Nurturing the Passion to Care

TITLE:LEPTOSPIROSIS
NAME:AMY MURNIZA BINTI AMRAN

GROUP:7D

MATRIC NUMBER:FIS-1207- 2611

LECTURER:MR.MAHATHIR BIN HAJI AZAHARI

INTRODUCTION Leptospirosis is a common public health problem worldwide with an estimated annual incidence ranging from 0.1 to 1 per 100 000 per year in temperate climates to 10 or more per 100 000 per year in the humid tropics. The estimated case-fatality rates in different parts of the world have been reported to range from <5% to 30% .These figures however are probably grossly underestimated because in many countries especially those where the disease is highly endemic, diagnostic capabilities are not readily available resulting in significantly poor surveillance and reporting of leptospirosis.

leptospira spp.

Leptospirosis also known as Weil's syndrome, canicola fever, canefield fever, nanukayami fever, 7-day fever, Rat Catcher's Yellows, Fort Bragg fever, black jaundice, and Pretibial fever is an infectious disease caused by pathogenic spirochete bacteria of the genus leptospira that are transmitted directly or indirectly from animals to human (i.e., a zoonotic disease). Pathogenic leptospires belong to the species Leptospira interrogans, which is subdivided into more than 200 serovars with 25 serogroups . The leptospiral serovars are naturally carried in the renal tubules of rodents, wild and domestic animals. Leptospirosis is usually a seasonal disease that starts at the onset of the rainy season and declines as the rainfall recedes. Sporadic cases may occur throughout the year with outbreaks associated with extreme changing weather events such as heavy rainfall and flooding.Leptospirosis is an infectious disease with broad range of clinical manifestations, ranging from mild flu-like illness to very severe disease with haemorrhagic manifestations and multiorgan failures. Severe leptospirosis commonly resulted in case fatalities if aggressive managements are not instituted at an early stage. In Malaysia, an increasing number of reported cases and outbreaks which had resulted in significant number of deaths have been observed over the past decade. Fletcher (1928) was the first person who began working on human leptospirosis in Malaysia. He reported the first

fatal case of human leptospirosis in 1925 due to 3 Leptospira icterohemorrhagiae and during this early period he was able to identify serovars icterohemorrhagiae, hebdomadis and pyrogenes from 21 patients. McCrumb et al. (1957) studied febrile illness in 614 military personnel operating in the jungle during the Malayan emergency. In their investigation, leptospirosis was shown to be the most common cause of fever in soldiers, accounting for 35% cases admitted for fever to a military hospital. Simultaneous investigations of 238 civilian adult males admitted to an urban hospital yielded a diagnosis of leptospirosis in only 13% of the cases. From 1953 to 1955, 30 pathogenic leptospiral serovars have been identified by Alexander et al. (1957) from both military personnel and civilians. Studies by Broom (1953), Robinson & Kennedy (1956) and McCrumb et al. (1957) showed the importance of leptospirosis as a febrile disease in military personnel and civilians in Malaysia. The incidence rate in Malaysia is estimated to be between 2 5 per 100,000 populations. The overall incidence of leptospirosis was 13%, with the Indians showing the highest incidence (16.7%) followed by the Malays (11.5%) whilst the Chinese (5.9%) were the least affected by the disease. The percentage of males (81.1%) affected were higher than females (18.9%) in a male female ratio of 4:1. The 20-29 years age group (17.1%) showed the highest prevalence whilst the young (less than 10 years), and old (above 60 years) groups showed low prevalence. This study indicated that human leptospirosis is probably an endemic infection in Malaysia. However there has been a significant increase in recent years. According to the statistics from the Ministry of Health, in 2006, an estimated 527 cases of leptospirosis is recorded and in the following year 2007, an increase in cases is found with a total of 929 reported cases. The Ministry of Health had reported that the number of confirmed cases had increased from around 263 in 2004 to 1418 in 2009. Statistics released by the Ministry of Health, Malaysia in Table 2 shows a gradual increase in the cases of leptospirosis especially in the states of Perak, Selangor and Pahang. Although fatality rates have decreased, incidence rates continue to rise, drawing the attention of the government and public alike. Recently in 2010 as well, the country was taken aback by the death of 6 individuals due to leptospirosis in Hutan Lipur Lubuk Yu, Maran. In Sibu, the bacteria causing the deadly leptospirosis disease has been detected on august 2010. There were two places affected by this infection which is Permai Road recreational lake and at the ponds at the Junaco Park National Service Training Camp. Besides that, three national service camps in Perak have been ordered to stop water activities to prevent leptospirosis.Initial investigation showed that the three camps which is Nilam Ehsan at Bidor, Gemilang Leadership at Gopeng and at Kuala Kangsar might be contaminated with the bacteria of leptospirosis on august 2010. Further test are being carried out as a preventive measure to prevent the spread of the disease.A recent wave beginning in July 2011 when eight people, who were among a search and rescue group looking for a drowning victim in a recreational area in eastern Pahang state have died of the disease and another water-borne bacteria. The latest victim was a 17-year-old boy who died after swimming in northern Kedah

state. Other than that, three popular picnic spots in Kedah have been ordered to close temporarily in the wake of an outbreak of leptospirosis.The three spots are Puncak Janing in Kuala Nerang, Lata Bayu in baling and Bukit Wang in Kubang Pasu. The victim who has died came for a picnic at Lata Bayu with two friends, who also contracted the disease.

