Erin Paul

LeptospirosisSource: La Voz del Sandinismo

Objectives

• Analyze an epidemic in Nicaragua for lessons about dealing with leptospirosis in emergencies and humanitarian crises.

• Describe the most common symptoms of the infection

• Describe diagnosis techniques and treatment• Name public health interventions to prevent

transmission

Recent Outbreaks in Nicaragua (1995, 2007, 2010)

• Three original patients with pulmonary hemorrhaging died.

• Doctors at the local Health Center thought it was dengue hemorrhagic fever.

• Other patients with high fever, muscle aches, headache, vomiting, and diarrhea

• During hurricane season after particularly heavy rains

Flooding before 2007 outbreak

Source: La Prensa

Leptospirosis

• Zoonotic disease passed from many kinds of wild and domestic animals

• Caused by a type of bacteria called a spirochete (leptospira interrogans)

Source: Dr. Scott Smith

History of the disease

• Severe form of leptospirosis studied by Adolf Weil

• Bacteria identified by Stimson

• Some evidence that incidence is increasing

Photo of Adolf Weil. Source: Wikipedia Creative Commons

Epidemiology

Source: cabi.org

Transmission

Symptoms

• Many cases are relatively mild

• Fever, muscle and bone pain, headache

• Conjunctival suffusion indicates leptospirosis

• Severe form also known as Weil’s disease

• Pulmonary problems are not common

• Renal and liver failure in severe cases

Differential Diagnosis

• Dengue• Malaria• Rickettsial disease (spotted fever)• Scrub typhus• Typhoid fever• Hantavirus• Influenza

Diagnosis

• Diagnosis via ELISA or MAT tests

• Dipstick test– Leptospira found in

blood for 7 – 10 days– Then leptospira

move to the kidneys and can be found in urine

Source: Clpmag.com

Treatment – Hospitalized patients

• Penicillin is the antibiotic of choice– 6 million units per day– Alternatives include doxycycline, ceftriaxone,

cefotaxime.• For children <8 years

– Azithromycin– Clarithromycin

• Supportive care for dehydration, hypotension, hemorrhage, etc.

Treatment -- Outpatients

• For outpatients (who can tolerate oral medications):• Doxycycline 100 mg twice daily orally, for 10 days

– Not for children under 8 or pregnant women– Amoxicillin 25 – 50 mg/kg divided in three doses

for children/pregnant women• For patients allergic to penicillin:

– Erythromycin 250 mg, 4 times a day for 5 days

Treatment

• Give doxycycline to people at a high risk for a short period of time

• Tetracycline is no longer recommended– Contraindicated with renal insufficiency– Renal insufficiency common in severe

leptospirosis• Treat with doxycycline if rickettsial diseases are also

endemic

Prevention

• Public health measures– Vector control (rodent control)– Improved sanitation

• Storm water drainage in urban areas

• Garbage management

– Disinfection of potable water supplies

• Education for high risk occupations– Sewer workers, butchers, etc.

• Avoid contact with flood waters and don’t swim in areas that may be contaminated

Relevant Sphere Standards to Control Leptospirosis

• Water quality• Excreta disposal• Solid waste

management• Drainage

Sanitation and Hygiene Education

Challenges

• No highly effective, widely available vaccine for humans

• Leptospirosis is frequently confused with other illnesses

• Rapid diagnostic tests have low sensitivity• Prevention is difficult

Conclusions – Leptospirosis in Complex Humanitarian Crises

• Most common symptoms are fever, headache, jaundice

• Frequently follows heavy rains• Treat with penicillin or doxycycline• Control rodents and treat drinking water for

prevention

References

• Clark, L. G. et.al., “Leptospirosis in Nicaragua: A Preliminary Report After the First Year of Study.” American Journal of Tropical Medicine and Hygiene 15 (1966): 735 -742.

• Effler, Paul V. et.al. “Evaluation of Eight Rapid Screening Tests for Acute Leptospirosis in Hawaii.” Journal of Clinical Microbiology 40 (2002): 1464 – 1469.

• Epino, Henry. Personal Communication. 03/08/2012.• Everett, E. Dale. “Microbiology, Epidemiology, Clinical Manifestations, and

Diagnosis of Leptospirosis.” Up-to-Date. Online database. Mar 23, 2010.• Everett, E. Dale. “Treatment and Prevention of Leptospirosis.” Up-to-date.

Online database. Accessed 03/04/2012.• Faine, S. et. al. Leptospira and Leptospirosis. Melbourne: MediSci, 1999.• Farr, R. Wesley. “Leptospirosis.” Clinical Infectious Diseases 21 (1995): 1-6• “Leptospirosis Burden Epidemiological Reference Group”. World Health

Organization. Website. Accessed 03/01/2012.

References, cont.

• Levett, Paul. N. “Usefulness of Serologic Analysis as a Predictor of the Infecting Serovar in Patients with Severe Leptospirosis.” Clinical Infectious Diseases 32 (2003): 447-452.

• Melghem, Lorena. Escuela y Casa Saludable: Una Experiencia Exitosa en Honduras. World Bank Water and Sanitation Program, 2003.

• “Outbreak of Acute Febrile Ilness and Pulmonary Hemorrhage – Nicaragua, 1995.” Journal of the American Medical Association 974 (1995): 1668.

• Ren, Shuang Xi, et.al. “Unique Physiological and Pathogenic Features of Leptospira Interrogans Revealed by Whole Genome Sequencing.” Nature 422 (2003): 888-893.

• The Sphere Project: Humanitarian Charter and Minimum Standards in Humanitarian Response. The Sphere Project. 2011.

• Zaki, S.R. and Shieh, W.J. “Leptospirosis Associated with Outbreak of Acute Febrile Illness and Pulmonary Hemorrhage – Nicaragua, 1995.” The Lancet 347 (1996): 535 – 536.