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Leptospirosis 2015
Leptospirosis is a zoonotic infection caused by the spirochete Leptospira, predominantly transmitted from animal reservoirs like rodents and domestic animals to humans under specific environmental conditions. Clinical manifestations range from mild anicteric symptoms to severe icteric leptospirosis, with significant epidemiological burden especially in tropical regions and vulnerable populations such as agricultural workers. Preventive measures, treatment guidelines, and international initiatives are being implemented to control and manage this disease effectively.
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Leptospirosis 2015
- 1. LEPTOSPIROSIS DEPT. OF COMMUNITYMEDICINE, UPRIMS&R, SAIFAI UNDER GUIDANCE OF : DR. A.M. DIXIT SIR PRESENTED BY: PRANJAL AGARWAL ROLL NO. 55
- 2. INDEX • HISTORY • WHATIS LEPTOSPIROSIS? • AGENT • SOURCE OF INFECTION • HOST FACTORS • ENVIRONMENTAL FACTORS • MODE OF TRANSMISSION • CLINICAL FEATURES • BURDEN OF DISEASE
- 3. INDEX (CONT.) • WORLDSTATUS • STATUS IN INDIA • OUTBREAKS • NICD GUIDELINES FOR PREVENTION & CONTROL • TREATMENT OF LEPTOSPIROSIS • INTERNATIONAL INITIATIVES • INITIATIVES BY INDIA • PREVENTION & CONTROL • REFERENCES
- 4. HISTORY • The spirochetewas first isolated in Japan by Inada in 1915 . • Weil described the clinical disease in 1886.(WEIL’S DISEASE) • Leptospirosis was known in China and Japan by “rich harvest jaundice” and “autumn fever”.
- 5. --RUDYARD KIPLING • IKEEP SIX HONEST SERVING* MEN. THEY TAUGHT ME ALL I KNEW. THEIR NAMES ARE: WHAT, WHY, WHEN, HOW, WHERE & WHO. *taken from Textbook of P.S.M. by K.Park 23rd edition Ch-3 : Epidemiology
- 6. WHAT IS LEPTOSPIROSIS? [Zoonoses +environmental disease + occupational disease]
- 7. • Leptospirosis isessentially animal infection by several serotypes of Leptospira (Spirochetes) and transmitted to men under certain environmental conditions.
- 8. AGENT • 2 species: L. interrogans •Pathogenic L. biflexa •Saprophytic The leptospira serovars predominantly present in India are L.ictohaemorrhageae
- 9. SOURCE OF INFECTION •Excreted in the urine of infected animals for a long time. • ANIMAL RESERVOIRS: o Rodents – mice, rats and voles. o Domestic animals – cattle, sheep, goat, water buffalo, pigs, horses, dogs may act as carriers. o RATS: R. norvegicus most important Mus musculus reservoirs
- 10. HOST FACTORS o AGE&SEX human infection: accidental. males > females due to greater occupational exposure. more frequent in age group 20-30 yrs o HIGH RISK GROUPS Agricultural workers Fishermen, sewer workers Lorry drivers and masons
- 11. ENVIRONMENTAL FACTORS • Drainage congestionand water logging • Soil salinization • Soil temperature • Seasonal variation – Starts at the onset of Rainy season & declines as the rains recede.
- 12. • Heavy RAINS& FLOODS • Poor housing • Limited water supply • Inadequate method of waste disposal
- 13.
- 14. MODES OF TRANSMISSION DIRECT CONTACT INDIRECT CONTACT DROPLET INFECTION NOTE- Directman to man infection is rare.
- 15. CLINICAL FEATURES Two typesof leptospirosis are described ICTERIC LEPTOSPIROSIS ANICTERIC LEPTOSPIROSIS I.P. = 10 days with a range of 4 to 20 days
- 16. ICTERIC LEPTOSPIROSIS o It isthe severe form of the disease. o It is characterized by jaundice and is usually associated with involvement of other organs. o About 5-10% of patients have these type of manifestations • ANICTERIC LEPTOSPIROSIS o It is the milder form of the disease. o Patients have fever, myalgia but do not have jaundice. o Almost 90% Of patients have this type of illness.
