Persidangan Kesihatan Persekitaran Pihak Berkuasa Tempatan 2015 8 – 9 September 2015, WP . Epidemiology and Current Situation of Leptospirosis in

Dr. Zainudin Abdul Wahab Sector Head for Zoonoses Leptospira Bacteria Disease Control Division Ministry of Health Malaysia Outline

 Introduction

 Etiological Agent

 Transmission

 Risk factor

 Clinical Presentation

 Laboratory Diagnosis

 Treatment of Leptospirosis

 Leptospirosis in Malaysia

 Prevention & Control (involving local authority)

 Conclusion Introduction Leptospirosis is an acute arthropod-zoonotic infection Scientific Beginning • It was first described by Adolf Weil in 1886 when he reported an "acute infectious disease with enlargement of spleen, jaundice and nephritis". Leptospira was first observed in 1907 from a post mortem renal tissue slice.

4 Leptospirosis: Causative agent

Genus: Leptospira, Family: Leptospiraceae Order: Spirochetales Previous classification system [serological classification]: 2 species (before 1989)  Pathogenic: L. interrogans }  Non pathogenic: L. biflexa } • L interrogans is divided further into 24 serogroups, serovars (> 200) and strains (LPS). • Genotypic classification: based on DNA hybridization studies; Morphology • The Leptospira appear tightly coiled thin flexible Spirochetes 5 – 15 microns long. • Fine spiral of 0.1 – 0.2 microns • One end appears bent forms a hook. • Actively motile • Seen best with dark field Microscopy. Leptospirosis: Transmission Modes of Transmission 1. Direct contact with urine or tissue of infected animal Through skin abrasions, intact mucus membrane 2. Indirect contact Broken skin with infected soil, water or vegetation Ingestion of contaminated food & water 3. Droplet infection Inhalation of droplets of infected urine Animals spread Leptospirosis

Rats, Mice, Wild Rodents, Dogs, Swine, Cattle are principle source of infection The above animals excrete Leptospira both in active infection and Asymptomatic stage The Leptospira survive and remain viable for several weeks in stagnant water. 2013 Risk Groups . Factors Responsible for the . High Risk Groups Emergence of Leptospirosis – Workers in the agricultural sectors – Search and rescue workers in high  Reservoir and carrier hosts risk environment  Flooding, drainage – Disaster relief workers congestion – People involved with  Animal-Human Interface outdoor/recreational activities –  Sewerage workers Human host risk factors – Livestock handlers – Pet shops workers – Military personnel – Travelers who are not previously exposed to the bacteria in their environment

Clinical Presentation

Anicteric Icteric 10% of Cases of 10% Common, Rare, Severe mild 15% 90%Cases of < 2% Mortality Mortality Sequence of Leptospira Infection Fever Viral fever, Malaria, Typhus Jaundice Malaria, Viral hepatitis, Sepsis Renal Failure Malaria, Hanta virus, Sepsis Meningitis

Diagnosis Bacterial / Viral causes Differential Differential Hemorrhagic Fever Dengue, Hanta virus, Typhus Laboratory diagnosis of infectious diseases 1. Isolation of infectious agent 2. Observation of infectious agent (direct microscopy) 3. Measure an immune response to the infectious agent (Antibody) : Rapid test, ELISA & MAT 4. Detect the infectious agent or its products - Ag / DNA / Biproducts : PCR 5. Biomarkers

When to do & What to do

Leptospiraemic phase: Detect DNA or Antigen

Immune phase : Detect Antibody Case Classification

• Clinical case • Confirmed case Acute febrile illness with history  Microscopic Agglutination Test of exposure to water and/ or (MAT), environment possibly  Positive PCR contaminated with infected  Positive culture for pathogenic animal urine with symptoms leptospires  Demonstration of leptospires in tissues using • Probable Case immunohistochemical staining A clinical case AND positive ELISA/other Rapid tests Treatment

• Mild flu like symptoms – symptomatic treatment • Mild cases – Doxycycline • Moderate to severe cases – Penicillin • Other drugs found to be effective – Ceftriaxone – Cefotaxime GLOBAL SITUATION OF LEPTOSPIROSIS

LEPTOSPIROSIS IN MALAYSIA 88 cases from 189 (42%)contacted from 26 countries. 29 hospitalized but no death Harian Metro 15 Mei 2009

