{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T09:40:04Z","timestamp":1789119604662,"version":"build-2803163510"},"update-to":[{"DOI":"10.1371\/journal.pntd.0013960","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T00:00:00Z","timestamp":1770681600000}}],"reference-count":33,"publisher":"Public Library of Science (PLoS)","issue":"2","license":[{"start":{"date-parts":[[2026,2,2]],"date-time":"2026-02-02T00:00:00Z","timestamp":1769990400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000265","name":"Medical Research Council","doi-asserted-by":"publisher","award":["MR\/S023275\/1"],"award-info":[{"award-number":["MR\/S023275\/1"]}],"id":[{"id":"10.13039\/501100000265","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosntds.org"],"crossmark-restriction":false},"short-container-title":["PLoS Negl Trop Dis"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Scrub typhus is a potentially life-threatening acute febrile illness found in many parts of Asia. This study aimed to estimate the cost of illness among scrub typhus cases in Tamil Nadu, South India and explore treatment-seeking behaviour.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods\/Principal Findings<\/jats:title>\n                    <jats:p>Cases were enrolled from a population-based cohort study on scrub typhus in 32,279 individuals living in rural villages. Data on direct and indirect costs were collected using structured questionnaires from 311 scrub typhus cases of which 26 were severe. Thirteen cases with severe infections (or their relatives) underwent in-depth interviews to understand treatment-seeking pathways.<\/jats:p>\n                    <jats:p>The mean age of cases was 41.1 years, and 64% were female. The average monthly household income was USD 236 (standard deviation, SD 155). The average number of workdays missed in severe infection was 18 days per episode (SD 22.2) compared to 4 days (SD 11.6) in non-severe illness. The mean overall cost of illness was USD 189 (SD 495), disaggregating to USD 1,321 (SD 1045) for severe cases and USD 86 (SD 209) for non-severe. In both severe and non-severe cases, hospital admission was common (69\/311) and was associated with a cost increase of over USD 400. Costs were almost twice as high in males compared to females. Catastrophic health expenditure exceeding 25% of annual income occurred in 10% of cases. Treatment by traditional healers, untrained practitioners, pharmacies and local clinics was sought even for mild fever of short duration. In-depth interviews revealed that patients preferred to have a one-off treatment enabling them to return to daily routines with little demand for fever diagnostics. There was demand for higher level of care and diagnostic procedures only when symptoms became severe or the case was a child or a pregnant woman.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Conclusions\/Significance<\/jats:title>\n                    <jats:p>Hospitalisation, common in both severe and non-severe patients, was the driving factor for high costs. Early case recognition may reduce hospitalisations and health expenditure in highly endemic settings.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pntd.0013960","type":"journal-article","created":{"date-parts":[[2026,2,2]],"date-time":"2026-02-02T18:56:19Z","timestamp":1770058579000},"page":"e0013960","update-policy":"https:\/\/doi.org\/10.1371\/journal.pntd.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["Cost of illness of scrub typhus in South India \u2013 a population-based, mixed-methods study"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0009-0009-3446-7753","authenticated-orcid":true,"given":"Carol","family":"Devamani","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adam","family":"Biran","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Koya","family":"Ariyoshi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"K.R.","family":"John","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ian","family":"Ross","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yoshinao","family":"Kubo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"Chandramohan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kundavaram Paul Prabhakar","family":"Abhilash","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wolf-Peter","family":"Schmidt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,2,2]]},"reference":[{"issue":"2","key":"pntd.0013960.ref001","doi-asserted-by":"crossref","first-page":"301","DOI":"10.4269\/ajtmh.13-0064","article-title":"Unresolved problems related to scrub typhus: a seriously neglected life-threatening disease","volume":"89","author":"DH Paris","year":"2013","journal-title":"Am J Trop Med Hyg"},{"issue":"3","key":"pntd.0013960.ref002","doi-asserted-by":"crossref","first-page":"589","DOI":"10.1099\/00207713-45-3-589","article-title":"Classification of Rickettsia tsutsugamushi in a new genus, Orientia gen. nov., as Orientia tsutsugamushi comb. nov","volume":"45","author":"A Tamura","year":"1995","journal-title":"Int J Syst Bacteriol"},{"issue":"10","key":"pntd.0013960.ref003","doi-asserted-by":"crossref","first-page":"954","DOI":"10.1056\/NEJMoa1603657","article-title":"Endemic Scrub Typhus in South America","volume":"375","author":"T Weitzel","year":"2016","journal-title":"N Engl J Med"},{"key":"pntd.0013960.ref004","unstructured":"Maina AN, Farris CM, Odhiambo A, Jiang J, Laktabai J, Armstrong J. Q fever, scrub typhus, and rickettsial diseases in children, Kenya, 2011\u20132012. 