Epidemiology of Murine Typhus in Taiwan from 2013 to 2020

Yeou-Lin Hsueh Center for Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taiwan, Republic of China

Search for other papers by Yeou-Lin Hsueh in
Current site
Google Scholar
PubMed
Close
,
Hsiang-Fei Chen Center for Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taiwan, Republic of China

Search for other papers by Hsiang-Fei Chen in
Current site
Google Scholar
PubMed
Close
,
Mei-Chun Chang Center for Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taiwan, Republic of China

Search for other papers by Mei-Chun Chang in
Current site
Google Scholar
PubMed
Close
,
Tsai-Ying Yen Center for Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taiwan, Republic of China

Search for other papers by Tsai-Ying Yen in
Current site
Google Scholar
PubMed
Close
,
Chien-Ling Su Center for Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taiwan, Republic of China

Search for other papers by Chien-Ling Su in
Current site
Google Scholar
PubMed
Close
,
Hsien-Chun Chiu Center for Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taiwan, Republic of China

Search for other papers by Hsien-Chun Chiu in
Current site
Google Scholar
PubMed
Close
,
Huai-Chin Hu Center for Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taiwan, Republic of China

Search for other papers by Huai-Chin Hu in
Current site
Google Scholar
PubMed
Close
,
Ya-Ting Chung Center for Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taiwan, Republic of China

Search for other papers by Ya-Ting Chung in
Current site
Google Scholar
PubMed
Close
,
Pei-Yun Shu Center for Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taiwan, Republic of China

Search for other papers by Pei-Yun Shu in
Current site
Google Scholar
PubMed
Close
, and
Su-Lin Yang Center for Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taiwan, Republic of China

Search for other papers by Su-Lin Yang in
Current site
Google Scholar
PubMed
Close
Restricted access

ABSTRACT.

Murine typhus is a flea-borne disease caused by Rickettsia typhi infection. The disease is a notifiable infectious disease in Taiwan. Specimens from suspected cases are required to be sent to the Taiwan Centers for Disease Control and Prevention for laboratory diagnosis. In this study, 204 cases of murine typhus were identified by bacterial isolation, real-time polymerase chain reaction, or indirect immunofluorescence assay between 2013 and 2020. The average incidence rate was 0.11/100,000 person-years (95% CI: 0.08–0.13). Murine typhus occurred throughout the year, but it was most prevalent in summer (May to August). The majority of patients were males (75%), residents of Kaohsiung city (31%), and worked in agriculture, forestry, fishing, and animal husbandry (27%). Fever was the most common symptom, present in 95.6% of patients, followed by headache (41%), myalgia (33%), and liver dysfunction (33%). Only 13% of patients had a rash. Up to 80% of cases were among hospitalized patients, and 43% of patients developed severe manifestations. Serological assays also indicated coinfection events. Seven patients showed a 4-fold increase in antibody titers against Orientia tsutsugamushi (N = 2), Coxiella burnetii (n = 2), and Leptospira (N = 3). In conclusion, murine typhus is an endemic and important zoonotic rickettsial disease in Taiwan that cannot be ignored. Further epidemiological surveillance and clinical characteristics should be continuously investigated to prevent and control murine typhus.

    • Supplemental Materials (PDF 303.70 KB)

Author Notes

Financial support: This work was supported by grants MOHW106-CDC-C-315-113112 (SPY) and MOHW110-CDC-C-315-114409 (SPY) from the Centers for Disease Control, Ministry of Health and Welfare, Taiwan, Republic of China. The funder had no role in the study design, data collection or analysis, decision to publish, or preparation of the manuscript.

Disclosure: The authors have no conflicts of interest to declare.

Authors’ addresses: Yeou-Lin Hsueh, Hsiang-Fei Chen, Mei-Chun Chang, Tsai-Ying Yen, Chien-Ling Su, Hsien-Chun Chiu, Huai-Chin Hu, Ya-Ting Chung, Pei-Yun Shu, and Su-Lin Yang, Center for Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, Taipei, Republic of China, E-mails: ishashark@cdc.gov.tw, xiangfei@cdc.gov.tw, newlover@cdc.gov.tw, d00849002@ntu.edu.tw, sue@cdc.gov.tw, Hsienchun@cdc.gov.tw, huaichinhu@cdc.gov.tw, killna7877@cdc.gov.tw, pyshu@cdc.gov.tw, and cerline@cdc.gov.tw.

