Introduction

Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi infection. The bacterium is an obligate intracellular pathogen maintained through transovarian and transtadial transmission in trombiculid mites that serve as vectors for the infectious disease [1,2]. The disease is endemic in Asia and the western Pacific area including northern Australia. The first description of a febrile disease thought to be scrub typhus, along with the morphology of the vector mites, appeared in Chinese literature in 313 A.D. [3]. Therefore, it seems to an ancient infectious disease that has long been confined to its endemic area, although several cases of suspected scrub typhus have been reported outside of the endemic region [4–7].

Global incidence of scrub typhus across the whole endemic region has been poorly defined due to the limited epidemiological data in many of the endemic countries. Nevertheless, it has been estimated that more than a million cases occur annually and a billion people are at risk [8]. In addition, there has been a rapid increase in scrub typhus cases, as well as sporadic local outbreaks during the last decade [9–13], making it a serious public health issue in the endemic area. Recent epidemiological data available in various resources (S1 Table), clearly demonstrates the gradual emergence of scrub typhus in several endemic countries (Fig 1). Even though the increasing number of reported cases of scrub typhus might be partly due to increased awareness and better surveillance systems in the developing countries [2,9], environmental change and human activity might be important factors contributing to the emerging trend [14–17]. Given that vector mites maintain the intracellular pathogen, ecological changes of the vector species in local endemic regions could be the primary cause of the emergence of scrub typhus, as recently observed in South Korea [15,16]. However, the distribution of mite species associated with scrub typhus in the whole endemic region has been poorly monitored and the currently available vector map issued by the World Health Organization (WHO) is based on data before 1974 [18–20].

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Fig 1. Epidemiological trends of scrub typhus incidence in several endemic countries from 2000 to 2014.

Regional map shows the distribution of scrub typhus (gray area) and the annual incidence of several endemic countries during 2000 ~ 2014 are presented. The graphs are based on the data summarized in S1 Table. Red line: reported cases, pink area: incidence rate/10⁶.

https://doi.org/10.1371/journal.pntd.0005408.g001

Another critical issue of scrub typhus is the apparent antigenic diversity of O. tsutsugamushi throughout the region of endemicity [1]. The antigenic heterogeneity has been a serious obstacle for developing effective diagnostic methods, as well as a universal scrub typhus vaccine [1,2]. Historically, the antigenic variation of O. tsutsugamushi was characterized by several serological techniques using whole bacterial antigens, such as complement fixation and immunofluorescence assay. Based on serological analyses, the bacterial pathogen has been classified into various strains, including Karp, Gilliam, and Kato prototypes [21]. The defined “serotypes” have been changed into “genotypes” since a 56 kDa type-specific antigen, tsa56, occupying approximately 20% of whole bacterial proteome [22], was identified to be a major bacterial surface antigen reactive to strain-specific antibodies [23]. Genetic analysis of the tsa56 gene has provided the most useful standard to differentiate the genotypes of O. tsutsugamushi [22,24,25] and a growing number of tsa56 sequences has been deposited in the international nucleotide database [26]. As the number of tsa56 sequences increases, more diverse genotypes of O. tsutsugamushi have been identified [1,27]. Nevertheless, the question of how the genetic diversity of tsa56 gene has evolved remains unsolved. In addition, the potential relationship between genotype variation and epidemiological changes has been poorly assessed in the global level.

In order to understand the evolutionary pathway of genotypic diversification of O. tsutsugamushi, as well as the environmental basis associated with the epidemiological changes of scrub typhus, we collected and analyzed the data of tsa56 genes, including genetic sequences and their spatiotemporal information. We also searched and reviewed references containing information on the Leptotrombidium species, the primary vectors of scrub typhus, to update the vector map and examine ecological changes of the “natural host” of O. tsutsugamushi in the whole endemic region. The systemic analysis of genotype diversity and geographical distribution of the vector hosts may not only provide valuable insight into the factors affecting epidemiological changes, but also enhance our current knowledge required for developing better diagnostics and an effective vaccine for scrub typhus.

