Orientia tsutsugamushi: Infectious substances pathogen safety data sheet 

Section I: Infectious agent


Orientia tsutsugamushi

Agent type









Synonym or cross-reference

Also known as Rickettsia tsutsugamushiFootnote 1. O. tsutsugamushi is the causative agent of scrub typhus, also known as "tropical typhus" and "tsutsugamushi disease"Footnote 2.


Brief description

O. tsutsugamushi is a gram-negative, coccobacilli bacterium measuring 0.5 μm by 1.2-3.0 μmFootnote 3. The cell wall of the bacterium lacks lipopolysaccharide and contains minimal peptidoglycanFootnote 4. The genome contains large proportions of mobile genetic elements. O. tsutsugamushi cannot be grown in media as it is an obligate intracellular pathogen and must be cultured in vitroFootnote 5. O. tsutsugamushi can be cultured within the yolk sac of chicken embryos or in cell lines, such as HeLa, Vero, BHK, or L929Footnote 3,Footnote 6. O. tsutsugamushi can also be cultivated in miceFootnote 3.


O. tsutsugamushi enters host cells by induced phagocytosis and replicates by binary fission in the cytoplasm of eukaryotic host cells. After replicating in host cells, O. tsutsugamushi is released from host cells in a manner similar to budding of enveloped virusesFootnote 7.

Section II: Hazard identification

Pathogenicity and toxicity

O. tsutsugamushi is the causative agent of scrub typhus. Symptoms may include general malaise, coughing, headache, fever persisting 9 to 19 days, rash, and lymphadenopathyFootnote 6,Footnote 8,Footnote 9. Other characteristics of the disease include focal or disseminated vasculitis and perivasculitis, involving the lungs, heart, liver, spleen, and the central nervous systemFootnote 8. The disease can lead to complications, such as pneumonia, myocarditis, meningoencephalitis, acute renal failure, or gastrointestinal bleedingFootnote 8. O. tsutsugamushi is transferred through mite bites and an eschar can develop at the site of the bite, beginning as a red papule which later ulcerates and blackensFootnote 6.

The mortality rate varies from less than 1% to 50%Footnote 9,Footnote 10,Footnote 11; median mortality rate for untreated patients is 6% and 1.4% for treated patientsFootnote 12. Mortality rates are higher in cases involving complications, including acute respiratory distress syndromeFootnote 13,Footnote 14, pneumonitisFootnote 15,Footnote 16, thrombocytopeniaFootnote 2, pancreatitis, renal failure, aseptic meningitis, meningoencephalitis, gastrointestinal bleeding, and multi organ failureFootnote 8,Footnote 13,Footnote 17.

Virulence varies among different strains mostly due to the variable surface antigens across different O. tsutsugamushi strainsFootnote 3,Footnote 18,Footnote 19.These surface antigens can cause O. tsutsugamushi to persist in humans after the disease is resolved, as antibodies no longer recognize the changed surface antigensFootnote 20,Footnote 21. Relapses after completion of antibiotic treatment have been reportedFootnote 21,Footnote 22.


O. tsutsugamushi is endemic to 'tsutsugamushi triangle', which includes northern Japan, Korea, Southeast Asia, Southwest Pacific, and eastern RussiaFootnote 17. Scrub typhus incidence varies in different countries from 1 to 60 cases per 100,000 people per yearFootnote 12. Numerous outbreaks of scrub typhus have been documentedFootnote 17. Recent outbreaks include two Camp Fuji outbreaks in 2000 and 2011 with 9 and 8 cases, respectivelyFootnote 10,Footnote 17; Maldives in 2002 with 168 confirmed casesFootnote 10,Footnote 17; Thailand in 2006-2007 in which scrub typhus was suspected in 142 febrile childrenFootnote 17; and two outbreaks in Rajasthan, India in 2012 and 2013Footnote 17. Sporadic cases of scrub typhus have been reported in areas outside the tsutsugamushi triangle, including United Arab Emirates, Chile and parts of AfricaFootnote 17.

Animals do not appear to show symptoms of the disease caused by O. tsutsugamushi despite being infected, as determined by the presence of serum antibodies.

Individuals living or working in areas where the mite vectors are highly prevalent are more susceptible to scrub typhusFootnote 23. Elderly individuals afflicted by scrub typhus are more at risk of developing complicationsFootnote 13. Additional risks for pregnant women include increased chance of miscarriage and premature deliveryFootnote 13.