Address correspondence to Pei-Yun Shu or Su-Lin Yang, Center for Diagnostics and Vaccine Development, Centers for Disease Control, Ministry of Health and Welfare, No. 161, Kunyang St., 115 Taiwan, Republic of China. E-mails: pyshu@cdc.gov.tw or cerline@cdc.gov.tw
  • 1.

    Azad AF , Radulovic S , Higgins JA , Noden BH , Troyer JM , 1997. Flea-borne rickettsioses: ecologic considerations. Emerg Infect Dis 3: 319327.

  • 2.

    Anstead GM , 2020. History, rats, fleas, and opossums: The ascendency of flea-borne typhus in the United States, 1910–1944. Trop Med Infect Dis 5: 37.

  • 3.

    Azad AF , 1990. Epidemiology of murine typhus. Annu Rev Entomol 35: 553569.

  • 4.

    Civen R , Ngo V , 2008. Murine typhus: An unrecognized suburban vector borne disease. Clin Infect Dis 46: 913918.

  • 5.

    Tsioutis C , Zafeiri M , Avramopoulos A , Prousali E , Miligkos M , Karageorgos SA , 2017. Clinical and laboratory characteristics, epidemiology, and outcomes of murine typhus: A systematic review. Acta Trop 166: 1624.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Chaniotis B , Psarulaki A , Chaliotis G , Gozalo Garcia G , Gozadinos T , Tselentis Y , 1994. Transmission cycle of murine typhus in Greece. Ann Trop Med Parasitol 88: 645647.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Soltani A , Borouji F , Abdollahi S , Arefe-sadat P , 2021. A systematic review of the arthropod-borne rickettsial diseases with a special emphasis on Iran. J Health Sci Surveill Syst 9: 208217.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Chikeka I , Dumler JS , 2015. Neglected bacterial zoonoses. Clin Microbiol Infect 21: 404415.

  • 9.

    Carter CN , Ronald NC , Steele JH , Young E , Taylor JP , Russell LH Jr , Eugster AK , West JE , 1997. Knowledge-based patient screening for rare and emerging infectious/parasitic diseases: A case study of brucellosis and murine typhus. Emerg Infect Dis 3: 7376.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Dumler JS , Walker DH , Mandell GL , Bennett JE & Dolin R Principles and Practices of Infectious Diseases. Philadelphia, PA: Elsevier Churchill Livingstone, 23062309.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Dumler JS , Taylor JP , Walker DH , 1991. Clinical and laboratory features of murine typhus in south Texas, 1980 through 1987. JAMA 266: 13651370.

  • 12.

    Whiteford SF , Taylor JP , Dumler JS , 2001. Clinical, laboratory, and epidemiologic features of murine typhus in 97 Texas children. Arch Pediatr Adolesc Med 155: 396400.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Doppler JF , Newton PN , 2020. A systematic review of the untreated mortality of murine typhus. PLoS Negl Trop Dis 14: e0008641.

  • 14.

    Osterloh A , 2020. The neglected challenge: Vaccination against rickettsiae. PLoS Negl Trop Dis 14: e0008704.

  • 15.

    Kuo CC , Wardrop N , Chang CT , Wang HC , Atkinson PM , 2017. Significance of major international seaports in the distribution of murine typhus in Taiwan. PLoS Negl Trop Dis 6: e0005430.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Chiang PS , Su SW , Yang SL , Shu PY , Lee WP , Li SY , Teng HJ , 2022. Delayed correlation between the incidence rate of indigenous murine typhus in humans and the seropositive rate of Rickettsia typhi infection in small mammals in Taiwan from 2007–2019. PLoS Negl Trop Dis 25: e0010394.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Kumar S , Stecher G , Tamura K , 2016. MEGA7: molecular evolutionary genetics analysis version 7.0 for bigger datasets. Mol Biol Evol 33: 18701874.

  • 18.

    Tsai KH , Wang HC , Chen CH , Huang JH , Lu HY , Su CL , Shu PY , 2008. Isolation and identification of a novel spotted fever group Rickettsia, strain IG-1, from Ixodes granulatus ticks collected on Orchid Island (Lanyu), Taiwan. Am J Trop Med Hyg 79: 256261.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Tsai KH , Lu HY , Tsai JJ , Yu SK , Huang JH , Shu PY , 2008. Human case of Rickettsia felis infection, Taiwan. Emerg Infect Dis 14: 19701972.