Harian Metro 16 Mei 2009

Malay Mail, 18 Mac 1995

The Star 28 Julai 2010 The Star 9 Ogos 2010 The Star online 29 Dec 2010 Harian Metro 7 Jan 2013

The Star online 9 Ogos 2010 Harian Metro 25 July 2011

Utusan Malaysia 3 Jan 2013

LUBUK YU, MARAN, 2010

Number of Leptospirosis Cases and Deaths

9000 from 2004 until July 100 8000 92 90 7000 80 71 70 6000 69 62 5,370 60

5000 55 7,806 Cases 48 50 Deaths 4000 47 4,457 40 3000 3,665 30 30 2000 20 20 22 22 20 1,976 2,268 1000 1,263 1,418 10 378 527 949 0 263 0

Year Cases Deaths Incidence & Mortality Rate of Leptospirosis 2004 until July 2015 (Annualised) in Malaysia 35 0.35 0.31 30 0.30 30.2 25 0.24 0.24 0.25 0.22 0.19 25.94 20 0.20 populations 0.17 0.16 0.17 15 15.00 0.15

IR/100,000 populations IR/100,000 10 12.49 0.10 0.08 MR/100,000 0.08 0.08 6.99 7.94 5 1.98 0.05 3.49 4.55 5.01 1.45 0 1.03 0.01 0.00

Year Incidence Rate (IR) Mortality Rate (MR)

Leptospirosis Cases in 5 major State 2004 until July 2015 in Malaysia 2000 1500 1000 Cases 500 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year

Incidence Rate (IR) of Leptosirosis in 5 major State 2004 until July 2015 150.00 (Annualised IR) in Malaysia

Kelantan 100.00 Perak Sabah Sarawak 50.00

Selangor IR/100,000 populations IR/100,000 0.00 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year Number of Leptospirosis Cases by State until July 2015 in Malaysia 1400 1200 1000 Cases (2015) 800 Mean (2010-2014) Cases 600 400 200 0

Year

Number of Leptospirosis Deaths by State until July 2015 in Malaysia 10 8 Deaths (2015) 6 Mean (2010-2014)

4 Cases 2 0

Year 30 Leptospirosis Deaths in 5 major State 2004 until July 2015 in Malaysia 25 Kelantan Perak 20 Sabah 15 Sarawak Deaths 10 Selangor 5 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year

Mortality Rate (MR) of Leptospirosisin in 5 Major 2.00 State 2004 until July 2015 (Annualised MR) in Malaysia Kelantan 1.50 Perak Sabah 1.00 Sarawak Selangor 0.50

0.00 MR/100,000 populations MR/100,000 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year Number of Leptospirosis Cases by State in Malaysia 2013-2014 2000 1832 1800 1600 1400 2013 2014 1200 1030 1000 930 800 699 616 621

Number ofCases Number 600 350 374 387 400 288 302 191 200 141 20 25 0

Epid Week Number of Leptospirosis Cases by State in Malaysia 2014-2015 (Corresponding Week : EW1 – EW30) 1400 1270 1200

1000 879 2014 2015 800

600 513 461 476 Number ofCases Number 400 323 338 215 221 170 180 201 200 79 11 33 0

State Incidence Rate (IR) of Leptospirosis Cases by State in Malaysia 2014 & 2015 (Annualised IR) until EW30 140.0 126.7 120.0 2014(25.94) 2015 (30.20) 100.0

80.0 68.5 58.4 60.0 39.4 40.0 33.4 31.4 33.4 22.4 25.7 IR per 100,000 populations 100,000perIR 19.9 19.0 20.0 16.4 7.7 8.1 10.7 0.0

State Distribution of Leptospirosis Cases by Gender in Malaysia 2013-2014

2013 2014

Female, Female, 1252,28% 2750, 35% Male, Male, 5056,65% 3205,72% Distribution of Leptospirosis Cases by Age Group in Malaysia 2013-2014

2013 2014

218, 5% 0, 0% 454, 6% 356, 8% 11, 0% < 1 yrs 763, 10% 1 - 6 yrs 764, 17% 1466, 19% 7 - 18 yrs 576, 13% 1025, 13% 19 - 24 yrs 2532, 57% 4098, 52% 25 - 60 yrs > 6o yrs Distribution of Leptospirosis Cases by Occupation in Malaysia 2013-2014

