Discussion
Our findings suggest that there are over prescription of the test by the physicians. This is truer during the summer and autumn months where tests positive were proportionately low compared to the prescribed number of tests. The female gender is comparably more affected as opposed to male with 57.9% (n=44) of the positive cases being female. Our analysis shows that although the testing pattern differ across the months and seasons, the positive cases of the result are not determined by it. Proportionately, a smaller number of people were tested positive for high number of test prescriptions. The year 2019 noted significant scrub typhus cases accounting to 89.5%(n=68) of the total positive cases over the two years.
Bhutan has environmentally, climatically and occupationally favourable for transmission of scrub typhus infections. Zhemgang is the remotest and the least developed district in the country. In our study, the overall infection rate was 8.2% which is minimal compare to the study conducted in Nepal at Chitwan district in 20169. Panbang Hospital is located in lower altitude compare to Yebilaptsa and Zhemgang Hospital. It is a hot and humid place and share border with Indian state of Assam.A study conducted in Nepal indicate the potential cross-border transmission of scrub typhus infection, which may explain why Panbang has higher positive cases among the three health centres.
Scrub typhus infection is a public health problem in Bhutan. It remained silent after the first casein 2008. Adata-based research from 2009-2014 found that number of positive results increased over the years with the trend of seasons10. More female being tested positive in our study concurs with a study conducted in Himalayan region of India11 and that of Sri Lanka12. In rural Bhutan, females usually engaged more farm and livestock works than males which could be a possible explanation for this difference.
The seasonal variation in positive cases, although statistically not a significant predictor was shown to be higher in autumn and summer. Summer and autumn are the seasons for major farm works in rural Bhutan leading to increased exposure for outdoor activities. These are also the months of high rainfall with humid and hot climate compared to other seasons. This could explain the higher prevalence of the disease during these seasons. These findings are concurrent to the study from southern China describing climate variability of the Scrub Typhus13.
Through the years 2010 to 2014, scrub typhus was reported to be unknown among the health care workers in Bhutan. Our analysis showed high proportions of tests prescribed compared to the positive outcome. Other acutefebrile illnesses such as dengue and other rickettsialdiseasescan cause infectionssimilar to scrub typhus infection14. Physicians need to be clearly aware of the disease pathology and diagnosis mechanisms. This way over testing can be prevented and resources well utilized. Awareness of the Scrub Typhus and its diagnoses need to be reinforced. The programmatic approach to disease awareness, disease pathology and disease diagnosis must be reinforced among prescribing physicians. The field implementation must be enhanced in geographically and occupationally high risk of exposure groups.