LEPTOSPIROSIS IN DEVELOPING COUNTRIES

PROBLEMS IN DIAGNOSIS.
The project would be studied under the following aspects:

1. Introduction

2. Criteria for diagnosis of human leptospirosis

3. Data from Developing countries

4. Problems in diagnosis

5. Achievements and challenges

INTRODUCTION

Leptospirosis is under diagnosed and under reported in developing countries due to lack

of diagnostic facilities. The diagnosis of leptospirosis is complex, because the gold standard

tests are not easily available. Though rapid tests are available for the past two decades, they

have to be combined with the existing gold standard tests for confirmation of diagnosis. It

should be adequate to diagnose leptospirosis with rapid tests. I intend to review this literature

from developing countries in Asia, Latin America and Africa and suggest the need for utilizing

rapid tests for diagnosis.

CRITERIA FOR DIAGNOSIS OF HUMAN LEPTOSPIROSIS

The diagnosis of leptospirosis is made by the following tests :

1. Culture of blood, urine and tissues.

2. PCR

3. MAT (Microscopic Agglutination Test)

4. Rapid tests - Elisa IgM , Macroscopic Slide Agglutination Test (MSAT), ICT

Lateral flow assay (Leptochek IgM), Latex Agglutination test, Lepto-dipstick.

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 Culture, PCR and MAT are the gold standard tests and are available in specialized labs in

tertiary care centers. The rapid tests are simple and can be done at smaller centers. These tests

have been found to be more sensitive in the early diagnosis of leptospirosis by many studies and

should be suitable in developing countries for diagnosis of leptospirosis. Samples can be sent to

higher centers for the gold standard tests.

DATA FROM DEVELOPING COUNTRIES

Fredrico Costa has suggested that the estimated global incidence of leptospirosis is about

one million cases with a mortality of 59,000 cases (Global morbidity and mortality of

Leptospirosis. A systematic review. PLOS NTD 2015).

The actual number of diagnosed cases would be about 50,000 cases, with a large number

of cases from Asia, followed by Latin America, as highlighted by my previous comments.

The disparity between estimated and actual cases are lack of awareness about the disease

and lack of diagnostic facilities in developing countries. There is recently a greater awareness of

this disease and leptospirosis is considered as an important cause of non malarial acute febrile

illness in many Asian countries. In addition, rapid tests are frequently used in Sri Lanka and

India for the diagnosis of leptospirosis. In Sri Lanka, studies have revealed that Leptochek is

used as a screening test and confirmed by Elisa IgM or MAT.

The data given below are from the following Asian countries, where Leptospirosis has

been reported in large numbers.

Country No. of cases Year

Thailand 14285 2000
Sri Lanka 7406 2008
Philippines 5522 2012
Malaysia 3604 2012
Indonesia 877 2007
India <10000 2013

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 These are probably underestimated data, because of inadequate diagnostic facilities.

Leptospirosis contributes to about 15-20% of acute febrile illness and is usually mild and recover

early with empiric therapy. It is an important cause of non-malarial AFI. Therefore, they may

not be investigated due to lack of awareness of the disease or lack of diagnostic facilities by

primary care doctors, unless severe form with complications, such as jaundice, acute kidney

injury or pulmonary hemorrhage occur.

LEPTOSPIROSIS IN THE AMERICAS

Fredrico Costa et al in the article Surveillance for leptospirosis in the Americas

1996 - 2006 has stated that the annual leptospirosis cases notified from 24/48 countries is 4713.5

of which only 3 countries reported 3920 cases (83.1%).

Brazil : 3165.5 cases

Cuba : 558.5 cases

Costa Rica : 196 cases

8 countries reported 380 death, of which 349 (83.1%) were reported from Brazil

LEPTOSPIROSIS IN AFRICA

Leptospirosis is being recognized as an important cause of non malarial Acute Febrile

Illness (AFI) in many African countries. The prevalence of human leptospirosis ranged from

2.3% to 19.8% of AFI.

The Incidence rate of leptospirosis in the following countries is:

Tanzania : 75-102/100,000

Seychelles : 60-101/100,000

Reunion : 31-120/100,000

There is scarce epidemiological data from many countries, because of lack of awareness

of the disease and lack of diagnostic facilities.

