Dur brzuszny
Epidemiologia

Dur brzuszny (typhus) obejmuje trzy główne formy: epidemiczny (wszawy), endemiczny (mysi) oraz krzewiaczowy (scrub typhus), różniące się etiologią, epidemiologią i geograficznym zasięgiem. Dur epidemiczny występuje głównie w Ameryce Środkowej i Południowej, Afryce oraz Azji, z wysoką śmiertelnością w nieleczonych przypadkach (10-40%, wzrastającą do 60% u osób >50 lat). Dur endemiczny jest szeroko rozpowszechniony, zwłaszcza w ciepłych regionach przybrzeżnych USA (np. Teksas z ponad 6700 przypadkami w latach 2008-2023), z niską śmiertelnością (<4%). Dur krzewiaczowy, endemiczny w Azji i Pacyfiku, dotyka około miliona osób rocznie, z wskaźnikiem śmiertelności 6% u nieleczonych i 1,4% u leczonych, choć bez leczenia może sięgać 30-70%. Choroby wykazują sezonowość i są powiązane z czynnikami środowiskowymi, takimi jak higiena, kontakt ze zwierzętami i warunki sanitarne. W ostatnich latach obserwuje się rozszerzanie zasięgu geograficznego, zwłaszcza duru krzewiaczowego, poza tradycyjne obszary endemiczne, co wiąże się z globalizacją, zmianami klimatycznymi i urbanizacją.

  1. Dur brzuszny: Epidemiologia i nadzór
    1. Rozpowszechnienie geograficzne
    2. Zachorowalność i śmiertelność
    3. Sezonowość i trendy
    4. Czynniki ryzyka i grupy wysokiego ryzyka
  2. Systemy nadzoru i raportowanie
    1. Systemy krajowe i międzynarodowe
    2. Wyzwania w nadzorze i diagnostyce
    3. Inicjatywy w zakresie nadzoru
  3. Trendy i wyzwania epidemiologiczne
    1. Ponowne pojawienie się duru
    2. Wpływ zmian klimatycznych
    3. Rozszerzanie się zasięgu geograficznego
    4. Oporność na antybiotyki
  4. Strategie zapobiegania i kontroli
    1. Środki zapobiegawcze
    2. Edukacja i świadomość publiczna
    3. Znaczenie wczesnego wykrywania i leczenia
    4. Współpraca międzynarodowa i badania
  5. Wnioski i przyszłe kierunki
    1. Kolejne rozdziały

Dur brzuszny: Epidemiologia i nadzór

Dur brzuszny (typhus) stanowi istotne zagrożenie dla zdrowia publicznego, które historycznie odpowiadało za miliony zgonów na całym świecie. Chociaż obecnie jest rzadziej spotykany, w dalszym ciągu stanowi wyzwanie epidemiologiczne, szczególnie w określonych regionach geograficznych i populacjach ryzyka. W zależności od czynnika etiologicznego wyróżniamy trzy główne rodzaje duru: epidemiczny (wszawy), endemiczny (mysi) oraz wysypkowy krzewiaczowy (scrub typhus).12

Rozpowszechnienie geograficzne

Rozpowszechnienie geograficzne poszczególnych typów duru różni się znacząco:

  • Dur epidemiczny (wszawy) – występuje głównie w centralnej i południowej Ameryce, Afryce, północnych Chinach oraz niektórych regionach Himalajów. W Stanach Zjednoczonych odnotowano sporadyczne przypadki we wschodnich i centralnych częściach kraju, powiązane z ekspozycją na wiewiórki latające (Glaucomys volans).12
  • Dur endemiczny (mysi) – występuje na całym świecie, ale głównie w ciepłych regionach przybrzeżnych. W Stanach Zjednoczonych najwięcej przypadków notuje się w Teksasie (gdzie w latach 2008-2023 odnotowano ponad 6700 przypadków), Kalifornii i na Hawajach. W ostatnich 25 latach zaobserwowano ponowne pojawienie się tej choroby w wielu ośrodkach miejskich USA.123
  • Dur krzewiaczowy (scrub typhus) – endemiczny w regionie Azji i Pacyfiku, w tzw. trójkącie tsutsugamushi. Obszar ten obejmuje ponad 8 milionów km², od rosyjskiego Dalekiego Wschodu na północy, przez Pakistan na zachodzie, Australię na południu, po Japonię na wschodzie. Choroba zagraża miliardowi ludzi na całym świecie i powoduje zachorowania u miliona osób rocznie.12

Warto zauważyć, że w ostatnich latach odnotowano przypadki duru krzewiaczowego poza tradycyjnym obszarem endemicznym, w tym w Europie, Ameryce Południowej i na Bliskim Wschodzie, co sugeruje rozszerzanie się zasięgu geograficznego tej choroby.1

Zachorowalność i śmiertelność

Dane dotyczące zachorowalności na poszczególne rodzaje duru różnią się w zależności od regionu i dostępności systemów nadzoru:

  • Dur epidemiczny (wszawy) – według Światowej Organizacji Zdrowia w 2010 roku współczynnik śmiertelności z powodu duru wynosił około 1 na 5 milionów osób rocznie. Wskaźnik śmiertelności w przypadku nieleczonych infekcji wynosi 10-40%, przy czym śmiertelność wzrasta z wiekiem – rzadko występuje u dzieci poniżej 10 roku życia, ale może osiągać nawet 60% u osób powyżej 50 roku życia bez leczenia.12
  • Dur endemiczny (mysi) – zachorowalność jest prawdopodobnie znacznie niedoszacowana w regionach endemicznych. Śmiertelność jest niska – nawet bez leczenia nie przekracza 4% przypadków.12
  • Dur krzewiaczowy (scrub typhus) – szacuje się, że rocznie występuje około miliona przypadków na całym świecie. Analiza danych z kilku krajów azjatyckich wskazuje, że stanowi on około 25% wszystkich przypadków gorączki w niektórych regionach. Wskaźnik śmiertelności wynosi 6% dla pacjentów nieleczonych i 1,4% dla pacjentów leczonych, choć w niektórych badaniach wskazuje się na możliwość osiągnięcia śmiertelności nawet 30-70% bez odpowiedniego leczenia.12

Sezonowość i trendy

Występowanie duru często wykazuje wzorce sezonowe, różniące się w zależności od typu choroby i regionu:

  • Dur epidemiczny (wszawy) – wybuchy epidemii często występują w chłodniejszych miesiącach, gdy zakażona odzież nie jest prana.1
  • Dur endemiczny (mysi) – w Stanach Zjednoczonych przypadki mogą występować od kwietnia do lipca. W badaniach z Ameryki Łacińskiej zaobserwowano, że większość przypadków występuje w cieplejszych porach roku.12
  • Dur krzewiaczowy (scrub typhus) – w wielu regionach występuje sezonowo, z nasileniem w okresie monsunowym i po monsunowym (czerwiec-listopad). W północnej części prowincji Fujian w Chinach zaobserwowano dwa szczyty zachorowań – główny w czerwcu i lipcu oraz mniejszy w październiku i listopadzie.123

W ostatnich dekadach zaobserwowano wzrost liczby przypadków duru krzewiaczowego w wielu regionach Azji. Na przykład w Chinach zachorowalność wzrosła z 0,09/100 000 mieszkańców w 2006 roku do 1,93/100 000 w 2018 roku. Podobne trendy odnotowano w Tajlandii, Korei Południowej i Japonii.12

Czynniki ryzyka i grupy wysokiego ryzyka

Ryzyko zachorowania na dur jest związane z określonymi czynnikami środowiskowymi i demograficznymi:

  • Dur epidemiczny (wszawy) – występuje najczęściej wśród osób żyjących w przeludnionych, niehigienicznych warunkach, takich jak obozy dla uchodźców czy więzienia. Historycznie epidemie duru występowały w czasach wojny i deprywacji, na przykład w niemieckich obozach koncentracyjnych podczas II wojny światowej.12
  • Dur endemiczny (mysi) – związany z przeludnieniem, zanieczyszczeniem i złą higieną. W badaniach przeprowadzonych wśród bezdomnych w Houston i Marsylii wykryto wysokie wskaźniki seroprewalencji R. prowazekii i R. typhi.12
  • Dur krzewiaczowy (scrub typhus) – czynniki ryzyka obejmują pracę w rolnictwie, lokalizację toalet i kuchni na zewnątrz, obecność zwierząt w domu, nieużytki i pola ryżowe w pobliżu miejsc zamieszkania, brak środków ochrony przed gryzoniami, suszenie ubrań na krzewach oraz chodzenie boso. W badaniach z Korei zaobserwowano, że choroba częściej dotyka kobiet, prawdopodobnie ze względu na ich większe zaangażowanie w prace ogrodowe, co zwiększa ekspozycję na roztocza.12

W przypadku duru krzewiaczowego w Chinach zaobserwowano, że średni wiek pacjentów stopniowo wzrósł z 54 lat w 2012 roku do 59 lat w 2018 roku. Ogólnie 72,6% pacjentów mieszkało na obszarach wiejskich, a rolnicy i emeryci stanowili główne grupy zawodowe wśród chorych.1

Systemy nadzoru i raportowanie

Systemy krajowe i międzynarodowe

Systemy nadzoru nad durem różnią się w zależności od kraju i typu choroby:

