INTRODUCTION Most widespread zoonotic disease in the world, caused by leptospires, having 23 serogroups and 250 serovars. Also known as weil disease, mud fever, canicola fever, Japanese seven day fever, icterohemorrhagic fever, hemorrhagic jaundice, rice field fever, cane cutter fever and swamp fever. Case fatality rate may vary from 0.3- 8% Incidence per 100000 is 5.6 – 50 (ILS) Generally caused by infected urine of rodents
DISTRIBUTION• Worldwide disease• Most common in tropical and subtropical areas with high rainfall.• In India frequent outbreaks in Gujarat, Maharashtra, Karnataka, Kerala and Andaman islands.
ANNUAL LEPTOSPIROSIS OUTBREAK In south gujarat several years In orissa in 1999 after super cyclonein mumbai andthane2000,2002,2005,2006 Annual Outbreaks in A outbraks & N 1988, 93, in kerala few outbreaks at 99, 2001,2003 for last 10 various places in years tamil nadu
2002 – An outbreak (74 cases) of Leptospira interrogans serovar. copenhageni infection was reported in Mumbai. (1,516 cases) was reported in Karnataka State.• 2002 – An outbreak (143 cases, 11 fatal) of Leptospira interrogans serovars. canicola, pomona and hebdomadis infection was reported in Orissa. 2003 – An outbreak (27 fatal cases and 177 under treatment) involved 131 villages in South Gujarat. 2003 – An outbreak was reported in a nurses’ hostel in Chennai. 2004 – An outbreak (550 cases, 75 fatal) of suspected leptospirosis was reported in South Gujarat. 2005 – An outbreak (100 or more fatal cases) of suspected leptospirosis was reported in the area of Mumbai following local flooding. 2005 – An outbreak (49 cases) in Chittoor District, Andhra Pradesh was caused by contact with stagnant water. 2006 – An outbreak (258 cases) was reported in Karnatka. 2006 – An outbreak (11 cases, 1 fatal) was reported in Kerala. 2006 – An outbreak (150 cases or more, at least 60 fatal) was reported in Maharashtra. 2007 – An outbreak(151 cases) in karnataka
1992 – An outbreak (48 cases) in Madras followed a monsoon. 1993 – An outbreak (18 cases) of leptospirosis with pulmonary involvement was reported in north Andaman. This was the first report of pulmonary leptospirosis in India. 1997 – An outbreak (1,127 confirmed cases) was reported in Madras – 40.2% of these Leptospira interrogans serovar. icterohaemorrhagiae, 20.0% serovar. canicola and 14.9% serovar. automnalis. 1997 – Outbreaks (562 cases, total) were reported in Valsad (281 cases, 34 fatal) and Surat (281 cases, 34 fatal). 1999 – An outbreak (143 suspect cases, 28 confirmed cases, 11 fatal) in Orissa followed a cyclone. Serovars pomona, hebdomadis and canicola were identified. 2000 – An outbreak (18 children) in Mumbai followed local flooding. 2002 – An outbreak (16 fatal cases) was reported in south Gujarat. 2002 – Concrent outbreaks of leptospirosis and dengue were reported in Mumbai.