0% Self employed 0% 2% Firemen 1% 2% 0% 5% 6% 0%4% 1% 3% Laborer 1% 2% Health Care Worker 7% 9% 7% Technician/Engineer Others 32% 11% 2% 10% Government Servant 6% Private Sector 46% 12% Student 10% 8% 2% Transportation Food Handler 1% 0% Industrial 2% 0% 1% 2% Management 1% 2% 1% Farming Agriculture Unknown 2013 2014 Jobless SITUATION OF LEPTOSPIROSIS IN MALAYSIA 2015 ( until July, Epid Week (EW) 30/2015 ) Particular Number of State Cases 1. Total Cases (Cumulative) 5,370 Malaysia [ 3,829 (2014) ] – increasing 40% 2. 5 State with higher cases 1,270 1. Kelantan 879 2. Selangor 513 3. Sarawak 476 4. 461 5. 3. Total Deaths (Cumulative) 30 All States not included , Terengganu and WP Labuan 4. 5 State with higher cases 8 1. Kelantan of death 5 2. Perak 3 3. Selangor 2 4. Kedah/P.Pinang/N. Sembilan/Sabah /Sarawak 1 5. /Melaka /Pahang /WPKL 5. Total Outbreaks 14 (9 States) Selangor (2) /Sarawak (2) /N. Sembilan (2) /WPKL (2) (Cumulative) /Perak (1) /Kedah (2) /Terengganu (1) /Kelantan (1) /Sabah (1) 6. Number of Outbreak Cases 86 Selangor (14)/Sarawak (15) /N. Sembilan (17) /WPKL (20) /Perak (3) /Kedah (5) /Terengganu (3) /Kelantan (2) /Sabah (7) Trend of Leptospirosis in Malaysia 2011 - July, EW30/2015 300

250

200

150

100 Number ofCases Number 50

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53

Epid Week

2011 2012 2013 2014 2015 Trend of Leptospirosis in Malaysia 2014 - July, EW30/2015 300

250

200 Cases 150

Number ofNumber 100

50

0 1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526272829303132333435363738394041424344454647484950515253 Epid Week

2014 2015 Median (2011-2014) Trend of Leptospirosis in Malaysia 2014 - July, EW30/2015

300

250

200 cases 186

150

136 Number ofNumber 100 86

50

0 1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526272829303132333435363738394041424344454647484950515253 Epid Week

2014 2015 Mean Alert Threshold Epidemic Threshold Trend of Leptospirosis in Malaysia 2014 - July, EW30/2015

300

250

200

150

Number ofCases Number 100

50

0 1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526272829303132333435363738394041424344454647484950515253 Epid Week 2014 2015 Moving Mean Alert Threshold Epidemic Threshold Number of Leptospirosis Outbreak and Cases 120 9 State 2014 2015 8 8 100 7 Cases Num.of Cases NNum.of 80 6 6 Outbreak Outbreak 5 5 5

60 4 4 4 Johor 29 3 0 0 Cases 40 3 3 3 Outbreak 2 2 Kedah 9 4 5 2 20 1 1 0 0 Kelantan 14 5 2 1 N.Sembilan 6 2 17 2

State Perak 31 8 3 1 Cases Outbreak Sabah 10 4 7 1 Sarawak 7 3 15 2 Number of Leptospirosis Outbreak and Cases until July, 2015 in Malaysia Selangor 96 5 14 2 25 5 20 4 WP. Labuan 3 1 0 0 15 3 WPKL 64 6 20 2

Terengganu 0 0 3 1 Cases 10 2 2 2 2 2 2 Outbreak 5 1 1 1 1 1 Total 269 41 86 14 0 0

State Cases Outbreak Distribution of Areas of Leptospirosis Outbreak in Malaysia 2014 & 2015 (until July, EW 30/2015) 2014 2015 Farm, 2, Chalet, 1, Port , 1, 5% 7% Hostel, 3, 2% Forest 7% Reserve, 1, 7% Residential Residential Forest Reserve, 7, areas, 15, Depo Prisoners, 3, areas, 6, 17% 37% 21% 43% Recreation Recreation areas, 13, areas, 3, 32% 22% Prevention & Control (involving local authority)