  • Stany Zjednoczone – Obecnie dur krzewiaczowy, dur mysi i dur epidemiczny nie są chorobami podlegającymi obowiązkowemu zgłaszaniu na poziomie krajowym, chociaż poszczególne stany mogą wymagać zgłaszania. CDC przyjmuje próbki do badań w kierunku chorób riketsyjnych, w tym gorączek durowych, ale próbki powinny być przesyłane za pośrednictwem lokalnych departamentów zdrowia.1
  • Azja – Dur krzewiaczowy jest chorobą podlegającą obowiązkowemu zgłaszaniu w Bhutanie, Chinach, Japonii, Korei Południowej, Tajlandii i na Tajwanie. W Chinach wszystkie przypadki duru krzewiaczowego muszą być zgłaszane do Chińskiego Centrum Kontroli i Zapobiegania Chorobom.12
  • Europa – W Irlandii dur jest chorobą podlegającą obowiązkowemu zgłaszaniu.1

W Indiach zintegrowany program nadzoru nad chorobami (IDSP) monitoruje trendy chorób o potencjale epidemicznym w celu wczesnego reagowania na wybuchy epidemii. W stanie Mizoram w północno-wschodnich Indiach, w odpowiedzi na gwałtowny wzrost zachorowań na dur krzewiaczowy, rząd zintegrował badania przesiewowe i rejestrację przypadków duru krzewiaczowego i innych infekcji riketsyjnych we wszystkich placówkach opieki zdrowotnej, co jest pierwszym takim działaniem w Indiach.12

Wyzwania w nadzorze i diagnostyce

Nadzór nad durem napotyka na szereg wyzwań:

  • Ograniczona diagnozowanie i raportowanie – Dur jest często niedodiagnozowany lub błędnie diagnozowany ze względu na niespecyficzne objawy początkowe, które często przypominają inne choroby gorączkowe. Prowadzi to do niedoszacowania rzeczywistego obciążenia chorobą.12
  • Ograniczona dostępność diagnostyki laboratoryjnej – W Chinach w latach 2006-2016 odsetek przypadków duru krzewiaczowego potwierdzonych laboratoryjnie wynosił zaledwie 4,7%, przy czym wartość ta spadła z 16,3% w 2006 roku do 2,6% w 2016 roku.1
  • Opóźniona diagnoza – Opóźniona diagnoza duru krzewiaczowego zwiększa ryzyko zgonu. W Chinach mediana czasu od wystąpienia objawów do diagnozy zmniejszyła się z siedmiu dni w 2006 roku do pięciu dni w 2016 roku.1

Wyzwania te podkreślają potrzebę poprawy świadomości wśród pracowników służby zdrowia, zwiększenia dostępności diagnostyki laboratoryjnej oraz wzmocnienia systemów nadzoru.1

Inicjatywy w zakresie nadzoru

W odpowiedzi na rosnące zagrożenie durem, wiele krajów wdrożyło lub wzmocniło systemy nadzoru:

  • Tajwan – Nadzór nad durem endemicznym na Tajwanie obejmuje krajowy system statystyk chorób zakaźnych oraz samozgłaszanie za pośrednictwem bezpłatnej infolinii 1922 lub lokalnych organów zdrowia publicznego.1
  • Indie – W dystrykcie Alwar w Radżastanie wdrożono system nadzoru nad durem krzewiaczowym, obejmujący zarówno nadzór aktywny, jak i bierny. Zalecenia obejmują regularne monitorowanie raportów nadzoru i rejestrów na poziomie bloku i dystryktu oraz zapewnienie terminowego zgłaszania przypadków duru krzewiaczowego za pośrednictwem IDSP.1
  • Tajlandia – Krajowy system nadzoru w Tajlandii wykazał znaczny wzrost zgłaszanych przypadków duru krzewiaczowego w latach 2003-2018, co podkreśla znaczenie ciągłego nadzoru.1

Wczesne wykrywanie przypadków zakażeń poprzez systemy nadzoru aktywnego i biernego może przyczynić się do wdrożenia wczesnych działań interwencyjnych i zmniejszenia ryzyka lokalnej transmisji.1

Trendy i wyzwania epidemiologiczne

Ponowne pojawienie się duru

W ostatnich dekadach zaobserwowano ponowne pojawienie się duru w wielu regionach świata:

  • Dur endemiczny (mysi) – W ostatnich 25 latach dur mysi pojawił się ponownie z dużą siłą w wielu ośrodkach miejskich w Stanach Zjednoczonych. W południowym Teksasie, Kalifornii i Meksyku odnotowano wzrost liczby przypadków, co podkreśla ponowne pojawienie się patogenu w tych regionach.12
  • Dur krzewiaczowy (scrub typhus) – W ostatniej dekadzie przypadki duru krzewiaczowego zgłaszano w całych Indiach, nawet w regionach, które wcześniej nie miały historii tej choroby. W Mizoram w północno-wschodnich Indiach odnotowano gwałtowny wzrost zachorowań na dur krzewiaczowy w ostatnich pięciu latach.12

Ponowne pojawienie się duru przypisuje się różnym czynnikom, w tym zmianom klimatycznym, wylesianiu, urbanizacji, zwiększonej mobilności ludności oraz lepszemu wykrywaniu i raportowaniu przypadków.12

Wpływ zmian klimatycznych

Zmiany klimatyczne mogą mieć wpływ na zwiększoną częstość występowania duru:

  • W badaniu z Korei Południowej wykazano korelację między zachorowalnością na dur krzewiaczowy a elementami klimatycznymi zmienionymi przez globalne ocieplenie.1
  • W Tajlandii wzrost średniej miesięcznej temperatury z 24,5°C w 2003 roku do 25,5°C w 2018 roku korelował ze wzrostem zachorowalności na dur krzewiaczowy, co sugeruje wpływ zmian klimatycznych na obciążenie chorobą.1

Regiony tropikalne mają odpowiednie temperatury i wilgotność dla aktywności roztoczy i utrzymania patogenu w transmisji transowarialanej i transstadialnej w roztoczach.1

Rozszerzanie się zasięgu geograficznego

Obserwuje się rozszerzanie zasięgu geograficznego duru krzewiaczowego poza tradycyjny obszar endemiczny:

  • W ostatnich czasach choroba pojawiła się w innych obszarach nieendemicznych, takich jak Europa, Chile, Peru, Bliski Wschód i Afryka, czasami z innym gatunkiem bakterii, jak O. chuto obserwowana na Bliskim Wschodzie.1
  • Globalizacja i zwiększone podróżowanie przyczyniły się do rozprzestrzeniania się zakażonych osób na obszary poza regionami endemicznymi, zwiększając obawy o szerszy zasięg duru krzewiaczowego.1

Analiza powierzchni trendu pokazała, że zachorowalność na dur krzewiaczowy w Chinach wzrasta stopniowo z północy na południe oraz ze wschodu i zachodu do centralnej części kraju.1

Oporność na antybiotyki

Rosnąca oporność na antybiotyki stanowi poważne wyzwanie w kontroli duru:

  • Ponowne pojawienie się i geograficzne rozprzestrzenianie się duru krzewiaczowego w regionie Azji i Pacyfiku, a także wzrost oporności na antybiotyki, przypomina o pilnej potrzebie opracowania i przyjęcia skutecznych środków kontroli i zapobiegania.1
  • Eksperci uważają, że nastąpi ponowne pojawienie się choroby w związku z opornością na antybiotyki, wylesianiem i globalnym ociepleniem.1

Strategie zapobiegania i kontroli

Środki zapobiegawcze

Zapobieganie poszczególnym typom duru koncentruje się na kontroli wektorów i poprawie warunków sanitarnych:

  • Dur epidemiczny (wszawy) – Zapobieganie obejmuje dobrą higienę, czyste warunki życia i unikanie kontaktu z odzieżą zarażoną wszami.1
  • Dur endemiczny (mysi) – Zapobieganie jest bezpośrednio związane z kontrolą pcheł. Regularna kontrola pcheł jest zalecana w celu zmniejszenia ryzyka przenoszenia przez pchły do ludzi. Można zmniejszyć ryzyko zachorowania na dur mysi, unikając kontaktu z pchłami, na przykład poprzez zapewnienie ochrony przed pchłami dla zwierząt domowych oraz trzymanie gryzoni z dala od domu i miejsca pracy.123
  • Dur krzewiaczowy (scrub typhus) – Niektóre kraje, w tym Chiny, Korea, Japonia i Tajlandia, wdrożyły środki zapobiegawcze, takie jak kontrola gryzoni, stosowanie środków owadobójczych i systemy nadzoru.1

Populacja Laredo powinna być świadoma, że obecność zakażonych riketsją pcheł Xenopsyllia cheopis i Ctenocephalides felis, rozwój warunków środowiskowych zwiększających możliwość kontaktu dzikich i domowych zwierząt z ludźmi, może również zwiększyć możliwość manifestacji choroby.1

Edukacja i świadomość publiczna

Zwiększanie świadomości publicznej na temat duru jest kluczowym elementem strategii kontroli:

  • Niskie wskaźniki zgonów z powodu duru krzewiaczowego w Mizoram mogą być przypisane świadomości publicznej i organizacji szybkiej diagnostyki i leczenia – kluczowym inicjatywom odpowiednich departamentów zdrowia.1
  • Sprostanie ograniczeniom w diagnostyce i leczeniu duru krzewiaczowego wymaga wielostronnego podejścia, w tym zwiększenia świadomości wśród pracowników służby zdrowia i społeczeństwa, poprawy narzędzi diagnostycznych, opracowania nowych i skutecznych metod leczenia oraz wzmocnienia środków kontroli wektorów.1

