The deadly scrub typhus has so far killed eight people in Himachal Pradesh, while 573 have tested positive. These cases are apparently just the proverbial tip of iceberg, as a large number of cases in remote rural areas of the state are not reported as patients fail to reach the state capital for treatment. The disease had killed 40 people in the state last year.
According to data provided by Integrated Disease Surveillance Programme (IDSP) officials, from May 1, 2013, to August 30 this year, 3,050 persons were tested for scrub typhus, of which 573 were found positive. Many cases are being treated out the state, for which records are not maintained here, they said.
At Indira Gandhi Medical College and Hospital (IGMCH) here, out of 1,086 samples tested, 357 were found positive. At Dr Rajendra Prasad Medical College and Hospital in Kangra, out of 482 samples tested, 111 were positive. Five deaths were reported during the period, sources said.
"Scrub typhus testing facility is available only at Indira Gandhi Medical College and Hospital, Shimla. This causes delayed diagnosis, which proves fatal for them," said a senior official of health department.
Official sources said that early detection can ensure timely treatment which is very cheap. But due to late diagnosis, patients end up at IGMCH or Dr Rajendra Prasad Medical College and Hospital, Tanda, in Kangra in a serious condition, while some are referred to PGI Chandigarh.
Two days back, the state government has issued orders to make the test facility available at Dr Rajendra Prasad Medical College and Hospital in Kangra, the health officials said. Machines required for the specialized tests have already reached Kangra and tests would be taken up there soon, they said.
IGM Alisa test is considered the most accurate to confirm the disease as it has over 90% sensitivity. The test is available only at IGMCH while weil-felix test is available in the districts. District health officials have now been directed to conduct Alisa test from the kits provided to them under the AIDS programme, they added.
While health minister Kaul Singh Thakur could not be reached for comments as he was busy in Delhi, health director Kulbhushan Sood said directions have been issued to field staff to administer doxycycline tablets to patients having high fever and headache. "We have already brought down the death rate almost to zero," he added.
Scrub typhus
Scrub typhus is transmitted by some species of trombiculid mites ("chiggers", particularly leptotrombidium deliense), which are found in areas with heavy scrub vegetation. The bite of this mite leaves a characteristic black eschar, which makes it easy for the doctor to diagnose the infection.
Symptoms: Fever, headache, muscle pain, cough and gastrointestinal problems.
Signs: Maculopapular rash, eschar, splenomegaly and lymphadenopathies.
Complications: Pneumonitis, encephalitis, and myocarditis occur in late phases of the illness.
Treatment
Without treatment, the disease is often fatal. Since the use of antibiotics, case fatalities have decreased from 4%–40% to less than 2%.
The drug most commonly used is doxycycline; but chloramphenicol is an alternative. Strains that are resistant to doxycycline and to chloramphenicol are common in northern Thailand. Rifampin and azithromycin are alternatives. Azithromycin is an alternative in children and pregnant women with scrub typhus, and when doxycycline-resistance is suspected. Ciprofloxacin cannot be used safely in pregnancy and is associated with stillbirths and miscarriage. Combination therapy with doxycycline and rifampicin is not recommended due to possible antagonism.
Other drugs that may be effective are clarithromycin, roxithromycin, and the fluoroquinolones, but there is no clinical evidence on which to recommend their use. Azithromycin or chloramphenicol is useful for infection in children or pregnant women.