Methods

Results

Phylogenetic analysis of tsa56 genes

Phylogenetic analysis was performed using 206 unique tsa56 nucleotide sequences (S2 Table) and defined the genetic clusters based on branching supporting values (SH-like value ≥ 0.90) and the relative branch length from a node. At least 17 genotypes were defined by the phylogenetic analysis of the nucleotide sequences and named after the prototype strains (Fig 2). Based on the phylogenetic distances, 17 genotypes were further classified into 5 groups: Karp, Gilliam, TA763, Kato, and Shimokoshi. When we compared the 206 genes using protein sequences, the ranges of sequence similarity and identity in the amino acid level further support the grouping of genotypes (Fig 3 and S5 Table). Within each genotype, minimum similarity and identity among the gene members are generally over 80.0% and 70.0%, respectively, with the exception of the Shimokoshi genotype (min. similarity: 79.0%, min. identity: 68.2%). Among the gene members within a group, minimum similarity and identity are further reduced to 73.0% and 60.1%, respectively, as observed in the Shimokoshi group. Among all the collected genes, the minimum similarity (66.2%) was observed between members of Saitama and Shimokoshi genotypes and the minimum identity (52.9%) was detected between members of Kato_A and Shimokoshi genotypes. It is worth noting that gene members in the Gilliam genotype and in the TA763 group show relatively higher similarity to those of Karp group (Fig 3), although they are phylogenetically distant.

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Fig 2. Phylogenetic analysis of 206 tsa56 genes and their classification into genotypes and genogroups.

Phylogenetic relationships of 206 complete or nearly complete tsa56 genes (listed in S2 Table) covering more than 85% of coding sequences are presented. 17 genotypes were defined based on the branching supporting values (SH-like value ≥ 0.90) and the relative branch length from a node. They were further classified into 5 genogroups (Karp, Gilliam, TA763, Kato, and Shimokoshi) based on phylogenetic distances.

https://doi.org/10.1371/journal.pntd.0005408.g002

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Fig 3. Similarity and identity matrix for amino acid sequences of 206 TSA56 proteins.

Pairwise identity (upper triangle) and similarity (lower triangle) matrix of TSA56 sequences were constructed using the MatGAT2.1 program. The order of TSA56 sequences is the same as in Fig 2. Raw data values are presented in S5 Table.

https://doi.org/10.1371/journal.pntd.0005408.g003

Detection of genetic recombination in tsa56 genes

Since we observed a relative conservation of amino acid sequences among the genotype members belonging to phylogenetically distant groups, such as Gillam and TA763 members with Karp members, and it has long been proposed that genetic recombination might be a driving force for generating genetic diversity of the intracellular pathogen [22,27,43,45–47], we examined the genetic recombination of 17 prototype sequences of tsa56 using several different recombination detection programs. First, the evidence for recombination in the aligned 17 proto-genotype sequences was tested by the GARD method using the Datamonkey web server (http://www.datamonkey.org) [48]. This method detected evidence for recombination at multiple breakpoints predicted at nucleotide positions 295, 575, 958, and 1406 (p < 0.01) (Fig 4A). Detection of potential recombinant sequences, identification of potential parental sequences, and localization of possible recombination break points were further determined using the 3Seq [37], Bootscan [38], Chimaera [39], GENECONV [40], MaxChi [41], RDP [36], and SisScan [42] methods embedded in RDP suite [49]. As shown in Fig 4B and S6 Table, significant recombination events were detected in 11 proto-genotypes with a high degree of confidence (p < 0.05 for at least six out of seven recombination detection programs), but not in Saitama, Boryong, Kawasaki, TD, Shimokochi, and TA686 genotypes. Among the 11 proto-genotypes, 9 genotypes showed a single recombination event, whereas multiple recombination events were predicted in 2 genotypes, JG_A and Gilliam. The major parents, minor parents, and break points with statistical significance (p < 0.05) confirmed by MaxChi and BOOTSCAN programs are summarized in S6 Table. Fig 4C shows four representative recombination events observed in Karp_A, JG_C, TA763, and Kato_B genotypes. These results suggest that 6 genotypes, Saitama, Boryong, Kawasaki, TD, Shimokoshi, and TA686, may be the ancestral parents of the 11 recombinant genotypes. Based on the number of recombination events observed in the diverse genotypes, we speculate that the recombinant genotypes might have been generated by sequential recombination events among the parental genotypes (Fig 5). The 6 genotypes which lack any evidence of recombination, might be the first generation that contributed to the second generation (Karp_C, Karp_B, Karp_A, TA763_B, and Kato_B). Three members (Kawasaki, Shimokoshi, and Boryong) of the first generation also contributed to the third and fourth generations. Gilliam genotype, the sole member of the fourth generation, seems to have been generated by recombination between Boryong, Karp_B, and JG_C genotypes (Fig 5B). These results suggest that the genotype diversification of O. tsutsugamushi may be an ongoing process driven by continuous recombination events among preexisting genotypes.