Cases And Deaths In Gujarat In Last 15 Years Due To Leptospirosis 900 800 700No of cases and deaths 600 500 400 patients 300 deaths 200 100 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 YEAR
Cases In South Gujarat 100 90 88 83.8 80 70% of cases 60 50 2008 40 2009 30 20 9.3 8.8 10 6 1.4 1.1 1.3 0 farm labour and housewife student others animal handler Occupation
Deaths In South Gujarat 100 89.2 91.3 90 80 70No of deaths 60 50 2008 40 2009 30 20 10 7.4 3.3 1.6 2.8 0 0 0 farm labour and housewife students others animal handler occupation
Month wise Relationship between Rainfall (In mms)& Cases of Leptospirosis in Surat From YEAR 2006 to 2009 Year 2006 Year 2007 8000 100 20000 70 7000 Rain Fall (Mms) 60 80 Rain Fall (Mms) 6000 15000 50 5000 60 Cases Cases 40 4000 10000 30 3000 40 5000 20 2000 20 10 1000 0 0 0 0 Jun Jul Aug Sep Oct Nov Jun Jul Aug Sep Oct Nov Rain Fall Cases Rain Fall Cases year 2008 Year 2009 4500 90 4000 80 9000 8084 50 3500 70 8000 45 43 7000 40 3000 60 6000 35Rain Fall (Mms) Rainfall in mm No. of cases 2500 50 30 Cases 5000 28 2000 40 25 4000 20 1500 30 3000 2237 15 2000 1618 1000 20 10 1000 396 5 3 04 500 10 0 0 0 0 0 June July Aug Sept Oct Jun Jul Aug Sep Oct Nov Rain Fall Cases Rain Fall in MM Cases
Data Recent Outbreak 2011 Gujarat• Leptospirosis alarming statistics 2011(4780 cases diagnosed)• Aug 3 - 12 new lepto cases reported• Aug 7 - leptospirosis strikes south Gujarat, toll at 10• Aug 20 - 30 dead so far in south Gujarat• Sept 19- highest lepto patients in south Gujarat in last 15 years (Times Of India)• Sept 21 - Leptospirosis claims 137 lives in Gujarat (Hindustan Times)• Sept 30 - one more death, takes leptospirosis toll to 159 (The Hindu)
REFERAL CENTRES• Surat- Vyara, Bardoli, Medical College Surat• Navsari- Chikhali, Valod and District Hospital Surat• Valsad- Dharampur and District Hospital Bulsar.• Diagnostic tests for leptospirosis will be applied at the level of CHC, district hospital and MC. The referral centers have been identified in each district.
HISTORY• Adolf Weil described leptospirosis as a disease entity in 1886
RESERVIOR• Wild and Domestic animals: Rodents (Rats) Swine (Pigs) Cattle Other Wild Animals
HOST FACTORS• Age –Most affected age group is 20-40 yrs Children acquire infection from domestic dogs• Sex - Males are more prone to get infection• Occupation – Agricultural & live stock farmers• Immunity – A solid serovar specific immunity follows an infection
Risk Factors and Risk Groups1. Contact with contaminated environment• Agricultural workers• Sewage workers• Bare-foot walkers• Sports persons2. Contact with animal urine• Cattle farming• Pig farming• Veterinarians3. Contact with animal tissue• Butchers• Veterinarians• Laboratory personnel
MODES OF TRANSMISSION1 Direct contact- with urine or tissue of infected animal a. Through skin abrasions b. Intact mucus membrane2 Indirect contact- a. Broken skin with infected soil, water or vegetation b. Through ingestion of food & water contaminated with leptospira3 Droplet infection- Inhalation of droplets of infected urine
ENVIORMENTAL FACTORS• Rainfall; Contaminated environment• Poor Sanitation; Inadequate drainage facilities• Presence of rodents, cattle & stray dogs• Walking/ working bare foot poses high riskINCUBATION PERIOD Usually 10 days with range of 4 – 20 days
WHY SOUTH GUJARAT ????• Paddy cultivation and sugarcane (water loving crops)• Work practices by farmers and animal handlers.• Climatic conditions Heavy rainfall Flood situations Clay soil structure leads to water logging and high water tables Rodent carriers
PATHOGENESIS OF DISEASE Damage to small vasculitisLeptospira blood vessels Massive migration of fluid from Direct cytotoxic injury Intravesicular to interstitial compartment Immunological injury Renal dysfunction ,vascular injury To internal organs
NATURAL HISTORY Animal source - Exposure - Infection Overt Clinical Illness InapparentAnicteric Icteric No carrierRecovery Fatality Dead end
TYPES OF LEPTOSPIROSIS ANICTERIC ICTERICSEPTICEMIC IMMUNE PHASE JAUNDICE PHASE
ICTERIC LEPTOSPIROSISOrgan Clinical features Investigations reveal Increase in serumKidney Decrease in urine output Creatinine and Blood Urea Increase in serum Bilirubin with normal or mildlyLiver Jaundice, hepatomegaly elevated SGOT and SGPT and increase CPK Cough, haemoptysis, dyspnoea with in X ray chest shows lowerLungs crease in respiration rate and basal and mid zone opacities crepts ECG reveals type ofHeart Hypotension ,irregular pulse ArrhythmiaBlood Bleeding tendencies Decrease in Platelet count CSF shows increase in cellsBrain Altered consciousness with neck rigidity , increase in Protein and normal Sugar