W przypadku duru krzewiaczowego w południowych Chinach wyniki badań dostarczyły aktualnej wiedzy, która może umożliwić decydentom w zakresie zdrowia publicznego sformułowanie odpowiednich środków zapobiegania durowi krzewiaczowemu, a pracownikom medycznym przeprowadzenie ukierunkowanego postępowania w celu rozpoznania i leczenia ciężkich przypadków duru krzewiaczowego.1

Znaczenie wczesnego wykrywania i leczenia

Wczesne wykrywanie i leczenie ma kluczowe znaczenie dla zmniejszenia powikłań i śmiertelności związanej z durem:

  • Wielkim klinicznym i zdrowotnym wyzwaniem duru krzewiaczowego jest trudność w jego diagnozie, zwłaszcza wczesnej diagnozie. Wczesna diagnoza i wczesne leczenie mogą znacznie zmniejszyć powikłania i wskaźnik śmiertelności spowodowany przez Orientia.1
  • Rokowanie w przypadku duru krzewiaczowego jest ściśle związane z szybką diagnozą. Dlatego poprawa zrozumienia duru krzewiaczowego, zmniejszenie błędnych diagnoz i poprawa wczesnej diagnozy jest kluczem do leczenia.1

Badania wskazują, że średni wskaźnik śmiertelności dla pacjentów nieleczonych wynosi 6%, a dla pacjentów leczonych 1,4%, co podkreśla znaczenie wczesnej interwencji.1

Współpraca międzynarodowa i badania

Współpraca międzynarodowa i ciągłe badania są niezbędne do skutecznej kontroli duru:

  • Duża badanie kohortowe mające na celu dostarczenie podstawowych danych epidemiologicznych na temat transmisji duru krzewiaczowego, częstej choroby gorączkowej w Azji i innych częściach świata, pomaga lepiej zrozumieć epidemiologię, diagnostykę, leczenie i kontrolę duru krzewiaczowego.1
  • Badania te przyniosą korzyści populacjom regionów dotkniętych durem krzewiaczowym poprzez wpływ na postępowanie w przypadkach duru krzewiaczowego i zwiększenie świadomości w odniesieniu do występowania tej potencjalnie śmiertelnej choroby, która jest obecnie niedodiagnozowana.1

Ekonomiści zdrowia i specjaliści ds. zdrowia publicznego będą wykorzystywać te dane do obliczania regionalnego i globalnego obciążenia chorobą z powodu zakażenia durem krzewiaczowym i odpowiedniego przydzielania zasobów klinicznych i zdrowia publicznego.1

Wnioski i przyszłe kierunki

Dur pozostaje poważnym problemem zdrowia publicznego w wielu częściach świata, mimo znacznego postępu w jego kontroli i leczeniu. Ponowne pojawienie się duru w regionach, które wcześniej nie były endemiczne, rozprzestrzenianie się geograficzne poza tradycyjne obszary endemiczne oraz rosnąca oporność na antybiotyki podkreślają potrzebę ciągłej czujności, badań i współpracy międzynarodowej.12

Systematyczna diagnostyka i nadzór pomogły zidentyfikować prawdziwe obciążenie tymi infekcjami, które mogłyby łatwo pozostać niewykryte lub błędnie zdiagnozowane. Badania podkreślają znaczenie integracji badań przesiewowych w kierunku chorób riketsyjnych na poziomie okręgowym we wszystkich ośrodkach zdrowia.1

Przyszłe kierunki w epidemiologii i nadzorze nad durem powinny obejmować:

  • Wzmocnienie systemów nadzoru, szczególnie w regionach endemicznych i tych o rosnącej liczbie przypadków
  • Poprawę diagnostyki laboratoryjnej i zwiększenie dostępności testów diagnostycznych
  • Rozszerzenie edukacji i świadomości publicznej na temat duru i jego zapobiegania
  • Prowadzenie dalszych badań nad wpływem zmian klimatycznych na epidemiologię duru
  • Opracowanie skutecznych szczepionek, szczególnie przeciwko durowi krzewiaczowemu, uwzględniających różnorodność antygenową szczepów
  • Wzmocnienie współpracy międzynarodowej w zakresie nadzoru, badań i kontroli duru

W kontekście zmieniających się warunków klimatycznych i ponownego pojawiania się duru na całym świecie, regularne nadzorowanie jest konieczne, aby monitorować zmieniające się trendy w społeczności.1

Kolejne rozdziały

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Wybierz kolejny rozdział z menu poniżej, aby otworzyć nową podstronę kompedium wiedzy i uzyskać szczegółowe informację o leku, substancji lub chorobie.