- 17. SIGNS & SYMPTOMS •Fever with chills • Myalgia of calf, abdominal & lumbosacral muscles • Conjunctival Suffusion • Headache- throbbing, frontal • Renal infestation- mild proteinuria with few casts/cells • Pulmonary infestation- cough/chest pain/haemoptysis • PETECHIAL hemorrhage ANICTERIC
- 18.
- 19. • JAUNDICE • Fever(Sameas in anicteric leptospirosis but may be more severe) • All the symptoms and signs of Anicteric along with Organ Involvement. ICTERIC
- 20. • ORGAN INVOLVEMENT- ORGANCLINICAL FEATURES KIDNEY Decrease in urine output, features of uremia LIVER Jaundice, hepatomegaly LUNG Cough, haemoptysis, dyspnoea with increase in respiration rate and basal crepts HEART Hypotension, irregular pulse BLOOD Bleeding tendencies BRAIN Altered consciousness with neck rigidity
- 21. IS IT IMPORTANTTO STUDY LEPTOSPIROSIS??
- 22. BURDEN OF DISEASE •BEARS EPIDEMIC POTENTIAL • The annual incidence of leptospirosis is estimated 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.
- 23. MOST WIDESPREAD ZOONOSIS Leptospirosis istreatable and preventable! • If Leptospirosis is detected early, antibiotics can be administered that can successfully treat the disease.
- 24.
- 25. WORLD STATUS • 63%in AMERICAS (Brazil, Nicaragua, Argentina) • 15% in WESTERN PACIFIC • 14% in SOUTH EAST ASIAN REGION • 08% in EUROPE • Rest in AFRICAN & Eastern MEDITERRANEAN.
- 26. STATUS IN INDIA CoastalDistricts of • Gujarat • Maharashtra • Kerala • Tamil Nadu • Andhra Pradesh HAVE REPORTED • Karnataka OUTBREAKS • Andamans • Orissa
- 28.
- 29. OUTBREAKS • 1995 –1998 – Prevalent in the United States only. • 1999 - A post-cyclone outbreak was reported in Orissa, India • 2002 – Outbreak after flooding in Jakarta, Indonesia • 2002-05 – In South Gujarat • 2000,2002,2005 – After flooding in Mumbai, Maharashtra • 2008 – After flooding in Sri Lanka • 2009 – After Cyclone in Philippines • 2011 - Outbreak in Canyoning athletes in the Caribbean island of Martinique.
- 30. • July, 2015– Outbreak in Mumbai, Maharashtra CASES : 21, DIED : 12
- 31. CAN WE PREVENT& CONTROL LEPTOSPIROSIS?? + INITIATIVES TAKEN TILL DATE. H
- 32. Guidelines for Prevention andControl of Leptospirosis: National Institute of Communicable Diseases (Zoonosis Division) 2006
- 33. Recommended case definition Acute febrileillness with headache, myalgia and prostration associated with any of the following: • Conjuctival suffusion • Meningeal irritation • Jaundice • Hemorrhages (from the intestines; lung bleeding is notorious in some areas) • Cardiac arrhythmia or failure
- 34. CASE CLASSIFICATION • Suspected: Acase that is compatible with clinical description. • Confirmed: A suspect case with positive laboratory test.
- 35. Laboratory criteria for diagnosis Collection and Transportation of serum sample Labelling and transportation of the sample Collection of clinical samples for isolation of leptospires blood urine CSF Other specimen include autopsy tissues such as kidney or liver.
- 36. SEROLOGICAL DIAGNOSIS OF LEPTOSPIROSIS 1.Enzyme Linked Immuno Sorbent Assay (ELISA) 2. Rapid immunodiagnostics based on IgM detection.
