International Journal of Infectious Diseases (2008) 12, 351—357

http://intl.elsevierhealth.com/journals/ijid

REVIEW

The globalization of leptospirosis: worldwide

incidence trends
Georgios Pappas a,*, Photini Papadimitriou a, Vasiliki Siozopoulou a,
Leonidas Christou b, Nikolaos Akritidis c

a
Institute of Continuing Medical Education of Ioannina (ICMEI), Har. Trikoupi 10, Ioannina, 45333, Greece
b
1st Division of Internal Medicine of the Medical School at the University of Ioannina, Ioannina, Greece
c
Internal Medicine Department of the General Hospital ‘‘G. Hatzikosta’’ of Ioannina, Ioannina, Greece

Received 25 June 2007; accepted 18 September 2007

Corresponding Editor: William Cameron, Ottawa, Canada.

KEYWORDS Summary
Leptospirosis; Objectives: Leptospirosis continues to be a significant zoonosis of the developing world. Glo-
Epidemiology; balization, in the context of international travel, particularly for recreational activities and
Incidence military expeditions, has led to increased exposure of individuals from the developed world to the
disease, as recent outbreaks show.
Methods: We evaluated the trends in annual leptospirosis incidence for individual countries
worldwide through reports from national and international organizations, the published medical
literature on the subject, and web searches with the terms ‘leptospirosis’ and the individual
country names. Inter-country variations in leptospirosis incidence, when relevant official data
were available, were also analyzed.
Results: The Caribbean and Latin America, the Indian subcontinent, Southeast Asia, Oceania,
and to a lesser extent Eastern Europe, are the most significant foci of the disease, including areas
that are popular travel destinations.
Conclusions: Leptospirosis is a re-emerging zoonosis of global importance and unique environ-
mental and social correlations. Attempts at global co-ordination and recognition of the true
burden of an infectious disease with significant mortality should be encouraged.
# 2007 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Introduction endemicity in animal vectors and human exposure, it is gen-

Leptospirosis remains one of the most common and most
dreaded zoonotic infections worldwide.1 Traditionally related
to certain socioeconomic or climatic conditions that favor
* Corresponding author. Tel.: +30 26510 28289.
E-mail address: gpele@otenet.gr (G. Pappas).
erally confined to the developing parts of the world, being
randomly reported from industrialized countries2 often as an
imported disease following international travel to exotic des-
tinations.3 In recent years, a new trend in human leptospirosis
outbreaks has been observed related to recreational activities
among the wildlife (a form of tourism that is becoming increas-
ingly popular) and army expeditions, either for training or for
combat-related purposes in similar environments.4—7 Thus

1201-9712/$32.00 # 2007 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijid.2007.09.011
352 G. Pappas et al.

leptospirosis has become an important infectious agent to take
into account when preparing for such expeditions, and this is
reflected in efforts to define and utilize successful preventive
antibiotic administration policies.8
Eradication of the disease involves not only the duties of
the veterinarian but also adequate health and surveillance
networks in the developing world; awareness of the evolution
of the global incidence of human disease is important for
acknowledging the relative risks in international travel and in
highlighting world areas that should move at the epicenter of
enhanced disease surveillance and attempts at control from
international health organizations. We sought to define the
areas of the world where leptospirosis is at present a public
health problem and a potential risk for visitors, and to define
the patterns present in the changing (if changing) incidence
of the disease over the last decade.
Methods
Data on the prevalence of human leptospirosis for each
country from 1996 onwards were sought from health minis-
tries or other official national organizations, public health
international organizations, and the medical literature. The
medical literature was searched through MEDLINE (but also
general search engines), using leptospira/leptospirosis and
individual country and region names as keywords. ProMED-
mail, an electronic system reporting infectious disease out-
breaks, developed by the International Society for Infectious
Diseases, was also used. When available, official national
data were used, even if not in concordance with data from
international organizations. For countries without such offi-
cial data, data from international organizations were used.
The medical literature was used only when including signifi-
cant epidemiological information, or (in the case of seropre-
valence studies) in the absence of any other data regarding
disease status in a country. Serial data on incidence were
evaluated for the presence of epidemiologic trends for indi-
vidual countries. In calculating the annual incidence, when
this information was not provided in the source references,
population data derived from official publications such as the
CIA World Factbook9 were used.
Results
Table 1 lists the annual incidence of human leptospirosis for
certain countries, including the 28 countries with the highest
incidence, and other important countries. As is shown clearly
in Figure 1, the endemicity of the disease is mainly located in