  1. 13.04.2026
  2. www.leksykon.com.pl

Materiały źródłowe

  • #1 Typhus – Epidemiology
    https://www.vdh.virginia.gov/epidemiology/epidemiology-fact-sheets/typhus/
    Epidemic typhus, also called louse-borne typhus, is disease caused by a bacteria called Rickettsia prowazekii. While previously responsible for considerable illness worldwide, it is now considered rare. […] Murine typhus, also called endemic typhus or flea-borne typhus, is a disease caused by a bacteria called Rickettsia typhi. Murine typhus is spread to people through contact with infected fleas. People get sick with murine typhus when infected flea feces are rubbed into cuts or scrapes in the skin. Most cases of murine typhus in the United States are reported in people from California, Hawaii, and Texas. In most areas of the world, rats are the main animal host for fleas infected with murine typhus. […] The diagnosis of typhus depends on the type, but is often based on signs and symptoms of illness, as well as laboratory tests of skin or blood.
  • #1 Typhus: Background, Pathophysiology, Epidemiology
    https://emedicine.medscape.com/article/231374-overview
    Epidemic typhus occurs in Central and South America, Africa, northern China, and certain regions of the Himalayas. Outbreaks may occur when conditions arise that favor the propagation and transmission of lice (crowding and lack of sanitation). Brill-Zinsser disease develops in approximately 15% of people with a history of primary epidemic typhus. […] Sporadic cases of active infection with R prowazekii, the etiologic agent of epidemic typhus, have been reported. These occurred in the central and eastern portions of the United States and have been linked with exposure to flying squirrels (Glaucomys volans). […] In the last decades, there has been an increase in murine typhus cases in South Texas, which may reflect a re-emergence of R typhi in the rat population and/or a cycle involving opossums and cats.
  • #1 Murine Typhus: A Re-emerging Threat in the United States | COCA | CDC
    https://www.cdc.gov/coca/hcp/trainings/murine-typhus.html
    During this COCA Call, presenters will review the epidemiology, diagnosis, and treatment of murine typhus, and discuss its re-emergence in the United States. […] However, during the last 25 years, murine typhus has re-emerged with a vengeance across multiple urban centers in the United States. […] Discuss the epidemiology and ecology of murine typhus.
  • #1 A review of the global epidemiology of scrub typhus
    https://pmc.ncbi.nlm.nih.gov/articles/PMC5687757/
    Scrub typhus is a serious public health problem in the Asia-Pacific area. It threatens one billion people globally, and causes illness in one million people each year. […] The antigenic heterogeneity of O. tsutsugamushi precludes generic immunity and allows reinfection. As a neglected disease, there is still a large gap in our knowledge of the disease, as evidenced by the sporadic epidemiologic data and other related public health information regarding scrub typhus in its endemic areas. Our objective is to provide a systematic analysis of current epidemiology, prevention and control of scrub typhus in its long-standing endemic areas and recently recognized foci of infection. […] The traditional endemic area of scrub typhus is known as the tsutsugamushi triangle. It is a region covering more than 8 million km2, from the Russian Far East in the north, to Pakistan in the west, Australia in the south, and Japan in the east. There are one billion people at risk of infection; the endemic area is highly populated.
  • #1 Rising Menace of Scrub Typhus – Current Status and Challenges – Journal of Pure and Applied Microbiology
    https://microbiologyjournal.org/rising-menace-of-scrub-typhus-current-status-and-challenges/
    In recent times, the disease has surfaced in other non-endemic areas like Europe, Chile, Peru, Middle East, African peninsula and sometimes with a different species of the bacteria, like O.chuto seen in the Middle East. […] The gold standard diagnostic test has its problems. […] There is a gap of a decade in the research into this entity. Thus, a new look into the disease, its epidemiology and the challenges in its diagnostic scenario is an apt topic for discussion. […] Diagnosis is based on clinical suspicion with appropriate lab investigation. […] The median case fatality rate is reduced to 1.4% in treated patients from 6% seen in late or untreated ones. […] The treatment options for scrub typhus are- doxycycline and tetracycline. […] Different localities have different antigenic variants of O. tsutsugamushi strains showing no to weak cross-protection. Thus, an effective vaccine for scrub typhus must account for multiple strains thriving in the population. […] Despite its long presence, there needs to be more data citing its actual prevalence, serotypes involved and determinants of clinical course, especially in India.
  • #1 Typhus – Wikipedia
    https://en.wikipedia.org/wiki/Typhus
    According to the World Health Organization, in 2010 the death rate from typhus was about one of every 5,000,000 people per year. […] Only a few areas of epidemic typhus exist today. Since the late 20th century, cases have been reported in Burundi, Rwanda, Ethiopia, Algeria, and a few areas in South and Central America. […] Except for two cases, all instances of epidemic typhus in the United States have occurred east of the Mississippi River. An examination of a cluster of cases in Pennsylvania concluded the source of the infection was flying squirrels. Sylvatic cycle (diseases transmitted from wild animals) epidemic typhus remains uncommon in the US. The Centers for Disease Control and Prevention have documented only 47 cases from 1976 to 2010. An outbreak of flea-borne murine typhus was identified in downtown Los Angeles, California, in October 2018.
  • #1 Typhus: Background, Pathophysiology, Epidemiology
    https://emedicine.medscape.com/article/231374-overview
    Murine typhus occurs mainly in sporadic cases, and incidence probably is greatly underestimated in the more endemic regions. […] The incidence of scrub typhus is largely unknown, although it is estimated to be 1 million cases per year worldwide. Many cases are undiagnosed because of its nonspecific manifestations and the lack of laboratory diagnostic testing in endemic areas. […] Finally, experts believe there will be a re-emergence of disease in relation to antibiotic resistance, deforestation and global warming.
  • #1 A review of the global epidemiology of scrub typhus
    https://pmc.ncbi.nlm.nih.gov/articles/PMC5687757/
    The geographic distribution of scrub typhus is determined by the distribution of its vector and reservoir mites, primarily of the genus Leptotrombidium. Humans are accidental hosts. […] Scrub typhus has been a nationally notifiable disease in Bhutan, China, Japan, South Korea, Thailand, and Taiwan. […] The case fatality rate of scrub typhus varies among different countries, regions, and areas as well as different studies. The case fatality can be up to 30-70% if no appropriate treatment is received while the median case fatality rate for untreated patients is 6% and for treated patients is 1.4%. […] The reemergence and geographic expansion of scrub typhus in the Asia-Pacific area as well as the increase in antibiotic resistance reminds us of the urgency of developing and adopting effective control and preventive measures. […] The great clinical and public health challenge of scrub typhus is its difficulty in diagnosis, especially early diagnosis. Early diagnosis and early treatment can significantly reduce the complications and fatality rate caused by Orientia.
  • #1 Department of Agriculture | Typhus Fever – Rickettsia prowazekii
    https://www.nj.gov/agriculture/divisions/ah/diseases/typhus.html
    R. prowazekii is not transmitted from person to person. […] Epidemics of typhus usually occur where louse populations are high. Infections are typically seen in populations living in unsanitary, crowded conditions; outbreaks are often associated with wars, famines, floods and other disasters. […] The overall case fatality rate for untreated infections is 10 to 40%; the mortality rate increases with age. Infections are rarely fatal in children less than 10 years old; in people over 50 years old, the mortality rate can be as high as 60% without treatment. […] Surveillance and reporting guidelines for typhus.
  • #1 Typhus | AustinTexas.gov
    https://www.austintexas.gov/department/typhus
    Typhus prevention is directly related to flea control. The Epidemiology and Disease Surveillance Unit monitors the incidence of confirmed and probable typhus cases reported to the Austin/Travis County Health and Human Services Department and issues periodic updates of the status of the investigations. […] Murine or flea-borne typhus is endemic (regularly found) in Travis County. […] Cases can occur in April through July.
  • #1 Epidemiological and clinical characteristics of scrub typhus in northern Fujian, China, from 2015 to 2019 | BMC Infectious Diseases | Full Text
    https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-023-08451-1
    This study aimed to analyze the epidemiological and clinical characteristics of scrub typhus in northern Fujian Province on the southeast coast of China. […] The epidemic characteristics were analyzed, such as the annual number of cases, age distribution, sex distribution, and seasonal distribution in each region. […] Scrub typhus showed two peaks north of Fujian; the prominent peak was from June to July, and the other slight rise was from October to November. […] The main diagnostic methods in this area are based on specific eschar and epidemiology, while the positive rate of the Weil-Felix test is low. […] The results of this study can guide primary care institutions to improve the level of diagnosis and treatment of scrub typhus and take effective public health intervention measures in endemic areas.
  • #1 Epidemiologic changes of a longitudinal surveillance study spanning 51 years of scrub typhus in mainland China | Scientific Reports
    https://www.nature.com/articles/s41598-024-53800-y
    Scrub typhus may be one of the worlds most prevalent, neglected and serious, but easily treatable, febrile diseases. It has become a significant potential threat to public health in China. In this study we used national disease surveillance data to analyze the incidence and spatialtemporal distribution of scrub typhus in mainland China during 19521989 and 20062018. Descriptive epidemiological methods and spatialtemporal epidemiological methods were used to investigate the epidemiological trends and identify high-risk regions of scrub typhus infection. Over the 51-year period, a total of 182,991 cases and 186 deaths were notified. The average annual incidence was 0.13 cases/100,000 population during 19521989. The incidence increased sharply from 0.09/100,000 population in 2006 to 1.93/100,000 population in 2018 and then exponentially increased after 2006. The incidence was significantly higher in females than males (2=426.32, P0.001). Farmers had a higher incidence of scrub typhus than non-farmers (2=684.58, P0.001). The majority of cases each year were reported between July and November with peak incidence occurring during October each year. The trend surface analysis showed that the incidence of scrub typhus increased gradually from north to south, and from east and west to the central area. The spatial autocorrelation analysis showed that a spatial positive correlation existed in the prevalence of scrub typhus on a national scale, which had the characteristic of aggregated distribution (I=0.533, P0.05). LISA analysis showed hotspots (HighHigh) were primarily located in the southern and southwestern provinces of China with the geographical area expanding annually. These findings provide scientific evidence for the surveillance and control of scrub typhus which may contribute to targeted strategies and measures for the government.
  • #1 Epidemic Typhus Fever (louse-borne) – Epidemiology
    https://www.vdh.virginia.gov/epidemiology/epidemiology-fact-sheets/epidemic-typhus-fever-louse-borne/