MODES OF TRANSMISSION Leptospirosis is spread by Leptospires which are pathogenic or saprophytic. Pathogenic leptospires are normally found in the renal tubules of host animals while saprophytic leptospires are commonly isolated from wet or humid environments. Saprophytic leptospires species normally contaminate surface waters and do not cause infections to humans as they only feed on organic matter in water.Therefore, they do not require a host. On the other hand, pathogenic Leptospires need a host in order for them to survive and reproduce. Pathogenic Leptospires can spread through the urine of carrier animals to the environment. The animal hosts that carry this specific pathogenic leptospires are not harmed themselves. They are also known as natural maintenance hosts.Leptospirosis can spread directly or indirectly from hosts in the contaminated environment. Excretion of urine from the animal host causes the soil and water to be contaminated. Contaminated water is then

ingested by humans who then become infected. Besides that, food that is contaminated by urine can also transmit the pathogenic Leptospires to human. Other than the indirect ingestion of food and water, the Leptospires can invade the body when in direct contact with Leptospires through cuts as well as wounds. It also enters the human body through nasal, oral and conjunctiva mucosa if humans are in contact with contaminated water for a long period of time. After penetrating the human body, Leptospires then pass into the blood stream and from the blood stream the Leptospires attacks body tissues and organs. Leptospirosis can spread through air as well. Evaporation of urine containing Leptospires into air droplets can be inhaled by humans and thus cause infection. Even though transmission of the disease between human and human rarely happen, it should be noted that sexual intercourse as well as breast feeding can cause the transmission of the pathogenic Leptospires from human to human. In addition, an infected mother is able to pass the pathogenic Leptospires to her foetus. Excretion of Leptospires in the urine of humans also occurs continuously up to 11 months. The sources of pathogenic Leptospires are generally rodents and wild animals such as cattle, pigs, rats, buffaloes and dogs. They serve as main reservoirs for the pathogenic Leptospires. These infected maintenance hosts may excrete leptospires via their urine for up to a few months or years.The incidence of leptospirosis is seasonal at which most cases are reported during the rainfall season and after floods. There have been reports of "house dogs" contracting leptospirosis apparently from licking the urine of infected mice that entered the house. The type of habitats most likely to carry infective bacteria are muddy riverbanks, ditches, gullies, and muddy livestock rearing areas where there is regular passage of either wild or farm mammals. There is a direct correlation between the amount of rainfall and the incidence of leptospirosis, making it seasonal in temperate climates and year-round in tropical climates.Leptospirosis is also transmitted by the semen of infected animals. There are many conditions that are favourable for maintenance and transmission of Leptospirosis .Firstly,reservoir and carrier hosts.Leptospirosis has a very wide range of natural rodent, and non-rodent reservoir hosts especially rats, cattle, dogs, foxes, rabbits, etc. The animals act as carriers of the leptospires and excrete large number of leptospires in their urine, thus responsible for the contamination of large and small water bodies as well as soil. Secondly,the flooding and drainage congestion.Bodies with infected animal urine. Water logged areas may force rodent population to abandon their burrows and contaminate the stagnant water by their urine. Then,animal-human Interface.The potential for infection increases through exposure from occupational or recreational activities without proper protection. Poor cleanliness/sanitation in recreational areas may attract animal host such as rodent thus increases the risk of contamination. These may be due to poor maintenance of facilities, improper disposal of waste and public attitude/ apathy. Last but not least,human host risk factors .Several sections of the population are more susceptible to infection such as those not previously exposed to the bacteria in their environment (nave immunities), and those with chronic disease and open skin wounds.

HIGH RISK GROUPS Exposure depends on chance contacts between human and infected animals or a contaminated environment through occupational and/or recreational activities. Some groups are at higher risk to contract the disease such as workers in the agricultural sectors sewerage workers ,livestock handlers,pet shops workers ,military personnel,search and rescue workers in high risk environment,disaster relief workers (e.g. during floods).People involved with outdoor/recreational activities such as water recreational ,activities, jungle trekking,travelers who are not previously exposed to the bacteria in their environment especially those travelers and/or participants in jungle adventure trips or outdoor sport activities and people with chronic disease and open skin wounds are vulnerable to this disease.

