Based on the prevalence of antibody, an estimated 3% of the population of rural Malaysia is infected with Rickettsia tsutsugamushi each year, resulting in positive antibody rates in focal areas of 6 to 69%. Most of these infections do not appear to produce clinical scrub typhus. A wide range of seropositivity rates was found in areas otherwise resembling each other in predominant occupation, terrain, and nearby habitat. The prevalence rates however were significantly higher in people who worked in forested areas and significantly lower in people with urban occupations.
A serosurvey was conducted in 1995-97 among 1596 febrile patients from 8 health centres in Malaysia for antibodies against Orientia tsutsugamushi (OT), Rickettsia typhi (RT) and TT118 spotted fever group rickettsiae (SFGR) by using an indirect immunoperoxidase assay. A total of 51.4% patients had antibody against at least 1 of those rickettsiae. Antibody to SFGR was most prevalent (42.5%), followed by RT (28.1%) and OT (24.9%). The seroprevalences of antibodies to SFGR, RT or OT alone were 12.4, 3.6 and 4.3%, respectively. Antibodies against more than 1 species of rickettsiae were presence in 31.1% of the patients, suggesting the possibility of co-infection, previous exposures or serological cross-reactivities. Seroprevalence of the various rickettsiae varied according to locality, with SFGR antibodies being the most prevalent in most areas. There was no significant association of prevalence of rickettsial antibody with gender. The seroprevalence of OT, SFGR and RT increased with patient age but an increase of antibody titre with age was not significant. Those working in the agricultural sectors had significantly higher seroprevalence of OT, SFGR and RT than those not related with agricultural activities. Scrub typhus remains a public health problem with an estimated annual attack rate of 18.5%. Tick typhus and murine typhus as shown in this serosurvey appear much more widespread than scrub typhus in this country.
Malaysian, British and New Zealand soldiers were tested for evidence of infection with Rickettsia tsutsugamushi after several weeks' exposure to the infection during field exercises in Malaysia. 39 (5.0%) of 787 British and New Zealand soldiers developed immunofluorescent antibody (IFA) to R. tsutsugamushi to a titre of 1:50 and two (0.3%) to a titre of 1:100. 11 (1.5%) of 751 Malaysian soldiers also developed low titres less than or equal to 1:100. These low antibody levels were not correlated with clinical disease, and their significance is unknown. Seven (0.9%) of the Malaysians showed an IFA rise to greater than or equal to 1:200, and three of these experienced febrile illnesses, one lasting two weeks. An additional eight Malaysian soldiers had an IFA titre of greater than or equal to 1:400 when first tested and six of these also had a Proteus OXK agglutinin titre of greater than or equal to 1:160, indicating infection shortly before the study.
Serological surveillance for up to two years of 114 patients with laboratory confirmed scrub typhus showed that antibody to Rickettsia tsutsugamushi as demonstrated by the indirect fluorescent antibody test is short-lived. The mean reversion time from mean peak titre (1:499) was 48.9 weeks and the calculated annual reversion rate to a titre less than 1:50 was 61%. This can be used to estimate attack rates based on point prevalence of antibody. The relationship between antibody prevalence and attack rates observed by other workers was confirmed using this model. The possible uses of the finding and its implications in Malaysia are briefly discussed.
The overall comparisons of habitats are given in (Table III). The habitats are arranged in order of extent of alterations by man, with the least disturbed at the top. The highest average blood isolation rates came from the least disturbed areas. The highest monthly maximal rickettsial isolation rates from blood and maximal prevalence rates of antibody per month were also obtained at Bukit Lanjan, the habitat least altered by activities of man. The lowest average blood isolation rate (6%) and the lowest monthly maximal rickettsial isolation and antibody prevalence rates were obtained at Bukit Mandol, the habitat most extensively and intensively altered by man. The intermediate habitats had intermediate rates. We caution anyone interpreting these observations, however, in terms of human disease, which seem to be associated with hyperendemic foci. Here we are not dealing with hyperendemicity from the standpoint of human disease, but present evidence of widespread endemicity from which hyperendemic foci may derive. Also, we have not yet identified the prevalent strains and do not know their infectivity to man.
An explanation was sought for the disparity between the low reported incidence of scrub typhus and the high prevalence of antibody to Rickettsia tsutsugamushi in the rural population of Malaysia. A combination of isolation of the organism, titration of antibody by indirect immunofluorescence, and the Weil-Felix test was used to confirm infections. Scrub typhus was found to be very common, causing 23% of all febrile illnesses at one hospital. The infection was particularly prevalent in oil-palm workers, causing an estimated 400 cases annually in a population of 10,000 people living on one plantation. The clinical syndrome, whether mild or severe, was difficult to distinguish from that due to other infections. Eschars, rashes and adenopathy were uncommon. When used to examine early sera, the Weil-Felix test failed to confirm the diagnosis in most infections.20
Rickettsia tsutsugamushi isolations were attempted from blood samples obtained from rats captured in four adjacent habitats near Kuala Lumpur, Malaysia. Antibody surveys were also made. Rickettsial infections were most frequent in rats captured in the forest and in lalang grass (Imperata cylindrica) and least frequent in the most extensively disturbed habitat, an Orang Asli (aborigine) village. Forest rats such as Rattus sabanus (31%), as well as rats in the subgenus R. (Rattus), i.e. R. tiomanicus (26%) and R. argentiventer (35%) had frequent active infections. The house rat R. exulans had less frequent infections (15%). Frequency of antibody occurrence followed a similar pattern. No marked seasonal differences in the frequency of infections could be detected during the 18-month study.