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PROBLEMS IN DIAGNOSIS

1. CDC 2013 CRITERIA FOR DIAGNOSIS OF LEPTOSPIROSIS

A. Clinical criteria
B. Laboratory criteria
Supportive:

1. MAT : 1:200 or more to less than 1:800

2. IgM Antibodies detection
3. Demonstration of leptospira by DFM
Confirmed:

1. Culture - Isolation of organism

2. MAT : Seroconversion / Four fold rise in titre : Titre 1:800 or more.
3. PCR : Positive
C) Epidemiological linkage : flooding , Adventure sports
Case Classification:

1. Probable : Clinical / Epidemiological / laboratory tests without confirmation

(supportive criteria )
2. Confirmed : Same as above with confirmed tests
2. WHO LERG criteria for diagnosis of Leptospirosis (2011)
Confirmed:
Clinical signs and symptoms consistent with leptospirosis & one of the following:
1. Culture of the organism
2. MAT : Seonversion or four fold rise MAT titre : 1:400 or more
3. PCR positive (for pathogenic DNA)
4. Detection of leptospira by histology, histochemical and Immunostaining
5. Demonstration of Leptospira
Probable:
1. MAT : Titre of 1:100 or more
2. Elisa IgM positive
3. IgM or four fold rise by IFA

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 The CDC 2013 guideline has used a MAT titre of 1:800 or above to confirm the

diagnosis of leptospirosis and a titre of 1:200 to <1:800 as supportive evidence.

The LERG criteria 2011 has used a MAT titre of 1:400 or above to confirm the diagnosis

in single samples & a titre of 1:100 or above as probable leptospirosis.

There is always a confusion, whether single samples high titre can confirm the diagnosis,

as this titre can represent a rising titre of a current infection or declining titre of a past infection.

These high titres can persist for a number of years, as they can be due to both IgM and IgG

antibodies and therefore IgM antibody detection based rapid tests, such as Elisa IgM may be

valuable to confirm current infection. Combining Elisa IgM with MAT is ideal to confirm

diagnosis after 5 days of fever due to leptospirosis and at this stage, even low titres of MAT

(1:100) is acceptable. Titres of 1:400 or above is acceptable after 10 days of AFI.

3. Global Leptospirosis Environmental Action Network (GLEAN)

The plan of action of the GLEAN initiative for leptospirosis has adopted a strategy based
on the following 4 aspects
Predict,
Detect,
Prevent
Intervene.
Under Detection, Rudy A. Harkskreel, Royal Tropical Institute in the Brazil meeting has

suggested that:

1. In the first 5 days of acute illness, PCR is valuable in the diagnosis of leptospirosis.

2. In the late phase of acute illness (5-10 days), Rapid tests (Elisa IgM) are useful and

are more sensitive than MAT

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 3. MAT is done after 10 days in the early convalescent phase, to obtain the best results.

Combining PCR + Rapid tests or Rapid tests + MAT is a good strategy in acute phase

or early convalescent phase. But PCR and MAT can be done in higher centers only .

4. Modified Faines Criteria (2012):

Modified Faines Criteria (2012)

Clinical Data Epidemiological Bacteriological and Lab Findings
(PART A) Factors (PART B) (PART C)
Headache 2 Rainfall 5 Isolation of leptospira in
culture Diagnosis certain
Fever 2 Contact with
contaminated PCR 25
Temp >39C 2 4
Environment Positive Serology
Conjunctival suffusion 4 Elisa IgM Positive* 15
Animals Contact 1
Meningism 4 SAT Positive* 15
Total 10 Other Rapid Tests** 15
Myalgia 4
MAT Single positive High 15
titre*
Conjunctival suffusion +
Meningism + MAT Rising titre / 25
10 Seroconversion (paired sera)
Myalgia

* Any one of the tests

Jaundice 1
only should be scored.
**Latex agglutination
Albuminuria/Nitrogen test/Lepto ipstick/Lepto
2
Retention Tek lateral flow/Lepto
Tek Dri-Dot test
Hemoptysis / Dyspnea 2

Presumptive diagnosis of leptospirosis is made of:

Part A or Part A and Part B score : 26 or more
Parts A, B, C (Total) : 25 or more
A score between 20 and 25 suggests leptospirosis as a possible diagnosis.
Abbreviations: PCR,: Polymerase chain reaction; MAT: Microscopic agglutination test;
SAT: Slide agglutination test

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LEPTOSPIROSIS - CHENNAI EXPERIENCE IN DIAGNOSIS

1. In 1984, we published our experience with leptospirosis and acute renal failure. The

laboratory tests (MAT) were done in the veterinary college, as these facilities were not

available in medical Institutions.

2. In 1990-91, a collaborative study was done between our Institute and leptospirosis

laboratory, Barbados utilizing Elisa IgM & MAT to diagnose leptospirosis. Elisa IgM

was found valuable as a single diagnostic test to diagnose leptospirosis.