SIGN AND SYMPTOMS The incubation period for leptospirosis is normally 5-14 days and within a range of 2-30 days. However, unless the volume of bacteria invading the body is higher than the usual volume, a patient basically does not show signs and symptoms in less than 24 hours.The infection is normally systemic and infects the whole body. Generally, there are two types of infection that portray different signs and symptoms, which are anicteric leptospirosis and icteric leptospirosis. 90 percent of cases are anicteric leptospirosis, which means that jaundice does not occur in this infection. Patients who suffer from anicteric leptospirosis infection undergo phase 1 and phase 2 of the illness. In anicteric form of leptospirosis, the illness is always related with aseptic meningitis. This less severe type of leptospirosis is rarely fatal but is associated with pulmonary haemorrhage even without jaundice and may lead to death.In phase 1, also known as acute or septicemic phase, flu-like symptoms such as severe headache, sudden fever of 39C and above, eyes inflammation, muscle aches, diarrhea, fatigue, nausea and vomiting, chills, rigors and maculopapular rashes are seen. If the signs and symptoms mentioned above only lasts around 3-5 days, the patient is said to have recovered. However recovery may not be permanent.During phase 2 or the immune phase, anti-leptospira antibodies start to multiply such that organisms of leptospirosis can be found in the patients urine excretion. During this phase, infected patients fall sick again lasting for up to 30 days or more. However, some patients do not develop into phase 2 of the illness.The other 10 percent of cases develop into icteric leptospirosis which is also known as Weils syndrome. This second phase is much more severe than anicteric leptospirosis.A majority of the signs and symptoms are similar to anicteric leptospirosis but can develop into a more fatal condition. Organs including the liver, kidneys, brain, heart and central nervous system are harmed within 10 days. Jaundice and other signs of icteric leptospirosis become obvious at the early third week and late ninth week after the infection. This fatal infection tends to prolong the period of severe fever, jaundice, azotemia, hypotension as well as haemorrhagic vasculitis. Initial presentation may resemble pneumonia. The symptoms in humans appear after a 414 day incubation period. More severe manifestations include meningitis, extreme fatigue, hearing loss, respiratory distress,azotemia, and renal interstitial tubular necrosis, which results in renal failure and occasionally liver failure (the severe form of this disease is known as Weil's disease, though it is sometimes named Weil yndrome). Cardiovascular problems are also possible. The incubation period (time of exposure to first symptoms) in animals is anywhere from 2 to 20 days. In dogs the liver and kidney are most commonly damaged by leptospirosis. In addition, there are recent reports of a pulmonary form of canine leptospirosis associated with severe hemorrhage in the lungs similar to the human pulmonary hemorrhagic syndrome. Vasculitis may occur, causing edema and potentially disseminated intravascular coagulation (DIC). Myocarditis, pericarditis, meningitis, and uveitis are also possible sequelae. One should strongly suspect leptospirosis and include it as part of a differential diagnosis if the sclerae of the dog's eyes appear jaundiced (even slightly yellow). The absence of jaundice does not eliminate the possibility of leptospirosis, and its presence could indicate hepatitis or

other liver pathology rather than leptospirosis. Vomiting, fever, failure to eat, reduced urine output, unusually dark or brown urine, and lethargy are also indications of the disease.

Symptoms on patient of leptospirosis TREATMENT Leptospirosis can be treated only if it is diagnosed early to avoid complication. Untreated patient can lead to a more severe and potentially fatal stage. It is treated by primarily using antimicrobial therapy. Treatment with antibiotics is started before confirming if a patient has leptospirosis. This is because test and diagnosis may take a long time to process and the condition of the patient can become more serious if they continue to wait. Several antibiotics that are used to treat this disease are ampicillin, ceftriazone, doxycycline and penicillin. Doxycycline is an excellent choice of initial antimicrobial treatment for an individual. Oral doxycycline is used if the infections do not require hospitalization. The use of antibiotics decreases the duration of fever and most symptoms. However, there is considerable doubt as to whether antibiotic therapy is efficacious for leptospirosis. Nevertheless, a significant improvement is observed if the treatment is started on the fifth day or earlier .For mild illnesses, which include suspected cases, the amount of doxycycline needed is 100mg twice daily for seven days, while 2g is administered daily for seven days if amoxycillin or ampicillin is choosen. For more severe cases, 1 gm of ceftrioxine is given intravenously for seven days. However, if there is indication of organ dysfunction such as renal, hepatic, pulmonary, haemorrhagic and neurological to the patients, the patient should be transferred to referral healthcare.For hospitalized patients, intravenous penicillin G is given. Any organ system can be affected in severe leptospirosis leading to multiple organ failure. It is important for patients to be managed in a monitored setting because their condition can rapidly progress to cardiovascular collapse and shock. For patients with kidney failure, dialysis should be carried out. Even though there are antibiotics that can be used to treat the disease, taking steps to prevent infection is still the best option. After all, prevention is better than cure. Since there is currently no vaccine that is effective for any of the leptospirosis disease yet, avoiding

activities that expose to the bacteria is the way to go. If an individual who frequently comes into contact with potentially contaminated water or soil, protective clothing should be worn. PREVENTIVE AND CONTROL MEASUREMENTS