Host range

Natural host(s)

Humans. Rodents and other infected mammals are dead-end hosts. Antibodies to O. tsutsugamushi have been found in wild monkeys and dogsFootnote 29,Footnote 30, although the disease is not known to occur naturally in animalsFootnote 31.

Other host(s)

Chickens, goats, horses, and calves were susceptible to infection by O. tsutsugamushi in vaccine researchFootnote 29. Monkeys infected in an experimental setting developed clinical signs and symptoms that resembled human scrub typhusFootnote 32.

Infectious dose

Varies for different strainsFootnote 33. The 50% mouse infectious dose (MID50) for different O. tsutsugamushi strains was determined by intraperitoneal inoculation in mice; MID50 ranged between 6.2 and 7.8 (log10) depending on strain virulenceFootnote 33.

Incubation period

5 to 20 daysFootnote 6.


Transmission from animal to human hosts occurs in nature via bites from infected Leptotrombidium mites (also known as 'chiggers') that are vectors for O. tsutsugamushi. Mites require 36-72 hours for attachment to the host's skin and infection to occurFootnote 8. Once inside the host, the bacteria can enter the bloodstreamFootnote 24. Vertical transmission from mother to baby is unlikely but has been observedFootnote 25. Human to human transmission is rare but can occur via blood transfusionFootnote 26,Footnote 27.

There is potential for the bacterium to enter a host through damaged skin. Contact of O. tsutsugamushi with mucous membranes via inhalation of infectious aerosols in a laboratory setting has resulted in scrub typhus pneumonitisFootnote 28. Laboratory workers have also acquired O. tsutsugamushi infection via rat bites, needle-stick injuries or auto-inoculationFootnote 28.

Section III: Dissemination


Leptotrombidium mitesFootnote 17. After the disease is resolved, the bacterium can persist in human and animal hosts without symptomsFootnote 20,Footnote 21.


None. Infected animals can transmit O. tsutsugamushi to humans via bites, but this phenomenon is not common in natureFootnote 5.


Larval trombiculid mite species of the genus Leptotrombidium are vectors for O. tsutsugamushiFootnote 2,Footnote 34. The bacteria are transmitted to hosts via mite 'bites'. Mites attach to skin and feed using host pores or hair follicles but do not pierce the skin. O. tsutsugamushi are injected into the host as the mite feeds. Mites feed once during the larval stage of their life cycleFootnote 2.

Section IV: Stability and viability

Drug susceptibility/resistance

Tetracyclines (e.g., doxycycline), chloramphenicol, macrolides (e.g., azithromycin)Footnote 10,Footnote 35, rifampicinFootnote 36, and telithromycinFootnote 37 are effective against O. tsutsugamushi.

Doxycycline and chloramphenicol resistance have been reportedFootnote 25,Footnote 38.

Susceptibility to disinfectants

Information specific to O. tsutsugamushi is not available. Generally, rickettsiae are susceptible to 1% sodium hypochlorite, 70% ethanol, 2% glutaraldehyde, formaldehyde, and quaternary ammonium compoundsFootnote 39.

Physical inactivation

Moist heat (121°C for 15 min) and dry heat (170°C for 1 hour) are effective against O. tsutsugamushiFootnote 39. Treatment of blood products with riboflavin and light is effective at reducing O. tsutsugamushiFootnote 40.

Survival outside host

O. tsutsugamushi can survive for 7 days in blood at room temperatureFootnote 41, and up to 10 days in blood stored at 4°CFootnote 27.

Section V: First aid/medical


Diagnosis is accomplished through the monitoring of clinical symptoms, patient history, and laboratory testsFootnote 17. Patient serum can be tested for O. tsutsugamushi using ELISA-based testsFootnote 42, indirect fluorescent antibody testing or indirect immunoperoxidase testingFootnote 17. These are rapid methods that have high specificity for identification of O. tsutsugamushi antigens. PCR of DNA from eschar swabs and blood samples collected during the acute phase of the disease can also be used to diagnose O. tsutsugamushiFootnote 43,Footnote 44,Footnote 45.

Note: The specific recommendations for surveillance in the laboratory should come from the medical surveillance program, which is based on a local risk assessment of the pathogens and activities being undertaken, as well as an overarching risk assessment of the biosafety program as a whole. More information on medical surveillance is available in the Canadian Biosafety Handbook (CBH).

First aid/treatment

Doxycycline and azithromycin are commonly used to treat scrub typhusFootnote 10,Footnote 39. Antibiotics may be given orally or parenterally depending on the severity of the illnessFootnote 17. Early treatment results in better patient outcomes.