    Epidemic typhus fever occurs most commonly among people living in overcrowded unhygienic conditions, such as refugee camps or prisons. […] The disease is spread by human body lice infected with the bacteria that cause epidemic typhus fever. […] The way that the disease is spread from flying squirrels to humans is not well understood. […] The diagnosis of epidemic typhus fever is based on signs and symptoms of illness, as well as laboratory tests of skin or blood. […] Prevention involves good hygiene, clean living conditions, and avoiding contact with lice-infested clothing. […] The bacteria that cause epidemic typhus fever are considered possible bioterrorism agents because the organism can remain alive in lice feces for weeks and can be made into aerosols that, if breathed in, could cause disease.
  • #1
    https://pmc.ncbi.nlm.nih.gov/articles/PMC4001937/
    Rickettsia typhi is an intracellular bacteria who causes murine typhus. His importance is reflected in the high frequency founding specific antibodies against Rickettsia typhi in several worldwide seroepidemiological studies, the seroprevalence ranging between 3-36%. This infection is associated with overcrowding, pollution and poor hygiene. This disease is endemic in temperate climates and especially in coastal areas. In the United States, Asia, Australia, México and Spain. It has been shown by studies of incidence of this disease in different countries, which are seasonal, in which the majority of cases occurring in a year is higher during warm weather, while cold weather, infection is very low or almost zero. This disease occurs in all age groups and is relatively common in children. As regards distribution by sex, race and occupation of patient no significant differences, although people living in rural or disadvantaged areas are more prone to infection. In America, there are records of this disease caused by Rickettsia typhi in Mexico since 1928. Currently there have been reports of the presence of Rickettsia typhi in America in countries like Brazil in 2005, which reports the presence of rickettsial antibodies to Rickettsia typhi in a rural community as well as other Rickettsia and Rickettsia rickettsii, causal agent of Rocky Mountain Spotted Fever. The importance about these studies is the presence of R. typhi in the population which has already been infected possibly being misdiagnosed.
  • #1 The Epidemiology of Scrub typhus in Thiruvarur, Tamil Nadu | medRxiv
    https://www.medrxiv.org/content/10.1101/2024.12.06.24317365v1
    National Vector-Borne Disease Control Programme (NVBDCP) under the National Center for Vector Borne Diseases Control (NCVBDC), Govt. of India, Delhi has put forth efforts to combat diseases transmitted by vectors, under the overarching umbrella of the National Health Mission (NHM). […] Scrub typhus, a rickettsial infection with a harmless bite of infected chigger mite on humans, transmits the gram-negative bacteria Orientia tsutsugamushi causing the infection with rising mortality and morbidity rates across the globe. […] The living environment of the people plays a pivotal role in scrub typhus disease transmission. […] The univariate analysis showed a significant association between scrub typhus exposure with the people working in the agricultural fields, location of toilets, kitchen, presence of animals in homes, barren land and paddy fields near living areas, lack of protective implements against rodents, drying clothes on bushes, walking barefoot with more chances of being bitten by insects, mites or ticks resulting in rashes or Eschars, hospitalization due to fever, sneezing and headache.
  • #1 Epidemiological and Clinical Features of Patients with Scrub Typhus — Guangzhou City, Guangdong Province, China, 2012–2018
    https://weekly.chinacdc.cn/en/article/doi/10.46234/ccdcw2021.261
    Severe ST was found to be associated with the decreased levels of albumin (ALB) and platelet (PLT) count and increased levels of serum creatinine (CREA) and total bilirubin (TBIL) in the blood, as well as the occurrence of dyspnea for ST patients, with estimated relative contributions more than 10% in the final boosted regression trees models, which could be helpful for the recognization and treatment of severe ST in the early clinical management. […] The median (IQR) age of the patients was 57 (46-65) years, which gradually increased from 54 (42-62) in 2012 to 59 (49-66) in 2018. […] Overall, 72.6% of the patients resided in rural areas, with the proportion increased from 60.4% in 2012 to 80.0% in 2018, and farmers and retirees were the main occupations. […] The frequently seen symptoms and signs of ST patients included fever (98.2%), eschar (74.1%), anorexia (69.9%), headache (51.1%), weakness (43.7%), and cough (41.3%).
  • #1 Information for Public Health Officials | Typhus Fevers | CDC
    https://www.cdc.gov/typhus/php/info/index.html
    Scrub typhus, murine typhus, and epidemic typhus are not nationally notifiable conditions in the United States. However, your state may require reporting. […] Currently, scrub typhus, murine typhus, and epidemic typhus are not nationally notifiable conditions. However, your state may require reporting. Please check with your state and local health departments about reportable diseases. […] Specimens may be submitted to CDC for testing of rickettsial diseases, including typhus fevers. […] US healthcare providers should submit specimens through their health department for testing. Do not send specimens directly to CDC. […] Non-US healthcare providers should consult CDC prior to submitting specimens for testing.
  • #1 Typhus – Health Protection Surveillance Centre
    https://www.hpsc.ie/a-z/vectorborne/typhus/
    Typhus is a notifiable disease in Ireland. […] The number of typhus notifications […] The national notification rate per 100,000 population.
  • #1 Epidemiology of scrub typhus and other rickettsial infections (2018–22) in the hyper-endemic setting of Mizoram, North-East India | PLOS Neglected Tropical Diseases
    https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0011688
    In the past decade, scrub typhus cases have been reported across India, even in regions that had no previous history of the disease. […] However, in the last five years, the state has seen a substantial increase in the scrub typhus and other rickettsial infections. […] As part of the public health response, the Mizoram Government has integrated screening and line listing of scrub typhus and other rickettsial infections across all its health settings, a first in India. […] The integration of systematic surveillance and recording of rickettsial diseases across Mizoram has shed important insights into their prevalence, morbidity, and mortality. […] This study underscores the importance of active surveillance of rickettsial infections across India, as the burden could be substantially higher, and is probably going undetected.
  • #1 Evaluation of scrub typhus diagnosis in China: analysis of nationwide surveillance data from 2006 to 2016 | Infectious Diseases of Poverty | Full Text
    https://idpjournal.biomedcentral.com/articles/10.1186/s40249-019-0566-0
    During the 11-year study period, 93481 scrub typhus cases, including 57 deaths, were recorded in the nationwide surveillance system. […] The overall proportion of laboratory-confirmed cases was only 4.7%, and this proportion varied greatly among primary medical centres (2.8%), county level hospitals (4.2%), and city level hospitals (6.3%). […] Notably, the proportion of laboratory-confirmed cases has consistently decreased from 16.3% in 2006 to 2.6% in 2016, and the same decreasing trend was found among all three levels of medical care institutions. […] The interval time from illness onset to diagnosis for scrub typhus cases decreased greatly in China; however, the diagnosis rate of cases with laboratory-confirmed results must be increased among all levels of medical care institutions to reduce both the risk of death and the misuse of antibiotics associated with scrub typhus.
  • #1 Evaluation of scrub typhus diagnosis in China: analysis of nationwide surveillance data from 2006 to 2016 | Infectious Diseases of Poverty | Full Text
    https://idpjournal.biomedcentral.com/articles/10.1186/s40249-019-0566-0
    Scrub typhus remains a serious public health problem in China, and studies have shown that the annual incidence of scrub typhus has increased since 2006. […] The median Tdiag decreased from seven days (IQR: 311days) in 2006 to five days (IQR: 28days) in 2016, and the same decreasing trend was found for all three levels of medical care institutions. […] The Tdiag for both confirmed and probable cases increased with increasing medical care institution level. […] The majority of scrub typhus cases were probable cases, and the proportion of confirmed cases decreased sharply during the study period. […] Late diagnosis of scrub typhus increased the risk of death.
  • #1 Scrub typhus update: A re‑emerging global threat beyond the Tsutsugamushi Triangle and the physiological ramifications of scrub typhus infection (Review)
    https://www.spandidos-publications.com/10.3892/wasj.2025.322
    Data from the national surveillance system in Thailand reveal a marked increase in reported scrub typhus cases between 2003 and 2018. […] To understand the trends in scrub typhus cases within the Chungcheong region, epidemiological data were collected from 14,379 cases reported to the Korea Centers for Disease Control and Prevention between 2012 and 2022. […] The term Tsutsugamushi comes from two Japanese words: tsutsuga, meaning illness, and mushi, meaning insect. […] Globalization and increased travel have contributed to the spreading of infected individuals to areas outside the endemic regions, heightening concerns about the broader reach of scrub typhus. […] The incidence of scrub typhus and Orientia tsutsugamushi infection is continuously spreading globally. […] Addressing these limitations requires a multi-pronged approach, including increased awareness among healthcare providers and the public, improved diagnostic tools, the development of new and effective treatments, and strengthened vector control measures.
  • #1 Endemic Typhus Fever – Taiwan Centers for Disease Control
    https://www.cdc.gov.tw/En/Category/ListContent/bg0g_VU_Ysrgkes_KRUDgQ?uaid=EiDUt4f1JIrNGxmUTg1AEw
    Endemic typhus fever occurs in most parts of the world, particularly in the tropical and subtropical areas. […] In Taiwan, there were sporadic cases of endemic typhus fever occurring throughout the year. Most cases of endemic typhus fever are reported in Kaohsiung City, Pingtung County, Changhua County, Taichung City and Tainan City during 2018-2022. Early detection of infected cases can reduce the risk of widespread transmission. […] Endemic Typhus Fever Surveillance in Taiwan includes the Taiwan National Infectious Disease Statistics System and self-reporting through toll-free 1922 hotline or local public health authority.
  • #1 Evaluation of Scrub Typhus Surveillance System — Alwar District, Rajasthan, India, July–August 2020 | TEPHINET
    https://www.tephinet.org/learning/fead/evaluation-scrub-typhus-surveillance-system-alwar-district-rajasthan-india-july
    Scrub typhus (ST), a rickettsial disease, is an under reported and fatal illness accounting for 23% of all febrile illnesses. […] Sixteen Indian states reported ST outbreaks under central Integrated Disease Surveillance Programme (IDSP) between 2015-2019. […] We described and evaluated the ST surveillance system in Alwar district, Rajasthan for selected attributes, descriptively analyzed lab confirmed cases and provided evidence-based recommendations. […] Active and passive surveillance are core interventions of ST surveillance system. […] We recommend regular monitoring of surveillance reports and registers at block and district level and ensure timely reporting of ST cases through IDSP. Preventive measures and active case search should be strengthened for high transmission months between August to November.
  • #1 The estimated burden of scrub typhus in Thailand from national surveillance data (2003-2018) | PLOS Neglected Tropical Diseases
    https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0008233
