1. Erin Paul Leptospirosis Source: La Voz del Sandinismo

2. Objectives Analyze an epidemic in Nicaragua for lessons about dealing with leptospirosis in emergencies and humanitarian crises. Describe the most common symptoms of the infection Describe diagnosis techniques and treatment Name public health interventions to prevent transmission

3. Recent Outbreaks in Nicaragua (1995, 2007, 2010) Three original patients with pulmonary hemorrhaging died. Doctors at the local Health Center thought it was dengue hemorrhagic fever. Other patients with high fever, muscle aches, headache, vomiting, and diarrhea During hurricane season after particularly heavy rains

4. Flooding before 2007 outbreak Source: La Prensa

5. Leptospirosis Zoonotic disease passed from many kinds of wild and domestic animals Caused by a type of bacteria called a spirochete (leptospira interrogans) Source: Dr. Scott Smith

6. History of the disease Severe form of leptospirosis studied by Adolf Weil Bacteria identified by Stimson Some evidence that incidence is increasing Photo of Adolf Weil. Source: Wikipedia Creative Commons

7. Epidemiology Source: cabi.org

8. Transmission

9. Symptoms Many cases are relatively mild Fever, muscle and bone pain, headache Conjunctival suffusion indicates leptospirosis Severe form also known as Weil’s disease Pulmonary problems are not common Renal and liver failure in severe cases

10. Differential Diagnosis Dengue Malaria Rickettsial disease (spotted fever) Scrub typhus Typhoid fever Hantavirus Influenza

11. Diagnosis Diagnosis via ELISA or MAT tests Dipstick test –Leptospira found in blood for 7 – 10 days –Then leptospira move to the kidneys and can be found in urine Source: Clpmag.com

12. Treatment – Hospitalized patients Penicillin is the antibiotic of choice –6 million units per day –Alternatives include doxycycline, ceftriaxone, cefotaxime. For children <8 years –Azithromycin –Clarithromycin Supportive care for dehydration, hypotension, hemorrhage, etc.

13. Treatment -- Outpatients For outpatients (who can tolerate oral medications): Doxycycline 100 mg twice daily orally, for 10 days –Not for children under 8 or pregnant women –Amoxicillin 25 – 50 mg/kg divided in three doses for children/pregnant women For patients allergic to penicillin: –Erythromycin 250 mg, 4 times a day for 5 days

14. Treatment Give doxycycline to people at a high risk for a short period of time Tetracycline is no longer recommended –Contraindicated with renal insufficiency –Renal insufficiency common in severe leptospirosis Treat with doxycycline if rickettsial diseases are also endemic

15. Prevention Public health measures –Vector control (rodent control) –Improved sanitation Storm water drainage in urban areas Garbage management –Disinfection of potable water supplies Education for high risk occupations –Sewer workers, butchers, etc. Avoid contact with flood waters and don’t swim in areas that may be contaminated

16. Relevant Sphere Standards to Control Leptospirosis Water quality Excreta disposal Solid waste management Drainage

17. Sanitation and Hygiene Education

18. Challenges No highly effective, widely available vaccine for humans Leptospirosis is frequently confused with other illnesses Rapid diagnostic tests have low sensitivity Prevention is difficult

19. Conclusions – Leptospirosis in Complex Humanitarian Crises Most common symptoms are fever, headache, jaundice Frequently follows heavy rains Treat with penicillin or doxycycline Control rodents and treat drinking water for prevention

20. References Clark, L. G. et.al., “Leptospirosis in Nicaragua: A Preliminary Report After the First Year of Study.” American Journal of Tropical Medicine and Hygiene 15 (1966): 735 -742. Effler, Paul V. et.al. “Evaluation of Eight Rapid Screening Tests for Acute Leptospirosis in Hawaii.” Journal of Clinical Microbiology 40 (2002): 1464 – 1469. Epino, Henry. Personal Communication. 03/08/2012. Everett, E. Dale. “Microbiology, Epidemiology, Clinical Manifestations, and Diagnosis of Leptospirosis.” Up-to-Date. Online database. Mar 23, 2010. Everett, E. Dale. “Treatment and Prevention of Leptospirosis.” Up-to-date. Online database. Accessed 03/04/2012. Faine, S. et. al. Leptospira and Leptospirosis. Melbourne: MediSci, 1999. Farr, R. Wesley. “Leptospirosis.” Clinical Infectious Diseases 21 (1995): 1-6 “Leptospirosis Burden Epidemiological Reference Group”. World Health Organization. Website. Accessed 03/01/2012.

21. References, cont. Levett, Paul. N. “Usefulness of Serologic Analysis as a Predictor of the Infecting Serovar in Patients with Severe Leptospirosis.” Clinical Infectious Diseases 32 (2003): 447-452. Melghem, Lorena. Escuela y Casa Saludable: Una Experiencia Exitosa en Honduras. World Bank Water and Sanitation Program, 2003. “Outbreak of Acute Febrile Ilness and Pulmonary Hemorrhage – Nicaragua, 1995.” Journal of the American Medical Association 974 (1995): 1668. Ren, Shuang Xi, et.al. “Unique Physiological and Pathogenic Features of Leptospira Interrogans Revealed by Whole Genome Sequencing.” Nature 422 (2003): 888-893. The Sphere Project: Humanitarian Charter and Minimum Standards in Humanitarian Response. The Sphere Project. 2011. Zaki, S.R. and Shieh, W.J. “Leptospirosis Associated with Outbreak of Acute Febrile Illness and Pulmonary Hemorrhage – Nicaragua, 1995.” The Lancet 347 (1996): 535 – 536.