Note: The specific recommendations for first aid/treatment in the laboratory should come from the post-exposure response plan, which is developed as part of the medical surveillance program. More information on the post-exposure response plan can be found in the CBH.


No vaccine is currently available; however, vaccine development is ongoingFootnote 10.

Note: More information on the medical surveillance program can be found in the CBH, and by consulting the Canadian Immunization Guide.


Antibiotics such as chloramphenicol and tetracycline protect against scrub typhus. The World Health Organisation recommends prophylactic treatment under special circumstancesFootnote 31.

Note: More information on prophylaxis as part of the medical surveillance program can be found in the CBH.

Section VI: Laboratory hazard

Laboratory-acquired infections

There are 9 known documented cases of laboratory-acquired scrub typhusFootnote 28,Footnote 46. Exposure to O. tsutsugamushi in a laboratory setting during a procedure involving cell homogenization resulted in one lab worker developing scrub typhus pneumonitisFootnote 28. The worker was not wearing a protective maskFootnote 28. Laboratory workers have also acquired O. tsutsugamushi infection via rat bites, and needle-stick or glassware injuriesFootnote 28.

Note: Please consult the Canadian Biosafety Standard (CBS) and CBH for additional details on requirements for reporting exposure incidents. A Canadian biosafety guideline describing notification and reporting procedures is also available.


Blood, biopsy specimens.

Primary hazards

Inhalation of airborne or aerosolized infectious material, bites/scratches of an infected animal, and autoinoculation with infectious material.

Special hazards


Section VII: Exposure controls/personal protection

Risk group classification

O. tsutsugamushi is a Risk Group 3 human pathogenFootnote 47 and a Risk Group 2 animal pathogen.

Containment requirements

Containment Level 3 facilities, equipment, and operational practices outlined in the CBS for work involving infectious or potentially infectious materials, animals, or cultures.

Protective clothing

Wear protective clothing to prevent mite bites when working or residing in Leptotrombidium mite habitats. The applicable Containment Level 3 requirements for personal protective equipment and clothing outlined in the CBS is to be followed. At minimum, use of full body coverage dedicated protective clothing, dedicated protective footwear and/or additional protective footwear, gloves when handling infectious materials or animals, face protection when there is a known or potential risk of exposure to splashes or flying objects, respirators when there is a risk of exposure to infectious aerosols, and an additional layer of protective clothing prior to work with infectious materials or animals.

Note: A local risk assessment will identify the appropriate hand, foot, head, body, eye/face, and respiratory protection, and the personal protective equipment requirements for the containment zone must be documented.

Other precautions

Thorough cleaning of skin and clothing with detergent after a potential encounter with Leptotrombidium mites can reduce risk of O. tsutsugamushi infectionFootnote 17. Insect repellents can be used to prevent mite bitesFootnote 17. All activities involving open vessels of pathogens are to be performed in a certified biological safety cabinet (BSC) or other appropriate primary containment device. The use of needles, syringes, and other sharp objects are to be strictly limited. Additional precautions must considered with work involving animals or large scale activities.

Section VIII: Handling and storage


Allow aerosols to settle. Wearing protective clothing, gently cover the spill with absorbent paper towel and apply suitable disinfectant, starting at the perimeter and working towards the centre. Allow sufficient contact time before clean up (CBH).


Regulated materials, as well as all items and waste are to be decontaminated at the containment barrier prior to removal from the containment zone, animal room, animal cubicle, or post mortem room. This can be achieved by using decontamination technologies and processes that have been demonstrated to be effective against the infectious material, such as chemical disinfectants, autoclaving, irradiation, incineration, an effluent treatment system, or gaseous decontamination (CBH).


The applicable Containment Level 3 requirements for storage outlined in the CBS are to be followed. Primary containers of regulated materials removed from the containment zone are to be stored in a labelled, leak-proof, impact-resistant secondary container, and kept either in locked storage equipment or within an area with limited access.

An inventory of RG3 and RG4 pathogens, and SSBA toxins in long-term storage, to be maintained and to include:

  1. specific identification of the regulated materials; and
  2. a mechanism that allows for the detection of a missing or stolen sample in a timely manner.

Section IX: Regulatory and other information

Canadian regulatory information

Controlled activities with O. tsutsugamushi require a Human Pathogens and Toxins Licence issued by the Public Health Agency of Canada.