Tropical typhus bears a close clinical resemblance to mild typhus fever, but it does not spread from man to man, nor does it give rise to epidemics. Lice are not the vectors of the virus. There are two kinds of tropical typhus, the W. form and the K. form. In the W. form, the serum agglutinates the ordinary strains of B. proteus X. 19, and Wilson's B. agglutinabilis, but it does not agglutinate the non-indologenic strain, Kingsbury. In the K. form the serum agglutinates the non-indologenic strain, Kingsbury, but it does not agglutinate the ordinary strains of B. proteus X. 19, or B. agglutinabilis.
The W. form of tropical typhus is a disease of the house and the town; the majority of those affected are indoor workers, such as clerks and shopkeepers, particularly those who deal with foodstuffs. MAXCY has found that the " endemic typhus " or Brill's disease of the United States, which is clinically identical with tropical typhus, has a similar distribution. The like is true of the typhus-like fever described by HONE in Australia which is probably the same disease as the W. form of tropical typhus.
The distribution of the K. form is very different, it is essentially a disease of the open country and affects outdoor workers. It has a patchy distribution and outbreaks occur particularly in areas which, after being cleared of jungle, are allowed to grow up in weeds and scrub. For this reason, we propose the name scrub-typhus for the K. form of tropical typhus. Some of the cases of typhus-like diseases described in India are probably the same as scrub-typhus.
An account is given of an outbreak of sixty-one cases of scrub-typhus on an oil-palm estate where cases of the tsutsugamushi disease had occurred among the European staff. This outbreak illustrates the limited distribution of the disease. Five adjacent estates, served by the same hospital, were unaffected, and the outbreak was confined almost entirely to one of the three Divisions of the oil-palm estate. This Division differed from the other two in being overrun with weeds and undergrowth, with which scrub-typhus is always associated. An attack appears to confer immunity. The cases occurred among the newly recruited labourers, those who had been on the estate for a long time escaped infection. Coolies recruited in the Federated Malay States were as susceptible as those from India, from which it appears that the Indian population of Malaya has not been generally exposed to infection. The outbreak consisted entirely of the K. form of tropical typhus (scrub-typhus); there were no cases of the W. form (? endemic typhus).
Attention is drawn to the relationship of scrub-typhus and the tsutsugamushi disease by the occurrence of the latter on the same estate. The tsutsugamushi disease of the East Indies and scrub-typhus both occur in circumscribed areas which are covered with undergrowth, and their symptoms are much alike There are, however, the following points of distinction : (a) The fever of tsutsugamushi does not end abruptly at the end of the second week as it does in scrub-typhus, nor is convalescence so rapid. (b) A primary sore and bubo are present in tsutsugamushi, but absent in scrub-typhus. (c) The titre of agglutination with B. proteus, Kingsbury, is low in the tsutsugamushi disease but very high in scrub-typhus. In some cases of the tsutsugamushi disease, the serum agglutinates B. proteus, Kingsbury, in higher dilutions than that of normal persons, but not to titres nearly so high as in scrub-typhus.
It is suggested that the two diseases have a similar ~etiology and that scrubtyphus, like the tsutsugamushi disease, is carried by trombiculae.
A short description of the tsutsugamushi disease is given, followed by a note on the conditions under which it occurs in Sumatra and the Malay States. Abandoned agricultural land which has grown up in weeds is particularly dangerous. Small rodents are the reservoirs of the virus which is carried from them to man by larval mites. Trombicula akamushi is the carrier in Japan, and T. deliensis in Sumatra. The disease has been conveyed to monkeys by inoculation and also by the bites of infected mites. A description is given of four mites which are commonly found in the ears of rats in the Malay States, and a method for the examination of the mites is described. Black rats, to the number of 130, were examined. Sixteen were trapped in an abandoned portion of an oil-palm estate where three Europeans became infected with the tsutsugamushi disease, and T. deliensis, the Sumatran carrier, was found on ten of them. Thirty rats were caught in other parts of the estate, and T. deliensis was found on nine. Thirty rats were caught in other rural districts, where the disease was not known, and T. deliensis was found on only one. Fifty-four rats caught in the town of Kuala Lumpur were examined, with the result that T. deliensis was found in none. The conclusion is reached that T. deliensis is probably the carrier in the Malay States, as it is in Sumatra.