Table 1 Annual incidence of leptospirosis worldwidea

Countries with the highest incidence Countries for which no Other countries
data are available,
Rank Country Annual incidence per Country Annual incidence per
probably endemic
million population million population
1 Seychelles 432.1 India Belarus 3.4
2 Trinidad and Tobago 120.4 Malaysia Bulgaria 3.7
3 Barbados 100.3 Bangladesh Chile 1.6
4 Jamaica 78 Vietnam Colombia 1.6
5 Costa Rica 67.2 Laos Czech Republic 1.8
6 Sri Lanka 54 Nepal France 3.9
7 Thailand 48.9 Cambodia Germany 0.7
8 El Salvador 35.8 Indonesia Greece 3
9 New Zealand 26 Myanmar Honduras 3.1
10 Uruguay 25 China Hungary 3.1
11 Cuba 24.7 Iran Ireland 2.2
12 Nicaragua 23.3 Suriname Italy 0.7
13 Croatia 17.3 Haiti Lithuania 2.2
14 Russia 17.2 Peru Mexico 1
15 Ukraine 15.3 Netherlands 1.9
16 Dominican Republic 13.8 Panama 1.3
17 Brazil 12.8 Paraguay 1.9
18 Ecuador 11.6 Serbia and Montenegro 1.5
19 Argentina 9.5 Singapore 2
20 Romania 9.4 South Korea 2.8
21 Australia 8.9 Spain 0.3
22 Portugal 6.8 UK 0.6
23 Denmark 6 USA 0.1
24 Latvia 5.6 Venezuela 3.8
25 Slovenia 5.4
26 Philippines 4.8
27 Slovakia 4.4
28 Taiwan 4.1
a
Data as indicated in the text.
The globalization of leptospirosis 353