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Fig 4. Detection of intragenic recombination in tsa56 genes using 17 proto-genotype sequences.

A. Recombination breakpoints within tsa56 sequences were detected using the GARD program. Support probabilities for inferred recombination break-points are shown on the left side of the breakpoint plots. B. Intragenic recombination events in tsa56 sequences found using the RDP suite. The schematic diagrams of indicated genotypes present the putative major and minor parent sequences of each genotype (by color codes) and the location of predicted breakpoints. Detailed information of the recombination events predicted by the RDP suite is summarized in S6 Table. The genotypes without significant recombination are marked with (*). C. Representative BOOTSCAN evidence for recombination origin on the basis of pairwise distance, modeled with a window size 200 nt, step size 20 nt, and 100 Bootstrap replicates. The threshold of significance for the analysis was set as 70% bootstrapping value (dash line).

https://doi.org/10.1371/journal.pntd.0005408.g004

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Fig 5. Hierarchical relationship of 17 proto-genotype sequences.

A. Based on the recombination events and the parental origins of the tsa56 sequences shown in Fig 4, the hierarchical relationship of 17 genotypes was estimated and is presented as sequential generations. B. Recombination events in Gilliam genotype sequence, the last generation in A, were analyzed by similarity plot on the basis of pairwise comparison with Boryong, Karp_B, and JG_C genotypes as parental sequences (scanned with a window size 200 and step size 20 nt).

https://doi.org/10.1371/journal.pntd.0005408.g005

Genetic diversification of a bacterial gene can be attributed to point mutations as well as genetic recombination. Therefore, we analyzed the relative contribution of recombination and point mutation to the diversification of tsa56 genes and compared these results to those of 52 other O. tsutsugamushi genes collected from nine genomes that are completely sequenced or undergoing sequencing (Fig 6 and S7 Table). Average recombination rate per base pair (ρ/bp) of the 53 genes is 0.083, with a range of 0.003 (rpsB) to 1.131 (rpsT), and average mutation rate per base pair (θ/bp) is 0.020, with a range of 0.010 (trmU) to 0.086 (tsa56). The detecting per site ρ/θ value for the overall gene sets is 4.071, suggesting that recombination occurred more frequently than point mutation. Interestingly, the mutation rates of tsa56 and sca family genes, encoding outer membrane proteins [50], are generally higher than other house-keeping genes, even though their recombination rates were near average value. When we recalculated per site recombination and mutation rates using 206 unique tsa56 genes, ρ/bp and θ/bp are 0.041 and 0.050, respectively, indicating that mutation rate is slightly higher than recombination rate (per site ρ/θ value = 0.812, S7 Table). These results suggest that genetic diversification of the major outer membrane protein, TSA56, might be driven by recombination as well as frequent point mutation. Based on the Ka/Ks ratio, an indicator of selective pressure acting on a protein-coding region, most O. tsutsugamushi genes, including tsa56, predominantly evolve by purifying selection with the exception of rplM, scaA, and scaE, which may evolve under positive selection.

