Scrub Typhus (ST), a zoonotic disease caused by Orientia tsutsugamushi and transmitted by Leptotrombidium mites, poses persistent public health challenges across the “tsutsugamushi triangle,” notably in South and Southeast Asia. In India, ST has re-emerged over the past decade; however, its socioeconomic burden remains largely underexplored. This study investigates the multifaceted impacts of ST in the Soreng and Mangan districts of Sikkim, examining both direct costs (medical expenses) and indirect costs (income loss, caregiver burden), while assessing systemic gaps in diagnosis, treatment, surveillance, and community-level management.

This mixed-methods study combines retrospective case tracing and household-level surveys with participatory stakeholder engagement, utilizing structured questionnaires and focus group discussions to capture diverse perspectives and contextual insights. Lab-confirmed ST cases were purposively sampled from PHC records spanning 2021–2025. Qualitative insights were drawn from saturation sampling included 93 Accredited Social Health Activists (ASHAs) and key stakeholders 9 Medical Officers in Charge (MOICs), 8 laboratory personnel, and 6 pharmacists and store managers, ensuring thematic depth and contextual nuance. District-level variations in disease profiles were present. Female patients dominated in both Soreng (52.5%) and Mangan (68.4%), with peak incidence among individuals aged 30–44 in Soreng and 15–29 in Mangan. Healthcare-seeking behavior differed significantly: Soreng patients predominantly accessed PHCs (97.5%), while Mangan residents utilized both PHCs (52.6%) and district hospital (47.4%). Self-reported comorbidities were present in 45% of cases, correlating with extended hospital stays (mean duration: 9.4 days vs. 5.3 days). Additionally, 65% of patients self-reported experiencing mental health impacts, underscoring the psychosocial burden associated with illness.

Economic analyses revealed heightened vulnerability, with 62.7% of households incurring moderate catastrophic health expenditure (CHE) and 32.2% experiencing extreme CHE substantially higher than national benchmarks (9.1–13.4%). The elevated CHE incidence observed may partly reflect the sensitivity of health-focused surveys and the influence of a smaller sample size, which can amplify the visibility of high-cost health events in vulnerable populations. Gendered caregiving burdens were notable, with female caregivers assuming longer care responsibilities (35.5 vs. 20.5 days for males).

Systemic evaluations, guided by the WHO Health Systems Resilience Framework, highlighted constrained absorptive capacity (e.g., reagent shortages) and limited adaptive capacity (e.g., fragmented diagnostic feedback). While ASHAs facilitated health education and community level referrals, inconsistent translation of awareness into preventive behavior pointed to weak institutional-community linkages.

The findings underscore how infrastructure asymmetries between Soreng and Mangan shape health-seeking behaviours and economic consequences. Stakeholders consistently advocated for improved diagnostic technologies, such as ELISA, to enhance ST response capabilities. Broader implications extend to addressing public health risks at the human–wildlife interface and strengthening conservation informed health interventions in ecologically vulnerable settings.