The pathogenicity of Malaysian isolates of Orientia tsutsugamushi was investigated by a mouse virulence assay. The isolates could be differentiated as low (4 isolates), moderately (3 isolates) and highly virulent (2 isolates) based on the different responses in infected mice. No direct correlation between severity of human scrub typhus infections and virulence of the O. tsutsugamushi in mice was observed. Mice infected with virulent strains of O. tsutsugamushi showed splenomegaly, ascitis accumulation and enlargement of kidneys and livers whereas avirulent O. tsutsugamushi strains were asymptomatic and exhibited ruffled fur for a short period after infection. There was low antibody response in mice infected with isolates of low pathogenicity as compared with those of highly virulent isolates. Upon dissection of the infected mice, enlargement of mouse organs such as spleen, kidney and liver was noted. Presence of rickettsemia in mice was confirmed by the growth of O. tsutsugamushi in the L929 cells when inoculated with blood from infected mice. O. tsutsugamushi was also cultured from the peritoneal exudates of the infected mice. However, DNA of O. tsutsugamushi was only detected in the peritoneal exudates (by PCR) and blood (by cell culture) and not from other tissue samples.
The seroprevalence of various Orientia tsutsugamushi (OT) strains among Malaysian patients with suspected scrub typhus infections was determined using an indirect immunoperoxidase (IIP) assay. IgG against a single OT strain were detected in six sera (3 Karp, 1 Gilliam and 2 TC586), whereas IgM antibodies against a single OT strain (Gilliam) were noted in 3 sera (Gilliam). IgG reactive to all OT strains were present in 33 (47.1%) of the 70 sera and IgM reactive to all OT strains were present in 22 (78.6%) of the 28 sera. The fact that most sera were reactive to multiple OT strains suggests that group-specific antigens are involved in scrub typhus infections, whereas very few were due to strain-specific epitopes present on these strains. Peak IgG and IgM titers were noted more frequently against Gilliam, Karp, and TA763 strains: this suggests that these strains may be the commonest infecting strains among Malaysian patients. Two predominant OT polypeptides consistently reacted with patients' sera were the 70 kDa and 56 kDa proteins.
The seroprevalence of Orientia tsutsugamushi (OT), Rickettsia typhi (RT) and TT118 spotted fever group rickettsiae (SFGR) among blood donors and febrile Malaysian patients in the urban areas was determined. Of the 240 blood donors, 5.4%, 9.2% and 1.7% had either present or previous exposure to OT, RT and SFG rickettsiae, respectively. Patients admitted to an urban hospital had high seroprevalences of OT (43.5%) and RT (22.9%), as compared to SFGR (11.6%). Antibody levels suggestive of recent infections of scrub typhus, murine typhus and tick typhus were detected in 16.8%, 12.7% and 8.2% of patients respectively. No significant difference was noted in the distribution of rickettsial antibodies among urban patients from 2 geographical locations. However, the serologic patterns of rickettsial infection in the urban areas were different form those of rural areas.
Five pesticides were evaluated against laboratory colonies of Leptotrombidium fletcheri (Womersly and Heaslip) by the Pasteur pipet technique. The pesticides were dieldrin (LC50 = 3.6 ppm, LC99 = 18.2 ppm), bromopropylate (LC50 = 9.2 ppm, LC99 = 239.6 ppm), dicofol (LC50 = 27.8 ppm, LC99 = 118.1 ppm), fenthion (LC50 = 15.4 ppm, LC99 = 29.7 ppm), and malathion (LC50 = 84.7 ppm, LC99 = 313.9 ppm). Dieldrin was the most toxic. Dicofol was recommended for further evaluation in field trials.
A rapid diagnostic system for scrub typhus using nested polymerase chain reaction (PCR) was applied to clinical samples from Malaysian Aborigines. Whole blood from twenty-four patients suspected of scrub typhus infection were tested using nested polymerase chain reaction and sera were evaluated by the indirect immunoperoxidase test. Antibody responses towards Rickettsia tsutsugamushi were observed in seventeen patients with the majority having high titers of IgG antibodies. Seven patients were seronegative. The nested PCR amplified R. tsutsugamushi DNA from six patients, of which two were negative serologically and four had high titers of IgG antibodies. Second samples collected seven days after treatment were negative by PCR testing. Nested PCR is highly sensitive and specific and may be used to provide rapid confirmation of scrub typhus cases in endemic region.
An IgM dot-immunobinding assay (IgM-DIA) was developed for the diagnosis of scrub typhus infection. The whole cell antigens of Karp, Kato and Gilliam strains of Rickettsia tsutsugamushi were immobilized onto nitrocellulose paper and reacted with patients sera. The presence of IgM R. tsutsugamushi specific antibody in the patient sera could be detected by the observation of a visible brown dot on the nitrocellulose paper. The IgM-DIA has a sensitivity of 90.4% and specificity of 81.4% as compared to the indirect immunoperoxidase test. The IgM-DIA is rapid, simple, cost-effective, does not require microscope or incubator. It is recommended as a rapid screening test for the diagnosis of scrub typhus infection in the field or rural area within the hyperendemic region.
A seroepidemiological survey of 837 people and 383 febrile patients was performed in rural areas of Sabah. We determined that the rickettsial diseases scrub typhus and endemic typhus were uncommon causes of febrile illness, as was tick typhus, except in forest dwelling peoples. The rate of occurrence of SFGR specific antibody was 16.5% among 412 forest dwellers, indicating that tick typhus may be a frequent cause of illness in this population.