  • 20.

    Chen HF , Peng SH , Tsai KH , Yang CF , Chang MC , Hsueh YL , Su CL , Wang RY , Shu PY , Yang SL , 2022. Molecular epidemiology of scrub typhus in Taiwan during 2006–2016. PLoS Negl Trop Dis 16: e0010369.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Weng TC , Yen TS , 1961. Clinical observation on two weeks fever (murine typhus) in Taiwan. J Formos Med Assoc 60: 594602.

  • 22.

    Yao-Shen CS-RW , Yung-Ching L , 1995. Flea-borne (endemic) typhus: A case report. Taiwan Epidemiology Bulletin 11: 263266.

  • 23.

    Psaroulaki A , Christou C , Chochlakis D , Tsiligianni I , Sandalakis V , Georgalis L , Ioannou I , Giorgalas G , Tselentis Y , 2012. Murine typhus in Cyprus: A 9-year survey. Trans R Soc Trop Med Hyg 106: 489495.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Punda-Polić V , Luksić B , Capkun V , 2008. Epidemiological features of Mediterranean spotted fever, murine typhus, and Q fever in Split-Dalmatia County (Croatia), 1982–2002. Epidemiol Infect 136: 972979.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Robaina-Bordón JM , Carranza-Rodríguez C , Hernández-Cabrera M , Bolaños-Rivero M , Pisos-Álamo E , Jaén-Sánchez N , Hernández-Betancor A , Suárez-Hormiga L , Pérez-Arellano JL , 2021. Murine typhus in Canary Islands, Spain, 1999–2015. Emerg Infect Dis 27: 570573.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Chang BJ , Kim SJ , Lee WC , Lee MJ , Choe NH , 2018. Comparative study on the epidemiological trends and aspects of murine typhus in Korea in the last decade (2006–2015). J Glob Infect Dis 10: 121124.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Rodríguez-Alonso B , Almeida H , Alonso-Sardón M , Velasco-Tirado V , Robaina Bordón JM , Carranza Rodríguez C , Pérez Arellano JL , Belhassen-García M , 2020. Murine typhus. How does it affect us in the 21st century? The epidemiology of inpatients in Spain (1997–2015). Int J Infect Dis 96: 165171.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Roberts T et al., 2021. A spatio-temporal analysis of scrub typhus and murine typhus in Laos: Implications from changing landscapes and climate. PLoS Negl Trop Dis 15: e0009685.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Trung NV et al., 2019. Clinical manifestations and molecular diagnosis of scrub typhus and murine typhus, Vietnam, 2015–2017. Emerg Infect Dis 25: 633641.

  • 30.

    Labropoulou S et al., 2021. Sunbathing, a possible risk factor of murine typhus infection in Greece. PLoS Negl Trop Dis 15: e0009186.

  • 31.

    Kuo CC , Shu PY , Mu JJ , Wang HC , 2015. High prevalence of Rickettsia spp. infections in small mammals in Taiwan. Vector Borne Zoonotic Dis 15: 1320.

  • 32.

    Dzul-Rosado K , Lugo-Caballero C , Tello-Martin R , López-Avila K , Zavala-Castro J , 2017. Direct evidence of Rickettsia typhi infection in Rhipicephalus sanguineus ticks and their canine hosts. Open Vet J 7: 165169.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Nogueras MM , Pons I , Ortuño A , Segura F , 2009. Seroprevalence of Rickettsia typhi and Rickettsia felis in dogs from north-eastern Spain. Clin Microbiol Infect 15 (Suppl 2 ):237238.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Nogueras MM , Pons I , Ortuño A , Miret J , Pla J , Castellà J , Segura F , 2013. Molecular detection of Rickettsia typhi in cats and fleas. PLoS One 8: e71386.

  • 35.

    Nogueras MM , Pons I , Pla J , Ortuño A , Miret J , Sanfeliu I , Segura F , 2013. The role of dogs in the eco-epidemiology of Rickettsia typhi, etiological agent of murine typhus. Vet Microbiol 163: 97102.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Richards AL et al., 1997. Seroepidemiologic evidence for murine and scrub typhus in Malang, Indonesia. Am J Trop Med Hyg 57: 9195.

