2. Introduction:
Zoonotic disease.
Leptospirosis occurs worldwide but is most common in
tropical and subtropical areas with high rainfall.
Found where man comes in contact with the urine of
infected animals.
2
3. ALSO KNOWN AS
Cane cutter’s fever,
Cane field fever,
Harvest fever,
Haemorrhagic jaundice,
Mud fever,
Rat catcher’s disease,
Rice field worker’s fever,
Swamp fever,
Swine herd’s disease,
Weil’s disease
3
4. History:
1886- Adolf Weil First Described The Disease,
1907- Stimson ( Named Organism As Spirochaeta
Interrogans)
1915 – (1) Inada And Ido (Japan)
- Spirochaete Icterohemorrhagiae
(2) Uhlenhuth & Fromme (Germany)
- Spirochaete Icterogenes
1918- Noguchi (Named Leptospira)
4
5. Problem Statement:
Global Burden :
It Is Highly Prevalent In The Tropics With 73% Of Cases
Occurring In This Zone, Particularly In South–east Asia, East
Sub-Saharan Africa, The Caribbean, And The Oceania Region.
The Who Has Estimated That There Are 873,000 Cases
Annually With Over 40,000 Deaths From It.
Temperate Climate [ 0.1-1 Per 100,000 Per Year]
Humid Tropics [10-100 Per 100,000 Per Year]
Outbreaks & High-exposure Risk Groups Incidence May
Reach Over 100 Per 100,000
5
6. South East Asia Region:
Seasonal outbreaks- Gujarat & Northern Thailand
Major outbreaks- Orissa [1999], Jakarta [2002],
Mumbai [ 2005], Srilanka [2008]
India:
In India, it has been documented from all over the coastal
areas including other states like Goa, Delhi, Andhra Pradesh,
UP, Assam, Punjab, Haryana, Himachal Pradesh, etc.
Part wise most of the cases are reported from the southern
part of India (25.6%), followed by 8.3%, 3.5%, 3.1%, and 3.3%
from the northern, western, eastern, and central parts of India,
respectively.
6
7. Most outbreaks occur in - Andaman, Gujarat,
Maharashtra, Kerala, TN, Karnataka, Orissa, West
Bengal
30 outbreaks: reported since 2013 [TN(majority)]
Recent outbreak: Kerala (2018)
7
9. Assam
In 2015, few outbreaks were reported in Tinsukia and
Dibrugarh districts.
In 2018 highest number of cases(22) reported from
Dibrugarh district
In 2019 highest cases(21) from Dima-Hasao.
In 2020, All Assam 35 cases were reported with the
highest cases from Dibrugarh (11) followed by Kamrup
Rural (7)
In 2021, till 1st of July 23 cases were reported with the
highest cases from Kamrup District (5)
9
10. Why is there a lack of recognition of Leptospirosis?
Leptospirosis may present a wide variety of clinical
manifestations. These may range from a mild “flu”-like illness
to a serious and sometimes fatal disease.
It may also mimic many other diseases, e.g. dengue fever
and other viral hemorrhagic diseases.
Icterus (jaundice) is a relatively common symptom in
Leptospirosis but is also found in many other diseases
involving the liver such as the various forms of hepatitis.
The diagnosis is confirmed by laboratory tests, but these are
not always available, especially in developing countries.
For these reasons, Leptospirosis is overlooked and
underreported in many areas of the world.
10
12. AGENT:
SPIROCHETALES (ORDER)
LEPTOSPIRACEAE (FAMILY) SPIROCHETACEAE (FAMILY)
LEPTOSPIRA( GENUS)
1. L. INTERROGANS (PATHOGENIC)
• Having the potential to cause diseases
• Are maintained in nature in the renal tubules of certain animals
2. L. BIFLEXA (SAPROPHYTIC)
• Found in wet and humid environments ranging from surface water
and moist soil to tap water
• Do not cause disease
12
15. CONCEPT OF SEROVAR
The basic systematic unit “Serovar” is defined on the
basis of antigenic similarities.
Each serovar has a characteristic antigenic makeup.