- 37. TREATMENT OF LEPTOSPIROSIS 3 LEVELS PHCLEVEL CHC/ DIST HOSPITAL LEVEL TERTIARY LEVEL
- 38. TREATMENT AT PHC/CHC/DIST. HOSPITALS INENDEMIC AREAS • CLINICAL SUSPECT- Tab. Doxycycline 100 mg twice daily for 7 days. • MILD DISEASE & RAPID IMMUNODIAGNOSTIC TEST +VE - Inj. Crystalline penicillin 20 lacs I.U. i.v. every 6 hrly in adults for 7 days.(CHILDREN - 2 – 4 lacs units/kg/day for 7 days.) • IF FEATURES OF ORGAN DYSFUNCTION PRESENT, REFER TO HIGHER CENTRE.
- 39. TREATMENT AT MEDICAL COLLEGE/TERTIARY CENTRE 2 STEP TREATMENT CHEMOTHERAPY ORGAN SPECIFIC CARE Adults : T. Doxycycline 100 m.g. twice a day for seven days; Children : < 6 yrs. Cap. Amoxy/Ampicillin Organ specific and symptomatic treatment.
- 40. INTERNATIONAL INITIATIVES • INTERNATIONAL LEPTOSPIROSISSOCIETY The International Leptospirosis Society Inc. (ILS) was formed in 1994 to promote knowledge on leptospirosis through the organisation of regional and global leptospirosis meetings.
- 42.
- 43. Leptospirosis Burden Epidemiology ReferenceGroup (LERG) • The LERG, an advisory group to the DirectorGeneral of the WHO on the epidemiology of leptospirosis, was established in 2009 following an informal WHO consultation in 2006. • The Objective„: to provide estimates for human leptospirosis worldwide, according to age and sex and by WHO region
- 44. INITIATIVES BY INDIA • APilot Project on Control of Leptospirosis was approved as a “New Initiative” in the 11th Five Year Plan in 5 endemic states with the objective to reduce the morbidity and mortality in pilot project areas. • Proposal for Leptospirosis control in the 12th Plan
- 45. Proposal for Leptospirosis controlin the 12th Plan AIM : To expand and implement the strategy for prevention and control of Leptospirosis developed during 11th Plan in all the endemic states during the 12th Plan period. NCDC is the nodal agency for this project. The thrust areas of the project are- —Early diagnosis & treatment of Leptospirosis —Strengthening of lab & patient management facilities —Training of manpower —IEC in the community —Inter- sectoral coordination BUDGET : Rs. 3.69 crores
- 46. Who CAN HELPIN CONTROLLING THE DISEASE??
- 47.
- 48. PREVENTION & CONTROL Protectionof people against contagion by available means. Health education Vaccination of animals Rodent control Mapping of water bodies for establishing a proper drainage system Health impact assessment of developmental projects Leptospirosis should be made a reportable disease in all endemic states Chemoprophylaxis
- 49. VACCINATION OF ANIMALS Species Nameof the vaccine Dog Novivac-DHPPI-2L Eurican-DHPPI-2L Vanguard-DHPPI-2L Duramax-DHPPI-2L Cattle Leptavoid Spirovac Leptoferm-5 Cattle & swine Farrowsure-Plus
- 50. REFERENCES 1. Textbook ofPreventive & Social Medicine by K.Park 2. Report of the Second Meeting of the Leptospirosis Burden Epidemiology Reference Group 2011 3. Leptospirosis situation in the WHO South-East Asia Region 4. Sethi S, Sharma N, Kakkar N, Taneja J, Chatterjee SS, et al. (2010) Increasing Trends of Leptospirosis in Northern India: A Clinico- Epidemiological Study. PLoS Negl Trop Dis 4(1): e579. doi:10.1371/journal.pntd.0000579 5. A Global Research Agenda for Leptospirosis ER Cachay, JM Vinetz J Postgrad Med. Author manuscript; available in PMC 2008 March 20.Published in final edited form as: J Postgrad Med. 2005; 51(3): 174–178.