2014."},{"issue":"4","key":"pntd.0013960.ref005","doi-asserted-by":"crossref","first-page":"147","DOI":"10.4103\/0974-777X.192966","article-title":"Acute Undifferentiated Febrile Illness in Patients Presenting to a Tertiary Care Hospital in South India: Clinical Spectrum and Outcome","volume":"8","author":"KPP Abhilash","year":"2016","journal-title":"J Glob Infect Dis"},{"issue":"4","key":"pntd.0013960.ref006","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1258\/td.2010.100132","article-title":"Acute undifferentiated febrile illness in adult hospitalized patients: the disease spectrum and diagnostic predictors - an experience from a tertiary care hospital in South India","volume":"40","author":"A Chrispal","year":"2010","journal-title":"Trop Doct"},{"issue":"2","key":"pntd.0013960.ref007","doi-asserted-by":"crossref","first-page":"278","DOI":"10.4103\/ijmm.IJMM_19_147","article-title":"Clinico-epidemiological analysis of scrub typhus in hospitalised patients presenting with acute undifferentiated febrile illness: A hospital-based study from Eastern India","volume":"37","author":"B Behera","year":"2019","journal-title":"Indian J Med Microbiol"},{"issue":"2","key":"pntd.0013960.ref008","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0007160","article-title":"Hospitalisations and outpatient visits for undifferentiated fever attributable to scrub typhus in rural South India: Retrospective cohort and nested case-control study","volume":"13","author":"CS Devamani","year":"2019","journal-title":"PLoS Negl Trop Dis"},{"issue":"7","key":"pntd.0013960.ref009","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0009619","article-title":"The burden of scrub typhus in India: A systematic review","volume":"15","author":"E Devasagayam","year":"2021","journal-title":"PLoS Negl Trop Dis"},{"issue":"9","key":"pntd.0013960.ref010","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0005838","article-title":"Estimating the burden of scrub typhus: A systematic review","volume":"11","author":"A Bonell","year":"2017","journal-title":"PLoS Negl Trop Dis"},{"issue":"9","key":"pntd.0013960.ref011","doi-asserted-by":"crossref","first-page":"792","DOI":"10.1056\/NEJMoa2208449","article-title":"Intravenous doxycycline, azithromycin, or both for severe scrub typhus","volume":"388","author":"GM Varghese","year":"2023","journal-title":"N Engl J Med"},{"issue":"6","key":"pntd.0013960.ref012","doi-asserted-by":"crossref","first-page":"559","DOI":"10.4103\/ijmr.IJMR_3917_20","article-title":"Costs & outcomes of hospitalized scrub typhus infection in a tertiary hospital in south India","volume":"157","author":"KJ John","year":"2023","journal-title":"Indian J Med Res"},{"issue":"5","key":"pntd.0013960.ref013","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2017-018020","article-title":"Quantifying the financial burden of households\u2019 out-of-pocket payments on medicines in India: a repeated cross-sectional analysis of National Sample Survey data, 1994\u20132014","volume":"8","author":"S Selvaraj","year":"2018","journal-title":"BMJ Open"},{"issue":"3","key":"pntd.0013960.ref014","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1093\/heapol\/czr029","article-title":"Insured yet vulnerable: out-of-pocket payments and India\u2019s poor","volume":"27","author":"R Shahrawat","year":"2012","journal-title":"Health Policy Plan"},{"issue":"11","key":"pntd.0013960.ref015","doi-asserted-by":"crossref","first-page":"1089","DOI":"10.1056\/NEJMoa2408645","article-title":"Incidence of Scrub Typhus in Rural South India","volume":"392","author":"C Devamani","year":"2025","journal-title":"N Engl J Med"},{"issue":"7","key":"pntd.0013960.ref016","doi-asserted-by":"crossref","first-page":"976","DOI":"10.1177\/1049732304266795","article-title":"Premises, principles, and practices in qualitative research: revisiting the foundations","volume":"14","author":"K Charmaz","year":"2004","journal-title":"Qual Health Res"},{"key":"pntd.0013960.ref017","author":"LA Robinson","year":"2019"},{"key":"pntd.0013960.ref018","doi-asserted-by":"crossref","first-page":"112475","DOI":"10.1016\/j.socscimed.2019.112475","article-title":"Measuring, valuing and including forgone childhood education and leisure time costs in economic evaluation: Methods, challenges and the way forward","volume":"237","author":"L Andronis","year":"2019","journal-title":"Soc Sci Med"},{"issue":"2","key":"pntd.0013960.ref019","article-title":"Progress on catastrophic health spending in 133 countries: a retrospective observational study","volume":"6","author":"A Wagstaff","year":"2018","journal-title":"Lancet