Background Scrub typhus is a major yet neglected vector-borne disease in Thailand, where it has been nationally notifiable for over two decades. However, long-term changes in its epidemiology, including reporting rates, transmission intensity, disease severity, and seasonal patterns, have not been comprehensively characterised at the national level.

Methodology We analysed 22 years of national surveillance data for scrub typhus in Thailand (2003–2024) using a latent process model that jointly fits reported cases with published nationwide seroprevalence data and antibody kinetics to estimate reporting rates and underlying transmission dynamics across all 77 provinces of Thailand.

Findings Over the 22-year study period, 143096 cases and 119 deaths were reported nationally. Estimated reporting proportion broadly mirrored transmission intensity, being higher in high-burden regions and lower elsewhere. A synchronous decline in detection was observed across all regions during the COVID-19 pandemic, followed by rapid rebound by 2024. After accounting for these reporting dynamics, the force of infection was highest in the northern provinces but also substantial in the northeast and south, with upward trends in some provinces. Susceptibility among older adults aged 65 and above increased progressively over the study period, reversing the pattern observed two decades earlier. Case-fatality in the 25–35-year reference group was low and declined from 0.14% (95% Credible Interval [CrI]: 0.06–0.29%) to 0.06% (95% CrI: 0.02–0.12%), but relative case-fatality remained consistently highest among adults above 65 across all periods. Three geographically distinct seasonal patterns were identified, all stable over time.

Conclusion Over two decades, scrub typhus transmission in Thailand has been shown to extend well beyond its traditionally recognised northern focus, with substantial burden in previously underappreciated regions, while the demographic profile of those most affected has shifted progressively toward older adults. These findings support the need for regionally tailored surveillance, age-targeted clinical preparedness, and sustained investment in understanding the ecological drivers of transmission.

Key messages Scrub typhus is a common but neglected cause of fever in Thailand, where it has been reported through the national surveillance system for over two decades. However, trends in reported cases can be misleading because they reflect not only true changes in transmission but also variation in diagnosis and reporting over time and across regions. We developed a model that combines surveillance data with seroprevalence surveys and antibody kinetics to separate true changes in transmission from variation in reporting, allowing us to estimate how transmission intensity, disease severity, and seasonal patterns have evolved from 2003 to 2024 across all 77 provinces. We found that substantial transmission occurs not only in the well-studied northern provinces but also in the northeast and south, where the disease has received less attention. Susceptibility has progressively shifted toward older adults, who also face the highest case-fatality, while three distinct seasonal patterns vary by region but have remained stable over time. These findings suggest that scrub typhus control in Thailand requires a shift from a predominantly northern focus toward regionally tailored strategies that account for local transmission timing, an ageing at-risk population, and the ecological drivers that sustain transmission in each setting.

The authors have declared no competing interest.

This study was supported by Wellcome Trust (220211/Z/20/Z) and Doherty Institute Strategic Partnership for prevention, surveillance and response to infectious diseases across the Indo-Pacific Region (SPARKLE) - Australian Department of Foreign Affairs and Trade (DFAT). The funders had no role in study design, data collection, analysis, decision to publish, or manuscript preparation.

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