It is a disease that is easily preventable and curable when detected and treated early. Sadly, poor compliance with health advisories issued by the Health Department has been leading to unnecessary loss of lives due to leptospirosis in the State.
Leptospirosis is a zoonotic bacterial disease that is transmitted through contact of the skin and mucous membranes with water or mud contaminated with rodent urine. A leptospirosis outbreak in the aftermath of a disaster was an eventuality that the department was prepared to tackle and sufficient warnings had been issued to the public. However, the department’s health advisories do not seem to have been taken seriously by the general public.
Leptospirosis is transmitted through contact of the skin and mucous membranes with water or mud contaminated with rodent urine. During heavy flooding, the infectious organism is spread to larger and distant areas and hence everyone who comes into contact with flood waters are at risk of contracting the infection. Despite the availability of a drug with proven efficacy as a pre-exposure and post-exposure prophylactic against leptospirosis, the refusal of people to take the drug continues to baffle the department.
Never too late for doxycycline
“Doxycycline has been found to be over 70% efficient even when one has been exposed to the infectious agent. The majority of those who have taken the drug will not get the disease if consumed as per the guidelines. Even if one were to contract the infectious agent, it would be only anicteric leptospirosis (a mild, self-limiting flu-like illness),” says R. Aravind, Head of Infectious Diseases, Thiruvananthapuram Government Medical College.
“About 90% of the cases occurring in the community will always be anicteric and may not even be captured by the heath system data. It is only in 5-10% cases of icteric leptospirosis or Weil’s syndrome, with multi-organ involvement, that we expect the mortality to go up to 15%,” he says.
Pulmonary haemorrhage
Pulmonary involvement is usually a late complication of leptospirosis, which affects all major organs. In the leptospirosis outbreak in South Gujarat in 2006, in the aftermath of heavy flooding, nearly 57 % of the deaths had been due to pulmonary haemorrhage. A similar situation seems to be happening in Kerala too right now a Doctors report pulmonary haemorrhagic syndrome as the lethal complication that seems to be setting in by the third or fourth day of the illness, leading to increased mortality
The situation in private sector, as per reports, is not alarming and serious cases of lepto complications are still being dealt by the Government Medical Colleges.
“What we are seeing in our ICUs are late presentation of patients, with pulmonary involvement and multi-organ failure setting in on the third or fourth day itself. The patient then requires ventilation and dialysis. If leptospirosis complications present as pulmonary haemorrhage and/or myocarditis, then 50-70% mortality should be expected in any clinical settings,” says Dr. Aravind.
While pulmonary haemorrhagic presentation is not new, the sudden spike in the number of cases with this complication is worrying.
One of the problems in the clinical scenario is that leptospirosis has a wide spectrum of symptoms which may mimic the clinical symptoms of tropical diseases like dengue, H1N1 or Scrub typhus and hence the diagnosis of an acute undifferentiated febrile illness could be very difficult. Medical literature says that in up to 8% of the cases, there could be co-infections .
Laboratory diagnosis of leptospirosis continues to be a challenge, because current serological tests which tests for antibodies, like ELISA, do not give confirmatory results in the acute phase of the disease.
In recent years, the Health Department has introduced RT PCR tests for leptospirosis screening at the State Public Health Laboratories, which can give confirmatory results within the first week itself, in the early phase of the disease. But these are not widely available. However, in public health settings, especially in a post-disaster scenario, there is no significance for laboratory confirmation of leptospirosis, senior health officials point out.
“If there is a history of exposure to floodwaters and clinical symptoms include myalgia (muscle pain, localised to calf and lumbar region) and fever (might be very mild), the presumptive diagnosis should be leptospirosis. We cannot wait for lab tests, the patient should be started on Doxycycline or Crystalline Penicillin therapy immediately, depending on the symptoms,”an official said.
Treatment protocol
While the treatment guidelines have remained the same, but with the case numbers going up, the Health Department has optimised the protocol so that doctors in PHCs/CHCs can be more sure when to refer a patient to a higher centre.
Accordingly, any person presenting with fever and myalgia and should be given presumptive treatment with doxycycline,100 mg twice a day for seven days.
He should be followed up daily and if at all there are any red flag signs – breathing difficulty, hypotension, jaundice, reduced urine output, any bleeding manifestations, altered sensorium – he should be referred to a tertiary care centre and administered Penicillin therapy or third generation alternatives like ceftriaxone immediately to prevent the patient progressing into further complications.
The measures taken by the Health department are adequate in the current situation but Health officials are worried that if the numbers were to go up, the health system resources could be under strain as more patients would require high-end care.
“People are right now cleaning their houses, which means that even though floodwaters have receded, they are continuously being exposed to infectious agents. It is important that even when on doxycycline, they use personal protective equipment and that they wash their hands well,”
