The incidence of Orientia tsutsugamushi infection in rural South India

Scrub typhus is a common bacterial infection in Asia caused by Orientia tsutsugamushi. This serological cohort study estimated the incidence of infection in a rural population in South India. Participants were enrolled through systematic sampling in 46 villages at baseline, and revisited the following year. Blood samples were tested for IgG antibodies using ELISA, followed by indirect immunofluorescence assays (IFA) in those positive for ELISA at both rounds. A case was defined as sero-conversion (ELISA), or at least a 4-fold titre increase (IFA), between the two time points. In addition to crude incidence rate estimates, we used piecewise linear rates across calendar months, with rates proportional to the monthly incidence of local hospital cases to address seasonality and unequal follow-up times. Of 402 participants, 61.7% were female. The mean age was 46.7 years, (range 13–88). 21 participants showed evidence for serological infection. The estimated incidence was 4.4 per 100 person-years (95% CI 2.8–6.7). The piecewise linear rates approach resulted in a similar estimate of 4.6 per 100 person years (95% CI 2.9–6.9). Considering previous estimates of symptomatic scrub typhus incidence in the same study population, only about 2–5% of infections may result in clinically relevant disease.