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Leptospirosis and Ciguatera Destination Oceania Workshop 9/28/2016 Leptospirosis . One of the most common bacterial zoonoses worldwide Leptospirosis and Ciguatera . >1 million cases and 60,000 deaths per year . Identified as a Neglected Zoonotic Disease by WHO Destination Oceania Workshop . Genus Leptospira: >20 species, >250 serovars ICTMM, Brisbane, September 2016 . Can infect any mammal species, cause chronic renal infection and urinary excretion of leptospires . Leptospires can survive in environment for weeks or months Colleen Lau depending on environmental conditions MBBS (UWA), MPH&TM (JCU), PhD (UQ), FRACGP, FACTM NHMRC Fellow, Research School of Population Health, ANU Travel Medicine Doctor, Travel Medicine Alliance Australia Costa F et al. Global Morbidity and Mortality of Leptospirosis: A Systematic Review. PLoS Neglected Tropical Diseases 2016. Leptospirosis Leptospirosis >250 serovars >250 serovars . Zoonotic disease Bacteria in Animals . Zoonotic disease Bacteria in Animals Environment Environment . Pathogen: Infection . Pathogen: Infection Leptospira Enzootic cycle Leptospira Enzootic cycle . Emerging infectious Urine . Emerging infectious Urine disease with strong disease with strong environmental environmental Soil & Direct Water Contact drivers of drivers of Humans transmission transmission Occupational exposure Occupational exposure Outdoor recreation Rodents, pets & wildlife Poor sanitation Flooding Risk Factors Risk Factors – Australia Variables Drivers of transmission & emergence Variables Drivers of transmission & emergence Individual behaviour Occupation – farming, abattoirs, veterinary, military, sewage, outdoor work Individual behaviour Occupation – farming, abattoirs, veterinary, military, sewage, outdoor work Recreation – swimming, rafting, caving, ecotourism, travel Recreation – swimming, rafting, caving, ecotourism, travel Culture & lifestyle Culture & lifestyle Natural environment Tropics, subtropics Natural environment Tropics, subtropics Rainfall, flooding, cyclones, extreme weather events Rainfall, flooding, cyclones, extreme weather events Hydrology Hydrology Environmental degradation Environmental degradation Islands Islands Anthropogenic environment Land use, e.g. farming Anthropogenic environment Land use, e.g. farming Urbanisation, urban slums Urbanisation, urban slums Poor sanitation and hygiene Poor sanitation and hygiene Poverty Poverty Animals Species Animals Species Biodiversity Biodiversity Farming practices – subsistence livestock Farming practices – subsistence livestock International transport – livestock, rodents International transport – livestock, rodents 1 9/28/2016 Risk Factors – Pacific Islands Morbidity & Mortality by Region Variables Drivers of transmission & emergence Region/Country Morbidity Cases Mortality Deaths Individual behaviour Occupation – farming, abattoirs, veterinary, military, sewage, outdoor work Recreation – swimming, rafting, caving, ecotourism, travel Global 14.8 1,030,000 0.8 58,900 Culture & lifestyle North America 3.6 12,800 0.2 600 Natural environment Tropics, subtropics Rainfall, flooding, cyclones, extreme weather events Western Europe 3.9 16,300 0.2 800 Hydrology Environmental degradation High-income Asia Pacific 7.0 14,800 0.3 700 Islands East Asia 10.3 142,000 0.5 6,900 Anthropogenic environment Land use, e.g. farming Urbanisation, urban slums South Asia 18.0 289,000 1.0 16,500 Poor sanitation and hygiene Poverty South-East Asia 55.5 266,000 3.0 14,200 Animals Species Oceania 150.7 16,700 9.6 1,100 Biodiversity Farming practices – subsistence livestock Morbidity and mortality cases/100,000/year International transport – livestock, rodents Costa F et al. Global Morbidity and Mortality of Leptospirosis: A Systematic Review. PLoS Neglected Tropical Diseases 2016. Morbidity & Mortality by Country Global Environmental Change & Leptospirosis Morbidity Mortality Morbidity & Mortality: . Climate change and extreme weather events – flooding Temperate regions 0.7 0.1 Cases/100,000/year . Floodwaters disseminate bacteria in the environment Tropical regions 12.9 0.7 . People displaced from homes Asia Morbidity Mortality . Animals displaced from habitats Oceania Morbidity Mortality Sri Lanka 300.6 18.0 . Sanitation and infrastructure disrupted Solomon Islands 262.9 12.1 Vietnam 49.7 2.1 Samoa 136.7 7.7 High intensity contact between humans, animals, and pathogens in a Thailand 39.4 2.1 Vanuatu 121.2 6.4 highly contaminated environment Indonesia 39.2 2.2 French Polynesia 97.5 4.6 . Population growth – urbanisation, urban slums, poverty Malaysia 37.0 1.7 New Caledonia 68.5 3.0 . Poor sanitation, high flooding risk, overcrowding, rodents+++ Cambodia 33.7 1.8 Fiji 54.4 3.1 . Agricultural intensification India 19.7 1.1 Hawaii 37.4 2.1 . Both commercial and subsistence livestock Nepal 16.7 0.9 Australia 10.5 0.4 Philippines 15.0 0.7 . Environmental degradation and biodiversity loss New Zealand 3.5 0.2 China 10.5 0.5 . Invasive species (e.g. rodents) more easily established Costa F et al. Global Morbidity and Mortality of Leptospirosis: A Systematic Review. PLoS Neglected Tropical Diseases 2016. Queensland 2011 Wynwood et al. Tropical Biomedicine 2014. 