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Indian Journal of Medical Microbiology, Vol. 24, No. 4, October-December, 2006, pp. 322-325 Supplement Clinico-epidemiological aspect of leptospirosis in South Gujarat Patel BK, Gandhi SJ, Desai DC Commissionerate of Health Services and Medical Education (HS), Block No-5, Dr. Jivraj Mehta Bhavan, Ganghi Nagar - 382 010, Gujarat Code Number: mb06102 Leptospirosis, first detected in Gujarat in the year 1994 has now become endemic in South Gujarat, which has been witnessing occurrence of leptospirosis during every monsoon. This has led to high mortality, mainly among poor farm laborers. [Table - 1][Table - 2][Table - 3][Table - 4][Table - 5] give details of leptospirosis, with year-wise, sex and age-wise distribution in the different districts of South Gujarat. Leptospirosis is an infectious disease caused by the pathogenic Leptospira spp, of which more than 20 serogroups and more than 200 serovars are known. They are transmitted directly or indirectly from animals to humans. Human to human transmission occurs rarely. Forty per cent of the patients infected with leptospires seroconvert asymptomatically; of the remaining 60%, 90% suffer the milder anicteric form and 10% the severe icteric form. The various predisposing factors for the spread of these pathogens in a specific area include dense population of rodents, presence of large numbers of domesticated, stray and wild animals, high rainfall and stagnation of water in the area for long period, high percentage of humidity, lack of sunshine for long periods and agricultural cropping practices of the area (mainly paddy and sugar-cane growing area) etc. Functional definition of leptospirosis in Gujarat In view of the different patterns of clinical presentation of leptospirosis seen in South Gujarat, a Gujarat-specific functional case definition of leptospirosis has been designed. This case definition has to be followed by all practicing doctors for effective implementation of the Leptospirosis Control Programme. In leptospirosis endemic districts (Surat, Valsad, Navsari) all cases of fever and with any two of the following symptoms, namely i) myalgia, ii) conjunctival suffusion [Figure - 1] and iii) agricultural worker or a person with history of contact with animals should be considered as suspected cases of leptospirosis. Case diagnosis and treatment at health care units The medical officer can get a case directly from the field or may get a referred case. A scoring form is used to diagnose a suspected case of leptospirosis on the basis of presenting signs and symptoms. He evaluates the patient for evidence of organ dysfunction based on functions of the vital organs [Table - 1]. Rapid laboratory tests like Lepto dip-stick, Lepto- lateral flow and Lepto- check assays or ELISA is performed. If the health facility is of a lower level (PHC), all suspected cases of leptospirosis without evidence of organ dysfunction are shifted to higher health facility (CHC). Before shifting the suspected case of leptospirosis, crystalline penicillin (20 lakh units) is given intravenously after negative test dose (ANTD). Patients, with organ dysfunction are shifted to a tertiary care center (District hospital/ New Civil Hospital, Surat) with duly filled referral slip with proper identification number of the patient. The treatment of leptospirosis is divided into two parts, namely chemotherapy and organ-specific supportive care. In chemotherapy, the following is practiced. a) Any case of fever: (Presumptive treatment) Tablet of chloroquine - 600 mg stat (10 mg/Kg body weight) Capsule of doxycycline -100 mg twice a day for seven days This regime is to be followed only during rainy season. b) All suspected leptospirosis cases Intravenous injection of penicillin (20 lakh units) every 6 hours for 7 days. Strategies for the control of leptospirosis in the district of South Gujarat. These are being applied for the last 10 years. Enumeration and treatment of all fever cases using active surveillance in the field by paramedical staff will be treated on the presumptive treatment as shown above. Diagnostic tests for leptospirosis will be applied at the level of CHC, district hospital and MC. The referral centers have been identified in each district, for example:
Score form (originally designed by WHO and modified on the basis of clinical presentation of leptospirosis cases in South Gujarat; modification was done to increase the sensitivity and specificity of the scores) is used at the field and PHC level to diagnose a suspected case of leptospirosis. This form is used to suspect a case of leptospirosis on the basis of presenting signs and symptoms. Chemoprophylaxis is given to all persons working in agricultural farms and engaged in agricultural practices, persons handling cattle and involved in animal husbandry activities. They are given cap doxycycline 200 mg once a week for a period of 6 weeks, the period coinciding with the period of maximum rains and water stagnation in a particular district. The signal for chemoprophylaxis will be given from the level of CDHO in a district. Training is given at the level of district and region by Medical College Surat (PSM and Microbiology Department) and respective CDHO, RDD for the medical personnel and at the level of PHC for the para medical personnel. The documentation of the activities for control of leptospirosis is being done by Medical College, Surat. Control rooms are established. In the respective districts, the Municipal Corporation, RDD and the State Epidemic Cell monitor the activities on a day-to-day basis and the information is compiled and submitted to the higher authorities. The grants are released well in advance from the state level to the respective districts for procurement of drugs, diagnostics kits, referral services, anti- rodent activities, etc. [Table - 2][Table - 3][Table - 4][Table - 5][Table - 6] provide the distribution of leptospirosis in South Gujarat. Public awareness is also created through television and pamphlets distributed in Peripheral Health Centers. Regular meetings at regional and state level are organized to co-ordinate between various department like the Agricultural, Animal Husbandry, Water Supply and Irrigation, Navsari Agricultural University and local self-government establishments. A two day workshop was organized at Surat in January 2006 to streamline anti-rodent activities carried out by the Agriculture Department with grants allotted by health department. Experts from National Plant Protection Institute, Hyderabad and Plague Surveillance Unit, Bangalore were invited to orient the officers from various departments about the different modalities of rodent control. Present Status and Future Earlier, cases of leptospirosis had symptoms of hepato-renal involvement, with several of them being fatal due to hepatic and renal failures. Currently, there are more patients with symptoms of acute pulmonary involvement and intra-alveolar hemorrhage resulting in death in a very short span of time. Over the years the number of cases showed a declining trend but the absolute percentage of mortality increased, particularly during 2005. Also, there is a trend of this disease spreading from rural to urban areas; e.g., cases have been reported from Municipal Corporation, Surat and also in Nagar Palika due to heavy rains and acute water stagnation in 2005. The Fifth Annual National Conference of the Indian Leptospirosis Society was held at Surat from January 20th to 22nd, 2005 to disseminate the information regarding capacity building to control this disease and policies were decided regarding the activities of the concerned departments. A grant of Rs. 65 lakhs from CRF was allotted to the Government Medical College, Surat to strengthen the Microbiology department and laboratory. Adequate stock of medicines is maintained in Surat, Valsad and Navsari districts. Constant interactions are maintained with NICD, who have suggested that intravenous penicillin may be administered instead of the capsule doxycycline. Changing patterns of climatic conditions, the infecting serovars, alterations in the signs and symptoms of the disease, environment management especially with reference to rodent control will necessitate periodical reviewing and modifications of policies undertaken for the effective control of this disease. Copyright 2006 - Indian Journal of Medical Microbiology The following images related to this document are available:Photo images[mb06102t6.jpg] [mb06102t3.jpg] [mb06102f1.jpg] [mb06102t5.jpg] [mb06102t4.jpg] [mb06102t2.jpg] [mb06102t1.jpg] |
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