    Scrub typhus is a major cause of acute febrile illness in the tropics and is endemic over large areas of the Asia Pacific region. […] The national and global burden of scrub typhus remains unclear due to limited data and difficulties surrounding diagnosis. […] Scrub typhus reporting data from 2003-2018 were collected from the Thai national disease surveillance system. […] From 2003-2018, 103,345 cases of scrub typhus were reported with the number of reported cases increasing substantially over the observed period. […] The burden of scrub typhus in Thailand is high with disease incidence rising significantly over the last two decades. […] However, disease burden is not uniform with northern provinces particularly affected. […] Our report, along with existing epidemiological data, suggests that scrub typhus is the most clinically important rickettsial disease globally.
  • #1 Epidemic Typhus Fever – Taiwan Centers for Disease Control
    https://www.cdc.gov.tw/En/Category/ListContent/bg0g_VU_Ysrgkes_KRUDgQ?uaid=D_xP9wiZMEqTJ6rnm8iy7w
    There were no cases of epidemic typhus fever in Taiwan. Early detection of infected cases by active and passive surveillance system can implement early response activities and reduce the risk of local transmission. […] Taiwan National Infectious Disease Statistics SystemEpidemic Typhus Fever […] Selfreporting through tollfree 1922 hotline or local public health authority.
  • #1
    https://journals.lww.com/epidem/fulltext/2009/11001/impacts_of_climate_on_the_incidence_of_scrub.603.aspx
    Scrub typhus is a vector-borne zoonotic disease caused by Orientia tsutsugamushi. […] The incidence of Scrub typhus in Korea has shown increasing trend during last decades. […] We assessed the correlations between the incidence of Scrub typhus and climate elements obtained from Korea Meteorological Administration. […] Climate change may have an effect on increasing trend of Scrub typhus. […] Our results show the possible evidences that the incidence of Scrub typhus is affected by climate elements changed by global warming.
  • #1 The estimated burden of scrub typhus in Thailand from national surveillance data (2003-2018) | PLOS Neglected Tropical Diseases
    https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0008233
    The results of this study reveal a high burden of scrub typhus in Thailand that has increased significantly over the last two decades. […] Although cases have been reported from all 77 provinces from 2003-2018, the burden of disease is not uniform with a handful of northern provinces particularly affected. […] The association of elevation and scrub typhus incidence in our study reflect findings from southern China. […] In addition, an increase in average monthly temperature from 24.5C in 2003 to 25.5C in 2018 correlated with an increase in scrub typhus incidence. […] This finding is also similar to reports from southern China and together, are suggestive of the influence of climate change on disease burden. […] Despite this weakness, a scrub typhus surveillance system based on a similar clinical criteria for probable cases can play a valuable role in allowing the disease burden to be extrapolated, particularly in regions where scrub typhus is the dominant eschar-associated disease.
  • #1 Rising Menace of Scrub Typhus – Current Status and Challenges – Journal of Pure and Applied Microbiology
    https://microbiologyjournal.org/rising-menace-of-scrub-typhus-current-status-and-challenges/
    Scrub typhus is endemic in the area known as the tsutsugamushi triangle and has recently spread its fangs into various other continents like South America and Africa. […] Although the disease is endemic in India, there is a lack of appropriate sero-epidemiology in community settings. […] Scrub typhus constitutes about 25.3% of cases among acute onset febrile illness in India. […] Sero-prevalence of this infection in India is between 9.3% and 27.9%, and the mortality rate is around 30% among untreated individuals, as noted in passive national surveillance systems. […] The agent O. tsutsugamushi is maintained in its reservoir mites by transstadial and transovarian transmission and transmitted to man by bite of the larvae (chigger) in cases of human encroachment into mite habitat. […] Tropical regions have appropriate temperatures and humidity for chigger activity and maintaining the pathogen in transovarian and transstadial transmission in the mites.
  • #1 Epidemiologic changes of a longitudinal surveillance study spanning 51 years of scrub typhus in mainland China | Scientific Reports
    https://www.nature.com/articles/s41598-024-53800-y
    The seasonal pattern of scrub typhus cases begins to increase dramatically in April through September, before reaching a peak in October and returning to low, constant levels of transmission in the winter months of December through March. […] The trend surface analysis showed that the incidence of scrub typhus increased gradually from north to south, and from east and west to the central area. […] The spatial autocorrelation analysis showed that a spatial positive correlation existed in the prevalence of scrub typhus on a national scale, which had the characteristic of aggregated distribution (I=0.533, P0.05). […] The hotspots (HighHigh) were primarily located in the southern and southwestern provinces of China, such as, Yunnan, Guangxi, Guangdong and Fujian etc., and the geographical area expanded annually.
  • #1 Scrub typhus update: A re‑emerging global threat beyond the Tsutsugamushi Triangle and the physiological ramifications of scrub typhus infection (Review)
    https://www.spandidos-publications.com/10.3892/wasj.2025.322
    Scrub typhus, caused by Orientia tsutsugamushi, is a miteborne zoonotic disease endemic to Asia and the Pacific. […] The World Health Organization (WHO) classifies scrub typhus as a neglected tropical disease and a major public health issue in the Asia-Pacific region. […] It is estimated that globally, more than a billion individuals are at risk of contracting scrub typhus, with approximately one million cases being reported annually. […] Some countries, including China, Korea, Japan and Thailand, have implemented preventive measures, such as rodent control, insecticide use and surveillance systems. A system for monitoring scrub typhus cases was introduced in 1952. […] Scrub typhus has drawn considerable attention after thousands of confirmed cases and several fatalities were reported in India during 2023.
  • #1 A Path Analysis to Understanding the Epidemiology of Murine Typhus in South Texas | Journal of Mathematics and Statistics | Science Publications
    https://thescipub.com/abstract/jmssp.2024.37.44
    This study aims to investigate statistically if there is a causality for the murine typhus endemic disease related to precipitation, temperature and the natural cycle of flea development in South Texas. […] The results of the path analysis support this hypothesis. Graphical research indicates that the number of murine typhus cases reaches a maximum during the month of May, when the temperature is between 65-80F with about 70% humidity for flea development and the precipitation increases the probability that bacteria, fleas and hosts get into contact with humans. […] The results of this research suggest that the Laredo population should be made aware that the presence of rickettsia-infected Xenopsyllia cheopis and Ctenocephalides felis, the development of environmental conditions that increase the possibility of contact of wild and domestic animals with human beings can also increase the possibilities of the manifestation of the disease.
  • #1 Epidemiology of scrub typhus and other rickettsial infections (2018–22) in the hyper-endemic setting of Mizoram, North-East India | PLOS Neglected Tropical Diseases
    https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0011688
    Given the rapid spread of scrub typhus and other rickettsial infections in the state, the Mizoram Government integrated screening and line listing of scrub typhus and other rickettsial infections from 2018 onwards across all its health centers. […] The systematic diagnosis and surveillance have helped identify the true burden of these infections, which could have easily gone undetected or misdiagnosed. […] In this study, the Mizoram Governments initiative to systematically diagnose and record the incidence of scrub typhus and other rickettsial infections across all the testing units has shed important insights on the magnitude of the disease burden in Mizoram; spatial analysis indicates scrub typhus cases are widespread in both urban and rural settings. […] The low rickettsial death rates in Mizoram could be attributed to public awareness and the set-up in place for rapid diagnosis and treatmentkey initiatives of the concerned health departments. […] Overall, this study details the importance of integrating the screening of rickettsial diseases at the district level across all the health centers.
  • #1 Epidemiological and Clinical Features of Patients with Scrub Typhus — Guangzhou City, Guangdong Province, China, 2012–2018
    https://weekly.chinacdc.cn/en/article/doi/10.46234/ccdcw2021.261
    Scrub typhus (ST) causes public health challenges in the tsutsugamushi triangle in the Asia-Pacific area greater than 13 million square kilometers, affecting an estimated one million people each year. […] A retrospective study based on 4,501 hospitalized patients with ST in Guangzhou City, China, described the epidemiological and clinical characteristics, laboratory findings of ST, and determined the related factors and a predictive model for severe disease. […] The current study provided updated knowledge that might enable public health policymakers to formulate appropriate measures to prevent ST and medical workers to perform targeted management to recognize and treat severe ST patients. […] This study described the epidemiological features and clinical outcomes of ST patients and assessed early predictors of severe disease by retrospective medical record review of 4,501 ST patients in 69 hospitals located throughout all 11 districts of Guangzhou City of southern China from January 2012 to December 2018.
  • #1 Epidemiological and clinical characteristics of scrub typhus in northern Fujian, China, from 2015 to 2019 | BMC Infectious Diseases | Full Text
    https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-023-08451-1
    The epidemiological characteristics of scrub typhus in different regions of China are still unclear, and the differences in clinical characteristics and temporal and regional distribution require further study. […] The First Hospital of Nanping City is the largest tertiary hospital in northern Fujian Province and a designated hospital for treating scrub typhus. […] Scrub typhus is a notifiable infectious disease in China. All cases of scrub typhus must be reported to the Chinese Centers for Disease Control and Prevention. […] The heat map statistics showed that there were two incidence peaks of scrub typhus in the northern region of Fujian. […] The prominent epidemic peak was from June to July each year, and the minor peak was from October to November each year. […] The prognosis of scrub typhus is closely related to the timely diagnosis. […] Therefore, improving the understanding of scrub typhus, reducing misdiagnosis, and improving early diagnosis is the key to treatment.
  • #1 Scrub typhus: Epidemiology, Diagnosis, Treatment, Prevention and Control in the Asia-Pacific Area and Worldwide
    https://utmb-ir.tdl.org/items/579af995-5c32-4394-8eeb-1434a6c204ea
    The long term goal of this study is to develop effective measures to control and even eradicate scrub typhus and other related infectious diseases. Scrub typhus is a serious public health problem in the Asia-Pacific area. It threatens one billion people globally, and causes illness in one million people each year. […] We first described the epidemiology of scrub typhus through a thorough review of the epidemiology and public health impacts of the disease. This specific aim helps us understand the disease, and provides a foundation for disease prevention and control. […] This project helps better understand the epidemiology, diagnosis, treatment, and control of scrub typhus.
