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.