3. In 1994, a leptospirosis laboratory was established in our Institute. MSAT, Elisa IgM and

MAT were done. We suggested that MSAT should be the screening test and MAT was

done in MSAT positive patients. Samples from other hospitals were sent to our

laboratory for diagnosis of leptospirosis.

4. In 2004, the Modified Faine's Criteria was evolved using a modified scoring system from

the original criteria and utilized rapid tests such as Elisa IgM and MSAT, along with

MAT to make the diagnosis easy for Indian Institutions.

5. In 2013, The Indian Guidelines for Diagnosis and Management of Human Leptospirosis

was published in API Medicine Update 2013. The Modified Faines Criteria included

PCR and other rapid tests for diagnosis, as an amendment.

I have shared my experience from 1984 to 2013 on leptospirosis and in the journal

references, I have placed these experiences, in detail. India is a developing country and

therefore, the problems and approach to the diagnosis and management of leptospirosis has to be

modified to suit Indian Institutions.

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 Leptospirosis contributed to 16.8% of Acute Febrile Illness (AFI) in North Chennai. In

4.4% of cases, there was co-infection of Leptospirosis and Malaria. Leptospirosis was the

second common cause of AFI. This hospital caters to patients lower socio-economic status .

During the period 1987-1991, leptospirosis was the leading cause of acute renal failure in

Chennai city contributing to 31% (120/387) of the cases. This was a period, when large number

of cases were reported during the monsoon months. 70 patients underwent dialysis and the

mortality was 20.8%.

There has been a decline in acute kidney injury due to leptospirosis from 31% in

1987 - 1991 to 8.5% in 1995 - 2004 and the reasons suggested were better awareness of the

disease, availability of diagnostic facilities and widespread use of antibiotics. In addition, the

virulent serovar Autumnalis had declined, probably due to intense rodenticidal activities. But,

mild leptospirosis is present due to various environmental risk factors. Empiric therapy has been

suggested for treatment, as diagnostic laboratory data come late.

The incidence of leptospirosis is estimated to be 10-100/100,000 cases/year in developing

countries. By this estimate, India should report 0.1 - 1 million cases per year, but less than

10,000 cases are reported. The difference between the estimated and actual incidence suggests

lack of awareness of the disease and lack of diagnostic facilities in many states of the country.

ACHIEVEMENTS AND CHALLENGES

Diagnosis of Leptospirosis
Laboratory support is needed
1. To confirm the Diagnosis
2. For epidemiological and public health reasons, to determine which serovar caused the
infection, the likely source of infection, potential reservoir and its location.
In Developing countries, to confirm the diagnosis, simple rapid diagnostic tests are
adequate. They can be confirmed by Elisa IgM.

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 For epidemiological reasons, the following tests are necessary - Culture, PCR and
MAT. They need specialized laboratories to do these tests.
The following 3 tier system can be applied.
1. Peripheral hospitals in urban and rural areas : Rapid tests are adequate to diagnose

leptospirosis in acute febrile illness.

2. Larger hospitals with microbiology department (Medical College Hospitals) : These

institutes can do Elisa IgM & MAT ( if available ) . Samples from peripheral hospital

should be sent to these institutes for further evaluation & confirm the diagnosis .

3. Regional Reference laboratories : These centers can do the cultures, MAT and PCR to

identify the serovars and guide the other centers .

Unless peripheral hospitals have adequate stocks of rapid tests, it would not be possible

to obtain reliable data on incidence / prevalence of Leptospirosis in developing countries.

Leptospirosis is managed by two group of doctors : 1. Clinicians 2. Microbiologists .

Clinicians take care of the clinical features and complications of leptospirosis. If

diagnostic facilities are not available, empiric treatment is utilized to save lives. They should be

made aware that leptospirosis is an important cause of tropical acute febrile illness. Otherwise,

leptospirosis is misdiagnosed and under reported leading to inadequate published data .

Microbiologists confirm the diagnosis utilizing the diagnostic tests. The important tests

are rapid tests, MAT, PCR and Culture. They should coordinate with the clinicians and make the

necessary investigations available. At the primary care level, rapid tests should be made

available, while PCR, MAT and Culture should be made available in higher centers.

Leptospirosis cannot be diagnosed without laboratory tests and therefore, microbiologists play an

important role.

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 The major problems in obtaining data are the lack of simple diagnostic tests at the

primary care level in both urban and rural areas. Various studies reveal that leptospirosis causes

about 20% of acute febrile illness in the tropical countries. Therefore, making simple rapid tests

available is essential in these centers. Adequate training of para medical staff to do these tests by

microbiologists is vital. Adequate funding is necessary for the diagnostic tests. At present,

samples are sent to higher centers for diagnosis and this leads to under reporting of a common

disease.

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