  • 37.

    Gikas A , Kokkini S , Tsioutis C , Athenessopoulos D , Balomenaki E , Blasak S , Matheou C , Tselentis Y , Psaroulaki A , 2009. Murine typhus in children: Clinical and laboratory features from 41 cases in Crete, Greece. Clin Microbiol Infect 15 (Suppl 2 ):211212.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38.

    Koliou M , Psaroulaki A , Georgiou C , Ioannou I , Tselentis Y , Gikas A , 2007. Murine typhus in Cyprus: 21 Paediatric cases. Eur J Clin Microbiol Infect Dis 26: 491493.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39.

    Silpapojakul K , Chupuppakarn S , Yuthasompob S , Varachit B , Chaipak D , Borkerd T , Silpapojakul K , 1991. Scrub and murine typhus in children with obscure fever in the tropics. Pediatr Infect Dis J 10: 200203.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40.

    Shalev H , Raissa R , Evgenia Z , Yagupsky P , 2006. Murine typhus is a common cause of febrile illness in Bedouin children in Israel. Scand J Infect Dis 38: 451455.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41.

    Znazen A , Hammami B , Mustapha AB , Chaari S , Lahiani D , Maaloul I , Jemaa MB , Hammami A , 2013. Murine typhus in Tunisia: A neglected cause of fever as a single symptom. Med Mal Infect 43: 226229.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42.

    Grouteau G , Lancelot O , Bertolotti A , Poubeau P , Manaquin R , Foucher A , Jaubert J , Parola P , Pagès F , Camuset G , 2020. Emergence of murine typhus in La Réunion, France, 2012–2017. Med Mal Infect 50: 2227.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43.

    Chaliotis G , Kritsotakis EI , Psaroulaki A , Tselentis Y , Gikas A , 2012. Murine typhus in central Greece: Epidemiological, clinical, laboratory, and therapeutic-response features of 90 cases. Int J Infect Dis 16: e591e596.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44.

    Gikas A , Doukakis S , Pediaditis J , Kastanakis S , Psaroulaki A , Tselentis Y , 2002. Murine typhus in Greece: epidemiological, clinical, and therapeutic data from 83 cases. Trans R Soc Trop Med Hyg 96: 250253.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45.

    Zimmerman MD , Murdoch DR , Rozmajzl PJ , Basnyat B , Woods CW , Richards AL , Belbase RH , Hammer DA , Anderson TP , Reller LB , 2008. Murine typhus and febrile illness, Nepal. Emerg Infect Dis 14: 16561659.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46.

    Hsu C-H , Hsieh L-P , 2014. Murine typhus with presentation of unilateral abducens nerve palsy: A case report. J Intern Med Taiwan 25: 3640.

  • 47.

    Kato CY , Chung IH , Robinson LK , Eremeeva ME , Dasch GA , 2022. Genetic typing of isolates of Rickettsia typhi. PLoS Negl Trop Dis 16: e0010354.

  • 48.

    Zhang LJ , Li XM , Zhang DR , Zhang JS , Di Y , Luan MC , Fu XP , 2007. Molecular epidemic survey on co-prevalence of scrub typhus and marine typhus in Yuxi city, Yunnan province of China. Chin Med J (Engl) 120: 13141318.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49.

    Phommasone K , Paris DH , Anantatat T , Castonguay-Vanier J , Keomany S , Souvannasing P , Blacksell SD , Mayxay M , Newton PN , 2013. Concurrent infection with murine typhus and scrub typhus in southern Laos–The mixed and the unmixed. PLoS Negl Trop Dis 7: e2163.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50.

    Lai CH , Huang CK , Chen YH , Chang LL , Weng HC , Lin JN , Chung HC , Liang SH , Lin HH , 2009. Epidemiology of acute Q fever, scrub typhus, and murine typhus, and identification of their clinical characteristics compared to patients with acute febrile illness in southern Taiwan. J Formos Med Assoc 108: 367376.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51.

    Lai CH et al., 2017. The epidemiology and characteristics of Q fever and co-infections with scrub typhus, murine typhus or leptospirosis in Taiwan: A nationwide database study. Zoonoses Public Health 64: 517526.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52.