Table 2 Selected regions, districts, and provinces with a

high human leptospirosis incidencea

Region/district/province Country Annual incidence

per million
population
Andaman Islands India 500
Loei Thailand 467.8
Guadeloupe France 311.9
Roi Et Thailand 299.3
North Queensland Australia 288
Khon Kaen Thailand 286.4
Kalasin Thailand 286
Figure 1 Global annual incidence of human leptospirosis. Lampang Thailand 269.3
Colors reflect incidence, in declining order: red, pink, green, Pollonaruwa Sri Lanka 247.2
yellow. Gold reflects areas with probable, but not estimated, Surin Thailand 240
high incidence. White reflects absence of data. Matale Sri Lanka 236
Kegalle Sri Lanka 228.2
Matara Sri Lanka 215
the Caribbean and Central and South America, as well as in Kalutara Sri Lanka 200
Southeast Asia and Oceania. Brunca Costa Rica 171
In developing this list, significant drawbacks became French Polynesia France 105.8
apparent. There were no data for many developing countries, Azores Portugal 83
and for certain developing countries the data may be con- New Caledonia France 59.3
sidered unreliable. In some countries, reported cases were a
Data as indicated in the text. Data for Andaman Islands are
found to range from significant numbers to zero within a year,
from an International Leptospirosis Society Survey, available at:
while the absence of reported cases for certain other coun- http://www.leptonet.net/html/ils_worldwide_survey.asp.
tries may not be as a result of absence of the disease when
neighboring countries appear to be hyperendemic. This latter
point seems to be the case for many Asian countries, includ- Nicaragua also come high on the list; in the latter, the
ing India, where the disease is known to be present, Malaysia, incidence is higher in the southern regions of Rio San Juan,
where an outbreak occurred during the Eco-Challenge that neighboring Costa Rica, and Carazo (annual incidence 50—60
took place in 2000, and the majority of Africa, where the per million), but also in the northern regions of Jinotega and
disease is known to cause random outbreaks, as occurred Nueva Segovia, neighboring Honduras, according to epide-
recently in Kenya. Another drawback was the low statistical miological reports from the Ministry of Health.13 This is in
significance of results from countries with small populations contrast to outbreaks in previous years, which, following
(for example, Vanuatu reported five cases in 2003, which Hurricane Mitch in 1998, were located in the regions of Esteli
equals an annual incidence of 24.3 per million population, and Chinandega. The significantly lower incidence of the
but reported no cases in 2004, incidence falling to zero). disease in Panama, Guatemala, and Honduras may represent
Inter-country variation was also significant, and for certain the actual situation or an artifact derived from inadequate
countries the burden of disease was high in some provinces surveillance systems. Cuba expresses significant scientific
while being non-existent in others. Table 2 summarizes such interest in the disease, having hosted three Leptospirosis
world areas and their annual leptospirosis incidence accord- International meetings in the last 5 years (Institute of Tro-
ing to official data. pical Medicine ‘‘Pedro Kouri’’). For the Dominican Republic, a
contrast between data available from the Office Interna-
The Americas tional des Epizooties (OIE),14 used in estimating the incidence
in Table 1, and reports from ProMED,15 which denote extre-
The disease is absent from Canada and has been removed mely few cases for 2005, is characteristic of the inconsistency
from the notifiable diseases list in the USA, where few annual of data in various world regions.
cases occur, randomly related to recreational activities in The disease is endemic in the Caribbean islands, according
fresh water.5 Hawaii is the exception, with an estimated to annual reports from the Caribbean Epidemiology Centre:
annual incidence of 12.9 per million population.10 in 2000, more than 500 cases were confirmed from Caribbean
In Mexico, a small increase in reported annual cases has islands, leading to a cumulative annual incidence of >100 per
been observed in recent years according to data from the million population.16 Barbados retains an increased inci-
General Directorate of Epidemiology,11 the majority of cases dence, despite the active government attempts at preven-
in recent years originating from the South Atlantic region of tion and education on the risks for the disease.17 On the other
Veracruz. In Costa Rica, the incidence is higher in the Cen- hand, although Jamaica figures high in the endemicity list,
tral-South Pacific region of Brunca, and in the Huetar Atlan- leptospirosis is not a notifiable disease in this country.
tica and Huetar Norte regions, while being very low in the According to the Caribbean Epidemiology Centre, Trinidad
densely populated central regions of the country, according and Tobago and Suriname are the countries requesting eva-
to data from the National Epidemiological Surveillance Sys- luation of most samples in the region. The former, data
tem.12 Other countries of the region, such as El Salvador and derived from the local press,18 ranks second in the list of
354
global incidence. A recent outbreak following a flood was
reported from Guyana, with a characteristically high death
toll and a large campaign of prophylactic administration of
doxycycline to more than 120 000 people implemented by the
Panamerican Health Organization.19 The disease is also pre-
sent in Haiti, although official data for the last decade are
lacking; in 1995 the annual incidence per million was eight,
