Nationwide prevalence of Rickettsia felis infections in patients with febrile illness in Bangladesh

Tick-, flea- and mite-borne pathogens and associated diseases of public health importance in Bangladesh: a review

Background

This scoping review provides a baseline summary of the current records of the ticks, fleas, and mites of public health importance that are present in Bangladesh. It summarizes their geographic distributions and reports the levels of their infestation of livestock, pets, wildlife, and humans, and the clinical and epidemiological studies pertinent to these vectors and their pathogens.

Methods

Sixty-one articles were identified in a literature search, including 43 published since 2011.

Results

Twelve articles contained reliable information on ticks and their associated hosts. However, information on fleas and mites in Bangladesh is very limited. Seventeen species of ixodid ticks that commonly parasitize peridomestic animals and can bite humans are described: Rhipicephalus microplus, R. appendiculatus, R. sanguineus, Haemaphysalis bispinosa, Hyalomma anatolicum, and Amblyomma testudinarium. Thirty-eight veterinary articles describe livestock pathogens, including Babesia, Anaplasma, and Theileria, and the diseases they cause. Few of those studies used modern molecular techniques to identify these pathogens. Eleven articles reported human diseases or surveillance studies, 10 from the last 10 years. Two country-wide serosurveys of 1,209 and 720 patients, using Enzyme Linked Immunosorbent Assay (ELISA) and Indirect Immunofluorescence Assay (IFA), respectively, reported human exposure to Orientia tsutsugamushi (8.8%-23.7%), typhus and spotted-fever group rickettsiae (19.7%-66.6%), and Coxiella burnetii (3%). The seropositivity rates varied regionally. PCR-based studies confirmed that febrile patients in Bangladesh may be infected with O. tsutsugamushi, Rickettsia typhi, Rickettsia felis, or Bartonella elizabethae. Only limited molecular research has been done with dogs and cats. These studies have reported PCR-confirmed canine infections with Babesia gibsoni (30%), Anaplasma bovis (58%), or Rickettsia monacenis (14%, n=50), and feline infections with Rickettsia felis (21%, n=100). Similarly, fleas from cats tested positive for Rickettsia felis (20.6%).

Conclusions

These findings indicate that diseases borne by non-mosquito vectors in Bangladesh urgently require more attention from public health, medical, and veterinary specialists to establish their true occurrence.

Acute febrile illness among outpatients seeking health care in Bangladeshi hospitals prior to the COVID-19 pandemic

Understanding the distribution of pathogens causing acute febrile illness (AFI) is important for clinical management of patients in resource-poor settings. We evaluated the proportion of AFI caused by specific pathogens among outpatients in Bangladesh. During May 2019-March 2020, physicians screened patients aged ≥2 years in outpatient departments of four tertiary level public hospitals. We randomly enrolled patients having measured fever (≥100.4°F) during assessment with onset within the past 14 days. Blood and urine samples were tested at icddr,b through rapid diagnostic tests, bacterial culture, and polymerase chain reaction (PCR). Acute and convalescent samples were sent to the Centers for Disease Control and Prevention (USA) for Rickettsia and Orientia (R/O) and Leptospira tests. Among 690 patients, 69 (10%) had enteric fever (Salmonella enterica serotype Typhi orSalmonella enterica serotype Paratyphi), 51 (7.4%) Escherichia coli, and 28 (4.1%) dengue detected. Of the 441 patients tested for R/O, 39 (8.8%) had rickettsioses. We found 7 (2%) Leptospira cases among the 403 AFI patients tested. Nine patients (1%) were hospitalized, and none died. The highest proportion of enteric fever (15%, 36/231) and rickettsioses (14%, 25/182) was in Rajshahi. Dhaka had the most dengue cases (68%, 19/28). R/O affected older children and young adults (IQR 8-23 years) and was detected more frequently in the 21-25 years age-group (17%, 12/70). R/O was more likely to be found in patients in Rajshahi region than in Sylhet (aOR 2.49, 95% CI 0.85-7.32) between July and December (aOR 2.01, 1.01-5.23), and who had a history of recent animal entry inside their house than not (aOR 2.0, 0.93-4.3). Gram-negative Enterobacteriaceae were the most common bacterial infections, and dengue was the most common viral infection among AFI patients in Bangladeshi hospitals, though there was geographic variability. These results can help guide empiric outpatient AFI management.

Manifestations and Management of Flea-Borne Rickettsioses

Murine typhus and flea-borne spotted fever are undifferentiated febrile illnesses caused by Rickettsia typhi and Rickettsia felis, respectively. These organisms are small obligately intracellular bacteria and are transmitted to humans by fleas. Murine typhus is endemic to coastal areas of the tropics and subtropics (especially port cities), where rats are the primary mammalian host and rat fleas (Xenopsylla cheopis) are the vector. In the United States, a cycle of transmission involving opossums and cat fleas (Ctenocephalides felis) are the presumed reservoir and vector, respectively. The incidence and distribution of murine typhus appear to be increasing in endemic areas of the US. Rickettsia felis has also been reported throughout the world and is found within the ubiquitous cat flea. Flea-borne rickettsioses manifest as an undifferentiated febrile illness. Headache, malaise, and myalgia are frequent symptoms that accompany fever. The incidence of rash is variable, so its absence should not dissuade the clinician to consider a rickettsial illness as part of the differential diagnosis. When present, the rash is usually macular or papular. Although not a feature of murine typhus, eschar has been found in 12% of those with flea-borne spotted fever. Confirmatory laboratory diagnosis is usually obtained by serology; the indirect immunofluorescence assay is the serologic test of choice. Antibodies are seldom present during the first few days of illness. Thus, the diagnosis requires acute- and convalescent-phase specimens to document seroconversion or a four-fold increase in antibody titer. Since laboratory diagnosis is usually retrospective, when a flea-borne rickettsiosis is considered, empiric treatment should be initiated. The treatment of choice for both children and adults is doxycycline, which results in a swift and effective response. The following review is aimed to summarize the key clinical, epidemiological, ecological, diagnostic, and treatment aspects of flea-borne rickettsioses.