On October 5th, 2015, the Epidemiology and Disease Control Division (EDCD) called a meeting to disseminate information about Scrub Typhus, an ascendant infectious disease in Nepal. It was about a field study jointly conducted by EDCD and WHO. Although Scrub Typhus was reported in Nepal in 2004, we have always underestimated its clinical significance.EDCD has now confirmed at least eight fatal cases of Scrub Typhus, while 75 have been reportedly infected. Cases have been reported from various parts of the country including Sankhuwasabha, Bhojpur, Khotang, Siraha, Dhading, Kailali and Kanchanpur districts. Scrub Typhus has recently been detected in Kathmandu, indicating that it continues to spread.
Scrub Typhus is transmitted by the bite of infected mite known as "Chigger" and has been seen in 2015 at various parts of India including Himalchal Pradesh, Kerala, Rajasthan, Karnataka and Tamil Nadu. Nearly one in 10 fever patients in Southern India is being identified with Scrub Typhus. It is most common during monsoon but the disease can also be seen during winter months and there have been several reported outbreaks of Scrub Typhus during the winter season in India. Clinicians as well as general public must therefore be aware of its early signs and symptoms.
These include sudden onset of high fever with chills, dry cough, flu-like symptoms, joints pain, rashes, red eye and swelling lymph nodes. Symptoms usually appear 5-20 days (average 10-12 days) after the bite of infected mite. These symptoms, however, overlap with other infectious diseases such as dengue, chikungunya, leptospirosis and typhoid. An Eschar, an inflammation of skin can be seen in Scrub Typhus, at the site of the bite, but may not always. Thus, finding mites and rats/mice can be helpful in confirming Scrub Typhus or identifying the source of the disease in reported areas. Accordingly, WHO and EDCD carried out field visits to reported districts and collected samples from patients, rats and parasitic organisms.
Test for Scrub Typhus is not routine in lab investigations. In fact, lab testing is not available in public or private hospitals in Nepal. Currently, confirmatory testing for Scrub Typhus is available only at the National Public Health Laboratory (NPHL). Accurate diagnosis, especially beyond the capital, is thus not possible. Although Weil-Felix, a serological test, is considered cheap, it has poor accuracy.
Chest x-ray can be helpful as patients with Scrub Typhus usually have higher rates of complications respiratory illnesses. Recently, many patients who died of respiratory complications in different parts of the country were later found to be suffering from Scrub Typhus.
If left untreated, it can lead to serious complications or even death. Complications such as including internal, heart related diseases (myocarditis), renal failure, encephalitis, jaundice, pneumonia with acute respiratory distress syndrome (ARDS) have been reported.
These complications usually appear after the first week of the illness. Since early diagnosis may not always be feasible, clinically suspected cases should be treated with appropriate antibiotics, which may prevent complications. It is thus important for health care providers to understand the trends of this disease.
In absence of vaccine against the Scrub Typhus, precaution is the best option, which includes wearing protective clothing to avoid mite bite; rats/mice control; and avoiding sitting on the ground or grass. After the devastating earthquake, people were forced to sleep outdoors, without adequate sheets/covers which brought them into contact with infected mites. Thus the government in coordination with other stakeholders must be better prepared to prevent future outbreaks. These include active surveillance, early detection and rats/mice control.
Currently, the government and WHO have jointly initiated surveillance in areas from where Scrub Typhus is being reported. This surveillance is mostly focused on rural areas. In fact, it has been given the alternative name of rural typhus. However, there has been an increase in the number of urban typhus infections.
Scrub Typhus was reported in Kathmandu in 2004, although it was not clear whether it was imported from rural areas. Recently, a patient with Scrub Typhus has been detected in Kathmandu, suggesting there might be other cases. Thus government and WHO must also give attention to private hospitals other than Sukraraj Tropical and Infectious Disease Hospital, a government hospital, to isolate Scrub Typhus in the capital.
Thankfully, human to human transmission or via contaminated blood has not yet been documented. Thus there is no need to panic, since it can spread only through infected mite bites, and is easily treatable. However, the risk of possible outbreak should not be underestimated, as Scrub Typhus has now already been established as one of the major emerging diseases in India.
The author is Medical Officer and Research Coordinator, Sukraraj Tropical and Infectious Disease Hospital
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