The following is a non-exhaustive list of applicable designations, regulations, or legislations:

Last file update

August, 2019

Prepared by

Centre for Biosecurity, Public Health Agency of Canada.


The scientific information, opinions, and recommendations contained in this Pathogen Safety Data Sheet have been developed based on or compiled from trusted sources available at the time of publication. Newly discovered hazards are frequent and this information may not be completely up to date. The Government of Canada accepts no responsibility for the accuracy, sufficiency, or reliability or for any loss or injury resulting from the use of the information.

Persons in Canada are responsible for complying with the relevant laws, including regulations, guidelines and standards applicable to the import, transport, and use of pathogens in Canada set by relevant regulatory authorities, including the Public Health Agency of Canada, Health Canada, Canadian Food Inspection Agency, Environment and Climate Change Canada, and Transport Canada. The risk classification and related regulatory requirements referenced in this Pathogen Safety Data Sheet, such as those found in the Canadian Biosafety Standard, may be incomplete and are specific to the Canadian context. Other jurisdictions will have their own requirements.

Copyright© Public Health Agency of Canada, 2023, Canada


Footnote 1

Catalogue of Life. 2016. Orientia tsutsugamushi. Catalogue of Life.

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Footnote 2

Mahon, S. E., and P. B. Smulowitz. 2016. Orientia tsutsugamushi (Scrub Typhus) Attack, p. 721. G. R. Ciottone, P. D. Biddinger, R. G. Darling, S. Fares, M. E. Keim, M. S. Molloy, and S. Suner (eds.), Ciottone's Disaster Medicine. Elsevier.

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Footnote 3

Yu, X. J., and D. H. Walker. 2005. Genus II. Orientia, p. 114. G. M. Garrity, D. J. Brenner, N. R. Krieg, and J. T. Staley (eds.), Bergey's Manual of Systematic Bacteriology, Second Edition. Volume Two: The Proteobacteria (Part C). Springer, USA.

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Footnote 4

Salje, J. 2017. Orientia tsutsugamushi: A neglected but fascinating obligate intracellular bacterial pathogen. PLoS Pathogens. 13:e1006657.

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Footnote 5

Luce-Fedrow, A., M. L. Lehman, D. J. Kelly, K. Mullins, A. N. Maina, R. L. Stewart, H. Ge, A. L. Richards, and J. Jiang. 2018. A review of scrub typhus ('Orientia tsutsugamushi' and related organisms): Then, now, and tomorrow. Tropical Medicine and Infectious Disease. 3:1-30.

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Footnote 6

Seong, S. -. M. -. Choi, and I. -. Kim. 2001. Orientia tsutsugamushi infection: Overview and immune responses. Microbes Infect. 3:11-21.

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Footnote 7

Ge, Y., and Y. Rikihisa. 2011. Subversion of host cell signaling by Orientia tsutsugamushi. Microbes Infect. 13:638-648.

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Footnote 8

Tay, S. T., H. A. M. Zan, Y. A. Lim, and R. Ngui. 2013. Antibody prevalence and factors associated with exposure to Orientia tsutsugamushi in different aboriginal subgroups in West Malaysia. PLoS. 7(8):e2341.

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Footnote 9

9. Taylor, A. J., D. H. Paris, and P. N. Newton. 2015. A Systematic Review of Mortality from Untreated Scrub Typhus (Orientia tsutsugamushi). PLoS Negl Trop. Dis. 9:e0003971.

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Footnote 10

Chattopadhyay, S., and A. L. Richards. 2007. Scrub typhus vaccines: Past history and recent developments. Hum. Vaccines. 3:73-80.

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Footnote 11

Charoensak, A., O. Chawalparit, C. Suttinont, K. Niwattayakul, K. Losuwanaluk, S. Silpasakorn, and Y. Suputtamongkol. 2006. Scrub typhus: chest radiographic and clinical findings in 130 Thai patients. J. Med. Assoc. Thai. 89:600-607.

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Footnote 12

Bonell, A., Y. Lubell, P. N. Newton, J. A. Crump, and D. H. Paris. 2017. Estimating the burden of scrub typhus: A systematic review. PLoS Negl Trop. Dis. 11:e0005838.

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Footnote 13

Rapsang, A. G., and P. Bhattacharyya. 2013. Scrub typhus. Indian J. Anaesth. 57:127-134. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3696258/.

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Footnote 14

Wang, C. C., S. F. Liu, J. W. Liu, Y. H. Chung, M. C. Su, and M. C. Lin. 2007. Acute respiratory distress syndrome in scrub typhus. Am. J. Trop. Med. Hyg. 76:1148-1152.