Glob Health"},{"key":"pntd.0013960.ref020","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1186\/s12962-023-00457-5","article-title":"Overview of the main methods used for estimating catastrophic health expenditure","volume":"21","author":"HA Nguyen","year":"2023","journal-title":"Cost Eff Resour Alloc"},{"key":"pntd.0013960.ref021","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1186\/s13561-015-0045-7","article-title":"Statistical models for the analysis of skewed healthcare cost data: a simulation study","volume":"5","author":"AS Malehi","year":"2015","journal-title":"Health Econ Rev"},{"key":"pntd.0013960.ref022","volume-title":"Qualitative research practice","author":"J Ritchie","year":"2003"},{"issue":"4","key":"pntd.0013960.ref023","doi-asserted-by":"crossref","first-page":"589","DOI":"10.1080\/2159676X.2019.1628806","article-title":"Reflecting on reflexive thematic analysis","volume":"11","author":"V Braun","year":"2019","journal-title":"Qual Res Sport Exerc Health"},{"issue":"1","key":"pntd.0013960.ref024","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1111\/j.2044-8287.2012.02077.x","article-title":"The model of pathways to treatment: conceptualization and integration with existing theory","volume":"18","author":"SE Scott","year":"2013","journal-title":"Br J Health Psychol"},{"key":"pntd.0013960.ref025","doi-asserted-by":"crossref","DOI":"10.1016\/j.ijid.2019.02.033","article-title":"Direct cost of illness for dengue in hospitalized children and adults at a referral hospital in India","volume":"84","author":"K Panmei","year":"2019","journal-title":"Int J Infect Dis"},{"issue":"9","key":"pntd.0013960.ref026","doi-asserted-by":"crossref","first-page":"5393","DOI":"10.4103\/jfmpc.jfmpc_694_21","article-title":"Economic burden estimation associated with dengue and chikungunya in Gujarat, India","volume":"11","author":"J Kaur","year":"2022","journal-title":"J Family Med Prim Care"},{"issue":"4","key":"pntd.0013960.ref027","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0002982","article-title":"Use of antimicrobials and other medical products in an ethnic minority context of South-Central Vietnam: A qualitative study of vulnerability","volume":"4","author":"M Ronse","year":"2024","journal-title":"PLOS Glob Public Health"},{"key":"pntd.0013960.ref028","doi-asserted-by":"crossref","unstructured":"Mohanty P, Jena PK, Kishore J. Gender disparity in health expenses, health insurance financing and out-of-pocket expenses for inpatient care in India. Int J Prev Curative Community Med.\u00a02019; 5(3): 3-10.\u00a0doi: 10.24321\/2454.325X.201918","DOI":"10.24321\/2454.325X.201918"},{"key":"pntd.0013960.ref029","first-page":"100372","article-title":"Gender disparities in health care expenditures and financing strategies (HCFS) for inpatient care in India","author":"SN Moradhvaj","year":"2019","journal-title":"SSM - Popul\u00a0Health"},{"issue":"11","key":"pntd.0013960.ref030","doi-asserted-by":"crossref","first-page":"1377","DOI":"10.1111\/tmi.12973","article-title":"Factors associated with treatment seeking for malaria in Madhya Pradesh, India","volume":"22","author":"MP Singh","year":"2017","journal-title":"Trop Med Int Health"},{"key":"pntd.0013960.ref031","doi-asserted-by":"crossref","first-page":"301","DOI":"10.1186\/1475-2875-8-301","article-title":"Treatment-seeking for febrile illness in north-east India: an epidemiological study in the malaria endemic zone","volume":"8","author":"HK Chaturvedi","year":"2009","journal-title":"Malar J"},{"issue":"5","key":"pntd.0013960.ref032","doi-asserted-by":"crossref","first-page":"662","DOI":"10.4269\/ajtmh.2008.79.662","article-title":"Characterization of \u201cYaa Chud\u201d medicine on the Thailand\u2013Myanmar border: selecting for drug-resistant malaria and threatening public health","volume":"79","author":"PN Newton","year":"2008","journal-title":"Am J Trop Med Hyg"},{"key":"pntd.0013960.ref033","volume-title":"Poor economics: Rethinking poverty and the ways to end it","author":"E Duflo","year":"2013"}],"updated-by":[{"DOI":"10.1371\/journal.pntd.0013960","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T00:00:00Z","timestamp":1770681600000}},{"DOI":"10.1371\/journal.pntd.0014712","type":"correction","label":"Correction","source":"publisher","updated":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T00:00:00Z","timestamp":1788998400000}}],"container-title":["PLOS Neglected Tropical Diseases"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pntd.0013960","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T18:44:27Z","timestamp":1770749067000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pntd.0013960"}},"subtitle":[],"editor":[{"given":"Joseph M.","family":"Vinetz","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,2,2]]},"references-count":33,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,2,2]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pntd.0013960","relation":{},"ISSN":["1935-2735"],"issn-type":[{"value":"1935-2735","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,2]]}}}