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Fig 6. Estimation of recombination and mutation rates of O. tsutsugamushi genes.

Recombination and mutation rate per site of 53 genes were calculated by LDhat installed in RDP program. Sequences of 53 gene sets were extracted from nine O. tsutsugamushi genomes available in NCBI database. Average recombination rate per base pair (ρ/bp) of 53 gene sets is 0.083 and average mutation rate per base pair (θ/bp) is 0.020 (blue lines). Genes encoding known membrane proteins are indicated as red dots. Detailed information of the gene sets is presented in S7 Table.

https://doi.org/10.1371/journal.pntd.0005408.g006

In addition to the point mutations, Indels of nucleotide sequences have often been observed in Rickettsial genes [51,52] and may also contribute to the genotypic diversification of Orientia. Extensive analysis of the aligned 206 tsa56 genes revealed 4,771 Indels at over 108 sites, especially in regions encoding variable domains [22]. However, only a few of them are consistently detected in a specific set of genotype sequences (S4 Table), indicating that, although they contributed to the diversification of tsa56 sequences, only fraction of Indels are conserved in a specific genotype.

Geographical distribution of O. tsutsugamushi genotypes

The geographical distribution of 324 tsa56 genes is presented in Fig 7 and S2 Table. The Karp group includes the largest number of isolates (175 genes) and genotypes in this group are found in most endemic countries. Among the genotype members in the Karp group, each country has a specific predominant genotype, such as Boryong in South Korea, Karp_C in Japan, and Karp_A in Taiwan and Cambodia. Genotype members of the Gilliam group (78 isolates) are also quite prevalent in the endemic countries. Among the genotype members in this group, the Kawasaki genotype is prevalent in South Korea and JG_C genotype is primarily found in Taiwan, Thailand, and Cambodia. The isolates belonging to the TA763 and Kato groups are mainly reported in Taiwan, but rarely in South Korea and China. The highly divergent Shimokoshi genotype is only reported in Japan. Even though the number of sequences isolated from each country is quite varied, the genotype diversity found in Taiwan located in the middle of endemic area of scrub typhus, is particularly notable. 14 genotypes out of 17 are found in Taiwan, compared to 5 genotypes in South Korea. When we compared the diversity and relative proportion of genotypes in Taiwan with those of the northern endemic area (China, Japan, and Korea) or southern endemic countries (Cambodia, Malaysia, Myanmar, Papua New Guinea, Thailand, and Vietnam), it is clear that not only the diversity, but also the relative proportion of each genotype in Taiwan are quite distinct from other endemic regions (Fig 7B). Prevalence of more divergent genotypes in a certain central locality than in countries at the boundary of the endemic region suggests that Taiwan might serve as a mixing ground for the diverse genotypes.

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Fig 7. Geographical distribution of O. tsutsugamushi genotypes in endemic countries.

A. The relative proportion of each genotype reported in the indicated endemic country is presented and the pie size is proportional to the number of sequences reported. The number of tsa56 sequences used for each country is as follows: Taiwan (123), Korea (69), Japan (52), Thailand (29), Cambodia (28), China (9), Malaysia (2), Myanmar (1), and Papua New Guinea (1). B. Relative proportion of each genotype reported from Taiwan, northern endemic area (Korea, Japan, and China), and southern countries (Thailand, Cambodia, Vietnam, Malaysia, Myanmar, and Papua New Guinea) is presented. The number of sequences from each group is indicated below the bar graphs.

https://doi.org/10.1371/journal.pntd.0005408.g007

Distribution of Leptotrombidium vector species

The distribution of vector mites is the primary factor affecting the epidemiological features of scrub typhus. However, the currently available vector map, published by the World Health Organization in 1989 [18], is primarily based on data before 1974 [1,3,19,20]. Therefore, we searched references and updated the geographical distribution of the Leptotrombidium species, the main vectors of scrub typhus (Fig 8 and S3 Table).