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Footnote 15

Watt, G., and P. Parola. 2003. Scrub typhus and tropical rickettsioses. Curr. Opin. Infect. Dis. 16:429-436.

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Footnote 16

Sirisanthana, V., T. Puthanakit, and T. Sirisanthana. 2003. Epidemiologic, clinical and laboratory features of scrub typhus in thirty Thai children. Pediatr. Infect. Dis. J. 22:341-345.

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Footnote 17

Xu, G., D. H. Walker, D. Jupiter, P. C. Melby, and C. M. Arcari. 2017. A review of the global epidemiology of scrub typhus. PLoS Negl Trop. Dis. 11:e0006062.

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Footnote 18

Valbuena, G., and D. H. Walker. 2013. Approaches to vaccines against Orientia tsutsugamushi. Front. Cell. Infect. Microbiol. 4:2:170.

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Footnote 19

Kim, H., N. Ha, G. Kim, C. Min, Y. Kim, N. T. H. Yen, M. Choi, and N. Cho. 2019. Immunization with a recombinant antigen composed of conserved blocks from TSA56 provides broad genotype protection against scrub typhus. Emerging Microbes & Infections. 8:946-958.

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Footnote 20

Hauptmann, M., J. Kolbaum, S. Lilla, D. Wozniak, M. Gharaibeh, B. Fleischer, and C. A. Keller. 2016. Protective and Pathogenic Roles of CD8+ T Lymphocytes in Murine Orientia tsutsugamushi Infection. PLoS. Negl. Trop. Dis. 10: (9): e0004991.

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Footnote 21

Chung, M. H., J. S. Lee, J. H. Baek, M. Kim, and J. S. Kang. 2012. Persistence of Orientia tsutsugamushi in humans. J. Korean Med. Sci. 27:231-235.

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Footnote 22

Olson, J. G., R. Fang, and D. T. Dennis. 1983. Risk of relapse associated with doxycycline therapy for scrub typhus. United States Naval Medical Research Unit no. Two.

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Footnote 23

Varghese, G. M., D. Raj, M. R. Francis, R. Sarkar, P. Trowbridge, and J. Muliyil. 2016. Epidemiology & risk factors of scrub typhus in south India. Indian J. Med. Res. 144:76-81.

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Footnote 24

Gothwal, S., S. S. Dhruw, R. Choudhry, and S. S. 2016. Neonatal Scrub Typhus: Case Report. Pediatr Emerg Care Med. 1:8.

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Footnote 25

Rajapakse, S., C. Rodrigo, and S. D. Fernando. 2011. Drug treatment of scrub typhus. Trop. Doct. 41:1-4.

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Footnote 26

Khaisuwan, S., P. Kantipong, G. Watt, and T. Burnouf. 2001. Transmission of scrub typhus by blood transfusion? Transfusion. 41:1454-1455.

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Footnote 27

Casleton, B. G., K. Salata, G. A. Dasch, D. Strickman, and D. J. Kelly. 1998. Recovery and viability of Orientia tsutsugamushi from packed red cells and the danger of acquiring scrub typhus from blood transfusion. Transfusion. 38:680-689.

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Footnote 28

Oh, M., N. Kim, M. Huh, C. Choi, E. Lee, I. Kim, and K. Choe. 2001. Scrub typhus pneumonitis acquired through the respiratory tract in a laboratory worker. Infection. 29:54-56.

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Footnote 29

Ridgway, R. L., and S. C. Oaks. 1988. Scrub Typhus. U. S. Army Medical Research Institute of Infectious Diseases, U. S. Army Medical Research and Development Command. ADA203564:8.

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Footnote 30

Irwin, P. J., and R. Jefferies. 2004. Arthropod-transmitted diseases of companion animals in Southeast Asia. Trends Parasitol. 20:27-34.

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Footnote 31

The World Health Organization. Frequently Asked Questions - Scrub Typhus. Regional Office for South-East Asia.

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Footnote 32

Walsh, D. S., E. C. Delacrus, R. M. Abalos, E. V. Tan, J. Jiang, A. L. Richards, C. Eamsila, W. Rodkvantook, and K. W. A. Myint. 2007. Clinical and histological features of inoculation site skin lesions in cynomolgus monkeys experimentally infected with Orientia tsutsugamushi.. Vector-Borne Zoonotic Dis. 7:547-554.

