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Leptospirosis in the Malaysian Army

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Leptospirosis in the Malaysian Army Melaysian J Parhol 1979; 2 : 1 1-14 LEPTOSPI ROSlS IN THE MALAYSIAN ARMY V SUPRAMANIAM MBBS, MSPH* Summary The status of leptospirosis among Malaysian army personnel is reviewed. Two cases have been reported from 1969 to 1978 and two deaths have been certified as due to leptospirosis. Serological studies revealed a 12% to 22% prevalence of antibodies indicating past infection. A study of febrile cases showed that only 4.6% of fever in Malaysian soldiers were due to leptospirosis compared to 12.2% in American servicemen sewing in Vietnam and 30% in British soldiers in Malaysia. The reasons are briefly mentioned. Control measures in the Malaysian army are outlined. INTRODUCTION into Kinrara Military Hospital Wing and Teren- Leptospirosis as an occupational hazard of dak Military Hospital also show no cases of soldiers operating in wet environments has been leptospirosis. However, annual health reports recognised since World War I when outbreaks indicate two cases in 1976 and no cases occurred among soldiers involved in trench between 1969 and 1975. Both the 1976 cases warfare. During World War II, the Vietnam were officers, one in Sarawak and the other in Wars and the First Malayan Emergency, leptos- Peninsular Malaysia. The death register showed pirosis was frequently seen among soldiers of all the death of a soldier in 1974 and another in ethnic groups(1). The Malaysian soldiers are no 1977 in Sarawak as possibly due to lepto- exception to their European counterparts in spi rosis. their susceptibility to leptospiral infections, but have a lower incidence. DISCUSSION Leptospirosis appears to occur infrequently in MATERIALS AND METHODS Malaysian soldiers. Cases consisted of two Leptospirosis is a notifiable disease in the detected at the Mentakab District Hospital and country and all cases diagnosed among soldiers the four mentioned above. This does not fit the are reported to appropriate authorities includ- pattern of leptospirosis observed in British ing the Medical Directorate at the Ministry of soldiers, who while operating in Peninsular Defence by medical officers on the ground. Malaysia during the First Malayan Emergency Military hospitals at Kinrara and Terendak in the 50's had a yearly incidence of more than submit monthly returns of all admissions and 100 cases. In 1954, the attack rate was 63 per discharges. A register of deaths of all serving 1000 soldiers at risk(1). In Borneo, during the military personnel is also maintained at the Indonesian confrontation (1962-661, "leptos- Medical Directorate. From all these returns pirosis ranked second to malaria in overall received from units and other pertinent infor- importance"(2). In one instance, the casualty mation, an annual health repdrt is prepared. It rate due to leptospirosis in a patrol of 21 was is an analysis of the health status of all service 43%(3). Arched41 wrote that leptospirosis in personnel and their families. Annual health Malaya was "a major medical problem and is reports are available from 1969. These were the almost a military one, confined to the soldier four sources of data made use of in searching operating in the jungle". It is, therefore, surpris- for cases of leptospirosis in soldiers. ing that Malaysian soldiers should be free from leptospirosis when compared to their British RESULTS counterparts who operated in the same environ- No cases of leptospirosis were reported between ment of tropical forests with hundreds of criss- 1977 and March 1979. Admissions for 1978 crossing streams and rivers, jungle swamps, *Staff Officer Grade II (Health), Medical Directorate, Ministry of Defence, Kuala Lumpur (Address for reprint requests). Malaysian J Path01 August 1979 stagnant pools, and abundant rainfall in Sabah, be extrapolated to the entire army population Sarawak and Peninsular Malaysia. These surface as the study sample is not representative of waters have been shown to be contaminated army population, the information broadly with leptospires and are capable of causing in- indicates the immunity status of soldiers against fection (5,6). Rodents and other mammalian leptospirosis. This is greater than the 5% for hosts are still present in abundance around us British soldiers. It is interesting that a higher and are known to be susceptible to the infec- percentage of recruits have antibodies com- tion(7). The methods of military operations pared to regular soldiers. This is because 90% of used are no different from those used by the our recruits are from rural areas where British namely, tracking the enemy on foot opportunities for leptospiral infection is through jungle marshes, swamps, flooded rice abundant( 10). fields, wading across rivers and streams and A summary of preventive measures taken by waiting in ambush on wet muddy ground. All