and an increasing trend was observed in 1996.20 The hyper-
endemic French territory of Guadeloupe is also located in this
region.
Although the disease is present in South America, it is not
notifiable in the majority of countries, and data on annual
cases are derived mostly by the OIE. Official data from the
Department of Epidemiology of Uruguay denote that the
disease is particularly endemic in the southeastern provinces
of Florida and Rocha (annual incidence 132 and 100 per
million population, respectively).21 There are no official data
available for Peru for recent years, although localized epi-
demiological studies in the Amazon Forest region have
stressed the endemicity of the disease.22,23 Data for Brazil
may represent in general the overall endemicity, as studies in
the Sao Paulo region have shown;24 studies in other regions
though, as in Santa Maria have shown a hundred-fold actual
incidence.25 The absence of continuous surveillance data
precludes drawing any conclusions, since the latter study
may have actually witnessed an outbreak. Urbanization of the
disease has consistently been demonstrated in Brazil.26,27 In
Argentina the majority of cases are reported from Buenos Aires
and the northern region of Santa Fe, according to the Direc-
torate of Epidemiology of the Ministry of Health.28 According
to the OIE, most cases in Venezuela (and the highest incidence,
almost double that of the country’s) present in the northern,
Caribbean districts of District Capital, Aragua, Anzoategui,
and Carabobo. OIE numbers for Ecuador, and the estimated
incidence, may actually be higher if ProMED reports on an
outbreak in the Pacific province of Manabi29 are taken into
account, with an estimated incidence for 2002 for this province
near 100 per million population.
Europe
Most of the factors related to leptospirosis endemicity (tro-
pical climate, stagnant waters, poor levels of sanitation,
flooding) are generally absent from Europe, and the overall
situation has not changed significantly over the past decade.
Local climate and environmental factors have sometimes
been implicated in fluctuations of annual reported cases,
as in France30 and the Czech Republic;31 in the latter country
an increase in annual cases was observed following floods
both in 1997 and 2002. An extended review of epidemiology
patterns of the disease in the last 40 years in Germany32
outlined a partial incidence increase since 1998 attributed to
rat population expansion and the re-emergence of canine
leptospirosis. Data from the Italian Ministry of Health33 show
a steady predominance of cases in the northern wealthy
provinces of Lombardia and Veneto. Data from the Portu-
guese Ministry of Health for the period 2001—200534 show an
increasing incidence in the Azores islands, which account
now for more than 50% of the annual cases.
Central and Eastern European countries demonstrate the
highest incidence as shown in Table 1, data derived from the
OIE. The actual extent and distribution of the disease in
G. Pappas et al.
Russia is unknown: outbreaks related either to floods35 or
to recreational activities like swimming in rivers,36 and a
trend for disease urbanization37 and the increased role of
canine leptospirosis38 are the main recent epidemiologic
characteristics.
Asia
Underreporting is a major problem in evaluating the presence
and the actual incidence of leptospirosis in many Asian
countries. In India, leptospirosis is a major health problem
obviously related both to the monsoons and poor sanitary
conditions, with multiple epidemics reported in recent
years.39—43 The Andaman and Nicobar Islands top the list
of the most endemic areas of the world, shown in Table 2, yet
no official incidence data on most provinces of India
exist. Similar environmental and sanitary conditions, with
the added burden of overcrowding, apply to neighboring
Bangladesh and Nepal, where the disease was recently recog-
nized as an important alternative diagnosis in patients with
suspected dengue and febrile diseases in general, respec-
tively.44,45 In Sri Lanka the disease is hyperendemic, espe-
cially in the south and north-central provinces, and in the
southern province of Sabaragamuwa, the annual incidence is
>140 per million population, according to data from the
Ministry of Health.46 The Seychelles islands possess the high-
est incidence worldwide, with annually reported cases and
incidence remaining more or less constant from 1988 onwards
according to Ministry of Health and Social Services reports.47
The incidence may actually be slightly higher, since tentative
surveillance yielded an annual incidence above 1000 per
million population in the 1995—1996 period.48 In this study,
serogroups Icterohaemorrhagiae and Hurstbridge, the latter
related to adverse outcome, were found to be the most
prevalent.
There are no data on the presence of leptospirosis in
countries plagued by war such as Afghanistan and Iraq. There
are also no data for Pakistan and the countries of the
Middle East. The disease is present in Iran, although data
are limited: a recent study identified 74 patients during a
period of three months in a northern region,49 while another
study yielded high seroprevalence, especially for serovar
Hardjo, in a tribal population of West-Central Iran.50 A recent
outbreak of leptospirosis in Tajikistan51 and a 1998 outbreak
in Kazakhstan raise worries about the emergence of the
disease in the former Soviet Republics of Central Asia.
The burden of human leptospirosis in Southeast Asia is
huge. Thailand has been the source of a protracted major
outbreak in the 21st century, subsequent to flooding, and
localized mainly in the northeast region of the country.52
