students, army personnel,
housewives and cardamom workers at large. The public health intervention is
targeted at humans, environmental and rodent/animal levels.

Treatment and Control of Scrub Typhus in Bhutan | 21

 14.1.1 Human Level

14.1.1.1 Awareness Program

Strategy Phase Targeted Audience Favorable time of Materials and Contents

intervention methods
Public and Prevention and General public May-June every Posters, leaflets, Signs and symptoms,
communities are Control (farmers, students, year coordinated media, audio-visual, personal protection,
informed on how army personnel, by DHOs and radio jingles, video clips, environmental management,
they can prevent housewives, spearheaded by the panel discussions
rodent and vector control,
themselves from cardamom workers) Zoonoses Program,
scrub typhus DoPH, MoH early reporting
Health workers Prevention, All health workers Throughout the Training materials: Background on scrub typhus,
are informed on treatment and [Medical Officers, year workshops, Power public health importance,
what they can do control Specialists, COs/ points, posters, leaflets clinical presentation early
to prevent and HAs, Nurses (Clinical/
in Dzongkha & English management, as per the
treat scrub typhus staff ) & Laboratory
national guideline

22 | Treatment and Control of Scrub Typhus in Bhutan

through training personnel]
and supervision
 14.1.1.2 Personal protection
i. Protective clothing and personal hygiene:
• Wear full clothing while visiting bushy/scrubby areas or
undertaking general agricultural practices like working in
cardamom and paddy fields. Long trousers (tucked into socks/
gumboots) are preferable when “bush walking”.
• Changing and washing the clothes worn at work.
• Taking shower after visiting bushy areas or agricultural work.
• Avoid walking barefoot outdoors.
• Use a suitable mat or other ground cover while sitting or lying
(including resting babies) on the grassy grounds.

ii. Repellants
• Apply insect repellent (containing dibutyl phthalate, benzyl
benzoate, diethyl toluamide) to all exposed skin areas on the
legs, onto socks and bottom half of trousers.
• Avoid diethyl-3-methylbenzamide (DEET) if under 12 months.

14.1.1.3 Chemoprophylaxis

Chemoprophylaxis has a role in the prevention of Scrub Typhus but its use in
Bhutan needs to be evaluated further.

14.2 Environmental management

The favored ecotype of the chigger and rodents of O. tsutsugamushi are scrubby
vegetation consisting of low lying trees and bushes and also specific habitats such
as rice fields, cardamom plantations, poorly maintained kitchen gardens, abandoned
plantations, overgrown forest clearings, shrubby fringes of fields and forests, grassy
fields and river banks as it provides optimal conditions (mites prefer warm, moist, and
shady places) for the infected mites and rodents to thrive. These ecological patches
which attract the natural host of mite vectors are called “mite islands”.

The environmental management strategies that reduce or eliminate vector breeding

grounds are:
• Clearing bushes and vegetations around settlements by cutting the grasses close
to the ground to destroy mite islands.
• Judicious use of insecticides (spraying chemicals/fogging/fumigation and dusting
with chemical insecticides) e.g. Lindane or Chlordane to soil and vegetation.
• Maintaining good environmental sanitation and proper toilet facilities
• Proper garbage disposal to control rodent population and reduce ’mite islands’

Treatment and Control of Scrub Typhus in Bhutan | 23

 • Avoiding piling of woods inside and/or against the wall of the houses
• Avoiding stacking hay or fodder near the human dwellings
• Keeping animals away from human dwellings

14.3. Rodent and vector control

The vector for transmission of scrub typhus is the larval stage of trombiculid mite;
chigger phase. These larvae feed on wild rodents which are key to maintenance of
population density of chiggers. A clean living-environment and control of rodents
decreases the incidence of scrub typhus significantly.
14.3.1 Control strategies for rodents
• Good sanitation by regular cleaning of inside and outside of
buildings
• Trapping of rodents using baits and disposal of dead rodents
appropriately by placing them in plastic bags that are sealed
tightly.
• Natural predators (cats).
• Management of food and kitchen waste.
• Habitat modification (make habitat unsuitable for rodents):
i. Storing grains and vegetables at a height above 0.5 m and
away from the wall
ii. Fill holes and cracks in the walls.
iii. Remove trash every day to decrease food for rodents.

14.3.2 Control strategies for mites

• Remove overgrown weeds/grasses near houses, toilets and
along the roads
• Apply lindane and chlordane on ground and vegetation

24 | Treatment and Control of Scrub Typhus in Bhutan

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