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Fig 8. Geographical distribution of nine Leptotrombidium species, the major vectors of scrub typhus.

Geographical distributions of nine representative Leptotrombidium species mediating scrub typhus are presented. If the collection sites of vector identification were specified with coordinates, they are indicated as red dots, otherwise the collection sites were indicated at province or county level as colored area. Blue: collected before 1974, red: collected after 1974, green: collected before and after 1974. Detailed information is available in S3 Table.

https://doi.org/10.1371/journal.pntd.0005408.g008

Three major Leptotrombidium species, L. palpale, L. pallidum, and L. scutellare, have been found in the northeastern area of endemicity [15,18,53–55]. In particular, L. scutellare has recently become the primary vector in northern China [56,57], South Korea [15], and Japan [53]. It is also notable that L. pavlovskyi, the primary vector responsible for scrub typhus in the Primorye region of Russia during the 1960s, was also prevalent in the 1990s, although O. tsutsugamushi could not be isolated from the vector species [58]. L. delicense is the primary vector in the southern parts of the endemic region, ranging from southern China to the north, Pakistan to the west, and northern Australia and western Pacific islands to the south. A number of studies have also reported the presence of L. delicense in south-eastern countries of the endemic region since 1974 (S3 Table). It appears that two Leptotrombidium species, L. scutellare in the northern part and L. delicense in the southern area of endemicity, might be the primary vectors for current scrub typhus. However, there is local variation of major vectors such as L. imphalum in eastern Taiwan [59], L. chiangraiensis and L. imphalum in northern Thailand [60]. In addition, L. scutellare has been recently reported to have expanded both northward to mainland China [56,57] and South Korea [15], and the southward to southern China [55] and Taiwan [59,61]. As a result, the southern provinces of mainland China and Taiwan have become mixing grounds for the two primary vector species, L. scutellare and L. delicense. It is also notable that L. imphalum, the primary vector in northern Thailand [60], has also been reported as the dominant mite in a local area of Taiwan [59], such that diverse vector species prevail in islands of Taiwan.

Presence of identical and sub-identical tsa56 genes in geographically distant countries

As mentioned above, there are 38 sets of identical sequences, including 156 sequences, among the selected 324 tsa56 genes (S2 Table). Interestingly, among the identical sequence sets, 10 sets of genes include sequences from two different countries (S8 Table), whereas 28 sets were only reported within a single country. For example, the same sequences belonging to Karp_C, Kawasaki, and JG_A have been reported from South Korea and Japan, even though the isolated years are different. Identical sequences in the Karp_A genotype have also been found in Taiwan and Thailand. In addition, we detected sequence pairs, showing only one or two base sequence differences (S8 Table), originated from two different countries, such as Boryong genotype from Korea and Taiwan. The presence of identical or sub-identical (1 ~ 2 different bases) tsa56 genes in geographically distant countries implies a potential migration or expansion of the bacterial clones, even though it needs to be confirmed whether other bacterial genes and/or the whole genomic sequences of the isolates are also identical. It is also intriguing that Taiwan emerged as a central node connected to northern countries (China, Japan, and Korea), as well as southern countries (Cambodia, Malaysia, and Thailand) when we linked the countries where the identical and sub-identical sequences have been reported (Fig 9A). Considering that prominent diversity in bacterial genotypes and mite vector species have been observed in Taiwan and its central location in the endemic area of scrub typhus, the subtropical region may potentially serve as a hub point mediating migration or expansion of vector mites, thereby contributing to the spread of diverse genotypes and their recombination.

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Fig 9. Potential expansion of O. tsutsugamushi clones throughout the endemic region.