- 51. REFERENCES(CONT.) 6. Human leptospirosis:Guidance for diagnosis, surveillance and control 2003 7. Leptospirosis – An Overview: TK Dutta, M Christopher; JAPI , VOL. 53, JUNE 2005, 545-51 8. The Prevention & Control of Leptospirosis by John TJ, J POSTGRAD MED September 2005 Vol 51 Issue 3 9. NCDC Newsletter Volume 4, Issue 1, January- March, 2015 10.NCDC Newsletter Volume-1, Issue-1, October 2012 11.NCDC Newsletter July–September 2014 Volume 3, Issue 3
- 52. EVERY LIFE ISPRECIOUS. LET’S SAVE IT.
- 53.
Editor's Notes
- #9 23 sero-groups and 200 serovars recognized from various parts of the world.
- #11 Agricultural workers such as rice fi eld planters, sugar cane and pineapple fi eld harvestors, livestock handlers, labourers engaged in canal cleaning operations are subjected to exposure with leptospires which have reservoir in rodents, cattle, swine, sheep, goats etc. Some occupational groups are – Fishermen, sewer workers and all those persons who are liable to work in rodent infested environment. Lorry drivers and masons - As lorry drivers may use contaminated water to wash their vehicles and masons may come in contact with the organisms while preparing the cement and sand mixture for construction work with contaminated water.
- #12 Drainage congestion and water logging Heavy concentrated rainfall leaves a lot of surplus water. Developmental activities like canal network, roads and railway lines obstruct natural drainage of rain water causing its accumulation for longer periods. The water logged areas force the rodent population to abandon their burrows and contaminate the stagnant water by their urine. The farmers and agricultural labourers working in the water logged contaminated fi elds catch the infection. 3.3 Soil salinization In fact, salinity and water logging are inter-linked problems. The salinity of the soil provides favorable environment for survival of leptospires for months together. 3.4 Soil temperature The soil of endemic areas in general has lower base saturation and the mean annual soil temperature at the depth of 50 cm is 220C or more and the difference between mean summer (June-August) and mean winter (December-February) temperature is less than 50C. This favors the survival of leptospires for long durations. Seasonal variation Leptospirosis is usually a seasonal disease that starts at the onset of the rainy season and declines as the rains recede. Sporadic cases may occur throughout the year. 7. High
- #15 Direct- lepto can enter body thru skin abrasns or intact mucous memb by direct cont with urine or tissue of inf animal Indirect- thru contact of broken skin with soil water or vegetation contam by urine of inf animals or thru ingestion of food contam by leptospirae Droplet infectn- thru inhalation while milking cows or goats by breathing air polluted with droplets of urine.
- #18 Fever - Patients have remittent fever with chills. It may be moderate to severe. • Myalgia-It is a very characteristic fi nding in leptospirosis. Calf, abdominal & lumbosacral muscles are very painful & severely tender. This symptom is very useful in differentiating leptospirosis from other diseases causing fever. There is associated increase in serum Creatinine Phosphokinase (C.P.K.) which helps in differentiating leptospirosis from other illnesses. • Conjunctival Suffusion- There is reddish colouration of conjunctiva. Very useful sign in leptospirosis. Usually bilateral, most marked on palpebral conjunctiva, it may be associated with unilateral or bilateral conjunctival haemorrhage. • Headache - Usually intense, sometimes throbbing, commonly in frontal region. It is often not relieved by analgesics. • Renal manifestations - Some form of renal involvement is invariable in leptospirosis. It usually occurs as asymptomatic urinary abnormality in the form of mild proteinuria with few casts & cells in the urine. Severe renal involvement in the form of acute renal failure, (which occurs in icteric leptospirosis) is rare. • Pulmonary manifestations - Manifested in most cases through cough & chest pain and in few cases by haemoptysis. Severe involvement leading to respiratory failure does not occur in anicteric leptospirosis. • Hemorrhage- Hemorrhagic tendencies are also present in some cases.