Serovars having antigenic similarities are formed into
serogroups, and over 200 pathogenic serovars divided
into 25 serogroups have been described.
15
16. Table: Distribution of Leptospira serovars in India
16
Prevalence State Animal species Serovars
HIGH T.N.
Kerala
Andaman
Cattle, goat , pig,
Buffalo , sheep
Pyrogenes, pomona,
hardjo,
Australis, atumnalis,
icterohemmorhagiae
MODERATE Maharashtra,
U.P. , Gujarat
Karnataka, M.P.
Cattle, goat , pig,
Buffalo , sheep,
Dog, horse
Pyrogenes, pomona,
hardjo,
Canicola, javanica,
icterohemmorhagiae
RARELY
REPORTED
Punjab, J&K, H.P. ,
Rajasthan ,
North eastern Hills
Cattle, sheep Pyrogenes,
Canicola,
icterohemmorhagiae
17. Epidemiological importance of Serovars:
A certain serovar may develop a commensal or comparatively mild
pathogenic relationship with a certain animal host species. For instance,
cattle are often associated with serovar Hardjo,
dogs with Canicola and
rats with Icterohaemorrhagiae and Copenhageni.
Commonly known serovars are
L. interrogans serovars Pomona (swine),
L. interrogans Bratislava (swine),
L. interrogans Canicola (dogs),
L. interrogans Bovis (cattle),
L. interrogans Autumnalis (raccoons),
Icterohemorrhagiae and Copenhageni (rats)
17
18. How can leptospirosis be recognized in
animals?
Cattles Milk drop syndrome, icterus,
haemoglobinuria, abortions
Pigs(Chroni
c cases)
Abortion, Stillbirth, infertility
Dogs Asymptomatic( renal carrier state), severe
icterohaemorrhagic disease, acute
interstitial nephritis
*Majority of cases in herd animals either asymptomatic
or present as
bizarre clinical entities
17
19. (C) ENVIRONMENTAL FACTORS:
Pathogenic Leptospires are maintained in nature in the
renal tubules of certain animals.
Saprophytic Leptospires are found in many types of wet or
humid environments ranging from surface waters and moist
soil to tap water.
Saprophytic Halophilic (Salt-loving) Leptospires are found
in seawater.
The soil of endemic areas in general has lower base
saturation and the mean annual soil temperature at the
depth of 50 cm is 22˚C or more and the difference between
mean summer (June-August) and mean winter (December-
February) temperature is less than 5˚C. This favors the
survival of Leptospira for long durations.
19
20. (B) Host Factors:
Man- Accidental Host
Prevalence- Males> Females
- Most Common Age Group: 20- 45 Yrs.
High-risk Groups:
1) Agricultural Workers
2) Some Occupational Groups
3) Fisherman And Sewer Workers.
4) Lorry Drivers And Masons
5) Leisure And Recreational Activities Pertaining To
Water
20
21. Survive For Weeks In Infected Urine-contaminated Soil &
Water (Ph- 6.8-8)
- Temp.
- Acidity
- Salinity
Die Rapidly :
- Acid Urine
- Non-aerated Sewage
- Salty And Brackish Water
Warm & Humid Conditions – Ideal For Survival.
21
22. Modes of Transmission:
Direct or Indirect exposure to the urine of infected animals
Handling infected animal tissues
Ingestion of contaminated food and water
Entry of infection
Through cuts and abrasions in the skin
Intact mucous membranes (nose, mouth, eyes)
Occasionally inhalation of droplets of urine
Via drinking water
Human to Human transmission is very rare as man is an incidental host
Human transmission can occur by sexual intercourse, trans-placentally,
and by breast milk.
Leptospira requires a chemotaxis mechanism for adhesion and trans-
membrane passage.