A. Linkage map indicates the presence of identical (solid line) or sub-identical (one or two base difference, dotted line) tsa56 genes in geographically distant endemic countries. B. The East Asia/Australasia major flyway of migratory birds is presented as blue lines. The primary habitats of 21 key bird species in the flyway are overlaid on the regional map (Data available at http://www.eaaflyway.net/).

https://doi.org/10.1371/journal.pntd.0005408.g009

Discussion

The O. tsutsugamushi genome is quite unique in that up to 40% of its genome contains dispersed repeat sequences, primarily composed of mobile genetic elements including conjugative transfer (tra) components of a type IV secretion system and transposases [43]. Previously, sex pili-like cell surface appendages for conjugal DNA transfer were observed in Rickettsia belli, which encodes a tra cluster phylogenetically close to those of O. tsutsugamushi [45,62]. It is possible that genetic recombination occurs via a similar mechanism among O. tsutsugamushi. Coinfection of multiple genotypes in a single host might facilitate the genetic recombination among different genotypes. Indeed, mixed infection of multiple genotypes has often been reported in the vector mites [63,64] and human patients [46,47,65]. Given that humans are dead-end hosts, recombination between different strains more likely occurs in the mite vectors or in the rodent reservoirs. In addition to the conjugative transfer system, O. tsutsugamushi retains a relatively large repertoire of genes for recombination and repair processes, which may ensure genomic flexibility during recurrent host changes and induce genetic variation, especially in surface antigens for immune evasion [45,66]. Considering that tsa56 encodes the major outer membrane protein that plays a significant role in bacterial invasion into host cells [67,68] and the neutralizing antibodies against it provide protection [69], immunological pressure on the bacterial antigen during mammalian host infection might be a crucial driver for genetic diversification via point mutations, Indels, and genetic exchange among different genotypes. Indeed, our current study revealed that the mutation rate of tsa56 gene is substantially higher than other house-keeping genes (Fig 6). This higher mutation rate was also observed in a group of outer membrane proteins encoded by sca family genes [50,70,71]. It is notable that the mutation rate of the scaA gene, which encodes a potential bacterial adhesin [72], is the second highest compared to other included genes. In addition to the point mutations, intragenic recombination may also contribute to the genetic diversity of the outer membrane proteins. Even though the recombination rate of the tsa56 gene is similar to those of other Orientia genes (Fig 6), intragenic shuffling of the gene fragments has significantly contributed to the genotype diversification (Fig 4). Given that the extracellular domain of TSA56 includes highly variable domains [22], as well as multiple antigenic domains [73], intragenic recombination observed among the diverse genotype sequences can result in substantial shifts in genetic variation [27] and antigenicity [74]. In consistent with these, similar result was reported from a study using multiple tsa56 sequences isolated from human patients from three countries in Southeast Asia [75]. They also suggests that weak divergence in the core genome and ancestral haplotypes are maintained by permanent recombination in mites while the tsa56 gene is diverging in higher speed potentially due to selection by the mammalian immune system [75]. Due to the wide antigenic variation, immunity generated by vaccine trials, or even after natural infection, do not provide effective cross-reactivity among numerous genotypes, and reinfection with scrub typhus is relatively common in highly endemic areas [76]. Various studies also showed inter-genotype variation in virulence in humans and rodents, ranging from unapparent disease to consistent fatal infection when untreated [1]. Considering that each genotype generation (Fig 5) classified based on the sequential recombination events in this study includes both virulent and avirulent genotypes and the relative virulence in challenged animals appears to be highly mouse-strain specific [77,78], the genetic recombination of tsa56 gene may not be specifically associated with virulence for individual genotypes although detailed analysis on the degree of virulence need to be examined.