- #23 leptospirosis remains one of the top ten infectious hazards reported globally in the Event Management System (EMS).
- #26 More than half of these leptospirosis alerts (63%) occurred in the Americas Region, particularly in Brazil (142 alerts), Nicaragua (45) and Argentina
- #29 In the wake of hurricane Mitch in 1995, an outbreak of leptospirosis with pulmonary haemorrhages was reported in Nicaragua. In 1998, there was an outbreak in the continental United States. 1998 also saw an outbreak in Peru and Ecuador following heavy flooding. A post-cyclone outbreak was reported in Orissa, India in 1999. Major outbreaks in South-East Asia were reported in the past due to cyclone in Orissa (1999), flooding in Jakarta (2002), Mumbai (2005) and in Sri Lanka (2008)
- #33 ) Prevention and Control of Leptospirosis The outbreaks of leptospirosis, an emerging zoonotic disease, are increasingly been reported from many states/UTs such as A& N Islands, Kerala, Gujarat, Tamil Nadu and Karnataka. In addition, cases have also been reported from Goa, Andhra Pradesh and Assam.. The proposal is to expand and implement the strategy developed during 11th Plan in all the endemic states during the 12th Plan period. The strategy evolved and guidelines formulated will be shared and distributed to all endemic states. The suspected cases of leptospirosis will get timely and appropriate treatment and awareness in community will help in reducing mortality and morbidity due to leptospirosis. An amount of Rs. 3.69 crore is proposed in 12th Plan to carry out this activity
- #34 2.2 Activities in the 11th Plan A pilot project on Control of Leptospirosis was approved as a New Initiative in the 11th Five Year Plan in March, 2008 and was carried out in 5 endemic states. The project was carried out in 4 districts of Gujarat (Surat, Navsari, Valsad and Tapi), 2 districts of Kerala (Kottayam and Allepey), 2 districts of Tamil Nadu (Villupuram and Thiruchirapalli,) 4 districts of Maharashtra (Ratnagiri, Thane, Sindhudurg, Raigad ) and 2 districts of Karnataka (Mangalore & Shimoga). The objective of the pilot project was to reduce the morbidity and mortality due to Leptospirosis in pilot project areas. 2.3 Budget A total of Rs. 2.36 Crores allocated, of which Rs. 2.31 Crores spent. 2.4 Pilot Project Strategies • Reduction of morbidity • Strengthening laboratory diagnostic capacity • Strengthening of patient management facilities • Developing trained manpower • Creating awareness regarding timely detection and appropriate treatment of patients 2.5 Outcome of the Pilot Project Clinically suspected Leptospirosis patients in leptospira-endemic project areas during rainy season were given presumptive treatment of leptospirosis at PHCs. All suspected leptospirosis cases whether positive or negative with rapid immunodiagnostic test having features of organ dysfunction were immediately shifted to higher centre. With the implementation of the 194 components of pilot project strategy there has been reduction in morbidity and mortality due to leptospirosis in pilot project areas. The strategy for prevention and control of leptospirosis has been found to be feasible and implemenable and shall be provided to the States for further implementation. 2.6 Gaps in the 11th Plan The Pilot project was carried out only in five endemic states of the country. The remaining endemic states were not covered. The intersectoral coordination was inadequate during the implementation of Pilot project in the 11th five year plan. 195 2.7 Proposal for Leptospirosis control in the 12th Plan The proposal is to expand and implement the strategy for prevention and control of Leptospirosis developed during 11th Plan in all the endemic states during the 12th Plan period. The strategy evolved and guidelines formulated will be shared and distributed to all endemic states. 2.7.1 Does the strategy need change/paradigm shift? The strategy of the pilot project was critically reviewed in different meetings chaired by DGHS and in the meetings of Standing Committee on Zoonoses. The strategy was found to be effective and implementable and can be provided to the States for further implementation. Thus there is no change required or proposed in the strategy. 2.7.2 Ownership The roles and responsibilities of various components at centre, state and intersectoral level shall be clearly defined in consultation with the states. 