22
24. PATHOPHYSIOLOGY 24
Infection
Leptospirosis appeared in
blood
Invade all
tissue/organ
Avirulent strain
Cleared from body
by host immune
respond
kidney
Shed in urine for weeks to
months
Produce
endotoxin
Vasculitis and
leakage
Hypovolemic shock/vascular
collapse
25. Leptospiral lipopolysaccharide helps in the preparation of
endotoxins & produces hemolysin that causes lysis of
RBCs& also causes Damaged to the endothelium of small
blood vessels leading to localized ischemia in organs,
resulting in renal tubular necrosis, hepatocellular and
pulmonary damage, meningitis, myositis, and placentitis.
Subsequently cleared from the body by the host's immune
response to the infection.
However, they may settle in the convoluted tubules of the
kidneys and be shed in the urine for a period of a few weeks
to several months and occasionally even longer.
They are then cleared from the kidneys and other organs but
may persist in the eyes for much longer.
25
26. INCUBATION PERIOD: Average 10 days (4 -20 days)
Clinically types of Leptospirosis are-
26
Anicteric
• Milder form(>90% cases)
• Fever with chills
• Myalgia
• Headache
• Cough and chest pain
• May disappear within 2-3
days/progress to severe disease
• Leptospirosis-associated
pulmonary hemorrhage syndrome
(LPHS) has a mortality rate of up
to 74% and is considered a major
cause of death in leptospirosis
patients.
Icteric
• Severe form (5-10% cases)
• Jaundice
• Fever
• Myalgia
• Calf muscle tenderness
• End organ failure
• Combined renal and liver failure
with Leptospirosis referred to as
Weil’s disease
29. FIG: TYPICAL COURSE OF LEPTOSPIROSIS 29
2-10days
Incubation
period
4-7days
Septicemic
phase
0-30+days
Immune
phase
1-3days
Interphase
Bacteria
enter body
through cuts/
mucosal
surfaces
Bacterial
flagella aids
tissue
penetration
Abrupt onset
of fever,
headache,
muscle pain,
nausea
Leptospirosis
isolated ( CSF,
blood, tissues)
Mostly
anicteric,
5-10% have
jaundice
Fever &
other
symptoms
resolve
temporily
prior to onset
of immune
phase
Recurring fever &
involves CNS
Antileptospiral Abs
lead to clearance of
organisms ( except
kidney tubules)
Leptospires may
be shed in urine for
long periods
31. SURVEILANCE
Rationale for surveillance- Surveillance provides the basis for
intervention strategies in human or veterinary public health.
Recommended types of surveillance
Immediate case-based reporting of suspected or confirmed cases from
the peripheral level (hospital/general practitioner/laboratory) to the
intermediate level. All cases must be investigated since investigation
can identify environmental point sources of transmission and lead to
control measures.
Routine reporting of aggregated data of confirmed cases from
intermediate to central level. Hospital-based surveillance may give
information on severe cases of Leptospirosis. Sero-surveillance may
give information on whether Leptospiral infections occur or not in
certain areas or populations.
31
32. International:
The International Leptospirosis Society* collects
worldwide data on Leptospirosis.
Recommended minimum data elements
Case-based record
Age, sex, geographical information, occupation
Clinical symptoms (mortality; severe clinical manifestations
of jaundice, acute renal failure, or hemorrhage)
Hospitalization (Y/N)
Date of onset
Exposure (animal contact, flooding)
Microbiological and serological data
Date of diagnosis.
32
33. Aggregated data reporting
Number of the suspect and confirmed cases
Number of hospitalizations
Number of deaths
Number of cases by type (causative Serovar/Serogroup) of Leptospirosis.
Recommended data analyses, presentations, and reports
Number of cases by age, sex, occupation, area, date of onset, causative
Serovars/Serogroups, (presumptive) infection source, and transmission
conditions (graphs, tables, maps).
Frequency distribution of signs and symptoms by case and causative
Serovar (tables).
Reports of outbreaks, preventive measures, and surveillance of the human
population and populations of feral and domestic animals.
33
34. Performance indicators for surveillance
Completeness and timeliness of reporting.
Proportion of suspect and confirmed cases.
Number of detected and investigated outbreaks.
Number of reported cases compared with Sero-
surveillance data.