Data from the Ministry of Health underline the dramatic,
sustained incidence in certain regions53 (see also Table 2).
Fears of the emergence of leptospirosis outbreaks following
the 2004 tsunami disaster did not materialize though, pos-
sibly due to the beneficial effect of salt water mixing with
fresh waters.3 A recent study from the Thailand—Myanmar
border confirmed leptospirosis as the second, post-malaria,
most frequent cause of fever in this region.54 There are no
official data for Vietnam, Lao People’s Democratic Republic,
Cambodia, and Indonesia, but studies on the incidence of
the disease in certain patient populations (jaundiced,55,56
non-malaria febrile patients55) and seroprevalence55 have
The globalization of leptospirosis
confirmed the endemicity of the disease. Hurstbridge was the
most common serovar identified in this study, while a ser-
oprevalence study in the Mekong Delta of Vietnam showed
evidence of recent infection in 41/1400 tested individuals, a
seroprevalence of 18.8%, and Bataviae the most common
serogroup identified.57 A recent seroprevalence study in
children in South Vietnam yielded a seroprevalence rate of
11%.58 There are also no data for Malaysia, host of the most
significant recreational event-related outbreak;4 further-
more the disease has been incriminated in 12.6% of febrile
patients in a large study.59 Data from the OIE for Philippines
are in concordance with a significant, climate-related (mon-
soons, floods) burden, while microbiological studies from this
region have shown a predominance of serogroup Javanica,
serovar Poi.60
There are no official data for China; the disease though is
certainly endemic, and the cause of periodic outbreaks in
certain provinces.61 Taiwan exhibits a significant steady
burden of disease; according to OIE data, the disease is
believed to have only emerged in the last 30 years.62 A steady
number of annual cases are reported annually to the OIE from
South Korea. For Japan, only the South Pacific island of
Okinawa presents a significant disease burden.63
Oceania
In continuity with the hyperendemic Southeast Asia zone,
Oceania also exhibits a significant burden of leptospirosis.
In Australia, according to data from the Department of
Health and Ageing,64 most cases are derived from Queens-
land, where the annual incidence is 28 cases per million
population, the remaining cases emerging from New South
Wales. North Queensland is one of the world areas with the
highest endemicity. The disease is mainly an occupational
one, associated with the livestock and horticultural (bana-
nas, sugar cane) industries. The peak of cases in recent
years was noted in 1999, and was attributed to prolonged
rainfall in North Queensland and a concomitant increase in
the rodent population. Data for New Zealand are from the
OIE and a recent overview of the changing epidemiology of
the disease in this country,65 the latter stressing the con-
tinuing decline in annual incidence and the emergence of
new serovars such as Leptospira borgpetersenii serovar
Ballum, implicating an increasing trend of acquisition of
the disease through exposure to infected fresh water.
Certain French autonomous territories of Oceania are also
hyperendemic according to OIE data, including French
Polynesia and New Caledonia. The reported annual cases
for the latter region are continuously and significantly
decreasing, although the adequacy of reporting cannot
be ascertained; studies stress that the incidence may actu-
ally be much higher.66,67
Africa
As expected, little is known about the incidence of lepto-
spirosis in Africa. The OIE reports acknowledge the presence
of the disease in Morocco with low endemicity, Eritrea, and
Ethiopia, with no specific data available. A recent outbreak in
Kenya68 stresses that the disease is present but remains
undiagnosed. A 15% seroprevalence was demonstrated in a
study in Gabon.69
355
Conclusions
In a rapidly changing world, where borders are continuously
crossed due to international tourism trends, tropical infec-
tions including leptospirosis have emerged as significant
causes of imported morbidity, and in the case of leptospiro-
sis, mortality. For a disease for which a lot is still to be
learned on its pathogenesis and treatment principles,2
awareness of disease epidemiology and patterns of global
incidence may allow for enhanced practices of prevention.
This is especially important since in recent years leptospirosis
outbreaks have characteristically been present in young
healthy populations, including athletes and military recruits,
while urbanization of the disease is of increasing concern.
As expected, global coordination, either under the aus-
pices of international humanitarian organizations or through
specialized societies such as the International Leptospirosis
Society (ILS), is the warranted first step towards disease
control. The World Health Organization and ILS have recently
initiated the development of a global database called Lep-
toNet (accessed at http://www.leptonet.net).
Obviously adequate disease notification is a futile target,
since many endemic countries exhibit inadequate health and
surveillance networks. In the era of molecular medicine,
notification on Leptospira species and serovars prevailing
in different regions (a subject only briefly touched on in
the present study as being of specialized interest — relevant
information can be found in an ILS report)70 may allow
for better recognition of trends and risks and better imple-
mentation of other preventive measures.
Conflict of interest: No conflict of interest to declare.
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