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Background: The risk factors for scrub typhus in Vietnam remain unknown. Scrub typhus caused by Orientia tsutsugamushi often presents as an undifferentiated febrile illness and remains under appreciated due to the limited availability of diagnostic tests. This tropical rickettsial illness is increasingly recognized as an important cause of non-malaria acute undifferentiated fever in Asia. This study aimed to investigate behavioural and ecological related risk factors of scrub typhus to prevent this potentially life-threatening disease in Vietnam. Methods: We conducted a clinical hospital-based active surveillance study, and a retrospective residence-enrolment date-age-matched case-control study in Khanh Hoa province, Vietnam, from August 2018 to March 2020. Clinical examinations, polymerase chain reaction and enzyme-linked immunosorbent assay IgM tests were applied to define cases and controls. All enrolled participants filled out a questionnaire including demographic socio-economic status, personal behaviors/protective equipment, habitat connections, land use, and possible exposure to the vector. Multivariable conditional logistic regression was used to define the scrub typhus associated risk factors. Results: We identified 44 confirmed cases and matched them with 152 controls. Among cases and controls, the largest age group was the 41-50 years old and males accounted for 61.4% and 42.8%, respectively. There were similarities in demographic characteristics between the two groups, with the exception of occupation. Several factors were significantly associated with acquisition of scrub typhus, including sitting/laying directly on household floor [adjusted OR (aOR) = 4.9, 95% CI: 1.6-15.1, P = 0.006], household with poor sanitation/conditions (aOR = 7.9, 95% CI: 1.9-32.9, P = 0.005), workplace environment with risk (aOR = 3.0, 95% CI: 1.2-7.6, P = 0.020), always observing mice around home (aOR = 3.7, 95% CI: 1.4-9.9, P = 0.008), and use of personal protective equipment in the field (aOR = 0.4, 95% CI: 0.1-1.1, P = 0.076). Conclusions: Ecological and household hygiene-related factors were more associated with scrub typhus infection,than individual-level exposure activities in the hyper-endemic area. These findings support local education and allow people to protect themselves from scrub typhus, especially in areas with limitations in diagnostic capacity
