By Saurabh Gurung, Sunita Pradhan
Maya Rai, 38, is a tea garden worker in a pristine Darjeeling estate. Her days, which start at 4:30 a.m., are often a chaotic brew of cleaning, cooking, livestock care and readying her children for school. After a busy early morning, she walks to the tea garden to pluck leaves from 8 a.m. to 4 p.m. As a daily wage earner, she toils for long hours for less than ?300. After this she also must carry firewood for her hearth and fodder from the nearby forest and agricultural land for her cattle and goats. Maya, like most women in the region , cannot afford to stop working. For her, every febrile illness is ‘just another fever’.
One monsoon, fever hit her hard. She assumed it would pass with some rest and a few home remedies, but soon, she was too weak to work. At the local Public Health Center (PHC), with no clear diagnosis, she was sent home with painkillers. But her condition did not improve. Fever persisted, along with cough, nausea, breathlessness and discomfort. Seven wage-less days later, she was taken to a private hospital in town, hours away from the village. There, a rapid test confirmed ‘scrub typhus’ , an infectious disease caused by a bacterium called Orientia tsutsugamushi. She was prescribed antibiotics and rest. Maya survived, unlike many others. Late diagnosis of scrub typhus often progresses to complications including acute respiratory distress, liver inflammation, kidney failure and multiorgan dysfunction syndrome (MODS).
Although Maya missed her wages, she was fortunate to avoid hospitalisation and its costs. Others get hospitalised and run into debts for treatment and stay in distant towns. One such instance is the case of 35-year-old Ganga Chettri, a homemaker in rural west Sikkim. Her treatment required travel to the nearest district hospital, then a tertiary care centre and eventually a private hospital for diagnosis. By then, her organs were already critical, requiring multiple days of hospitalisation. Saving her implied a substantial financial cost to the family.
At the time of infection, Ganga was breastfeeding her two-year-old and caring for her four-year-old. Her illness meant leaving her children in the care of a family member. The lack of proper employment compelled her to borrow money for the treatment.
Drawing on such case descriptions and interviews, the commentary explores the systemic challenges that allow scrub typhus to persist in rural Darjeeling and Sikkim, particularly among women.
Resurgence of scrub typhus
Locally known as kira le toke ko bimari (a disease from an insect bite) in the Darjeeling-Sikkim region of the Indian Himalayas, scrub typhus is emerging as a public health concern in India. Reported from several states across the country, it is the most common re-emerging rickettsial infection in India and other Southeast Asian countries, and affects one million people annually around the globe.
Scrub typhus was once confined to the Asia-Pacific’s ‘Tsutsugamushi Triangle’, a geographic stretch from northern Japan to Russia and northern Australia. Today, this has changed, and scrub typhus poses a threat to about a billion people worldwide. In India, the disease is steadily resurging, often hiding within fevers that puzzle doctors in remote Himalayan clinics.
In some regions scrub typhus may account for up to 50% of undifferentiated fevers in hospitals. The first cases of scrub typhus in India were documented during World War II in Assam and West Bengal.
The history of scrub typhus in these hills reads like a forgotten chapter resurfacing. The Indian Himalayan region saw a dramatic re-emergence of the disease between 2003 and 2007. Himachal Pradesh, Darjeeling, Jammu and Kashmir, Uttarakhand and Sikkim, all reported a sharp rise in cases. Darjeeling district saw an outbreak in 2005, nearly 45 years after its last documented occurrence. Regular outbreaks continue to be reported in Kurseong and Mirik through the Integrated Health Information Portal (IHIP). Sikkim, too, has seen an increasing scrub typhus activity since 2004.
The persistent presence of scrub typhus in Darjeeling and Sikkim presents a significant public health challenge. Despite this trend, knowledge gaps remain. Epidemiological data are patchy, and public awareness and health information are limited, making the disease difficult to track and manage.