2 9/28/2016 Examples of Outbreaks related to Flooding Outbreaks Related to Recreational Activities Place Event Outbreak Place Outbreak Event 11% of 474 athletes Illinois 1998 Triathlon, 876 participants Fiji 525 cases seropositive Cyclones and flooding 2012 52 deaths 10-day eco-challenge event involving jungle trekking, caving, New Caledonia 15 severe cases 42% attack rate among 189 Cyclone and flooding Borneo 2000 outrigger sailing, kayaking, climbing, scuba, mountain biking. January 2011 2 deaths 304 athletes from 26 countries and 29 states of USA interviewed athletes New Caledonia 135 cases La Nina, heavy rainfall and Guam 2002 “Extreme adventure” outdoor event 21 of 105 participants 2009 5 deaths flooding 8 met case definition Guam “Extreme adventure” outdoor Martinique 2011 Canyoning, 45 participants 21 of 105 participants 7 confirmed by PCR 2002 event 6 developed fever Sri Lanka 2012 Whitewater rafting, 20 office workers Philippines > 2000 cases 17/19 seropositive Severe flooding 2009 167 deaths Attack rate: 8.1% Queensland, Australia > 100 cases Adult swimmers: 23.1% Severe flooding Reunion 2013 Triathlon, 160 participants 2011 No deaths Lower risk in those who wore neoprene suits Leptospirosis in Travellers Emerging Disease in Travel and Recreation . Australia: 35% from recreation/travel, 19% overseas . Hawaii: 0% in 1970s, to 50% in 1990s from recreation . California: 85% from recreation . UK: >50% from travel . Israel: 42% from travel Lau et al. Leptospirosis – An Emerging Disease in Travellers. Trav Med & Inf Dis 2011 Katz et al. Leptospirosis in Hawaii. Am J Trop Med & Hyg 2002 Meites et al. Re-emerging leptospirosis, California. Emerg Inf Dis 2004 Kariv et al. The changing epidemiology of leptospirosis in Israel. Emerg Inf Dis 2001 Case Reports in Travellers Clinical Presentation – Early Phase . Incubation 5 to 14 days (range 1 to 30 days) . Acute onset of fever and chills . Headache . Myalgia, especially calf tenderness . Jaundice . Conjunctival suffusion . Rash – macular, papular, urticariform . Nausea, vomiting, abdominal pain . Dizziness, lethargy, malaise . Eye pain, photophobia . Many have asymptomatic or mild infections Ref 3 9/28/2016 Complications in the Late Phase Laboratory Diagnosis . Acute lung injury, including pulmonary haemorrhage, ARDS . Acute renal failure Biphasic illness . Acute liver failure . Myocarditis, pericarditis, cardiac arrhythmias . Coagulopathy and haemorrhage . Neurological complications (aseptic meningitis, encephalitis, convulsions, Guillain-Barré Syndrome, transverse myelitis) . Uveitis . Case fatality rate of up to 30% . Patients with suspected leptospirosis and any symptoms or signs suggestive of . First 7 to 10 days – Blood cultures or PCR the above complications should be treated immediately and urgently referred if . After first week – Serology required . Might need to repeat serology for rising titres Tulsiani, SM, Lau, CL, Graham, GC, Van Den Hurk, AF, Jansen, CC, Smythe, LD, McKay, DB & Craig, SB. Emerging tropical diseases in Australia. Part 1. Leptospirosis. Ann Trop Med Parasitol 2010, 104: 543-56. Treatment Misdiagnosis and Under-diagnosis . Early phase Common because of . Antibiotics shorten duration of illness, reduce mortality & complications .Non-specific clinical presentation, overlapping clinical features with other . Oral Amoxycillin or Doxycycline infections (Alternatives: Erythromycin, Azithromycin, Clarithromycin) .Low index of suspicion by clinicians . IV Crystalline Penicillin G (Alternatives: Ampicillin, Ceftriaxone or other 3G cephalosporins, Erythromycin) .Concurrent outbreaks of leptospirosis and other infections . Late phase complications .Poor availability of diagnostic tests . Supportive treatment, e.g. ventilation, haemodialysis, management of .Variable sensitivity and specificity of RDTs and ELISA arrhythmias, coagulopathies, shock .‘Wrong’ serovars in MAT panel . Steroids controversial – no robust evidence to support the routine use of high dose steriods. One study showed higher risk of nosocomial infections Preventive Strategies for Travellers Preventive Strategies – Travellers Prophylactic antibiotics: . Avoid swimming in polluted rivers and streams . Little evidence on effectiveness, and routine use is not recommended . Avoid swimming and contact with flood waters . Avoid walking barefoot . Pre-exposure prophylaxis for short-term intense exposures, e.g. recreational, . Cover up
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