Classification of O. tsutsugamushi genotypes has been primarily based on the sequence variation of tsa56 since it is unique to O. tsutsugamushi and highly variable in amino acid content due to multiple variable domains [1]. By the end of 2015, more than a thousand tsa56 sequences (size range, ~ 150 to > 2,000 bases) were deposited in international sequence databases. Most sequences include the variable portions of the gene and were annotated as a specific strain name and/or genotype name based on sequence analysis. Our current results using sequences covering a complete or nearly complete coding sequence (covering at least 85% of the open reading frame, ≥ 1,251 bases corresponding to 417 amino acids) showed that genetic recombination might have occurred at multiple sites within the coding region. Therefore, genotypic classification using a small fragment, including only parts of variable domains, may not be sufficient to completely identify inter-strain variation within the target gene. Sequence analysis using the complete or nearly complete sequences including all the variable domains, as well as the region beyond the recombination break points near the 3’ and 5’ ends (Fig 4 and S6 Table) of the tsa56 gene might be required to clearly define O. tsutsugamushi genotypes. In a previous study, Kelly et al. reported that O. tsutsugamushi genotypes can be classified into at least 9 definable clusters when they analyzed 135 complete or nearly complete (> 1,200 bases) tsa56 genes [1]. Here, we identified at least 17 clusters of genotypes, belonging to 5 definable groups, when using 206 complete or nearly complete sequences (≥ 1,251 bases). Based on our sequence analysis, similarity and identity in amino acids also need to be considered to define the genotypes or groups since some genotypes, such as Gilliam and TA763 members, show unexpected higher similarity in amino acid sequences with phylogenetically distant genotypes (Fig 3 and S5 Table). As the number of tsa56 sequences increases, the genetic variation is expected to further diversify when considering the high mutation rate and on-going recombination within the tsa56 gene.

Currently, the geographical distribution of O. tsutsugamushi genotypes is a critical issue for the development of effective diagnostics and vaccine [2]. Antigenic variation generated by genetic diversification of the immunogenic major outer membrane protein, TSA56, complicates diagnosis and efforts towards vaccine development. Therefore, an investigation of genotype diversity and prevalence in local endemic areas needs to be continued not only for the epidemiological monitoring of scrub typhus, but also for the improvement of diagnostic accuracy and vaccine development [47,74]. In this study, we examined the distribution of O. tsutsugamushi genotypes using the sequence data and the related geographical information. In addition, we also reviewed spatiotemporal changes of the primary vector species to assess the association with epidemiological changes of scrub typhus. Based on extensive data analyses, we found some compelling epidemiological features of scrub typhus. First, the prevalence of diverse genotypes of O. tsutsugamushi and multiple vector species in Taiwan is quite marked when compared to those of other endemic countries. The local prevalence of Leptotrombidium species is generally determined by multiple environmental factors such as temperature, precipitation, and host diversity [79,80]. Considering that L. deliense and L. scutellare are the major vectors of scrub typhus in the southern tropical area and northern temperate region, respectively (Fig 8), the presence of both mite species as dominant vectors might be a good indicator of vector diversity. The subtropical climate of Taiwan, as well as its location in the center of the endemic area, might provide a natural environment for such a vector diversity. Although L. deliense is a major vector throughout the islands of Taiwan, L. imphalum and L. pallidum, which are also primarily found in tropical area and temperate region, respectively, were more dominant in some Taiwanese provinces [80]. In addition, L. deliense was replaced by L. scutellare during the winter season in islands with lower winter temperature than the other areas, such that the former is responsible for summer scrub typhus and the latter for winter scrub typhus [80]. It is also interesting to note that the recent exponential increase of scrub typhus cases in mainland China has been primarily associated with regional clusters of the southern subtropical area [9,57], which is geographically close to Taiwan. Recently, the presence of highly diverse mite species was reported in the Yunnan province, the main hotspot of scrub typhus in mainland China [9], where L. scutellare and L. deliense are the major mite species [79,81]. The dominance of the two major vectors, as well as species diversity, are associated with local altitude and latitude gradients, suggesting an importance of climate and environmental conditions for codominance of mite species [79]. Although the genotype diversity of O. tsutsugamushi in endemic hotspots of southern China has been poorly defined, fluctuation and variety of the vector species due to environmental factors could also be associated with epidemiological features of scrub typhus in local endemic regions. Additionally, local changes in prevalent mite species harboring O. tsutsugamushi have been continuously reported in other subtropical and temperate area of endemic regions [16,80]. Ecological changes in the specific endemic locality may provide the environmental basis for the diversification of O. tsutsugamushi genotypes and/or their prevalence.