How scrub typhus spreads
At its core, scrub typhus in humans is linked to a tetrad of small mammals (especially rats), tiny mites, a bacterium called Orientia tsutsugamushi, and their shared environment. The disease is transmitted by the larval stage of trombiculid mites, commonly known as chiggers. It is only this larval stage that transmits the disease through its bite. These chiggers feed on small mammals like rats for blood meals. Rats are crucial for maintaining chigger populations. Rats can also carry the bacteria and infect feeding mites. Adult mites and nymphs, found in the soil and vegetation, do not transmit the disease.
Humans contract the infection when exposed to mite-infested habitats or rat-dense environments, where the chiggers spill over from rodents to humans. These spillovers increase with rising rodent population, mite proliferation, or intensified human-rat interactions. Drivers like changes in land use, weather patterns, natural hazards, deforestation, urbanization, and garbage generation – factors creating favourable conditions for disease emergence – likely facilitate these spillovers.
Diagnostic and systemic challenges
A suggestive sign of scrub typhus is an eschar, a dark, necrotic scab at the bite site. Other symptoms include high fever, severe headache, muscle pains, and gastrointestinal discomfort. In rural areas with limited resources, distinguishing it from malaria, dengue, enteric fever, or leptospirosis is challenging without reliable diagnostics. If left untreated, the disease can be fatal. With 74.85% of Sikkim’s and 60.58% of Darjeeling’s populations living in rural areas (Census 2011), a significant portion remains vulnerable to delayed diagnosis and treatment.
Diagnostic infrastructure is another bottleneck. In rural Darjeeling, samples for confirmatory tests are often sent to larger facilities, adding days to diagnostic delay. Many patients begin self-medication while waiting for the results. The movement of tourists and migrant workers further complicates the understanding of the origin of infections.
Underreporting remains a persistent issue. Some private hospitals and clinics, though seeing significant patient loads, often struggled to log cases to the Integrated Health Information Portal (IHIP), a central surveillance database, forming the backbone for early warning systems and rapid action for zoonotic diseases in India. These issues, combined with understaffed data units, inadequate capacity, lack of internet access, and inaccessibility of IHIP to all, challenge the private and rural health units to report to the IHIP.
Underreporting hampers the ability to detect trends, identify clusters and guide context-specific interventions.
Healthcare access gaps in tea plantations
The Plantation Labour Act of 1951 has a provision for adequate healthcare access for the workers by the tea estate management. Implementation falters as provisions are limited to impairments during work and general care, with no special attention to zoonotic diseases like scrub typhus.
Previously, in cases of prolonged illness or work-related injury, estate doctors, health staff, or management personnel would visit workers at home, provide medicines, and assist with dressing wounds, particularly injuries sustained in falls or accidents within the tea plantation. The diminishing healthcare access is attributed to plummeting profits and a decrease in permanent workers, who alone are entitled to such services.
The plantation workers also mention a lack of personal protective equipment, leaving them exposed to vector contact. With this, battling scrub typhus in the tea plantations of Darjeeling has its own challenges.
The need for integrated responses in vulnerable regions
The Himalayan region, marked by inaccessibility, fragility, marginality, and rich biodiversity, is especially vulnerable to diseases shaped by ecological, social, environmental and climatic changes . The COVID–19 pandemic showed that mountain regions are not spared by global health threats. Scrub typhus, though smaller in scope, is another reminder of this vulnerability.
Improved diagnostic infrastructure, stronger data systems, appropriate capacity building, awareness building, cross-sectoral collaboration, strengthened surveillance, and research are essential to address this neglected zoonotic disease. An integrated portal, at the central or state level, where animal, environmental, and human health data are jointly captured for critical zoonotic diseases, would be important. This would enable timely risk pattern detection, strengthen early warning systems, support evidence-based, context-specific decision-making, and facilitate coordinated response across sectors.
The steady rise of scrub typhus is a warning signal, urging us to better understand and appreciate the interconnectedness between human, animal and environmental health in the Himalayas. The production landscapes like the tea plantations of Darjeeling require special focus, where the majority are socially and economically the most disadvantaged. Diseases like scrub typhus have the capacity to spiral the community into a cycle of poverty.
This article is republished from Mongabay under a Creative Commons license. Read the
Related
