Persidangan Kesihatan Persekitaran Pihak Berkuasa Tempatan 2015 8 – 9 September 2015, WP Labuan. Epidemiology and Current Situation of Leptospirosis in Malaysia 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 Common, Rare, Severe mild 15% 90% of Cases < 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, PAHANG 2010 Number of Leptospirosis Cases and Deaths 9000 from 2004 until July 2015 in Malaysia 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 Kelantan 1500 Perak 1000 Sabah Cases Sarawak 500 Selangor 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 per100,000IR 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. Kedah 461 5. Terengganu 3. Total Deaths (Cumulative) 30 All States not included Perlis, 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. Johor/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 2014 in Malaysia 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.