2.7.3 Capacity building Training of professionals regarding prevention, diagnosis, management and control of Leptospirosis will be undertaken. This will help in early case detection and proper management of the patients. 2.7.4 Inter-sectoral co-ordination Sensitization of other sectors viz. veterinary and agriculture will be undertaken to establish intersectoral coordination for prevention and control of Leptospirosis. 2.7.5 Strengthening of patient management facilities Funds will be provided for strengthening the existing patient management facilities. 2.7.6 Information, Education and Communication IEC will enhance awareness in the general public regarding prevention and control of Leptospirosis. The awareness will result in early reporting of cases to treatment facilities. 2.7.7 Monitoring of the activities The activities would be periodically monitored and evaluated by undertaking visits to the endemic areas. On day to day basis monitoring will be done by the designated officers of the state governments. 196 2.7.8 Outcome The suspected cases of leptospirosis will get timely and appropriate treatment and awareness in community will help in reducing mortality and morbidity due to leptospirosis in endemic states. 2.7.9 Budget The estimated total cost is Rs. 3.69 Crores
- #37 is of particular value as a serological screening test because of its relative simplicity in comparison to the MAT (Microscopic Agglutination Test). Lepto dip-stick, Lepto lateral flow and Lepto Tek Dri Dot assays are based on IgM detection.
- #49 15.1 Protection of people against contagion by available means Hygienic methods such as avoidance of direct and indirect human contact with animal urine are recommended as preventive measures. Workers in fl ooded fi elds should be cautioned against direct contact with contaminated water or mud and should be advised to use rubber shoes and gloves. In case of any cuts or abrasion on the lower extremities of the body, the worker should apply an antiseptic ointment e.g. betadine, before entering the fi eld and after exit. 15.2 Health education The main preventive measure for leptospirosis is to create awareness about the disease and its prevention. This has to be carried out by an intensive educational campaign. 15.3 Vaccination of animals Leptospiral vaccines confer a limited duration of immunity. Boosters are needed every one to two years. Vaccination should however be very selective and used only in endemic situations having high incidence of leptospirosis. The vaccine must contain the dominant local serovars. While this prevents illness, it does not necessarily protects from infection and renal shedding. Details of vaccines available are listed below: 22 Guidelines for Prevention and Control of Leptospirosis Species Name of the vaccine Company Dog Novivac-DHPPI-2L Eurican-DHPPI-2L Vanguard-DHPPI-2L Duramax-DHPPI-2L Intervet, Norway Merial, France Pfi zer, Animal Health, USA Fortdodge Lab, USA Cattle Leptavoid Spirovac Leptoferm-5 Schering Plough Animal Health, UK USDA, USA USDA, USA Cattle & swine Farrowsure-Plus Pfi zer Animal Health, USA 15.4 Rodent control It is established beyond doubt that rodents are the major reservoirs of bacterium Leptospira interogans with more than 200 serovars. Possibly in a human infested area, where signifi cant number of Leptospira cases are reported, selective rodent control measures should be undertaken. 15.5 Mapping of water bodies for establishing a proper drainage system The mapping of water bodies and human activities in water logged areas should be carried out. This will help to identify the high risk population. Farmers may be educated to drain out the urine from the cattle shed into a pit, instead of letting it fl ow and mix with water bodies (rivers, ponds etc.) 15.6 Health impact assessment of developmental projects Health impact assessment should be made mandatory for all developmental projects along with environmental assessment 15.7 Leptospirosis should be made a reportable disease in all endemic states. 15.8 Chemoprophylaxis During the peak transmission season Doxycycline 200 mg, once a week, may be given to agricultural workers (eg. paddy fi eld workers, canal cleaning workers in endemic areas) from where clustering of cases has been reported. The chemoprophylaxis should not be extended for more than six weeks.