    Hechemy KE , Raoult D , Fox J , Han Y , Elliott LB , Rawlings J , 1989. Cross-reaction of immune sera from patients with rickettsial diseases. J Med Microbiol 29: 199202.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 53.

    Robinson MT , Satjanadumrong J , Hughes T , Stenos J , Blacksell SD , 2019. Diagnosis of spotted fever group Rickettsia infections: The Asian perspective. Epidemiol Infect 147: e286.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 54.

    Blacksell SD , Jenjaroen K , Phetsouvanh R , Tanganuchitcharnchai A , Phouminh P , Phongmany S , Day NP , Newton PN , 2010. Accuracy of rapid IgM-based immunochromatographic and immunoblot assays for diagnosis of acute scrub typhus and murine typhus infections in Laos. Am J Trop Med Hyg 83: 365369.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55.

    Rolain JM , Gouriet F , Brouqui P , Larrey D , Janbon F , Vene S , Jarnestrom V , Raoult D , 2005. Concomitant or consecutive infection with Coxiella burnetii and tickborne diseases. Clin Infect Dis 40: 8288.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 56.

    Tsai KH , Lu H-Y , Huang J-H , Fournier P-E , Mediannikov O , Raoult D , Shu P-Y , 2009. African tick bite fever in a Taiwanese traveler returning from South Africa: Molecular and serologic studies. Am J Trop Med Hyg 81: 735739.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57.

    Lai CH , Chang LL , Lin JN , Tsai KH , Hung YC , Kuo LL , Lin HH , Chen YH , 2014. Human spotted fever group rickettsioses are underappreciated in southern Taiwan, particularly for the species closely-related to Rickettsia felis. PLoS One 9: e95810.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 58.

    Yang WH , Hsu MS , Shu PY , Tsai KH , Fang CT , 2021. Neglected human Rickettsia felis infection in Taiwan: A retrospective seroepidemiological survey of patients with suspected rickettsioses. PLoS Negl Trop Dis 15: e0009355.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 59.

    Ng CP , Lo CB , Wong KK , Chung CH , 2002. A returned traveler with persistent fever due to murine typhus. Hong Kong Med J 8: 457459.

  • 60.

    Takeshita N , Imoto K , Ando S , Yanagisawa K , Ohji G , Kato Y , Sakata A , Hosokawa N , Kishimoto T , 2010. Murine typhus in two travelers returning from Bali, Indonesia: An underdiagnosed disease. J Travel Med 17: 356358.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 61.

    Azuma M , Nishioka Y , Ogawa M , Takasaki T , Sone S , Uchiyama T , 2006. Murine typhus from Vietnam, imported into Japan. Emerg Infect Dis 12: 14661468.

  • 62.

    Angelakis E , Botelho E , Socolovschi C , Sobas CR , Piketty C , Parola P , Raoult D , 2010. Murine typhus as a cause of fever in travelers from Tunisia and Mediterranean areas. J Travel Med 17: 310315.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 63.

    Walter G , Botelho-Nevers E , Socolovschi C , Raoult D , Parola P , 2012. Murine typhus in returned travelers: A report of thirty-two cases. Am J Trop Med Hyg 86: 10491053.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 64.

    Stafford IA , Centeno FH , Al Mohajer M , Parkerson G , Woc-Colburn L , Burgos-Lee AJ , Rac M , Dunn J , Muldrew K , 2020. Successful detection of unrecognized Rickettsia typhi in pregnancy using cell-free next-generation sequencing. Case Rep Obstet Gynecol 2020: 6767351.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 65.

    Centeno FH , Lasco T , Ahmed AA , Al Mohajer M , 2021. Characteristics of Rickettsia typhi infections detected with next-generation sequencing of microbial cell-free deoxyribonucleic acid in a tertiary care hospital. Open Forum Infect Dis 8: ofab147.

    • PubMed
    • Search Google Scholar
    • Export Citation
Past two years Past Year Past 30 Days
Abstract Views 1307 1307 49
Full Text Views 50 50 1
PDF Downloads 54 54 2
 
 
 
 
Affiliate Membership Banner
 
 
Research for Health Information Banner
 
 
CLOCKSS
 
 
 
Society Publishers Coalition Banner
Save