the the Malaysian armed forces is outlined below:- conditions for infection present before are A. Personal Measures present today. Why then is leptospuosis not 1. Personal hygiene: reported in Malaysian sotdiers? This may be due a. Earty treatment of cuts and abrasions. to several factors: b. Hygiene of the feet. (i) Lack of awareness of the disease by 2. Minimise exposure: medical officers. a. Cross rivers at narrowest and shallow- (ii) Cases are seen too early in the disease est place. when definite symptoms and signs are not b. Avoid splashing while crossing rivers present or characteristic signs are few. and other bodies of water. (iii) Lack of laboratory facilities as well as c. Avoid contact with mud on banks. inadequate use of available facilities. B. General Measures (iv) Leptospirosis is self-limiting. 1. Health education and standing instru- (V) Masking of symptoms and signs by the ctions while on operations and use of broad spectrum antibiotics. exercises(1l). (vi) Inadequate reporting of cases. 2. Treatment of water supplies. Use of rain Two studies on Malaysian soldiers have been water for all purposes in the absence of a carried out which indicate leptospiral infections potable water supply. are common. The first study was for leptos- 3. Restrictions on bathing and swimming. pirosis in febrile Malaysian soldiers (Tan, un- 4. Medial intelligence i.e. creating a high published). Table I shows the results of the index of suspicion of leptospirosis among various studies. British soldiers had the highest clinicians. percentage of leptospirosis, the Americans 12% 5. Protection of food supplies by storing and Malaysian soldiers only 5%. The difference food above ground in protected meat between the British and the Americans is safes and containers to prevent con- probably due to the mode of operations. The tamination from urine of rats and other Americans are frequently airlifted while the animals. British having to track on foot in the Malaysian 6. Rodent control and rat-proofing. jungles had greater exposure to contaminated 7. Proper refuse disposal by deep burial or water and a higher risk of infection(3). The burning. lower incidence in Malaysian soldiers may be In conjunction with the Institute for Medical due to immunity derived from constant ex- Research, we have recently started to study posure to leptospirosis as shown in Table II. leptospirosis among febrile army cases. This 12% of Malaysian soldiers had protective anti- study involves four army centres in Kuala bodies in this study. Though the results cannot Lumpur, Malacca, Kluang and Port Dickson. LEPTOSPIROSIS IN THE MALAYSIAN ARMY TABLE l PERCENTAGE OF LEPTOSPI ROSIS CASES AMONG FEBRILE PATIENTS Study Period Subjects No. examined Percentage Positive 1960-1 961 British soldiers in 93 3 0 Malaysia (Tan, unpublished) 1960-1961 Malaysian soldiers 43 (Tan, unpublished) 1975-1976 Malaysian patients 1437 (Brown et al., 1976)' 1970-1 972 American servicemen 1650 in Vietnam (Bernam et al., 1 973)9 TAB LE l l LEPTOSPIRAL ANTIBODY PREVALENCE IN HEALTHY SUBJECTS Study Year Subjects No. examined Percentage Significant 1970 Malaysian Recruits 1 50 22 (Tan & Lopes, 1972)" 1970 Malaysian soldiers 140 (Tan & Lopes, 1972)' 1960-1961 British soldiers in 204 Malaysia (Tan, unpublished) ACKNOWLEDGEMENTS 5. Baker HJ. Leptospirosis in Nlalaysia. Milit The author thanks Brigadier-General D.A. Med 1965; 130: 1101-2. Lopes JMN, Director of Medical Services, 6. Alexander AD, Evans LB, Baker MF, Malaysian Armed Forces for permission to Baker HJ, Ellison D, Nlarriapan M. publish this paper and Dr. Dora SK Tan of IMR, Pathogenic leptospiras isolated from KL for constructive criticism. Malaysian surface waters. Appl Microbiol 1975; 29: 30-3. REFERENCES 7. Smith CEG, Turner LH, Harrison JL, 1. Murphy LC, Alexander AD. Significance Broom JC. Animal leptospirosis in of the leptospiroses in military medicine. M a l ay a. I . Methods, zoogeographical Milit Med 1957; 121 : 1-10. background, and broad analysis of results. 2. McElligott HF. Leptospirosis. Handout of Bull WHO 1961; 24: 5-21. Roy Army Med College, London, 1968. 8. Brown GW, Lee CK, Huxsoll D L, et a/ 3. MacKay-Dick J. Some aspects of Iepto- Leptospirosis in Malaysia: a common spirosis in Malaysia. J Roy Army Med Cps cause of short-term fever. Southeast 1971; 117: 108-16. Asian J Trop Med Public Health 1976; 7: 4. Archer TC. Medical problems of the 380-3. operational infantry soldier in Malaya. J 9. Berman SJ, Tsai CC, Holmes K, Fresh JW, Roy Army Med Cps 1958; 104: 1-13. Watten RH. Sporadic anicteric leptospiro- Mab ysian J Pathol August 1979 sis in South Vietnam. A study in 150 Malaysian Armed forces. Southeast Asian patients. Ann Intern Med 1973; 79: J Trop Med Public Health 1972; 3: 167-73. 208-1 1. 10. Tan DSK, Lopes DA. A preliminary 11. Malaysian Armed Forces Council instruc- study of the status of leptospirosis in the tion No. 18/66. .
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