Prevention and control should be targeted at: (a) The infection source; (b) The route of transmission between the infection source and the human host; (c) Prompt and proper treatment of infection AND: (d) Surveillance (d) Prophylaxis, ? Vaccination (e) Risk communication, awareness & colloboration Prevention & Control (involving local authority) (a) Reduce the infection source: • Reduce rodent population using rodenticide or mechanical trapping and ? Biological mean • Use rodent –proof material to cover food storage • Scheduled & proper garbage disposal to eliminate food for rodent in surrounding human habitation • Unclogged drain to deny rodent of shelter, food &water • Maintain environmental sanitation i.e. housing areas and recreational parks by regular cleaning • Food premises inspection & rating. Closure of unhygienic eating places ( cover ready-to-eat-food, proper disposal of left over food. Prevention & Control (involving local authority) (b) The route of transmission between the infection source and the human host: • Avoid contact with potential contaminated water such as stagnated water / drain : ablution, washing • Apply water proof plasters for wound before coming into contact with water • Avoid unnecessary contact with flood water • Wear rubber boots, glove for high risk occupation (abattoir , sewerage workers) • Prohibit use or closure of contaminated water bodies until risk assessment has been conducted and control measures have been instituted and found to be effective. Reopening of affected area can only be carried out after reassessment has shown that the risk has been controlled effectively. Prevention & Control (involving local authority)

(c) Prompt and proper treatment of infection. Advise people who have been exposed to possible contaminated water source either through occupation or recreational activities to wash themselves with clean water and seek immediate medical treatment if developed symptoms within the incubation period Prevention & Control (involving local authority) (d) Surveillance – Preventive measures must be based on knowledge of the groups at particular risk of infection and the local epidemiological factors. – Data verified & registered in e-Notifikasi – Investigation to identify the probable source of infection – to take environmental sample where ever is appropriate for evidence (i.e. water, rodent, soil etc) – Identified risk factor must be recorded in ‘comment’ column in e- Notifikasi – Analyze the data from e-Notifikasi – Strategized control & preventive measures. Prevention & Control (involving local authority)

(d) Prophylaxis, ? Vaccination – Get prophylaxis for people with short term of exposure i.e. soldier conducting jungle operation (e) Risk communication, awareness & collaboration – Create awareness about the disease and its prevention: health staff & public and recreational park operators using various media – Promote interagency collaboration such as with local authorities, Wildlife Department, Department of Veterinary Services, JLKN, etc. to maintain cleanliness in the respective environmental settings, especially rodent control

Prevention Prevention is difficult due to wild animal infection Good sanitation, Immunization of live stock Personal hygiene, PPE, Water treatment No useful human vaccines – multiple serovars Doxycycline 200 mg weekly for at risk groups Guidelines and References  MOH. Garispanduan Pemeriksaan Kesihatan Persekitaran Kem PLKN Jabatan Latihan Khidmat Negara. 2008  MOH. Guidelines For The Diagnosis, Management, Prevention And Control Of Leptospirosis In Malaysia. 2011  Surat Pekeliling Ketua Pengarah Kesihatan Malaysia Bil. 33/2010: Pemberitahuan Pewartaan Penyakit Leptospirosis Sebagai Penyakit Yang Perlu Dinotifikasi Di Bawah Akta 342, Pencegahan Dan Pengawalan Penyakit Berjangkit 1988.  Surat Pekeliling Ketua Pengarah Kesihatan Malaysia Bil. 16/2012 : Langkah-langkah Penambahbaikan Bagi Mengurangkan Risiko kejadian Penyakit leptospirosis Di Kalangan Pelatih Program PLKN Challenges of Leptospirosis Re-emerging Infection

• Awareness • Early & accurate diagnosis • Prompt treatment • Prevention and control measures • Laboratory capacity building • Multiagency cooperation & collaboration The Way Forward

• Providing continue awareness for healthcare personnel and public: In service training, guidelines, seminar, media, articles etc • Strengthening lab capacity • Sharing of surveillance information • Coordinated response • ‘One Health’ approach – bridging of the medical, veterinary professionals and related agencies in the control and prevention of leptospirosis (early & prompt treatment, livestock's farms, garbage disposal, institutional hygiene, recreational areas sanitation and research) Conclusion

• Leptospirosis is an important re-emerging zoonosis as a result of interface between human and animal (environment). • Awareness, control & protective measures, early detection and prompt treatment are the keys to reducing the morbidity & mortality risks from Leptospirosis. • Way forward through the scope of the One Health approach of collaboration and continued core capacity building. Thank You