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Footnote 33

Nagano, I., S. Kasuya, N. Noda, and T. Yamashita. 1996. Virulence in mice of Orientia tsutsugamushi isolated from patients in a new endemic area in Japan. Microbiol. Immunol. 40:743-747.

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Footnote 34

Coleman, R. E., T. Monkanna, K. J. Linthicum, D. A. Strickman, S. P. Frances, P. Tanskul, T. M. Kollars Jr., I. Inlao, P. Watcharapichat, N. Khlaimanee, D. Phulsuksombati, N. Sangjun, and K. Lerdthusnee. 2003. Occurrence of Orientia tsutsugamushi in small mammals from Thailand. Am. J. Trop. Med. Hyg. 69:519-524.

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Footnote 35

Kim, Y. S., H. J. Yun, S. K. Shim, S. H. Koo, S. Y. Kim, and S. Kim. 2004. A comparative trial of a single dose of azithromycin versus doxycycline for the treatment of mild scrub typhus. Clin. Infect. Dis. 39:1329-1335.

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Footnote 36

Panpanich, R., and P. Garner. 2002. Antibiotics for treating scrub typhus. Cochrane Database Syst. Rev. (3):CD002150.

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Footnote 37

Kim, D. M., K. D. Yu, J. H. Lee, H. K. Kim, and S. H. Lee. 2007. Controlled trial of a 5-day course of telithromycin versus doxycycline for treatment of mild to moderate scrub typhus. Antimicrob. Agents Chemother. 51:2011-2015.

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Footnote 38

Watt, G., C. Chouriyagune, R. Ruangweerayud, P. Watcharapichat, D. Phulsuksombati, K. Jongsakul, P. Teja-Isavadharm, D. Bhodhidatta, K. D. Corcoran, G. A. Dasch, and D. Strickman. 1996. Scrub typhus infections poorly responsive to antibiotics in northern Thailand. Lancet. 348:86-89.

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Footnote 39

Narang, R. 2016. Biology of Orientia tsutsugamushi, p. 385. S. Thomas (ed.), Rickettsiales: Biology, Molecular Biology, Epidemiology, and Vaccine Development. Springer, Cham, Switzerland.

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Footnote 40

Rentas, F., R. Harman, C. Gomez, J. Salata, J. Childs, T. Silva, L. Lippert, J. Montgomery, A. Richards, C. Chan, J. Jiang, H. Reddy, J. Li, and R. Goodrich. 2007. Inactivation of Orientia tsutsugamushi in red blood cells, plasma, and platelets with riboflavin and light, as demonstrated in an animal model. Transfusion. 47:240-247.

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Footnote 41

Mitscherlich, E., and E. H. Marth. 1984., p. 326. Anonymous Microbial Survival in the Environment. Springer-Verlag.

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Footnote 42

Blacksell, S. D., A. Tanganuchitcharnchai, P. Nawtaisong, P. Kantipong, A. Laongnualpanich, N. P. J. Day, and D. H. Paris. 2016. Diagnostic Accuracy of the InBios Scrub Typhus Detect Enzyme-Linked Immunoassay for the Detection of IgM Antibodies in Northern Thailand. Clin. Vaccine Immunol. 23:148-154.

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Footnote 43

Janardhanan, J., J. A. Prakash, O. C. Abraham, and G. M. Varghese. 2014. Comparison of a conventional and nested PCR for diagnostic confirmation and genotyping of Orientia tsutsugamushi. Diagn. Microbiol. Infect. Dis. 79:7-9.

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Footnote 44

Kim, D. M., G. Park, H. S. Kim, J. Y. Lee, G. P. Neupane, S. Graves, and J. Stenos. 2011. Comparison of Conventional, Nested, and Real-Time Quantitative PCR for Diagnosis of Scrub Typhus. J. Clin. Microbiol. 49:607-612.

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Footnote 45

Le Viet, N., M. Laroche, H. L. Thi Pham, N. L. Viet, O. Mediannikov, D. Raoult, and P. Parola. 2017. Use of eschar swabbing for the molecular diagnosis and genotyping of Orientia tsutsugamushi causing scrub typhus in Quang Nam province, Vietnam. PLoS Negl Trop. Dis. 11:e0005397.

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Footnote 46

Pike, R. M. 1979. Laboratory-Associated Infections: Incidence, Fatalities, Causes, and Prevention. Annu. Rev. Microbiol. 33:41-66.

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Footnote 47

Public Health Agency of Canada. 2015. Human Pathogens and Toxins Act (HPTA). 2016:.

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