LAB DIAGNOSISDirect evidence Indirect evidenceDemonstration of leptospirae Demonstration ofor isolation of organism antibodies to leptospires•Microscopy •Genus specific• Staining MSAT•Isolation of leptospires ELISA•Animal inoculation leptodip stick•PCR lepto dridot lepto lateral flow •Serovar specific MAT
Suspected Clinical case“Includes presence of acute febrile illness withHeadache, Myalgia and prostration associatedwith any of the following symptoms likeConjunctival effusion, Meningealirritation, Anuria or oliguria and / orProteinuria, jaundice, haemorrhages (from theintestine, lung) cardiac arrhythmia orfailure, skin rash and a history of exposure toinfected animals or an environmentcontaminated with animal urine. Other commonsymptoms include nausea, vomiting, abdominalpain, diarrhoea, and arthralgia”
Confirmed Case“A suspect case which gets confirmed bystandard laboratory investigations is termedas a Confirmed Case. Laboratory criteria fordiagnosis are: Isolation of the organism fromblood or CSF during first week of illness andfrom urine after 10 days; Positiveserology, preferably MicroscopicAgglutination Test (MAT); Supportiveserologic findings i.e. a Leptospiraagglutination titre of >200 in one or moreserum specimens”
TREATMENT• Symptomatic treatment• Inj. Crystalline Penicillin 20 lakh units i.v 6th hourly for 7 days• Children-2 to 4 lakh units/kg of Inj. CP for 7 days• Other drugs- Erythomycin, Ampicillin, Ceftriaxone• Maintain adequate fluids and hydration• Chemoprophylaxis - Doxycycline 100mg BD for 7 days
• Any case of fever: (Presumptive treatment) Tablet of chloroquine - 600 mg stat (10 mg/Kg body weight) Capsule of doxycycline -100 mg twice a day for seven days This regime is to be followed only during rainy season. b) All suspected leptospirosis cases Intravenous injection of penicillin (20 lakh units) every 6 hours for 7 days
IMMUNIZATION• Immunity to leptospirosis is relatively serovar specific. Thus, immunization protects against disease caused by the homologous serovar or antigenically similar serovars only.
STEPS TAKEN BY GOVT OF GUJARAT AND NICD• A project taken for controlling Leptospirosis in Endemic Districts of South Gujarat, by isolating circulating• Lepto Serovars amongst cattle population & co-relation of them, if any, to increasing mortality &• extension of Human Leptospirosis in newer areas of South Gujarat.• Soil samples are also taken for the pH analysis from high risk villages of south Gujarat by Agriculture• department as per recommendation by NICD Delhi.• List of 84 high risk villages of Surat, Navsari and Valsad districts are given to Agriculture Department for soil collection and analysis from Health Department.
• IEC activities were carried out during ‘Krishi Rath Mahotsav’ to educate and inform community regarding leptospirosis during 7/5/08 to 6/6/08 in the Surat, Navsari and Valsad districts.• Guidelines are prepared and distributed to all districts for prevention and control of Leptospirosis for the• year 2008 for implementation in districts which was prepared by PSM Department, Medical College Surat on 19/06/2008 after multiple meetings with experts.• An active surveillance has been started from 1st June 2008 in leptospirosis endemic districts like Surat, Navsari and Valsad. All fever cases (> 15 years of age) surveyed are given Capsule Doxycycline 100 mg./twice a Day for 7 days along with antimalarial treatment as per the decided guidelines.
CHANGES IN PATTERN OF DISEASES It has been observed over last few years that earlier patients use to report with hepatic & renal complications. But over last two to three years numbers of patients are reporting with pulmonary (respiratory) complications in which patients become critically ill within a short span of life so very less time is available for their survival even at the level of well equipped Medical College Hospital.
CHALLENGES• Mimics other diseases; clinical diagnosis is essentially one of exclusion• Severe form around 20% with organ failure requiring secondary and tertiary care• Definitive diagnosis through laboratory; not widely available• Is yet to be considered a priority disease in most SEA countries• Generalized underreporting of cases• Prevention and control remains difficult to implement
References• http://www.whoindia.org/LinkFiles/Communicable_Diseases_Repo rt_of_the_Leptospirosis_meeting_Final.pdf• WHO_CDS_CSR_EPH_2002.23• Scenario of Leptospirosis in Gujarat, India Epidemiological Investigations & Public Health Interventions Dr. S. J. Gandhi, Deputy Director, Epidemic Control Programme, Gujarat, India• K.park (21st Edition): Epidemiology of Communicable diseases chapter 5: leptospirosis;267.• http://www.newsfirst.lk/english-news/?view=news_more&id=2260