Geographical distribution of scrub typhus and risk of Orientia tsutsugamushi infection in Indonesia: Evidence mapping

BackgroundScrub typhus is a potentially fatal acute febrile illness caused by bacteria in the genus Orientia. Though cases have been documented, a comprehensive body of evidence has not previously been compiled to give an overview of scrub typhus in Indonesia. This study aimed to address this key knowledge gap by mapping and ranking geographic areas based on existing data on the presence or absence of the pathogen in humans, vectors, and host animals. Methodology/Principal FindingsWe performed searches on local and international electronic databases, websites, libraries, and collections including Embase, Medline, and Scopus to gather relevant evidence (including grey literature). After extracting data on the presence and absence of the pathogen and its vectors, we ranked the evidence based on the certainty for the presence of human infection risk. The country was divided into subnational units, and each were assigned a score based on the evidence available for that unit. We presented this in an evidence map. Orientia tsutsugamushi presence has been identified on all the main islands (Sumatra, Java, Borneo, Celebes, Papua). About two thirds of the data points were collected before 1946. South Sumatra and Biak had the strongest evidence for sustaining infectious vectors. There was only one laboratory confirmed case in a human identified but 2,780 probable cases were documented. The most common vector was Leptotrombidium deliense. Conclusions/SignificanceOur review highlights the concerning lack of data on scrub typhus in Indonesia, the fourth most populous country in the world. The presence of seropositive samples, infected vectors and rodents confirm O. tsutsugamushi is widespread in Indonesia and likely to be causing significant morbidity and mortality. There is an urgent need to increase surveillance to better understand the burden of the disease across the archipelago and to inform national empirical fever treatment guidelines. Author summaryScrub typhus is a febrile illness common in the Asia Pacific area. It is caused by bacteria in the genus Orientia and spread via the bite of Trombiculid mites. While we know that scrub typhus is present in Indonesia, there is very limited information on how widespread the problem is. To address this problem, this study aimed to create a map of geographic areas that are at risk of scrub typhus by analysing existing data on human, mites, and other animals. By doing so, we hope to provide a better understanding of the extent and distribution of scrub typhus in Indonesia. Evidence of Orientia tsutsugamushi, has been reported from all the five main islands of Indonesia. South Sumatra and Biak had the strongest evidence. However, there was no evidence of presence or absence in about two thirds of the regions and most of the data points were collected before 1946. While the available data suggest that scrub typhus is prevalent in Indonesia, up-to-date information is lacking. Therefore, it is crucial to increase scrub typhus surveillance to improve our understanding of its burden and distribution, and eventually inform treatment strategies.