34
35. Recommended case Definition
Suspected case :
Acute febrile illness with headache + Myalgia + Prostation+
h/o exposure to infected animal or environment contaminated
with animal urine [with any of the following]
1. Conjunctival Suffusion
2. Meningeal Irritation
3. Anuria/ Oliguria ± Proteinuria
4. Jaundice
5. Hemorrhagic manifestations [Lung/Intestine]
6. Calf muscle tenderness
7. Nausea/ Vomiting/ Abdominal pain/ Diarrhoea
35
36. Probable: Suspected case + positive presumptive laboratory diagnosis.
Confirmed: Suspect/Probable case + confirmatory laboratory test.
CRITERIA FOR DIAGNOSIS:
Presumptive: -Positive result in IgM based Immuno-assays
- MAT of 100/200/400 or above
- Demonstration of leptospires
Confirmatory:- Isolation
- ≥ 4 fold rise in MAT
- Rapid test (+)
- Sero-conversion
- PCR
36
37. 37
Different approaches for laboratory diagnosis
culture microscopic
Isolation
Dark field
microscopy,
Immunofluroscence
microscopy,
Silver Impregnation
Techniques
immunologic
PCR
Microscopic
Agglutination Test
[MAT],
Immunochromatogra
phy,
ELISA,
Latex based
agglutination test
molecular
38. Suspected
Leptospirosis
Refer to
PHC
Refer to CHC/
District hospital
Ask/ Look for
Severe Myalgia
Oliguria/Anuria
Jaundice
Blood in cough
Breathlessness
Confusion
Cold extremities
Look for
other causes
of fever
Community Surveillance by Paramedics/ Volunteers/Field
workers
38
Note: Field Worker shall daily report (A) Number of persons surveyed (B) Number of
fever cases (C) Fever cases referred and (D) Any death following fever
No Yes
Absent Present
39. Guidelines for fever case management at PHC level for Medical Officers
39
Suspected case
Rapid diagnostic
test
Prepare slide for
malarial parasite
Doxycycline
(-)Complete
course of
Doxycycline
(+)Probable Case
Organ involvement
(+)Report to CMO
for LL no.
Refer to higher
centre
Ask/ Look for
Severe Myalgia
Oliguria/Anuria,
jaundice
Blood in cough/
vomit/ stool
Breathlessness
Confusion, irregular
pulse
Cold extremities
(-)Complete
course of
Doxycycline
41. Suspected/Probable Case 41
Perform rapid diagnostic test
Perform biochemical test
Ask/ Look for
Severe Myalgia
Oliguria/Anuria
Jaundice
Blood in cough
Breathlessness
Confusion
Cold extremities
Rapid diagnostic test (+/-)
No organ involvement present
Ensure complete course of Doxycycline
Worsen general condition
Bleeding tendency
Confusion
Breathlessness
Any one of above
Rapid diagnostic test
(+/-)
Organ involvement
present
Complete course Inj. Crystalline penicillin
after negative test dose [7days]
Treat patient [organ involvement]
Report to district CMO for line
listing (LL) number
Refer to higher
centre
Doxycycline
42. TREATMENT :
CHEMOTHERAPY:
Inj. Crystalline penicillin/ Ceftriaxone/
Cefotaxime/Erythromycin
Adults--- T. Doxycycline 100 mg twice a day × 7 days
Children---- < 8 yrs. Cap. Amoxy/ Ampicillin (30-50 mg/ kg/
day 6 hourly) × 7 days
Pregnant & lactating mothers---- Cap Ampicillin 500 mg
6 hourly
ORGAN-SPECIFIC CARE:
Mechanical ventilation with PEEP/ Hypovolemia correction/
diet & nutrition/ dialysis
42
43. PREVENTION AND CONTROL
"To prevent and control leptospirosis effectively, it is essential to coordinate
multisectoral collaboration involving a multidisciplinary team or known as
the One Health approach"
Prevention of leptospirosis is based on the control of reservoir hosts using
environmental and personal hygiene. Control measures against
leptospirosis should comprise of–
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 flooded fields 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 abrasions on the lower extremities of the body,
the worker should apply an antiseptic ointment e.g. betadine, before
entering the field and after exit.