  • #1 GtR
    https://gtr.ukri.org/projects?ref=MR%2FS023275%2F1
    Scrub typhus appears to be very common in affected regions, accounting for up to a third of all fever cases in some settings. […] This study is the first large scale cohort study specifically designed to gain a fundamental understanding of scrub typhus epidemiology in a region that is highly affected by the disease. […] This is a population based cohort study in a highly endemic rural setting in south India aiming at estimating the incidence of serological, symptomatic and severe scrub typhus infection. […] This large cohort study aims at providing fundamental epidemiological data on the transmission of scrub typhus, a common febrile illness in Asia and other parts of the world. […] The research will benefit the populations of regions affected by scrub typhus by impacting on case management of scrub typhus and raise awareness with respect to the occurrence of this potentially fatal disease which is currently underdiagnosed.
  • #1 GtR
    https://gtr.ukri.org/projects?ref=MR%2FS023275%2F1
    The research will help doctors understand the risk of progression from mild to complicated scrub typhus infection and initiate or withhold empirical treatment as required. […] Health economists and public health practitioners will make use of these data by calculating the regional and global burden of disease for scrub typhus infection and allocate clinical and public health resources accordingly.
  • #1
    https://journals.lww.com/jfmpc/fulltext/2024/13100/_is_it_time_to_initiate_scrub_typhus_surveillance.61.aspx
    Community prevalence studies are necessary to understand the burden and changing trends of the disease. […] A community seroprevalence of 8.9% warrants further epidemiological surveys and surveillance in the context of climate change, antigenic heterogeneity of O. tsutsugamushi, diagnostic variability, overlapping clinical presentation of scrub typhus, and its high-case fatality rate. […] Regular surveillance may also help to understand the changing trend of the prevalence and to necessitate appropriate public health action. […] We report a community seroprevalence of 8.9% of scrub typhus among healthy adults in Bengaluru Rural District during the months of October to December 2022. […] In the context of changing climatic conditions and re-emergence of scrub typhus globally, regular surveillance is required from this and wider geographies especially from the countries in the Tsutsugamushi triangle to monitor the changing trend in the community.
  • #2 Epidemic typhus – UpToDate
    https://www.uptodate.com/contents/epidemic-typhus
    Epidemic typhus is a potentially lethal, louse-borne, exanthematous disease caused by Rickettsia prowazekii. The epidemiology, pathogenesis, clinical manifestations, diagnosis, and treatment of epidemic typhus will be discussed here. Throughout the Middle Ages and into the early part of the 20th century, periodic epidemics of R. prowazekii infection killed millions of people. As an example, during the eight-year period from 1917 to 1925, over 25 million cases of epidemic typhus occurred in Russia, causing an estimated three million deaths. It has been estimated that epidemic typhus has caused more deaths than all the wars in history. Epidemic typhus is now a rare disease, but subsequent developments illustrate that an understanding of its epidemiology, clinical features, and treatment is still important to clinicians.
  • #2 Global seroprevalence of scrub typhus: a systematic review and meta-analysis | Scientific Reports
    https://www.nature.com/articles/s41598-024-61555-9
    Scrub typhus, a neglected disease, is a significant health concern in the Tsutsugamushi triangle of the AsiaPacific and has raised global concerns due to recent cases occurring outside this region. […] Strengthening surveillance and implementing disease control measures are needed in the affected regions. […] Understanding the global prevalence of scrub typhus is essential for effective disease control and prevention strategies. […] This systematic review and meta-analysis aims to provide a comprehensive quantitative assessment of the global prevalence of Scrub typhus infections. […] The results of our analysis reveal a pooled prevalence rate of 24.93%, indicating that roughly one-fourth of all febrile cases worldwide are positive for scrub typhus. […] Our estimations indicate that approximately 30% of individuals diagnosed with scrub typhus exhibit the presence of eschars, with variations observed across different countries.
  • #2 Flea-borne Typhus | Texas DSHS
    https://www.dshs.texas.gov/notifiable-conditions/zoonosis-control/zoonosis-control-diseases-and-conditions/flea-borne-typhus
    Flea-borne typhus is a rickettsial disease caused by Rickettsia typhi. […] In the United States, Texas reports the highest number of flea-borne typhus cases annually. […] Over 6,700 cases of flea-borne typhus were reported between 2008 and 2023. […] Laboratory testing is required to confirm a diagnosis of flea-borne typhus. […] More than 60% of reported cases are hospitalized.
  • #2 Department of Agriculture | Typhus Fever – Rickettsia prowazekii
    https://www.nj.gov/agriculture/divisions/ah/diseases/typhus.html
    R. prowazekii is not transmitted from person to person. […] Epidemics of typhus usually occur where louse populations are high. Infections are typically seen in populations living in unsanitary, crowded conditions; outbreaks are often associated with wars, famines, floods and other disasters. […] The overall case fatality rate for untreated infections is 10 to 40%; the mortality rate increases with age. Infections are rarely fatal in children less than 10 years old; in people over 50 years old, the mortality rate can be as high as 60% without treatment. […] Surveillance and reporting guidelines for typhus.
  • #2 Typhus: Causes, Symptoms, and Diagnosis
    https://www.healthline.com/health/typhus
    Typhus outbreaks usually only occur in developing countries or in regions of poverty, poor sanitation, and close human contact. […] Epidemics of typhus are more common in poor, unsanitary, and crowded areas. […] The overall mortality rate for untreated typhus depends on the type of typhus and other factors, such as age and overall health status. […] Endemic/murine typhus is rarely deadly, even without treatment. Death occurs in no more than 4 percent of cases, according to an article in Clinical Infectious Diseases.
  • #2 Rising Menace of Scrub Typhus – Current Status and Challenges – Journal of Pure and Applied Microbiology
    https://microbiologyjournal.org/rising-menace-of-scrub-typhus-current-status-and-challenges/
    Scrub typhus is endemic in the area known as the tsutsugamushi triangle and has recently spread its fangs into various other continents like South America and Africa. […] Although the disease is endemic in India, there is a lack of appropriate sero-epidemiology in community settings. […] Scrub typhus constitutes about 25.3% of cases among acute onset febrile illness in India. […] Sero-prevalence of this infection in India is between 9.3% and 27.9%, and the mortality rate is around 30% among untreated individuals, as noted in passive national surveillance systems. […] The agent O. tsutsugamushi is maintained in its reservoir mites by transstadial and transovarian transmission and transmitted to man by bite of the larvae (chigger) in cases of human encroachment into mite habitat. […] Tropical regions have appropriate temperatures and humidity for chigger activity and maintaining the pathogen in transovarian and transstadial transmission in the mites.
  • #2
    https://pmc.ncbi.nlm.nih.gov/articles/PMC4001937/
    Rickettsia typhi is an intracellular bacteria who causes murine typhus. His importance is reflected in the high frequency founding specific antibodies against Rickettsia typhi in several worldwide seroepidemiological studies, the seroprevalence ranging between 3-36%. This infection is associated with overcrowding, pollution and poor hygiene. This disease is endemic in temperate climates and especially in coastal areas. In the United States, Asia, Australia, México and Spain. It has been shown by studies of incidence of this disease in different countries, which are seasonal, in which the majority of cases occurring in a year is higher during warm weather, while cold weather, infection is very low or almost zero. This disease occurs in all age groups and is relatively common in children. As regards distribution by sex, race and occupation of patient no significant differences, although people living in rural or disadvantaged areas are more prone to infection. In America, there are records of this disease caused by Rickettsia typhi in Mexico since 1928. Currently there have been reports of the presence of Rickettsia typhi in America in countries like Brazil in 2005, which reports the presence of rickettsial antibodies to Rickettsia typhi in a rural community as well as other Rickettsia and Rickettsia rickettsii, causal agent of Rocky Mountain Spotted Fever. The importance about these studies is the presence of R. typhi in the population which has already been infected possibly being misdiagnosed.
  • #2 Epidemiologic changes of a longitudinal surveillance study spanning 51 years of scrub typhus in mainland China | Scientific Reports
    https://www.nature.com/articles/s41598-024-53800-y
    The seasonal pattern of scrub typhus cases begins to increase dramatically in April through September, before reaching a peak in October and returning to low, constant levels of transmission in the winter months of December through March. […] The trend surface analysis showed that the incidence of scrub typhus increased gradually from north to south, and from east and west to the central area. […] The spatial autocorrelation analysis showed that a spatial positive correlation existed in the prevalence of scrub typhus on a national scale, which had the characteristic of aggregated distribution (I=0.533, P0.05). […] The hotspots (HighHigh) were primarily located in the southern and southwestern provinces of China, such as, Yunnan, Guangxi, Guangdong and Fujian etc., and the geographical area expanded annually.
  • #2 The estimated burden of scrub typhus in Thailand from national surveillance data (2003-2018) | PLOS Neglected Tropical Diseases
    https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0008233
    Scrub typhus is a major cause of acute febrile illness in the tropics and is endemic over large areas of the Asia Pacific region. […] The national and global burden of scrub typhus remains unclear due to limited data and difficulties surrounding diagnosis. […] Scrub typhus reporting data from 2003-2018 were collected from the Thai national disease surveillance system. […] From 2003-2018, 103,345 cases of scrub typhus were reported with the number of reported cases increasing substantially over the observed period. […] The burden of scrub typhus in Thailand is high with disease incidence rising significantly over the last two decades. […] However, disease burden is not uniform with northern provinces particularly affected. […] Our report, along with existing epidemiological data, suggests that scrub typhus is the most clinically important rickettsial disease globally.
  • #2 Epidemic typhus – Wikipedia
    https://en.wikipedia.org/wiki/Epidemic_typhus
    Epidemic typhus, also known as louse-borne typhus, is a form of typhus so named because the disease often causes epidemics following wars and natural disasters where civil life is disrupted. Epidemic typhus is spread to people through contact with infected body lice, in contrast to endemic typhus which is usually transmitted by fleas. […] Though typhus has been responsible for millions of deaths throughout history, it is still considered a rare disease that occurs mainly in populations that suffer unhygienic extreme overcrowding. Typhus is most rare in industrialized countries. It occurs primarily in the colder, mountainous regions of central and east Africa, as well as Central and South America. […] Epidemic typhus has historically occurred during times of war and deprivation. For example, typhus killed millions of prisoners in German Nazi concentration camps during World War II. The unhygienic conditions in camps such as Auschwitz, Theresienstadt, and Bergen-Belsen allowed diseases such as typhus to flourish. Situations in the twenty-first century with potential for a typhus epidemic would include refugee camps during a major famine or natural disaster.