Prevention and control should be targeted at 3 different sources, which are the infection source, routes of transmission between the infection source and human host, and prompt and proper treatment of infection.The Malaysian government has taken the first step in order to create awareness among the public regarding the leptospirosis disease and its prevention. This needs to be done through multiple strategies in order to reach the specific target groups. This could be done by using the electronic, printed and interpersonal means. It is important to ensure that messages delivered are relevant, timely and culturally acceptable to the target groups. A proper needs assessment has to done to ascertain the target groups needs in order to alleviate their fear and concerns.The Ministry of Health has organized health education activities to motivate the public about taking preventive actions. Next,alert public or users regarding the hazards of possible contaminated areas. Health hazard warning signage should be posted in areas found to be contaminated through environment risk assessment (cooperation with local authorities).Eradication of leptospirosis is not the best treatment after the occurrence of disease, but the most important step is the preventive action taken before the infection itself. The prevention of leptospirosis must be tackled at the source of the infection.

Exposure through water contaminated by urine from infected animals is the most common route of infection and rodents are animals that are recognized as the major reservoirs in the transmission of leptospirosis. Therefore, establishing rodent control programs is one of the essential components in prevention and control of this disease. The leptospirosis bacteria commonly infect animals such as rodents. Hence, in order to diminish the incidence of leptospirosis infection, the public must practice some preventive actions such as practicing good personal hygiene. Some practical steps that can be taken include wearing of footwear to prevent the transmission of leptospirosis bacteria through feet. Besides that, elimination of infected animal reservoirs at home and occupational site are steps of practicing good sanitation.The use of rodenticides is also successful in minimizing the risk of disease transmission. The government should place a signboard stated that it is an infected area of Leptospirosis bacteria.

A signboard at an infected area of leptospirosis Since soil and water are easily contaminated with infected animal urine such as rats, it is best to avoid any direct contact with this soil and water. As rats are the major hosts of these bacteria, one of the steps to control this disease is by controlling the rat population. Therefore, practicing good sanitation can control the rat population. In addition,persons with occupational or recreational exposure to potentially contaminated water or soil should wear waterproof protective clothing such as rubber boots and gloves,cover skin lesions with waterproof dressings,wash with clean water immediately after exposure and seek immediate medical treatment if develop symptoms within the incubation period.

Wash hand with clean water Another preventive action is the use of chemoprophylaxis measure. For leptospirosis, doxycycline is normally used as a prophylactic measure. Doxycycline is an antibiotic that is used to diminish the infection for short term protection in high-risk environments among people who have a strong likelihood of exposure. It is more effective as chemoprophylaxis if doxycycline is given 200mg once a week. It was found that administration of doxycycline can reduce the rate of symptomatic leptospirosis from 6.8% to 3.1% and the percentage of preventive efficacy is about 54%. However, this treatment did not reduce the rate of infection. Moreover,the government should advise people to vaccinate their pets against leptospirosis and promote cleanliness at the recreational areas, food premises as well as housing area.They should also promote interagency collaboration such as with local authorities, Wildlife Department (PERHILITAN), Department of Veterinary Services (JPV), National Training Service Department (JLKN), etc. to maintain cleanliness in the respective environmental settings, especially rodent control.

Vaccination of domestic animals is another control measure that can be used to prevent the transmission of leptospirosis to human. This type of prevention provides certain protection, but it is not fully effective because some vaccinated animals that have been infected may excrete the bacteria in their urine. Even though vaccination cannot eradicate leptospirosis, it

is still useful in minimizing the transmission of leptospirosis infection from animals to humans. After decades of research, there is still no effective vaccine for human use.

Dog vaccine for leptospirosis.

CONCLUSION In summary, leptospirosis is not a new disease Malaysia but has been around since 1925. Its recurrence in the recent years proves to be a source for concern. Therefore, the Malaysian government should continue to work out measures to tackle this infection so that its incidence does not continue to rise. Although there are antibacterial treatments available, there is yet to be a vaccine available for prophylaxis treatment of leptospirosis in humans. Thus, it is essential for the general public to be informed of steps to take to prevent the spread of leptospirosis in the country. REFERENCES 1. http://en.wikipedia.org/wiki/Leptospirosis 2. http://jknpahang.moh.gov.my/v3/uploaddir/muatturun/Guidelines%20Leptospirosis% 202011.pdf 3. http://www.webmedcentral.com/article_view/2764