43
44. 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.
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 a high incidence of leptospirosis.
The vaccine must contain the dominant local serovars.
While this prevents illness, it does not necessarily protect from
infection and renal shedding
44
45. Rodent control- In a human-infested area, where a
significant number of Leptospira cases are reported,
selective rodent control measures should be undertaken.
Mapping of water bodies for establishing a proper
drainage system:
The mapping of water bodies and human activities in
waterlogged 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 flow and mix with
water bodies (rivers, ponds, etc.)
45
46. Leptospirosis should be made a reportable disease in
all endemic states.
Chemoprophylaxis
During the peak transmission season Doxycycline 200
mg, once a week, may be given
to agricultural workers (e.g. paddy field 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.
46
47. Control can done in the form of Interventions:
At source of infection ( reservoir host/ carrier/
shedder)
At the transmission route
At the level of human host
47
48. At the source of infection
Infected animal can be isolated/treated with antibiotics
Rodents can be poisoned/trapped/denied access to human
living environment by erecting fences, screens, rodent proof
buildings etc
Keep the surrounding clean, cutting down shrubs and tall
grass, installing adequate sanitation, proper waste disposal
Vaccination for the immunization of pets and farm animals
Excreta from domestic animals should be disposed properly
to avoid contamination
48
49. FUMIGATION OF RAT BURROWS
49
With calcium cyanide( cyanogas/cymag), and sulfur dioxide
50. AT THE TRANSMISSION ROUTE
High-risk group should wear protective clothing (boots,
gloves, aprons, mask)
In case of any cuts and abrasions in the body, workers
should apply antiseptic ointment with a waterproof dressing
Washing after exposure to urine splashes/contaminated soil
or water
Disinfecting contaminated areas ( scrubbing floors in
stables, butcheries)
Providing clean drinking water
50
51. At the level of Human Host
Raising awareness: among both the general population and
risk groups
Antibiotic prophylaxis: During the peak transmission season
Doxycycline 200 mg once a week, may be given to
agricultural workers from where clustering of cases has been
reported.
Vaccination: SPIROLEPT( Whole cell vaccine) by Sanofi
and Pasteur
1ml sc. In 2 doses 14 days intervals Biannual
revaccination
Education to health care workers and upgradation of
knowledge
51
52. NEW INITIATIVES FOR THE PREVENTION OF
LEPTOSPIROSIS
Govt of India, launched a pilot project as New Initiative
under the 11th five-year plan
Programme for Prevention and Control of
Leptospirosis (PPCL) launched under the 12th five-year
plan
Launched in endemic states: Gujarat, Kerala, Tamil
Nadu, Maharashtra, Karnataka, and UT of Andaman
&Nicobar Islands
Nodal agency: National Centre For Disease Control
(NCDC)
52
53. Objective: To reduce the morbidity and mortality due to
Leptospirosis
Strategies of the programme:
• Trained manpower
• Strengthening surveillance
• Strengthen diagnostic laboratory in programme states
• Create awareness: timely detection and appropriate
treatment of patients
• Advocacy for strengthening the patient management
system
• Strengthening Inter-Sectoral coordination
53
54. Strengthening of laboratories under
programme PPCL
Government Medical College Surat
PGI Chandigarh
RMRC Dibrugarh
NIVEDI, Bangalore
ELISA laboratory test to be done at public health laboratories
under IDSP
These laboratories should provide confirmatory diagnostic
services for leptospirosis, and perform Microscopic
Agglutination Tests (MAT).
NIVEDI= national institute of veterinary epidemiology and
disease informatics
54
55. Recommendations:
Better control strategies and immediate response system involving
multisectoral approaches including health and non-health
sectors
(e.g. land development, rural/urban settlement, animal
husbandry, municipalities)
Capacity building and specific training of health care personnel,
especially the link workers, to establish a robust reporting and
surveillance system.
Establishing rodent control Programmes.
Practice of preventive actions by the public: e.g.; Practicing good
personal hygiene
55