  • #2 Epidemic typhus – Wikipedia
    https://en.wikipedia.org/wiki/Epidemic_typhus
    The CDC lists the following areas as active foci of human epidemic typhus: Andean regions of South America, some parts of Africa; on the other hand, the CDC only recognizes an active enzootic cycle in the United States involving flying squirrels. Though epidemic typhus is commonly thought to be restricted to areas of the developing world, serological examination of homeless persons in Houston found evidence for exposure to the bacterial pathogens that cause epidemic typhus and murine typhus. A study involving 930 homeless people in Marseille, France, found high rates of seroprevalence to R. prowazekii and a high prevalence of louse-borne infections in the homeless. […] Typhus has been increasingly discovered in homeless populations in developed nations. Typhus among homeless populations is especially prevalent as these populations tend to migrate across states and countries, spreading the risk of infection with their movement. The same risk applies to refugees, who travel across country lines, often living in close proximity and unable to maintain necessary hygienic standards to avoid being at risk for catching lice possibly infected with typhus.
  • #2 Scrub typhus epidemiology and demographics – wikidoc
    https://www.wikidoc.org/index.php/Scrub_typhus_epidemiology_and_demographics
    It affects females more than males in Korea, but not in Japan, and this is conjectured to be because sex-differentiated cultural roles have women tending garden plots more often, thus being exposed to plant tissues inhabited by chiggers. The incidence is increasing day-by-day in southern part of Indian Peninsula.
  • #2 Epidemiological and clinical characteristics of scrub typhus in northern Fujian, China, from 2015 to 2019 | BMC Infectious Diseases | Full Text
    https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-023-08451-1
    The epidemiological characteristics of scrub typhus in different regions of China are still unclear, and the differences in clinical characteristics and temporal and regional distribution require further study. […] The First Hospital of Nanping City is the largest tertiary hospital in northern Fujian Province and a designated hospital for treating scrub typhus. […] Scrub typhus is a notifiable infectious disease in China. All cases of scrub typhus must be reported to the Chinese Centers for Disease Control and Prevention. […] The heat map statistics showed that there were two incidence peaks of scrub typhus in the northern region of Fujian. […] The prominent epidemic peak was from June to July each year, and the minor peak was from October to November each year. […] The prognosis of scrub typhus is closely related to the timely diagnosis. […] Therefore, improving the understanding of scrub typhus, reducing misdiagnosis, and improving early diagnosis is the key to treatment.
  • #2 Epidemiology of scrub typhus and other rickettsial infections (2018-22) in the hyper-endemic setting of Mizoram, North-East India | medRxiv
    https://www.medrxiv.org/content/10.1101/2023.04.21.23288926v1.full-text
    In the last decade, there has been an emergence of scrub typhus in many parts of India. […] In Mizoram, North-East India, there has been a steep increase in scrub typhus and other rickettsial infections in the last 5 years. […] As part of the public health response, the Mizoram Government has integrated screening (by rapid immunochromatographic test and/or Weil-Felix test) and line listing of scrub typhus and other rickettsial infections across all its health settings, a first in India. […] From 2018-22 (study period), 22914 cases were reported; of these, 19651 were positive for scrub typhus. […] Aizawl district is the worst affected, with 10580 cases (46.17%). […] The average incidence rate of rickettsial infections is 3.54 cases per 1000 persons-year, and the case fatality rate is 0.35.
  • #2 Historical Review: Rickettsial Diseases and Their Impact on U.S. Military Forces | Health.mil
    https://www.health.mil/News/Articles/2019/08/01/Rickettsial-Diseases-and-Their-Impact
    Rickettsial diseases are vector-borne bacterial infections that cause acute febrile illness throughout the world. They are spread via arthropod vectors including ticks, fleas, mites, and lice. […] Despite the widespread distribution of rickettsial diseases worldwide, they are frequently overlooked as a cause of illness and/or misdiagnosed. This is partly due to the non-specific nature of the early symptoms of rickettsial diseases, which frequently present as undifferentiated febrile illness that is often indistinguishable from other infectious diseases, especially those common in tropical and subtropical regions (e.g., malaria, dengue fever, leptospirosis). […] Rickettsial diseases have had a significant impact on public health and have been a significant cause of morbidity and mortality in both civilian and military populations.
  • #2 Murine Typhus: A Review of a Reemerging Flea-Borne Rickettsiosis with Potential for Neurologic Manifestations and Sequalae
    https://www.mdpi.com/2036-7449/15/6/63
    Murine typhus is endemic to much of the world, especially along seaboard regions of the tropics and subtropics, where rats and their fleas play a role in the maintenance and transmission to humans. […] In parts of the United States, the disease is reemerging as an important cause of febrile illness, especially in Southern California and throughout Texas. […] The disease is well recognized in Southeast Asia, where it is an important cause of fever (especially in urban areas) in Thailand, Laos, Indonesia, and Vietnam. […] There are also contemporary reports of murine typhus in Asia, where it has been reported in Nepal, Bangladesh, and India. […] In North America, cases are recognized in Mexico and in the U.S. states of Hawaii, California, and Texas. […] The increased recognition of cases in Southern California, Texas, Mexico, and South America highlights the reemergence of the pathogen in these regions.
  • #2
    https://journals.lww.com/epidem/fulltext/2009/11001/impacts_of_climate_on_the_incidence_of_scrub.603.aspx
    Scrub typhus is a vector-borne zoonotic disease caused by Orientia tsutsugamushi. […] The incidence of Scrub typhus in Korea has shown increasing trend during last decades. […] We assessed the correlations between the incidence of Scrub typhus and climate elements obtained from Korea Meteorological Administration. […] Climate change may have an effect on increasing trend of Scrub typhus. […] Our results show the possible evidences that the incidence of Scrub typhus is affected by climate elements changed by global warming.
  • #2 Murine Typhus in Animals – Infectious Diseases – Merck Veterinary Manual
    https://www.merckvetmanual.com/infectious-diseases/rickettsial-diseases/murine-typhus-in-animals
    Murine typhus infection in people is primarily thought to occur through exposure of abraded skin with infectious flea feces; aerosolization of infectious materials may occur in limited settings. […] Known to occur worldwide, there are current foci of human cases of murine typhus in southern Texas, California, and Hawaii. The disease is thought to be underreported. […] R typhi is a zoonotic pathogen. Serologic evidence of exposure or past infection in dogs or cats is consistent with a heightened risk of human infections in a given area, although serology cannot pinpoint which rickettsial organism is present. […] Regular flea control is recommended to reduce risk of flea-associated transmission to people.
  • #2 Typhus: Background, Pathophysiology, Epidemiology
    https://emedicine.medscape.com/article/231374-overview
    Murine typhus occurs mainly in sporadic cases, and incidence probably is greatly underestimated in the more endemic regions. […] The incidence of scrub typhus is largely unknown, although it is estimated to be 1 million cases per year worldwide. Many cases are undiagnosed because of its nonspecific manifestations and the lack of laboratory diagnostic testing in endemic areas. […] Finally, experts believe there will be a re-emergence of disease in relation to antibiotic resistance, deforestation and global warming.
  • #3 Murine Typhus: A Review of a Reemerging Flea-Borne Rickettsiosis with Potential for Neurologic Manifestations and Sequalae
    https://www.mdpi.com/2036-7449/15/6/63
    Murine typhus is endemic to much of the world, especially along seaboard regions of the tropics and subtropics, where rats and their fleas play a role in the maintenance and transmission to humans. […] In parts of the United States, the disease is reemerging as an important cause of febrile illness, especially in Southern California and throughout Texas. […] The disease is well recognized in Southeast Asia, where it is an important cause of fever (especially in urban areas) in Thailand, Laos, Indonesia, and Vietnam. […] There are also contemporary reports of murine typhus in Asia, where it has been reported in Nepal, Bangladesh, and India. […] In North America, cases are recognized in Mexico and in the U.S. states of Hawaii, California, and Texas. […] The increased recognition of cases in Southern California, Texas, Mexico, and South America highlights the reemergence of the pathogen in these regions.
  • #3 Epidemiology of scrub typhus and other rickettsial infections (2018-22) in the hyper-endemic setting of Mizoram, North-East India | medRxiv
    https://www.medrxiv.org/content/10.1101/2023.04.21.23288926v1.full-text
    The average incidence rate of scrub typhus cases in Mizoram from 2018-2022 is 3.04 cases per 1000. […] The spatial distribution shows the scrub typhus cases are predominately distributed in the populated (North-Central) districts, especially along the arterial route between Aizawl and Serchhip. […] A spike in scrub typhus cases was observed during the monsoon and post-monsoon seasons (June to November). […] The most common clinical presentations were fever/persistent fever (85.03%), headache (29.35%), rash (26.80%), chills (21.36%), cough (9.21%), body ache (8.58%), and nausea (3.23%). […] Among the reported scrub typhus cases, 19.5% of individuals were hospitalized; the distribution was same across males and females. […] The proportion of rickettsial deaths is more in men (62.96%) than in women (37.04%). […] The significant association between eschar and death indicates the importance of genome sequencing to correlate strains with clinical severity.
  • #3 Typhus vs Typhoid Fever: What’s the difference?
    https://www.cedars-sinai.org/newsroom/typhus-vs-typhoid-fever-whats-the-difference/
    Typhus and typhoid fever have both been in the news as reported cases surface in Los Angeles. […] Los Angeles County sees an average of about 50 flea-borne typhus cases each year, except in 2018 when an outbreak caused that number to double. Typhoid fever, on the other hand, is less common in the U.S. It often manifests after a patient has traveled to Asia or India. The California Department of Public Health gets reports of about 75 cases of typhoid fever in the state each year. […] You can reduce your risk of getting flea-borne typhus by avoiding contact with fleas. For example, make sure your pets are treated with flea protection. Also, keep rodents away from your home and workplace. You can avoid typhoid fever by getting vaccinated and carefully choosing what you eat or drink when you travel to countries where typhoid fever is more common. Speak with your doctor before you travel to see if a typhoid vaccine is appropriate. Stick to bottled water and fully cooked food or fruits and vegetables that must be peeled. Washing your hands also is important.

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