Second, presence of identical or near-identical (1 ~ 2 different bases) tsa56 genes in geographically distant countries suggests a potential of international migration of O. tsutsugamushi, even though the genomic identity of the clones needs to be further verified. Considering that O. tsutusgamushi are obligate intracellular bacteria, their migration is absolutely dependent on the associated host vectors and/or reservoir animals. Moreover, larval mites do not migrate more than a few meters from where they hatch and usually form ‘mite islands’ ranging from a few cm to meters [19], so their ability to migrate on their own is very limited and their movement is mainly associated with the migration of hosts infested with chigger mites [3]. In addition to the wide spread of major vectors and diverse genotypes of O. tsutsugamushi over the endemic region including many islands in the Indian and Pacific Oceans [1], continuous fluctuation in the distribution of chigger mites at the local level suggests that parasitized small rodents and birds may be potential phoretic hosts of the infected mites [3,19,82,83]. A recent study reported a potential role of an exotic rodent species introduced from Southeast Asia and Pacific islands, Rattus exulans, as a host for chiggers in Taiwan [83]. Even though exotic R. exulans appears to play a relatively minor role in supporting chigger species infected with O. tsutsugamushi in Taiwan, the fact that both prevalence and loads of chiggers in R. exulans vary greatly with environment, along with the abundance and the ecological flexibility of R. exulans, implies a potential health risk as this species expands to areas with more chiggers [83]. Since the role and influence of exotic rodent species in local diversity and spread of the vector-borne disease are important but poorly assessed thus far, further investigation on the role of invasive rodent hosts on the dynamics of scrub typhus needs to be followed. Additionally, the association of migratory birds in spreading vector-borne infectious agents, such as Borrelia burgdorferi [84], Tick-borne encephalitis virus [85], and severe fever with thrombocytopenia syndrome virus [86], has been well documented. Considering that chigger mites attach and feed on host animals, including birds and rodents, for about 36–72 hours and withstand harsh environmental condition such as temperatures of -20°C for up to several weeks [87], they can travel hundreds to thousands of kilometers while attached to migratory birds, to a new geographic area that they may colonize if environmental conditions are optimal for their survival [88]. Since O. tsutsugamushi has rarely been recovered from tissues of wild birds [19,89], birds are more likely mechanical carriers for short- or long-distance transmission of chigger mites infected with O. tsutsugamushi rather than biological carriers. Based on our examination of the distribution of identical or near-identical tsa56 sequences, Taiwan was found to be the nodal point of clonal expansion to northern and southern parts of the endemic area (Fig 9A). This further supports the idea that Taiwan, located in the center of the endemic area, may serve as a hub point mediating potential migration or expansion of vector mites, thereby enabling the generation and/or spread of diverse genotypes. Taiwan is also located at the center of the East Asia/Australasia Flyway migratory bird routes crossing the endemic countries of scrub typhus, extending from Arctic Russia to the southern limits of Australia (Fig 9B). In addition, the major habitats of the migratory bird species appear to be correlated with the endemic area of scrub typhus. Therefore, consideration of avian migration patterns might be useful in understanding and predicting epidemiological changes, such as local outbreaks of scrub typhus, as well as spread of mite vectors and O. tsutsugamushi genotypes. Fluctuation and diversification of vector species harboring O. tsutsugamushi, potentially caused by environmental changes and influx from other endemic regions, could affect the epidemiological features of scrub typhus and facilitate the genetic recombination among the different genotypes, thereby enhancing the genotypic diversity of O. tsutsugamushi in local endemic regions. Careful monitoring of dominant mite species and the prevalence of O. tsutsugamushi genotypes associated with the vectors might be required to reveal the correlation of genotype diversification of O. tsutsugamushi with ecological vector changes.

Supporting information